单髁置换PPT课件.ppt

1、 王飞1.2019/11/26TheThe third hospital of hebei medical university third hospital of hebei medical university前言近些年来由于膝关节微创手术的流行，使得人们对单髁置换术的关注日益增加。2.2022-3-17The third hospital of hebei medical university单髁置换的历史与优点3.2022-3-17膝关节单髁置换术在寻找胫骨高位截骨或三间室全膝关节置换术治疗单间室病变的膝关节骨关节炎的替代治疗时，膝关节单髁置换的概念引起了人们的注意。4.2022-3-

2、17早在上个世纪70年代，单髁置换的假体设计、手术技术、适应症与禁忌症就被提出。5.2022-3-17然而当时部分学者对报告了单髁置换早期糟糕的结果，并且对单髁置换应用于外侧髁疾病意外的治疗提出质疑。6.2022-3-17随着假体的设计的改良、手术技术的成熟以及相关随访研究良好结果，增加了人们对单髁置换的信心。7.2022-3-17研究指出近20年来，单髁置换数量有着明显的增加。例如1998年到2005年单髁置换增加率是全膝关节置换的3倍。8.2022-3-17The third hospital of hebei medical university1234优良的生存率“微创手术”-翻修后效

3、果好. 单髁置换术的优点术后快速康复-良好的术后功能9.2022-3-1710.2022-3-17单髁置换术Oxford 活动假体，10年生存率为98%，20年存活率为91%。11.2022-3-171.较小切口2.较少截骨量3.较少软组织破坏12.2022-3-171.单髁置换术使用较小的切口、暴露范围小、保留前后叉韧带、出血量少、康复时间短、住院时间短。2.并且患者可以得到较好的活动度，以及接近正常的本体感觉。13.2022-3-171.术后当天下地活动2.术后2周膝关节活动度正常14.2022-3-17 健康人群范围 .UKA人群 -骨关节炎人群15.2022-3-17学者指出与TKA相

4、比单髁置换术的性价比更高16.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university翻修效果较好Levine 等人报道31例单髁置换行全膝翻修术取得与初次全膝置换相同的随访年限。17.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university研究指出单髁置换可能不会对翻修效果造成不良的影响18.2022-3

5、-17TheThe third hospital of hebei medical university third hospital of hebei medical university病例19.2022-3-17女，57岁，BMI=28，关节活动度0-120，20.2022-3-17CT示：内侧有的骨缺损。21.2022-3-1722.2022-3-17术后5年，效果佳。23.2022-3-17女，64岁24.2022-3-17术后6年，效果佳。25.2022-3-17TheThe third hospital of hebei medical university third hosp

6、ital of hebei medical university但是我们不建议将单髁置换进行较大规模的推广26.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university病人的选择面较窄27.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university经典的手术适应症（1989 kozinm and scott）

7、1、非炎症性孤立的膝关节内侧或外侧间室骨性关节炎，患者行走时疼痛，影响生活质量。 28.2022-3-17The third hospital of hebei medical university体重不超过82kg，活动量小，年龄大于60岁。髌股关节的轻度累及无膝前痛；轻微静息痛。前叉韧带完整，没有膝关节半脱位。膝关节活动度90，屈曲挛缩小于5膝关节内翻畸形小于10，膝关节外翻畸形小于15。29.2022-3-17The third hospital of hebei medical university内外侧间室骨关节炎30.2022-3-17The third hospital of h

8、ebei medical university髌股关节炎31.2022-3-17The third hospital of hebei medical university膝关节活动小于90体重指数较大32.2022-3-17The third hospital of hebei medical university膝关节内翻畸形大于10屈曲挛缩大于533.2022-3-17The third hospital of hebei medical university尽管近些年单髁置换术的人群有所放宽，（如年龄趋小、体重偏大、前叉韧带损伤患者的也可以做单髁置换）。但是单髁置换的人群选择相对全膝关

9、节置换还是苛刻的。34.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university即便是术前的临床检查和影响学检查提示为单髁置换的理想人选；但是当切开关节后往往会出现若干个手术禁忌症。35.2022-3-17The third hospital of hebei medical universitya01b02c03膝关节韧带松弛对侧以及髌股关节间室的退化关节内炎性改变切开关节后可能的禁忌36.2022-3-17TheThe third hospita

10、l of hebei medical university third hospital of hebei medical university单髁置换对医师的技术要求较高37.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university有学者研究指出初次翻修的原因中,假体松动占到43%，相邻间室骨关节炎的进展（26%），其他机械力学原因（15%）38.2022-3-17TheThe third hospital of hebei medical uni

