精選內(nèi)容
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膝關節(jié)置換術后應如何康復
劉萬軍醫(yī)生的科普號2024年07月08日32
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膝關節(jié)冠狀面對線CPAK分類系統(tǒng)_不是所有的膝關節(jié)、全膝關節(jié)置換都是一樣的(2024)
膝關節(jié)冠狀面對線CPAK分類系統(tǒng)_不是所有的膝關節(jié)、全膝關節(jié)置換都是一樣的(2024)Notallkneesarethesame?MacDessiSJ,vandeGraafVA,WoodJA,Griffiths-JonesW,BellemansJ,ChenDB.Notallkneesarethesame[J].BoneJointJ,2024,106-B(6):525-531.?轉(zhuǎn)載文章的原鏈接1:https://pubmed-ncbi-nlm-nih-gov-443.vpnm.ccmu.edu.cn/38821506/?轉(zhuǎn)載文章的原鏈接2:https://boneandjoint.org.uk/Article/10.1302/0301-620X.106B6.BJJ-2023-1292.R1?AbstractTheaimofmechanicalalignmentintotalkneearthroplastyistoalignallkneesintoafixedneutralposition,eventhoughnotallkneesarethesame.Asaresult,mechanicalalignmentoftenaltersapatient’sconstitutionalalignmentandjointlineobliquity,resultinginsoft-tissueimbalance.ThisannotationprovidesanoverviewofhowtheCoronalPlaneAlignmentoftheKnee(CPAK)classificationcanbeusedtopredictimbalancewithmechanicalalignment,andthenofferspracticalguidanceforbonebalancing,minimizingtheneedforsoft-tissuereleases.全膝關節(jié)置換術中的機械對線的目的是將所有膝關節(jié)對線到一個固定的中立位置,盡管并非所有膝關節(jié)都相同。因此,機械對線通常會改變患者的固有對線和關節(jié)線傾斜度,導致軟組織失衡。本文概述了如何使用“膝關節(jié)冠狀面對線(CPAK)”分類來預測機械對線引起的失衡,并提供了實用的指導,以平衡骨骼,減少對軟組織釋放的需要。?IntroductionIrrespectiveofthealignmentstrategyusedwhenundertakingtotalkneearthroplasty(TKA),surgeonsmustcontendwiththefactthatnotallkneesarethesame.InmechanicallyalignedTKA,balancingisusuallyperformedfollowingcompletionofthebonycutsandassessmentofthelaxityofthesoft-tissues.1Thelong-standingapproachforachievingbalanced“gaps”hasbeenbyreleasingorlengtheningligamentousandcapsularstructures,therebyalteringtheirinherentphysiologicalfunction.1,2Withagreateracceptancethatligamentsdonotcontract,3andthatimbalanceresultsfromsurgicalalterationstothepatient’sconstitutionalalignment,4amorenuancedapproachwith“bonebalancing”hasbeensuggested.5Bonebalancingmodifiesthealignmentbybiasingbonyresectionstowardsamoreconstitutionalorientation,therebymaintainingtheirfunctionandreducingthenecessityforsoft-tissuereleases.BonebalancingusinganinitialmechanicalalignmentplanrepresentsoneendofthespectrumofTKAalignmentstrategies,withunrestrictedkinematicalignmentattheother.6-10Subtlechangesofalignmentupto3°fromaneutralmechanicalaxisareoftenenoughtoimproveimbalance,andstillconsideredsafeforsurgeonswhowanttomaintainalignmentwithinthismoretraditionalwindow.11,12Restoringtheknee’sconstitutionalalignmentismorelikelytoachievesoft-tissuebalancecomparedwithusingmechanicalalignmentforallpatients.13,14TheCoronalPlaneAlignmentoftheKnee(CPAK)classificationisawidelyadoptedandpragmaticsystemthatoffersaframeworktounderstandtherelationshipbetweenthenativelowerlimbalignmentandjointlineobliquity(JLO)tothesoft-tissuebalance.14CPAKdefinesninekneephenotypesbasedonconstitutionalalignmentoftheknee,incorporatingthearithmetichip-knee-ankleangle(aHKA)andthejointlineobliquity.Inthisinstructionalreview,weusetheCPAKclassificationtounderstandwhynotallkneesarethesameintermsofimbalancewhenperformingmechanicallyalignedTKA.EachCPAKtypewillbeintroducedbasedonitsprimaryradiologicalandmorphologicalcharacteristics.AlterationstoconstitutionalalignmentthatresultwhenperformingmechanicallyalignedTKAwillbepresentedforeachCPAKtype,alongwiththeanticipatedchallengeswithbalance.Formostsurgeonswhousemechanicalalignment,andforthosewhohavenowadoptedanindividualizedapproach,understandingtheseconceptsisimportantforappreciatingwhyalignmentmatters.?RadiologicalassessmentPreoperativelonglegimagingthatallowsforassessmentofthemechanicalaxisisobtainedusingplainradiographswithdigitalstitching,biplanarimagingorwhole-legCTimaging.Thelateraldistalfemoralangle(LDFA)ismeasuredasthelateralanglesubtendedbythemechanicalaxisofthefemurandthearticularlinetangentialtothedistalfemoralarticularsurface.Themedialproximaltibialangle(MPTA)ismeasuredasthemedialanglesubtendedbythemechanicalaxisofthetibiaandthearticularlinetangentialtotheproximaltibialarticularsurface(Figure1).Apartfromhighlightinglossofjointspace,shortradiographsofthekneeareofnovalueintheassessmentofconstitutionalalignment,andthereforeoftheindividual’skneephenotype.15,16??Fig.1Longlegstandingradiographsshowingthemechanicalaxesofthefemurandtibia.Therightkneeshowsmeasurementofconstitutionalalignmentinanarthritickneeusingthearithmetichip-knee-ankleangle(aHKA)algorithm.Theleftnormalkneeshowsmeasurementofthethemechanicalhip-knee-ankleangle(mHKA).LDFA,lateraldistalfemoralangle;MA,mechanicalaxis;MPTA,medialproximaltibialangle.??TheconstitutionalcoronalalignmentiscalculatedusingtheequationaHKA=MPTA–LDFA,andtheconstitutionaljointlineobliquity(JLO)usingtheequationJLO=MPTA+LDFA.TheboundariesforconstitutionalalignmentofthelowerlimbusingtheaHKAarevarus<-2°,neutral-2°to+2°inclusive,andvalgus>2°.TheboundariesforconstitutionalJLOareapexdistal<177°,neutral177°to183°,andapexproximal>183°.TheCPAKtypeisthendeterminedbasedontheseboundaries(Figure2).??Fig.2TheCoronalPlaneAlignmentoftheKnee(CPAK)classificationwithboundaries.aHKA,arithmetichip-knee-ankle;JLO,jointlineobliquity.??DatafrompreviousstudiessupportthedescriptionsofeachCPAKtypediscussedhere.Alignmentcharacteristicsarederivedfromasampleof500kneesin250healthyadults,agedbetween20and27years(SupplementaryTablei);13soft-tissuelaxitydataarederivedfromasampleof137kneescomparingbalancebetweendifferentalignmentstrategies(SupplementaryTableii);17andloadsensordataarederivedfromasampleof138kneescomparingcompartmentalloadsbetweenalignmentstrategies(SupplementaryTableiii).4Inthisannotation,onlyCPAKTypesItoVIarediscussed,asmanyauthorshaveshownthatTypesVIItoIXarerareinthegeneralpopulation.14,18-23FortheLDFAandMPTA,wecharacterizeorientationas“neutral”if≤1°from90°;“mild”if>1°and≤2°from90°;“moderate”if>2°and≤4°from90°;and“significant”if>4°from90°.DescriptiveradiologicalmeasurementsandschematicphenotypictraitsarepresentedforeachCPAKtypeandforchangestoJLO.Alterationsinconstitutionalalignment,nativefemoraljointlineanatomy,lateralfemoralcolumnlength,andtheirsequelaearesummarizedinTableI.??TableI.TheimplicationsofmechanicalalignmentbasedonCoronalPlaneAlignmentoftheKneetype.CPAK,CoronalPlaneAlignmentoftheKnee;MA,mechanicalalignment;N/A,notapplicable.??CPAKTypeIThekneesin133ofthesampleofhealthyindividuals(26.6%)wereCPAKTypeI.ThisisthemostprevalentphenotypeinAsianandIndianpatientsundergoingTKA,andisthemostcommonvarusphenotypeglobally.18,19,23Thistypeischaracterizedbysignificantproximaltibialvarusandmilddistalfemoralvalgus,resultinginavarusaHKAandanapexdistalJLO.TheimplicationsformechanicalalignmentareshowninFigure3a.MehanicalalignmentwithCPAKTypeIkneesresultsinconsiderabletightnessoftheMCLduetotheshiftinaHKAfromvarustoneutral.Asthemagnitudeofchangeincreases,sodoesthelikelihoodoflateralcondylarlift-off,asignalofmajorimbalance.TheMCListightinbothextensionandflexion.Commonly,surgeonspartiallyorcompletelyreleasetheMCLinanattempttoachievebalance,butsecondaryincompetenceoftheMCLmayresultfromreleasingthiscriticalstructure.Alterationofconstitutionalvarustoneutralwillincreasethelengthoftheleg,andincreasetheneedforathickerpolyethyleneinserttocompensatefortheartificialincreaseinmedialgapheight.24AstheprimarycharacteristicofTypeIistibialvarus,avarustibialrecutwithmechanicalalignmentmayberequiredtoachievebalanceinbothextensionandflexion.??Fig.3Illustrationofsoft-tissueimbalanceinCoronalPlaneAlignmentoftheKnee(CPAK)TypesItoVI,showinghowmechanicalalignment(MA)altersconstitutionalalignmentandjointlineobliquity.a)MAwithCPAKTypeI.Theredwedgehighlightssignificanttibialvarus,andtheredarrowindicateselevationofthemedialjointline.b)MAwithCPAKTypeII.Thegreenwedgeshighlightmoderatefemoralvalgusandmoderatetibialvarus.Theredarrowindicateselevationofthemedialjointline,andtheorangearrowindicatesdistalizationofthelateralfemoralcolumn.c)MAwithCPAKTypeIII.Theredwedgeshighlightssignificantfemoralvalgus,andtheorangearrowindicatesdistalizationofthelateralfemoralcolumn.d)MAwithCPAKTypeIV.Thegreenwedgeindicatesmoderatetibialvarus.Theredarrowhighlightselevationofthemedialjointline.e)MAwithCPAKTypeV.f)MAwithCPAKTypeVI.Thegreenwedgehighlightsmoderatefemoralvalgusandtheorangearrowindicatesdistalizationofthelateralfemoralcolumn.aHKA,arithmetichip-knee-ankleangle;JLO,jointlineobliquity.??CPAKTypeIIThekneesof205ofthehealthyindividuals(41.0%)wereCPAKTypeII.Thisisthemostcommonkneephenotypeglobally.14,22Thistypeischaracterizedbymoderateproximaltibialvarusandmoderatedistalfemoralvalgus,resultinginaneutralaHKAandanapexdistalJLO.TheimplicationsformechanicalalignmentareshowninFigure3b.MechanicallyalignedTKAspecificallyaddressesCPAKTypeIIphenotypiccharacteristics.Asneutralconstitutionalalignmentismaintained,soft-tissuebalanceinextensionisusuallynotaltered.Furthermore,byapplyingexternalrotationtothefemoralcomponent,imbalanceinflexionisunlikely.The“anatomicalalignment”methodattemptedtoreplicateTypeIIbyrecreatinganapexdistalJLO,25butimprecisecuttingguidesresultedinthistechniquebeingabandoned.ThefollowingkinematicalterationsrequireconsiderationinCPAKTypeII.Thenativefemoraljointlineisraisedmediallythroughoutthearcofmotion,apotentialcauseofmid-flexioninstability.26Thelateralfemoralcolumnislengthened(distalized)inextensionandflexion.Ithasbeensuggestedthatthismayleadtoincreasedpatellofemoralretinaculartightnessinflexionbylateraldistalfemoralprostheticoverstuffing,27particularlyinkneeswithveryobliquejointlinessuchasthoseof≤170°.Theneedforsoft-tissuebalancingwithCPAKTypeIIisminimal.?CPAKTypeIIIThekneesof47ofthehealthyindividuals(9.4%)wereCPAKTypeIII.Thistypeisthemostcommonvalgusphenotypeandischaracterizedbyconsiderabledistalfemoralvalgusandmildproximaltibialvarus,resultinginavalgusaHKAandapexdistalJLO.TheimplicationsformechanicalalignmentareshowninFigure3c.Imbalancewithmechanicalalignmentoccursinextensionandtoalesserextentinflexion,astheaHKAisshiftedfromvalgustoneutral.Thedegreeoflateraltightnessisdependentontwovariables:themagnitudeofaHKArelativetothechangeprescribedbymechanicalalignment;andthevariabilityinconstitutionallaxityofthelateralsiderelativetomediallaxity.Inmanyknees,increasedconstitutionallaterallaxity,whichisfurtherincreasedafterresectionofthecruciateligaments,28–30cancompensateforthisshiftinaHKAandreducetheneedforlateralbalancing.However,inourexperience,whenpatientshaveanaHKAof≥5°,soft-tissueimbalanceinevitablyresults.AstheprimarycharacteristicofCPAKTypeIIIissignificantfemoralvalgus,adistalfemoralvalgusrecutmayberequiredtoachievebalanceinextension.?CPAKTypeIVThekneesof21ofthehealthyindividuals(4.2%)wereCPAKTypeIV,whichisararervarusphenotype,characterizedbymoderateproximaltibialvarusandmilddistalfemoralvarus,resultinginavarusaHKAandneutralJLO.TheimplicationsformechanicalalignmentareshowninFigure3d.AswithTypeI,therewillbeMCLtightnessinCPAKTypeIVwithmechanicallyalignedTKA.However,thistightnessismoreprominentinextensionthanflexion.14AsthemajoranatomicalcharacteristicinCPAKTypeIVistibialvarus,avarustibialrecutmayberequiredtorestorebalanceinbothextensionandflexion,althoughanadditionalvarusfemoralrecutcanbeconsidered.?CPAKTypeVThekneesof77ofthehealthyindividuals(15.4%)wereCPAKTypeV,whichisthetargetinmechanicallyalignedTKA.Thistypeischaracterizedbyneutraldistalfemoralandneutralproximaltibialanatomy,resultinginaneutralaHKAandneutralJLO.TheimplicationsformechanicalalignmentareshowninFigure3e.NobalancinginterventionsareusuallynecessaryforCPAKTypeVwithmechanicalalignment.However,unlikeCPAKTypeIIknees,thetibialjointlineisnotchanged,andsurgeonsshouldevaluatewhethertheroutine3°externalrotationofthefemoralcomponentisneeded.?CPAKTypeVIThekneesof16ofthehealthyindividuals(3.2%)wereCPAKTypeVI.Thistypemakesupapproximatelyone-quarterofallvalgusknees,andischaracterizedbymoderatedistalfemoralvalgusandmildproximaltibialvalgus,resultinginavalgusaHKAandneutralJLO.TheimplicationsformechanicalalignmentareshowninFigure3f.ComparedwithCPAKTypeIII,constitutionalvalgusiscontributedtobyfemoralvalgusand,toalesserextent,tibialvalgus.Thisresultsinaneutraljointlineobliquity.Soft-tissueimbalanceismostpronouncedinextension.14AsthemaincharacteristicofTypeVIisfemoralvalgus,avalgusfemoralrecutmayberequiredifthereismarkedlateraltightnessinextension.Ifthereremainssomeimbalance,orwhenfemoralrecutsarepreferablyavoided,areleaseoftheposterolateralcapsular(arcuate)complex,withorwithouttheposteriorbandoftheiliotibialband,maybeconsidered.31?DiscussionThisinstructionalannotationpresentsamethod,basedonconstitutionalalignment,forunderstandingandpredictingthesoft-tissueimbalancethatoftenresultswhenundertakingmechanicallyalignedTKA.Itprovidesclear,alignment-drivenreasoningbasedondeviationstocommonCPAKphenotypes.Imbalancesaremostprofoundinconstitutionalvarusknees,TypesIandIV.However,constitutionalvalgusknees,TypesIIIandVI,alsopresentintraoperativechallenges.Theabilitytounderstandthelikelihoodofencounteringimbalancepriorto,andduring,surgeryisempowering.Theconceptscanalsobeusedbythosewhouseagap-balancingapproachwithconventionalcuttingguides,astheystreamlinetheworkflowofbothtibial-andfemoral-basedtechniques.Mostimportantly,notallkneesarethesame,andtherewillbemuchvariationbetweenindividuals,evenwithineachCPAKtype.Thus,onepatientwithaTypeIIkneemayhaveaLDFAof88°andMPTAof88°,anothermayhaveaLDFAof84°andMPTAof83°.Treatingbothkneeswiththesamemechanicallyalignedresectionsislikelytobringaboutdifferentkinematicresults.Or,whenapatientwithaTypeIkneewithanaHKAof-3°mayonlyrequirea2°varusrecutinordertoobtainabalancedknee,another,alsowithaTypeIknee,butanaHKAof-7°,isunlikelytobebalancedwithasmallvaruscorrectionfrommechanicalalignment.Furthermore,CPAKisaclassificationsystemtodescribephenotypesandisnotgranularenoughtoprovideacomprehensivebreakdownofhowbalancingshouldbeexecutedwhenperformingmechanicallyalignedTKA.Furthermore,itisnotonlytheconstitutionalalignmentbutalsotheconstitutionallaxitythatdeterminesthebalanceofaTKA.Nativelaxitiesarehighlyvariableinboththecoronal(extensionandflexion)andsagittalplanes.32-35Thus,akneecanhaveitsconstitutionalalignmentperfectlyrestored,asinunrestrictedkinematicalignment,butstillhaveunbalancedgaps.17,36TargetingbalancedcoronalandsagittalgapsremainsamajorgoalinTKAandisthecornerstoneofthefunctionalalignmenttechnique.17,36,37However,theoptimalbalance,includingwhetherrectangularortrapezoidalconstitutionalgapsshouldbethenewtarget,remainspoorlydefined.Surgeonsmustcontinuetousetheirclinicalacumentoassesseachkneeonitsmerits,applyingtheknowledgeofoutcomesdeterminedbyphenotype,tooptimizealignmentandbalance.Conventionalcuttingguideswithmechanicalalignmenthavealsobeenreportedtohaveprecisionerrorsof>3°in30%ofcases,38withhalfofthosecasespotentiallydeviatingintomorethan3°varus(15%)andhalfintomorethan3°valgus(another15%).Forexample,ifasurgeonaimingformechanicalalignmentusingconventionalinstrumentsunintentionallyalterstheHKAofakneethathas5°ofconstitutionalvarusto≥4°ofmechanicalvalgus,thiscouldresultinaprofoundchangeinalignmentof9°,thetypeofsituationthatcouldoccurin1in6(15%)ofmechanicallyalignedTKAsundertakenusingconventionalcuttingguides.SeveretightnessoftheMCLwillresultinlateralcondylarlift-off.TheonlywaytocorrectthisimbalanceistoreleasetheMCLfromitstibialinsertion.Thiswillresultinanincreaseinbothmedialflexionandextensiongaps,thesubsequentneedforathickerpolyethyleneinsert,andaneteffectoflengtheningthelimb.24CorrectiontowardsamorevarusphenotypeispreferredtoacompletereleaseoftheMCL.Theinherentlimitationsofconventionalcuttingguidesarethattheydonotallowquantificationorvalidationoftheanglesofresectionorthefinalalignmentofthelimb.Aswegraduallyshifttowardsmorepersonalizedoperationsforourpatients,itishopedthatthisannotationwillencouragesurgeonstoconsidereachpatient’suniqueCPAKtype.This,inpart,maymaketheoutcomesofTKAmorepredictable,reducingtheneedforsoft-tissuereleaseswhileusingadjustmentsinalignmenttorestorethenativebalanceoftheknee.?Takehomemessage-Inthisreview,theCoronalPlaneAlignmentoftheKnee(CPAK)classificationisusedtoenhanceourunderstandingofwhynotallkneesarethesamewhenconsideringsoft-tissueimbalanceinmechanicallyalignedtotalkneearthroplasty.-Bonebalancinginterventionsbasedonanunderstandingofeachpatient’suniqueCPAKtypecanbeusedtoavoidunnecessarysoft-tissuereleases.-Theseconceptsmaybeconsideredbysurgeonsinterestedinamoreindividualizedalignmentstrategy,insteadofafixedmechanicalalignmenttargetforallpatients.在本綜述中,采用“膝關節(jié)冠狀面排列(CPAK)”分類來增強我們對在機械對線全膝關節(jié)置換術中考慮軟組織失衡時為何并非所有膝關節(jié)都相同的理解?;趯γ课换颊擢毺谻PAK類型的理解,可以實施骨平衡干預措施,以避免不必要的軟組織釋放。這些概念可能對有興趣采用更個性化對齊策略的外科醫(yī)生有所幫助,而不是為所有患者設定固定的機械對線目標。
