人工髋关节置换术的发展对康复提出的新挑战医学教学课件

1、人工髋关节置换技术发展对康复提出的新挑战第1页，共39页。人工髋关节第2页，共39页。Copyright 2011 Swedish Hip Arthroplasty RegisterPrimr total hftprotes i SverigePrimary total hip replacement in Swedenter analysis regarding reoperations and revisions.12000我Re-reporting国：21,8400/10000 年人工（髋）关节置换术Reporting to the RegistryThe number of prima

2、ry total hip arthroplasties performed in Swed-examples of such work. This year we publish written re-手术率1.68/每tral problem area for the Registrys work.千人5 SWEDISH HI P ARTHR O PLASTY RE GI STE R 2 01 0 20世纪最重Mostmedicaldepartments要records的fromreportre-operations技via the术webareapplication.创sent over新

3、Copiesthe yearofwith varying delay. Reviews of medical-record copies and systemized data collection centrally are necessary for Regis-All publications, annual reports and scientific reports are presented on our website. The Hip Arthroplasty Registry in collaboration with the Swedish Knee Arthroplast

4、y Reg- istry invites all departments to an annual user meeting at Arlanda.Local activity analysis anddevelopmentThe Registry has always intended that re-reporting should stimulate participating departments to carry out local anal- yses of their activity and that this should lead to measures for impr

5、ovement. The purpose of open comparisons is that16000140008000600040002000067 70 73 76 79 82 85 88 91 94 97 00 03 06 09they should put increased pressure on this process. In thepast few years we have, in each annual report, selected good en from 1967 (6 operations) to 2010 (15 935 operations).瑞典的初次全

6、ports髋置from 换two departments：1967about 年their （analyses.6例How）to ，2010年（15935例），stimulate all departments to carry out similar work is a cen- development of registries internationally, where the Swe-dish Hip Arthroplasty Register has been a model.This years productionOla Rolfson, who defended his th

7、esis on 10 December 2010, summarising the Registrys 10-year patient-related outcome第3页，共39页。人工髋关节置换术（THA）的目标 解除疼痛 恢复功能 改善外观第4页，共39页。THA康复的目标 消除或控制疼痛恢复关节活动度恢复肌肉强度恢复关节平衡感觉（本体觉） 延长人工关节使用寿命预防、治疗并发症前提：保持稳定性第5页，共39页。Fig. 4.失去功能Anteroposterior radiograph of the leftFighip joint shows a cranially dislocated

8、 total hip arthroplasty, even though the acetabular cup is in a proper position.早 期：对合稳定 中晚期：界面稳定第6页，共39页。稳定性的维持头臼对合假体-骨界面固定第7页，共39页。1960 Charnley 金属-塑料全髋low-frictionJohn Charnley 骨水泥的深入研究与推广第8页，共39页。磨损快 脱位率7%22mm 即刻稳定 早中期功能优异中晚期松动率高金属-塑料全髋骨水泥固定第9页，共39页。界面固定骨水泥非骨水泥早期机械性稳定 中远期生物性稳定假体形状 （力学分布）表面处理第10页

9、，共39页。对合稳定金属-聚乙烯陶瓷磨损率大大降低，减少松动金属-金属第11页，共39页。股骨头直径123evant designs and component orientations to further clarify our understanding of dislocation risk.We therefore evaluated: (1) the three-dimensional sta- bility of four different component designs; (2) whether various clinically relevant positions

10、of abduction andFig. 1 This is a schematic diagram illustrative of traditional jump distance measurements at 45 (left) and 0 (right).稳定性提高关节活动范围增大 脱位率降低磨损率降低第12页，共39页。远近端分别准备，获得最大填充多角度调整前 倾角、偏距、长度组配型假体获得远端固定、为近端移植骨愈合提供保证第13页，共39页。组配型假体直前后倾 8前后倾 15内翻外翻第14页，共39页。现代人工髋关节 更稳定 更大的活动范围 更耐磨？第15页，共39页。手术适应证

11、 最初 6075岁 疼痛无法缓解的关节炎（解除疼痛） 改善功能为次要目的第16页，共39页。年龄疾病In 1994，THR is an option for nearly all patients with diseases of the hipthat cause chronic discomfort and significant functional impairment第17页，共39页。第18页，共39页。手术适应证 无痛、有功能和稳定的髋关节，而且符合： 发育成熟髋关节疾病发展到了比较严重的程度 疼痛或功能障碍影响生活和工作 没有其他更好的治疗方法第19页，共39页。易脱位挑战：高

