《全膝关节置换术》PPT课件.ppt

全膝关节置换术的治疗方案,什么是骨性关节炎,骨关节炎是一种发生在滑膜关节、发展缓慢，以局部关节软骨破坏，并伴有相邻软骨下骨板骨质增生或骨唇形成为特征，由机械性、代谢、炎症和免疫等因素作用而造成的关节疾病。,病 理 特 点,病理特点为关节软骨变性破坏、软骨下骨硬化或囊性变、关节边缘骨质增生、滑膜增生、关节囊挛缩、韧带松弛或挛缩、肌肉萎缩无力等。,临 床 表 现,1 、关节疼痛及压痛 初期为轻度或中度间断性隐痛，休息时好转，活动后加重，疼痛常与天气变化有关。晚期可出现持续性疼痛或夜间痛。关节局部有压痛，在伴有关节肿胀时尤为明显。,2 、关节僵硬 在早晨起床时关节僵硬及发紧感，也称之晨僵，活动后可缓解。关节僵硬在气压降低或空气湿度增加时加重，持续时间一般较短，常为几分钟至十几分钟，很少超过30分钟。,3 、关节肿大 手部关节肿大变形明显，部分膝关节因骨赘形成或关节积液也会造成关节肿大。 4 、骨摩擦音(感) 由于关节软骨破坏、关节面不平，关节活动时出现骨摩擦音(感)，多见于膝关节。,5、关节无力、活动障碍 关节疼痛、活动度下降、肌肉萎缩、软组织挛缩可引起关节无力，行走时软腿或关节绞锁，不能完全伸直或活动障碍。,辅助检查,OA的X线表现可有：关节间歇狭窄、关节软骨下骨质硬化、边缘骨质增生、关节鼠形成及软骨下囊性变。,Work-up take long films of both lower limbs (standing, patellae facing forward, feet together) trace all previous X-rays and find the previous operation records (for revision cases) consider knee aspiration and bone (Indium111) scan if sepsis is suspected (for revision cases) 术 前 准 备 拍摄双侧下肢全长X光片 (站立位、髌骨向前、双足并拢) 回顾所有以前拍摄过的X光片并找出以往手术记录 (对于翻修病例) 如果怀疑感染可考虑行膝关节穿刺和铟111同位素骨扫描 (对于翻修病例),Pre-operative (medical) fill in the total knee replacement arthroplasty documentation form confirm the presence of all prostheses and special instruments that may be needed with OT staff make sure that allograft is available if that is part of the surgical plan 术 前 准 备 ( 医 生 ) 填写全膝关节置换术记录表 与手术室同事确认所需的假体和特殊器械均已到位 手术方案中若需植骨则事先确认有合适的异体骨可供选用,Pre-operative (therapists) baseline assessment by physiotherapist & occupational therapist assess range & quadriceps power, measure circumferences at knee joint, 10 cm. above it and 10 cm. below it teach post-op. exercises e.g. active knee mobilization, static quadriceps, straight-leg-raising, bridging 术 前 准 备 ( 治 疗 师 ) 由物理治疗师和职业治疗师进行基本状况评估 膝关节活动范围及股四头肌肌力评估在距离膝关节上下各10厘米处测量大腿及小腿的周径 指导术后的操练例如膝关节的主动活动股四头肌静力收缩直腿高举以及伸腰弯弓动作的练习,Operative supine position, apply foot positioner before draping (so that the knee can be locked in full flexion) thigh tourniquet is applied but is only inflated after draping (tourniquet only used for cementation after 2001) no bulking drape around foot and ankle surgical approach (Insall) with periosteum elevated from medial third of the patella is adopted patella is replaced routinely in rheumatoid arthritis, but not osteoarthritis intramedullary guide for femoral cuts and extramedullary guide for tibial cuts cut surfaces are cleansed with pulsatile lavage system before cementation (no need for cementless fixation) all three components are inserted with one pack of Endurance cement mixed in partial vacuum; if exposure is sub-optimal, cement the patellar button and tibial tray first, and then insert the femoral component with another pack of cement (cement gun after 2001) tourniquet is deflated after all components are inserted and before wound closure for hemostasis bulking dressing is applied afterwards for bilateral involvement with similar severity, both knees will be replaced under the same anaesthesia, one after the other - “one-stage, sequential” bilateral replacement,手 术 操 作 仰卧位在铺巾前放置足固定挡板以使术中膝关节在完全屈曲位时能被固定 使用大腿空气止血带并仅在消毒铺巾后才向止血带充气 (2001年后仅在注入骨水泥时才充气) 避免在足踝部铺过多的消毒巾 采用Insall手术入路从髌骨内侧三分之一处剥离骨膜将髌骨向外翻开以暴露整个膝关节节 类风湿性关节炎进行常规置换髌骨, 骨性关节炎则不需要 用髓内定位指导股骨远程切骨髓外定位指导胫骨近端切骨 切骨表面在骨水泥处理前用脉冲灌洗系统冲洗 (非骨水泥固定则不需要) 用一包在半真空条件下混和搅拌的Endurance骨水泥来固定所有三部份假体如果手术野暴露不佳则先用一包骨水泥固定髌骨和胫骨假体然后用另一包骨水泥固定股骨假体 (2001 年后采用骨水泥枪) 止血带在所有假体置入后、手术切口关闭前放松以利彻底止血 切口关闭后用大量敷料包扎 如果双侧膝关节病变程度相似可在同一次麻醉下将双侧膝关节先后置换。