膝关节骨关节炎手术治疗方案课件.ppt

1、HTO or UKA 1膝关节骨关节炎手术治疗方案单髁置换术（Uincomparmental Knee Arthroplasty，UKA）：只置换内侧部分关节面，可矫正轻度内翻，保留了患者所有的韧带，缓解关节内侧疼痛疗效确切，适用于单纯内侧软骨磨损患者。胫骨高位截骨术（High Tibial Osteotomy，HTO）：通过胫骨高位截骨，矫正力线，适用于合并严重内翻的膝关节骨关节炎，可延缓关节炎进展，保留了膝关节的正常活动功能称之为保膝治疗。随着技术水平的提高，内固定材料的稳定性增强，此术式越来越受骨科医师以及患者青睐，常用于早中期膝关节骨关节炎的治疗。2a Anatomical axes

2、and joint angles with standard values.Anatomical femorotibial angle(aFTA)=173175,anatomical lateral distal femoral angle(aLDFA)=81 2,anatomical medial proximal tibial angle(aMPTA)=87 3,anatomical lateral distal tibial angle(aLDTA)=89 3.b Mechanical axes and joint angles with standard values.Mechanic

3、al lateral distal femoral angle(mLDFA)=87 3,mechanical medial proximal tibial angle(mMPTA)=87 3,mechanical lateral distal tibial angle(mLDTA)=89 3.A=Tangent to the femoral condyles(knee base line).B=Tangent to the tibial plateau.3 MAD=mechanical axis deviation,significant for a displacement of 15 mm

4、 medially(varus deformity)(a)and by 10 mm laterally(valgus deformity)(b)from the center of the knee joint.mLDFA=mechanical lateral distal femoral angle,standard value 87 3mMPTA=mechanical medial proximal tibial angle,standard value 87 345678 The main patient-derived factors for decision making are:S

5、tage of osteoarthritis Ligamentous status Type of deformity and reducability Age Range of motion Obesity General medical status手术选择的主要患者因素：*骨关节炎的分期*韧带的稳定性*畸形的分型和可复性*年龄*膝关节活动范围*肥胖*患者一般状况Patient selection guidelines9The patient should be informed that limited pain relief must be expected if there is a

6、lready 4th degree osteoarthritis on the medial side with relative medial instability 1Stage of osteoarthritisSevere osteoarthritis and tibial deformity(Pagoda type -宝塔型)are contraindications for an osteotomy随着骨关节炎进展，截骨术的效果也随之下降外翻应力位外侧关节间隙明显变窄是HTO和单髁置换的排除标准1 Bonnin M,Chambat P(2004)Current status of

7、valgus angle,tibial head closing wedge osteotomy in medial gonarthrosis.Orthopde;33(2):135142.German截骨术是生理性手术，作用只是将最大负荷区域从内侧间室向中间和外侧转移HTO不适用于外侧半月板大部切除和严重外侧骨关节炎的病例HTO不适用于内侧严重骨缺损，外侧间室关节面倾斜的宝塔型胫骨平台，建议行膝关节单髁置换We rely more on stress x-rays in questionable cases10HTO和UKA 需要像这样完好的外侧间室a.This x-ray was made

8、under varus stress with the beam parallel to the joint plane and demonstrates full-thickness defect of the cartilage on the medial side.b.This x-ray was made under valgus stress and demonstrates a functionally intact lateral compartment.HTO as well as UKA require such an intact lateral compartment.1

9、1髌骨关节病变同时存在明确的内侧骨关节炎，髌骨关节退变应予忽略。建议行改良的双平面截骨术，前方截骨面斜向下方。这一改良避免了髌骨低位和髌股关节压力增加。现有文献表明存在髌股关节退变的病人至少可安全的行活动衬垫UKA而不增加中期和长期翻修率。Patellofemoral jointMany patients with medial joint pain have degenerative changes in the patellofemoral joint as wellIf the clinical symptoms are clearly those of medial osteoarth

10、ritis,these changes can be ignored in the decision-making process and should not guide the surgeon towards a TKAIn open-wedge HTO it is advisable to use the modified biplanar technique with the anterior osteotomy plane sloped downwardsCurrent literature indicates that at least mobile bearing UKAs ca

11、n be safely implanted in patients with patellofemoral degeneration without increasing the middle and long-term revision rate 4.4 Beard DJ,Pandit H,Gill HS,et al(2007)The infl uence of the presence and severity of pre-existing patellofemoral degenerative changes on the outcome of the Oxford medial un

12、icompartmental knee replacement.J Bone Joint Surg Br;89(12):15971601.12Ligamentous statusHTO在不稳定膝关节患者中有广泛的适应症HTO仅有的禁忌症是内侧副韧带严重缺陷存在继发外翻风险另一方面UKA良好的功能依赖于前交叉韧带完整1.HTO has a wide indication range in patients with instable knees and is a fundamental part of the therapeutic repertoire 2.The only contraind