曾紀洲醫(yī)生的科普號2024年07月02日263
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單髁置換手術適應癥與禁忌證
單髁置換UKA的適應癥從初級階段的UKA到現(xiàn)在,UKA的適應癥一直在擴大,禁忌癥越來越少。以前認為年齡、肥胖、髕股關節(jié)損傷等都屬于UKA的禁忌癥。隨著科學技術的發(fā)展,UKA材料和設計不斷改進,目前公認的UKA最佳適應癥包括:1、前內(nèi)側(cè)骨關節(jié)炎(AMOA),股骨內(nèi)側(cè)髁或脛骨內(nèi)側(cè)平臺骨壞死2、前交叉韌帶ACL完好、內(nèi)側(cè)副韌帶MCL功能完好3、外側(cè)軟骨正?;蜉p微退4、內(nèi)翻畸形<15°,屈膝畸形<15°,膝關節(jié)可主動屈曲≥90°UKA的禁忌癥目前對于UKA的禁忌癥,多數(shù)并沒有科學試驗數(shù)據(jù)的直接依據(jù),而只是絕大多數(shù)專家學者根據(jù)臨床經(jīng)驗做出的符合一般規(guī)律的推斷。主要包括:1、ACL、MCL缺失或嚴重損傷2、關節(jié)內(nèi)畸形不能被手動矯正3、屈膝畸形>15°,麻醉下膝關節(jié)被動屈曲<100°4、外側(cè)間室軟骨缺損5、炎癥性關節(jié)炎(類風濕性關節(jié)炎、化膿性關節(jié)炎、色絨炎等)
孫勝醫(yī)生的科普號2024年05月19日416
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單髁置換的假體選擇
單間室膝關節(jié)置換出現(xiàn)于20世紀50年代,在當時處于初級階段的UKA,因假體材料、設計、技術等客觀原因的制約,UKA適應癥很窄而禁忌癥很廣。目前臨床臨床上應用的UKA假體主要有活動平臺(MB)和固定平臺(FB)兩種。1、MB-UKAMB-UKA?可使膝關節(jié)的運動更接近自然生物力學且磨損率低,但易發(fā)生墊片脫位及假體撞擊等并發(fā)癥。襯墊脫位與內(nèi)側(cè)副韌帶碰撞目前MB-UKA的主要代表是Oxford牛津單髁假體,MB-UKA可以使膝關節(jié)的運動更近似于正常的人體膝關節(jié),減少脛股關節(jié)面的接觸應力,降低墊片的磨損。實現(xiàn)MB-UKA更佳生物力學表現(xiàn)的前提是假體的精準置入,故對術者的手術技術要求更高,學習曲線更長,且存在一定的墊片脫位發(fā)生率。2、FB-UKAFB-UKA較穩(wěn)定,無脫位風險,并發(fā)癥少但磨損率高。FB-UKA主要有ZUK假體和LinkSled假體,手術技術相對簡單,精準度要求相對低,但由于固定平臺的假體設計限制了負荷分散效能,活動時關節(jié)面的受力不能完全均勻分配,導致假體邊緣負荷過重,可能會增加聚乙烯墊片下表面磨損的發(fā)生,故更適合于一些韌帶松弛及活動量要求低的患肢。目前國內(nèi)外文獻對兩者的孰優(yōu)孰劣尚未形成統(tǒng)一標準。
孫勝醫(yī)生的科普號2024年05月19日308
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膝關節(jié)置換術后康復鍛煉方法
張榮凱醫(yī)生的科普號2024年05月16日158
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膝關節(jié)痛,做單髁置換還是全膝置換?
很多親愛的患者咨詢我,膝關節(jié)退變,藥物治療效果不理想,已經(jīng)到了關節(jié)置換的程度,但是不知道做單髁置換術(UKA)還是全膝關節(jié)置換(TKA)。其實,能回答這個問題的專業(yè)醫(yī)師都很少,患者來說,不清楚怎么選擇是很正常的。膝關節(jié)外傷、感染、老化等原因?qū)е玛P節(jié)疼痛,正規(guī)的治療需要進行以下幾個階梯,一般不能馬上選擇開刀。以下四個步驟是目前最權威的治療方案:基礎治療,藥物治療,修復性治療,重建治療,分別對應不同病情階段的關節(jié)炎患者。也就是說,癥狀輕中度的,都不需要置換關節(jié),到了終末期的膝關節(jié)炎,可以選擇關節(jié)鏡或者關節(jié)置換的治療方案。其中關節(jié)置換針對的是所有其他方法都不奏效的患者。那么,什么是單髁置換術呢。單髁是對應全膝置換而言的“相對微創(chuàng)”的手術,對于膝關節(jié)單側(cè)癥狀的,且符合適應證的患者,推薦選擇單髁置換術(具體適應癥比較專業(yè),患者有興趣的可以咨詢您的醫(yī)生,不再贅述)。單髁置換術相對來說,可以保留更多的骨量(手術截取的骨頭少),所以,中年左右的、活動量大的患者可以考慮單髁置換術。單髁置換術涉及的專業(yè)知識較多,選擇合適的假體、選擇固定平臺還是活動平臺,都是需要仔細考慮的問題。作為一種保膝的手段,單髁置換術的并發(fā)癥發(fā)生率和病死率相對全膝置換低。但是需要注意的是,單髁置換術不宜擴大適應癥,否則會帶來災難性的后果,不僅不能緩解患者的疼痛,反而增加了費用和翻修的風險。全膝關節(jié)置換術幾乎是關節(jié)炎的最終治療方法。對其他干預措施都無效的患者,無奈之下只能選擇做全膝關節(jié)置換術。糾結(jié)于選擇單髁還是全膝置換,不能建立在是不是微創(chuàng)的角度上片面解釋,解決問題才是最重要的,各種手術都有自己的優(yōu)點和局限性。絕不能搜點資料就對號入座。術式的選擇,這中間的評估過程比較復雜,建議咨詢關節(jié)外科的專業(yè)醫(yī)師。本人熱忱歡迎廣大患者來咨詢關于關節(jié)置換的選擇問題,希望為您解答疑惑。
羅益濱醫(yī)生的科普號2024年05月06日148
0
0
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一個膝關節(jié)置換病人的術前術后恢復情況
女性,68歲,因為關節(jié)磨損變形走路困難就診。給予行膝關節(jié)置換,爭得病人的同意,愿意作為科普給大家做示教。術后8個月走路樣子術后8個月晨練術后八個月晨練。良好的適應癥,熟練的手術技術,樂觀積極的心態(tài),努力的康復鍛煉,造就良好的手術效果。
陳東陽醫(yī)生的科普號2024年04月29日820
1
4
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單髁置換:哪些人的膝關節(jié)可以換一半?哪些人不可以?