,POST-OPERATIVE CARE: 术 后 处 理,Medical We do not use continuous passive motion (CPM) treatment anymore the aim is to have 90 degrees of knee flexion in the first week full weight bearing is allowed for cemented prosthesis mobilization under anaesthesia (MUA) at 2 weeks may be considered if the range is unsatisfactory (rarely performed) check long film of the lower limbs again at 4 - 6 weeks after the operation when the patient is walking well 医 疗 不给病人使用“持续被动运动”(CPM) 希望术后一周时患膝能达到屈曲90 度的活动范围 对使用骨水泥假体的病人允许完全负重 如果对膝关节活动度不满意可考虑术后两周时在麻醉下做手法活动松解(MUA) 但通常很少采用 如果病人行走良好在术后四至六周时再拍摄一次下肢全长X光片,Nursing watch out for excessive bleeding - additional compression bandage, off vacuum suction and inform dressing protocol: lotion - aqueous chlorhexidine 0.1% / normal saline bulking dressing (alternate layers of velban and crepe bandage for 3 times, total 6 layers) after surgery, debulking (to single layer of velban wound inspection when drain off then transparent dressing + gauze or adhesive dressing under elastic stocking wound inspection and swab for culture on D7 (change dressing) and then D14 off clips D14 and light dressing under elastic stocking avoid pillow at knee level, place it under the heel patient education - exercises and precautions 护 理 密切观察有无加压绷带或真空引流不畅引起的过量出血并及时报告 敷料护理方案: 洗液用0.1% 洗必太溶液或生理盐水 术后用大量敷料包扎 (交替用棉质和弹性绷带各三次总共六层) 术后第一天去除并改为单层棉质和弹性绷带包扎) 保持敷料的完整性直至术后第二至第四天将引流去除时同时观察手术切口情况 然后用纱布加透明敷料或黏性敷料覆盖外加弹性袜套 于第七天更换敷料时检查切口并做拭子培养第十四天时重复一次 于第十四天拆除手术切口的缝合钉轻薄敷料覆盖外加弹性袜套 避免在膝关节水平放置枕头应放于足跟下 对患者宣教并告知各注意事项,Rehabilitation - First 2 weeks D1/2 - on bulky dressing; static quadriceps, static gluteal, ankle hamstring stretching range of motion is documented daily, knee circumferences and quadriceps power are measured on D14 aim - achieve 90 degrees knee flexion without flexion contracture, and able to walk steadily with a frame on D14,术 后 康 复 - 两 周 内 第一至第二天在大量敷料覆盖下做股四头肌静力收缩练习臀肌静力收缩练习踝关节和足趾练习伸腰弯弓动作练习 (每天三次每次十回合) 第二或第三天 (去除引流后) 至第六天穿着弹性袜套增加膝关节的主动活动直腿高举练习及床上活动练习 第五至第七天起开始完全负重行走练习 第七天起进一步加强股四头肌和腘绳肌的力量练习必要时用冰疗 第八天起平地行走和上下楼梯练习对于用骨水泥固定假体的病人如果情况允许可逐步过渡至不扶拐行走腘绳肌牵拉练习 每天记录膝关节活动范围术后第14天测量膝周径和股四头肌肌力 目标膝关节屈曲达90度没有屈曲挛缩在第十四天时能够借助框架式助步器平稳地行走,Rehabilitation - After 2 weeks strengthen the muscles and train the gait - walking speed and endurance, stairs and slope management, hill walk program if indicated - passive stretching, hydrotherapy, home visit ADL training aims at maximal independence; prescription of assistive device if necessary functional training and reconditioning - in prepa