13、ication for HTO would be a significant deficiency of the medial collateral ligament(MCL)with risk of secondary ligamentous valgus3.UKA is strongly dependent on an intact anterior cruciate ligament(ACL).The revision rate is unacceptably high if a UKA is implanted in an ACL deficient knee 5 5Goodfello

14、w J,OConnor J,Dodd C,et al(2006)Unicompartmental arthroplasty with the Oxford knee.New York:Oxford University Press.13in many cases of preexisting MCL injuries the ligament can be retensioned by open-wedge osteotomy if the distal part is not detached during the procedure许多术前存在内侧副韧带损伤的病例，术中如果未松解内侧副韧带

15、远端部分，开放楔形截骨术可使内侧副韧带重新恢复张力whereas the indication for a HTO may still be given even in chronic ACL deficiency而存在慢性ACL缺陷患者仍适行HTO。Ligamentous status如果怀疑存在外侧间室骨关节炎，则建议行内外翻应力位片。若应力位外侧关节间隙消失，不建议HTO或UKA。如果屈膝20时狭窄的内侧关节间隙不能恢复正常宽度，则存在内侧副韧带挛缩，而非典型的前内侧骨关节炎，不应行UKA。侧位X线片骨关节炎累及整个胫骨内侧平台时，也同样不宜行UKA。在这些病例，退变进展至全关节骨关节炎

16、，或是与慢性ACL缺陷相关，单间室置换不能获得满意效果。14Type of deformityVarus malalignment of the leg and overload of the medial side may be caused by three factors:(1)Meniscectomy and wear on the medial joint side can cause narrowing of the medial joint space with resulting varus deformation.(2)An osseous deformity mostly

17、of the proximal tibia(metaphyseal varus)will lead to varus morphotype.(3)Theoretically,a lateral ligament defi ciency could also induce a deformity,but in practical terms this is extremely unusual and will not be discussed here下肢的内翻畸形和内侧间室超负荷由三种因素引起：（1）内侧半月板切除和内侧间室磨损引起内侧关节间隙变窄，导致内翻畸形。（2）胫骨近端畸形（干骺端内翻

18、）导致的内翻畸形。（3）理论上，外侧韧带缺陷也可能导致内翻畸形。15关于适应症，截骨术最适于纠正固有骨性畸形如果不存在骨性畸形，截骨矫正下肢机械轴将产生新的畸形和关节面的严重倾斜。已有研究证明，这种情况下虽然机械轴得到纠正，截骨术的疼痛缓解短暂且不持续，翻修率较高。An osteotomy is a procedure which best corrects an inherent bony deformityif there is no bony deformity,the osteotomy may induce a new deformity and a significant obli

19、quity of the joint line.It has been proven that in this situation,despite mechanical axis correction,the pain relief is short lived and inconstant,and the revision rate of such osteotomies is high.Type of deformity16Type of deformityThe construction of the mechanical medial proximal tibial angle(mMP

20、TA)in the frontal plane will not be precise in this situation.It is advisable to either project the joint line of the healthy joint compartment over to the medial compartment in order to define the former medial joint line 7 or to use the tibial bone varus angle(TBVA)7 Jenny JY,Bori C,Ballonzoli L,e

21、t al(2005)Difficulties and reproducibility of radiological measurement of the proximal tibial axis according to Lvigne.Rev Chir Orthop Rparatrice Appar Mot;91(7):658663.French机械胫骨近端内侧角（mMPTA）并不准确胫骨内翻角（TBVA）17下肢内翻畸形的原因对选择HTO还是UKA非常重要。发现胫骨干骺端内翻畸形非常重要，这提示术者更应选择截骨术。内翻畸形的主要原因为关节内磨损则提示选择UKA更加合理。在临床实践中，由于骨

22、关节炎的进展，内侧间室的关节线不再明显，这使得分析胫骨近端的解剖非常困难。此时冠状面的机械胫骨近端内侧角（mMPTA）并不准确，建议将外侧间室正常关节线透射至内侧间室以确定既往的正常内侧关节线，或使用胫骨内翻角（TBVA）。TBVA角依靠X线上残存的胫骨近端骺线确定胫骨近侧干骺端轴线。如果TBVA角明显，则应考虑行截骨术。18 The discussion on the importance of body weight on the development of osteoarthritis and on the outcome of orthopedic procedures is nev

