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人工關(guān)節(jié)置換概述,1,主 要 內(nèi) 容,一、相關(guān)知識(shí) （1）概念 （2）適應(yīng)證 （3）禁忌癥 二、病例介紹 （1）術(shù)前準(zhǔn)備 （2）手術(shù)配合,2,全髖關(guān)節(jié)置換術(shù)（THA） 全膝關(guān)節(jié)置換術(shù)（TKA）,是用人工生物材料置換髖、膝關(guān)節(jié)中已被破損的骨和軟骨，恢復(fù)關(guān)節(jié)活動(dòng)功能。 THA手術(shù)始于20世紀(jì)20年代，從髖臼杯成形術(shù)→股骨頭置換術(shù)（短柄、長(zhǎng)柄、雙動(dòng)頭）→全髖關(guān)節(jié)置換 TKA手術(shù)始于20世紀(jì)60年代 20世紀(jì)骨矯形中最成功的手術(shù)之一,3,髖關(guān)節(jié)的解剖,4,膝關(guān)節(jié)的解剖,5,關(guān)節(jié)置換適應(yīng)癥,1.原發(fā)性或繼發(fā)性骨性關(guān)節(jié)炎者（ 股骨髁、脛骨平臺(tái)創(chuàng)傷后骨折畸形愈合）2.創(chuàng)傷性疾病并發(fā)癥（股骨頭壞死、骨折不愈合）3.原發(fā)或者繼發(fā)性腫瘤4.自身免疫性疾病累計(jì)關(guān)節(jié)（RA、血友病、AS）5.先天性疾患（DDH、Perthes病）6.感染性疾?。P(guān)節(jié)結(jié)核、化膿性感染）,6,關(guān)節(jié)置換禁忌癥,有全身或局部的活動(dòng)性感染 主要運(yùn)動(dòng)肌癱瘓，屈伸功能喪失 骨組織嚴(yán)重缺損難以穩(wěn)定假體 衰竭，無(wú)法耐受手術(shù)相對(duì)禁忌癥：如老年癡呆、帕金森等,7,TKA手術(shù)適應(yīng)癥,A.屈曲攣縮畸形,8,TKA手術(shù)適應(yīng)癥,B.膝內(nèi)翻畸形,9,TKA手術(shù)適應(yīng)癥,C.膝外翻畸形,10,TKA手術(shù)適應(yīng)癥,D.屈曲攣縮內(nèi)翻畸形,11,TKA手術(shù)適應(yīng)癥,E.屈曲攣縮外翻畸形,12,TKA手術(shù)適應(yīng)癥,類風(fēng)濕性關(guān)節(jié)炎（RA）,13,TKA手術(shù)適應(yīng)癥,強(qiáng)直性脊柱炎（AS）,14,TKA手術(shù)適應(yīng)癥,創(chuàng)傷性關(guān)節(jié)炎,15,TKA手術(shù)適應(yīng)癥,膝關(guān)節(jié)結(jié)核強(qiáng)直后,16,TKA手術(shù)適應(yīng)癥,骨腫瘤切除術(shù)后,17,人工關(guān)節(jié)髖臼杯及內(nèi)襯,,18,人工關(guān)節(jié)股骨假體,19,人工膝關(guān)節(jié)的類型-單髁關(guān)節(jié),20,人工膝關(guān)節(jié)的類型-全膝關(guān)節(jié),不保留后交叉,保留后交叉,21,麻醉方式,*麻醉方式：多用連續(xù)硬膜外麻醉，類風(fēng)濕病人穿刺失敗可用椎板鉆孔插管或全麻。,22,術(shù)前準(zhǔn)備,1.術(shù)前一天訪視患者，查看病歷了解病人身體狀況和講解術(shù)前準(zhǔn)備。2.術(shù)前查看手術(shù)用物的完好，建立靜脈通道、配合麻師打麻醉、和器械護(hù)士清點(diǎn)手術(shù)臺(tái)上物品。,23,術(shù)前準(zhǔn)備,*用物準(zhǔn)備（洗手）：剖腹探查包、小面盆、手術(shù)衣、布類、大腹單、骨科包、骨科特殊器械、電刀筆、21#刀片、1#、4#、7#號(hào)線、吸引管、骨科引流裝置。,24,全膝關(guān)節(jié)置換術(shù)的流程,,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,,41,,42,43,tibial plateau 脛骨平臺(tái),Shaped in accordance with the anatomy of the tibial head 解剖設(shè)計(jì)和脛骨平臺(tái)良好匹配,Perfect coverage of the bone contact surface 完美覆蓋骨接觸表面,44,tibial plateau 脛骨平臺(tái),You avoid oversizing and any compromising of the popliteus muscle or dorsal capsule 避免過(guò)多處理或產(chǎn)生摑肌或背側(cè)關(guān)節(jié)囊的任何妥協(xié),45,tibial plateau,46,tibial plateau,47,polyethylene plateau 聚乙烯墊片,Dished surface provides