11、versity third hospital of hebei medical university之前的文献指出手术技术对单髁置换的手术的成功与否起到决定行作用。标准的手术技术能够减少是手术失败。39.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university相比全膝关节置换，单髁置换的器械单一，缺乏准确、模式化的器械。给操作者带来困难。40.2022-3-17TheThe third hospital of hebei medical univer

12、sity third hospital of hebei medical university41.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university假体大小的选择、位置的定位、力线的校准以及软组织的平衡较全膝关节置换难度大。42.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university单髁置换难度不

13、等于1/2全膝置换建议高年资、拥有5年以上100例/年全膝关节置换经验的大夫考虑单髁置换术。43.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university单髁置换的并发症44.2022-3-17The third hospital of hebei medical university研究指出单髁置换有着较高的并发症45.2022-3-17The third hospital of hebei medical university血栓、感染骨折、鹅足

14、滑囊炎术后疼痛46.2022-3-17The third hospital of hebei medical university术后膝关节疼痛是UKA常见的并发症 目前文献报 道UKA术后疼痛缓解率9096故仍有小部分患者术后感觉疼痛。严重者还需进行全膝置换。47.2022-3-17The third hospital of hebei medical university位置不正确钻孔太深矫形不足术后应力性骨折是UKA 一个比较常见的并发症。出现骨折往往需要进行全膝置换。48.2022-3-17The third hospital of hebei medical university假体

15、松动，磨损脱位相邻膝关节间室的退化49.2022-3-17The third hospital of hebei medical university有学者研究指出单髁置换10年生存率不为88.6%，相邻间室退化（51%），自后为假体松动和磨损或骨溶解50.2022-3-17The third hospital of hebei medical universityLewold报道14772例瑞典关节置换登记 中心结果。内侧髁置换失败病例的返修原因25是因为外侧间室关节炎进展。而外侧髁置换返修因对侧间室关节炎进展的比例为3551.2022-3-17The third hospital of h

16、ebei medical universitya关节间室的正常退化b关节假体的撞击髌股关节炎的加重可能的原因：52.2022-3-17The third hospital of hebei medical university有研究指出单髁置换术髌股关节炎指出正常退化为38%，由股骨假体撞击引起的退化为28%。53.2022-3-17The third hospital of hebei medical universitySquire 等对136名单髁置换患者随访11年后发现对侧骨关节炎的退化高达46%54.2022-3-17The third hospital of hebei medic

17、al university一些学者认为这是过度矫正力线所导致的55.2022-3-17The third hospital of hebei medical university单髁置换任何环节的失误都可以造成对侧关节间室退变，引起UKA失败。56.2022-3-17The third hospital of hebei medical university一些学者单髁置换失败原因包括假体松动占到43%，相邻间室骨关节炎的进展（26%），其他机械力学原因（15%）57.2022-3-17The third hospital of hebei medical university同样单髁置换任何

18、环节的失误都可以造成假体的松动与下沉。58.2022-3-17The third hospital of hebei medical university引起单髁置换假体磨损的原因是多样的。目前随着假体设计进步和假体材 料质量提高。手术技巧改进。因假体磨损和断裂而失败的病例减少。但在年轻、活动量大的患者人群，假体磨损返修的风险仍相对高。59.2022-3-17The third hospital of hebei medical university骨溶解也是导致假体磨损的一个不可忽视因素60.2022-3-17The third hospital of hebei medical unive

19、rsity在活动性假体中，假体衬垫起模拟半月板的作用，假体衬垫的脱位只见于活动性假体。假体衬垫脱位61.2022-3-17The third hospital of hebei medical universitySong等人认为假体衬垫脱位主要与内侧副韧带松弛有关。因为内侧副韧带松弛与衬垫脱位关系密切，因此Oxford假体不适用于外侧髁骨关节病及内侧副韧带生理性松弛者。62.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university单髁置换的翻修63

20、.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university尽管报道单髁置换、高位截骨翻修效果与初次全膝关节置换的效果无差异64.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical university单髁置换翻修相对于胫骨高位截骨翻修难度较大1骨量不足2需要取出假体3骨水泥的处理65.2022-3-17The third hospital of hebei medical university1单髁置换有利有弊小结2选择要谨慎，不建大规模推广66.2022-3-17TheThe third hospital of hebei medical university third hospital of hebei medical universityTHANKS67.2022-3-17