23、er ending.There is no clear correlation between body weight and results either for HTO or for unicondylar or total knee prosthesis,except for extreme obesity 1.Obesity因而不能仅因肥胖就放弃行HTO或单髁置换。与此相反，肥胖患者全膝关节假体的植入常需要扩大显露，手术风险增加1 Bonnin M,Chambat P(2004)Current status of valgus angle,tibial head closing wed

24、ge osteotomy in medial gonarthrosis.Orthopde;33(2):135142.German19 Literature and clinical practice in Europe and America indicate that the age limit for an osteotomy in males is 65 years and in females even may be as low as 55 years 1.欧美的文献和临床实践提示，男性行截骨术的年龄上限是65岁，女性更低至55岁 胫骨干骺端内翻畸形的病人行HTO时，术前畸形得到矫正

25、。由于这是预防性手术，不存在年龄的下限（骨骺未闭除外）1 Bonnin M,Chambat P(2004)Current status of valgus angle,tibial head closing wedge osteotomy in medial gonarthrosis.Orthopde;33(2):135142.German.Age20 HTO能够容许单间室骨关节炎患者最高的术后活动量 单髁置换手术风险极小，是老年患者的理想选择（甚至降低死亡率）选择单髁置换没有年龄上限 使用活动垫片假体ActivityHTO is the procedure which allows for

26、the highest postoperative activity level of a patient with monocompartmental osteoarthritis.the UKA is the ideal implant for older patients since the risks of surgery are minimal(“UKA is the meniscectomy of the old patient”).As long as the typical anteromedial osteoarthritis is treated,there is no u

27、pper age limit for this procedure and the risks of a total knee implantation can be avoided.Especially with the use of mobile bearing implants,up to one third of all patients scheduled for a total knee arthroplasty may be potential candidates for a unicondylar arthroplasty.21 Full extension is an im

28、portant prerequisite for a good result after HTO Correct 10 of flexion contracture during the open-wedge high-tibial osteotomy If more than 10of extension deficit is present,the indication for HTO should be questioned In patients with a flexion contracture over 10 and a maximum flexion below 100 an

29、UKA is not indicated 无伸膝受限是HTO获得良好结果的重要先决条件。开放楔形HTO能够矫正10的屈曲挛缩。如果伸直受限超过10，HTO的适应症则有疑问。单髁置换并不能改善膝关节的活动范围。如果患者屈曲挛缩超过10，最大屈曲小于100，则不建议单髁置换。Range of motion22 If there is an osseous deformity(usually in the femur)and if the patient is suitable for a recon_x0002_structive procedure,an osteotomy is advisab

30、le If the deformity is caused by pure wear of the lateral compartment,for example after lateral meniscectomy,and if no bony deformity is detected,a lateral unicondylar arthroplasty should be considered 11.孤立的外侧间室骨关节炎和外翻畸形的手术选择与内侧相似。如果外翻畸形仅是因为外侧间室的磨损引起（如外侧半月板切除后），不存在骨性畸形，则建议行外侧单髁置换。固定垫片单髁置换的良好结果已有报道，

31、而最近报道的双凹面活动垫片单髁置换结果也类似11 Servien E,Aitsiseli T,Neyret Ph,et al(2007)How to select candidates for lateral unicomppartmental prosthesis.Techn Knee Surg;6(1):5159.Lateral osteoarthritis23SummaryThe ideal patient for a HTO:1.Is younger than 65 years(male)respectively 55 years(female)2.Has congenital met

32、aphyseal varus deformity of the tibia(TBVA 5)3.Has an intact lateral compartment 4.Has almost normal range of motion(10extension deficit may be corrected by the surgery)5.Is a non-smoker 6.Has a certain pain tolerance 7.May have ACL or PCL deficiency(can be addressed by the surgery)8.Should preferab

33、ly have a BMI under 301.男性小于65岁，女性小于55岁2.存在先天性胫骨干骺端内翻畸形（TBVA5）3.外侧间室完好4.膝关节活动范围接近正常（手术可矫正10的屈曲挛缩）5.非吸烟患者6.可耐受一定程度的疼痛7.可存在ACL或PCL缺陷（对此手术可予处理）8.更适合于BMI小于30的患者24Summary The ideal candidate for a UKA:1.Is older than 55 years 2.Has no osseous deformity and mere intraarticular wear 3.Has intact ligaments(

34、ie,ACL,MCL)4.Has a deformity which reduces completely in 20of flexion under valgus stress 5.Has an intact lateral compartment 6.Has an almost normal range of motion 7.Has no inflammatory disease 8.Should preferably have a BMI under 30*年龄大于55岁*仅存在关节内磨损，无骨性畸形*韧带完好（如ACL，MCL）*内翻畸形在屈曲20外翻应力可以纠正*外侧间室完好*膝关节活动范围接近正常*无炎症性膝关节炎*更适合于BMI小于30的患者252627