12、龄 心肺功能差 卧床时间长 肌肉力量差 协调能力弱 术后神经系统失调多见 血栓 交流困难第20页，共39页。挑战：年轻患者 追求生活质量、要求高 活动量大 活动范围大 依从性不确定第21页，共39页。大量复杂病例高度脱位髋关节疾病 髋关节巨大骨溶解缺损 翻修髋关节畸形融合性髋关节髋臼内陷征 第22页，共39页。关节僵硬挛缩髋周肌肉萎缩 协调性差 同时伴脊柱僵硬 驼背畸形第23页，共39页。 巨大骨溶解 个体化定制型假体多次手术史创伤大卧床时间长易脱位数字化原型重建个性化假体设计 假体制作手术治疗第24页，共39页。儿时病变第25页，共39页。先天性髋关节脱位7cm神经最易受牵拉损伤第26页，共

13、39页。Anteversion ()P0.0570.060.0DDH股骨前倾角变异45.040.050.040.030.020.010.021.415.442.335.635.030.025.020.015.010.017.423.927.1 27.015.40.0DDH Normal DDH NormalP0.05中国DDH成人股骨前倾角变异较大，随脱位程度的增大 而增大，与国外的报道存在明显不同第27页，共39页。分次手术真臼位置重建 股骨近端截骨 内收肌切断 取髋屈膝保护神经第28页，共39页。Wilcoxand Ha髋关节屈曲The sigFig. 1. The drawing of

14、axis change postoperatively.膝关节屈曲Of 22(13.3 3.4; range, 5.6-23.0), who had preoperativepatient膝关节外翻the pa(range,膝前疼痛secondary coxarthrosis owing to Crowe type III anpostopelengthening was 18.2 7.2 mm (range, 2.3-37.4 mm).scores w35.8 to 13.7) and the femoral offset increased by1.6 4.4 mm (range, 7.7

15、 to 16.4 mm). The Insall-knee scperiod1.24; Table 3).after the operation. improvimprovcommittee, and informed consent was obtained from (P b .00下肢旋转力线改变 髂胫束张力增高268 The Journal of Arthroplasty Vol. 27 No. 2 February 2012膝关节压力增高Fig. 3. The graph depicting changes in lateral patellar tilt.Asterisk deno

16、tes a significant difference (P b .0001) (mean SD).Numerminimuwere reTo detevariablechangeMM anFig. 2. The angle of anteversion of the femoral neck wasanalysis of variance, Fig. 3, 1A, and 1B). The increasedisappeared 3 months after the operation (10.7 2.3;range, 5.0-17.0; Fig. 3 and 1C). Lateral pa

17、tellar tilt was numeri increased in all the patients with knee pain to 16.2 3.5 lation t (range, 11.0-22.0), from preoperative values of 9.7 2.6 (range, 4.9-15.7), and this was significantly largercompared to that seen in patients without knee pain strain ihips, to assess the value of leg lengthenin

18、g at kneeearlyjopvalues of 9.8 2.3 (range, 6.2-16.5; Table 2and). Significantto analyze whether these alterations have anyvalgume correlation was found between the magnitudeon ofclinicalchangescores. was sta in lateral patellar tilt and the presence of anterior knee of the pain (P b .0001). Material

19、s and Methods 16.1 mThe leg length inequality was 18.4 7.7 mmA total(range,of 126 hips of 104 patients were operated w 1.5-39 mm) before surgery and 0.3 1.5 mmTHA(4.9andto subtrochanteric shortening osteotomy(P b .00 5.4 mm) after surgery, and the average amount of leg Improhip dysplasia, between 20

20、05 and 2008. The indicat.001).Femoral anteversion decreased by 7.1 3.9 (range,for surgery were patients having extreme limitatio.001) (motion during daily activities and pain at nightscores (Salvati ratio was 1.06 0.062 (range, 0.84-1.24)respondingafter to at least 6 months of conserva operation and

21、 showed no change pared Patients who had a history of surgerypostope with preoperative values (1.06 0.065; range,traumaFig.0.84-3.inThethemeasurementipsilateralof the Qknee,angle of primarypatient the dayor secondwhereaosteoarthritis of the knee joint, patellofemoral arthr intra-articularstudy was a

22、pprovedor extraarticularby the institutionalligamentresearch ethicslesionsreductiin physical examination, Q angle greater than the pheach patient. The i ologic values, or pathologic genu varum and valg第29页，共39页。挑战 关节置换+截骨内固定 保护神经功能 保持关节稳定性 保证截骨愈合 髋关节康复 膝关节康复 对侧存在先天性脱位第30页，共39页。脱位并发症多样深静脉血栓异位骨化Fig. 4. Anteroposterior radiograph of the lefthip joint shows a cranially dislocated total hip arthroplasty, even though the acetabular cup is in a proper position