congruency of the articulating planes 深盤狀表面提供關(guān)節(jié)接觸面的匹配,It stabilizes the knee joint even in absence of the PCL 即使在PCL缺如的情況下也能穩(wěn)定膝關(guān)節(jié),Large area of load transmission, less wear 大的應(yīng)力傳導(dǎo)面，磨損少,48,,0 mm,,,,4 mm,,,8 mm,polyethylene plateau 聚乙烯墊片,In increasing flexion the femoral condyles glide backwards 增加屈膝時(shí)的后滾,49,polyethylene plateau 聚乙烯墊片,surgeons manual: ? …you can combine any size of femoral component with any size of tibial baseplate…“ 醫(yī)生手冊(cè)：“可以將任何型號(hào)的股骨假體和任何 型號(hào)的脛骨托進(jìn)行匹配,uniform mechanism of fixation of the polyethylene, which must have the size of the femoral component 聚乙烯墊片的統(tǒng)一固定機(jī)制，需要和股骨假體型號(hào)進(jìn)行匹配,50,,51,polyethylene plateau聚乙烯墊片,Restriction 限制,combination of a smaler tibial baseplate to a femoral Component 脛骨托的型號(hào)不要小于股骨假體,polyethylene plateau is oversized ! 等于或大于沒(méi)有問(wèn)題,52,polyethylene plateau聚乙烯墊片,53,polyethylene plateau,54,polyethylene plateau,55,,56,too much patello-femoral pressure or an incomplete tracking (?snapping“) of the patella causes anterior knee pain 太大的髕骨壓力或不完全髕骨軌道 (?snapping“)會(huì)導(dǎo)致膝前痛 10 % after TKR TKR后10%,57,femoral component and patella,reduction of patello-femoral pressure 減少髕股壓力,thin and high patellar glide髕骨軌道又薄又長(zhǎng)anatomical shaped patellar groove髕骨滑車解剖型設(shè)計(jì),58,femoral component and patella,reduction of patello-femoral pressure 減少髕-股壓力,,less invasive, ?ballanced“ approach is possible微創(chuàng)，“平衡的”入路成為可能backward translation in flexion reduces pressure to the patellar joint屈膝時(shí)的后滾同樣降低髕股關(guān)節(jié)壓力,59,femoral component and patella,no or less resection-arthroplasty of the patella 不需要或少的髕骨成型,resection of exophytic bone 截骨或植骨,,60,61,62,63,femoral component and patella 股骨假體和髕骨,?Ballanced“ patella “平衡”髕骨,,64,65,Surgeons manual: most important steps 外科醫(yī)生手冊(cè)：最關(guān)鍵的步驟,,?instruments with a good alignement allow an accurate surgical technique !“ “ “器械良好的對(duì)線是手術(shù)技術(shù)精確的表現(xiàn)”,66,,67,,68,femoral component and patella,69,,70,,71,,72,,73,,74,,75,,76,,77,,78,,79,,80,81,82,83,84,,85,86,87,88,89,人工全髖關(guān)節(jié)置換術(shù),視頻,90,人工關(guān)節(jié)置換術(shù)后并發(fā)癥,感染 松動(dòng) 脫位 術(shù)后疼痛 術(shù)后關(guān)節(jié)僵硬 假體周圍骨折 金屬過(guò)敏 炎性假瘤,91,,,謝謝聆聽(tīng)！,92,