單間室膝關節(jié)置換出現(xiàn)于20世紀50年代,在當時處于初級階段的UKA,因假體材料、設計、技術等客觀原因的制約,UKA適應癥很窄而禁忌癥很廣。近年來,隨著微創(chuàng)外科技術的發(fā)展和保膝理念的盛行,單髁置換術(UKA)在國內(nèi)逐漸開始流行。?隨著科學技術的發(fā)展,UKA假體材料及設計得到不斷改進,更多優(yōu)質(zhì)的假體類型不斷涌現(xiàn)。?目前臨床臨床上應用的UKA假體主要有活動平臺(MB)和固定平臺(FB)兩種。1、MB-UKAMB-UKA?可使膝關節(jié)的運動更接近自然生物力學且磨損率低,但易發(fā)生墊片脫位及假體撞擊等并發(fā)癥。目前MB-UKA的主要代表是Oxford牛津單髁假體,MB-UKA可以使膝關節(jié)的運動更近似于正常的人體膝關節(jié),減少脛股關節(jié)面的接觸應力,降低墊片的磨損。?實現(xiàn)MB-UKA更佳生物力學表現(xiàn)的前提是假體的精準置入,故對術者的手術技術要求更高,學習曲線更長,且存在一定的墊片脫位發(fā)生率。2、FB-UKAFB-UKA較穩(wěn)定,無脫位風險,并發(fā)癥少但磨損率高。FB-UKA主要有ZUK假體和LinkSled假體,手術技術相對簡單,精準度要求相對低,但由于固定平臺的假體設計限制了負荷分散效能,活動時關節(jié)面的受力不能完全均勻分配,導致假體邊緣負荷過重,可能會增加聚乙烯墊片下表面磨損的發(fā)生,故更適合于一些韌帶松弛及活動量要求低的患肢。目前國內(nèi)外文獻對兩者的孰優(yōu)孰劣尚未形成統(tǒng)一標準。UKA的適應癥從初級階段的UKA到現(xiàn)在,UKA的適應癥一直在擴大,禁忌癥越來越少。以前認為年齡、肥胖、髕股關節(jié)損傷等都屬于UKA的禁忌癥。隨著科學技術的發(fā)展,UKA材料和設計不斷改進,UKA經(jīng)歷了從實踐到認識、認識又反作用于實踐的前進的、上升的發(fā)展后,社會存在決定社會意識,目前公認的UKA最佳適應癥包括:1、前內(nèi)側(cè)骨關節(jié)炎(AMOA),股骨內(nèi)側(cè)髁或脛骨內(nèi)側(cè)平臺骨壞死2、ACL?完好、MCL功能完好3、外側(cè)軟骨正常或輕微退變4、內(nèi)翻畸形<15°,屈膝畸形<15°,膝關節(jié)可主動屈曲≥90°UKA的禁忌癥?目前對于UKA的禁忌癥,多數(shù)并沒有科學試驗數(shù)據(jù)的直接依據(jù),而只是絕大多數(shù)專家學者根據(jù)臨床經(jīng)驗做出的符合一般規(guī)律的推斷。主要包括:1、ACL、MCL?缺失或嚴重損傷2、關節(jié)內(nèi)畸形不能被手動矯正3、屈膝畸形>15°,麻醉下膝關節(jié)被動屈曲<100°4、外側(cè)間室軟骨缺損5、炎癥性關節(jié)炎(類風濕性關節(jié)炎、化膿性關節(jié)炎、色絨炎等)?特殊情況在一些文獻中,還可以看到涉及單髁置換術的聯(lián)合或復雜手術的病例:1、UKA+ACL重建2、UKA+HTO3、髕股關節(jié)和內(nèi)側(cè)單髁置換術4、雙室置換小結(jié)?這些病例提醒著我們,適應癥與禁忌癥在某些條件下可以轉(zhuǎn)變。針對不同病人,具體問題具體分析,為患者提供更具個性化的治療方案。
吳志偉醫(yī)生的科普號2024年03月16日108
0
0
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膝關節(jié)術后【膝關節(jié)鏡、膝關節(jié)置換等】早期如何進行康復鍛煉?
選擇膝關節(jié)鏡、膝關節(jié)置換手術的患者術前一般都是因為各種疾病造成了在關節(jié)活動時出現(xiàn)嚴重的疼痛。而為了避免疼痛的發(fā)生,只能減少關節(jié)的活動。久而久之,造成膝關節(jié)周圍肌肉組織力量減弱、肌肉萎縮、周圍韌帶組織粘連,整個關節(jié)就像一部銹住的機器,失去了正常運動的能力。為了恢復正常的活動能力,術后正確的康復鍛煉來恢復膝關節(jié)的活動度和力量是十分重要的。①股四頭肌+踝泵運動練習-增加您的大腿肌肉力量。盡量伸直您的膝關節(jié)勾住腳踝,每次持續(xù)30到60秒。在30分鐘內(nèi)重復左右腿交叉各15次,這樣的動作,然后休息30分鐘,一直重復練習直到您感覺大腿肌肉很疲憊。建議每天早中晚3組,每組30次。
孫勝醫(yī)生的科普號2024年03月11日721
6
6
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靠墻靜蹲和金雞獨立動作視頻解說
靠墻靜蹲和金雞獨立:本視頻前半部分為靠墻靜蹲,后半部分為金雞獨立。動作要點見視頻解說??繅o蹲可以練雙下肢的肌肉力量,我們很多術后患者練靠墻靜蹲后發(fā)現(xiàn),對側(cè)腿越來越粗而手術那一側(cè)腿越來越細,那是因為靠墻靜蹲的時候主要用力用在對側(cè)腿上了,而如果要練單側(cè)可以用金雞獨立。
袁鋒醫(yī)生的科普號2024年03月04日242
0
0
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擅長:目前主要從事髖膝關節(jié)外科疾病(包括骨性關節(jié)炎、類風濕性關節(jié)炎、強直性脊柱炎、成人髖臼發(fā)育不良、股骨頭壞死等)的診斷與治療,尤專于人工髖膝關節(jié)關節(jié)置換、翻修手術;膝關節(jié)炎保膝手術(單髁置換術以及截骨手術)、早期股骨頭壞死保髖手術。 -
推薦熱度4.8劉萬軍 主任醫(yī)師上海市第六人民醫(yī)院 骨科-關節(jié)外科
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膝關節(jié)損傷 15票
擅長:1、髖關節(jié)置換、膝關節(jié)置換手術(股骨頭壞死、嚴重骨折手術后髖關節(jié)炎、嚴重髖關節(jié)發(fā)育不良、嚴重類風濕性髖關節(jié)炎、髖關節(jié)僵直、嚴重老年骨質(zhì)增生性膝關節(jié)炎引起的關節(jié)痛)。 2、早期股骨頭壞死的保髖手術。 3、早期膝關節(jié)骨性關節(jié)炎的保膝手術(脛骨高位截骨HTO、單髁置換UKA、髕股關節(jié)置換PFA) 4、髖、膝關節(jié)翻修手術。 5、關節(jié)置換術后感染的手術治療。6、關節(jié)置換術后假體周圍骨折的手術治療。 7、計算機導航輔助和機器人輔助髖膝關節(jié)置換手術。 -
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擅長:擅長治療關節(jié)炎,膝關節(jié)退變性疾病,股骨頭壞死。膝關節(jié)疼痛、腫脹、退變增生,髖關節(jié)發(fā)育不良疼痛。尤其擅長小切口微創(chuàng)人工髖關節(jié)置換術,傷口小疼痛輕恢復快。擅長微創(chuàng)單髁置換術,人工膝關節(jié)置換術。特別擅長應用小切口微創(chuàng)技術治療復雜初次髖關節(jié)疾病及人工關節(jié)翻修。擅長人工智能輔助精準人工關節(jié)置換,擅長小切口微創(chuàng)機器人輔助髖關節(jié)置換術,具有豐富的臨床經(jīng)驗。