医院培训课件：《TKA易犯错误的原因和对策》

TKA易犯错误的原因和对策TKA

目的恢复力线恢复平衡终极目标屈伸稳定

活动良好TKA存在的错误

假体对线

8%患者>5°对线不良

Colwell（CORR）TKA存在的错误

软组织平衡

57%患者存在屈伸间隙不等

Insall（JOA）TKA存在的错误

髌股关节

40%患者轨迹紊乱

髌骨倾斜

Vince（CORR）TKA存在的错误

膝运动学

>60%人工膝关节

运动学异常

Dennis(CORR)力线不良导致早期失败胫骨旋转不良股骨切迹胫骨股骨旋转不良髌骨半脱位关节严重不稳TKA易犯错误对策如何保持力线平衡如何保持软组织平衡如何保证良好的膑股轨迹膝关节冠状面力线平衡

股骨远端和胫骨近端截骨冠状面对线良好伸直位骨性关节间隙对称如何做到膝关节冠状面力线平衡术前计划截骨量有所不同但内外侧差别不会改变软组织平衡术前评估软组织状态理解软组织的病理改变

术前检查下肢站立全长位膝关节正侧位术前检查有无韧带挛缩内侧应力位外侧应力位术前检查畸形纠正程度内侧软组织松解膝关节伸直位内外间隙相等

曲屈位内侧明显松弛-为什么？屈曲位内侧间隙明显增大？？？内侧间隙增大-怎么办？

AnatomyDeepMCLSuperficialMCLMedialheadgastrocnemiussemimembranosusPestendonsPopliteus？？？PosteriorCapsularPOligament胫股角变小内侧软骨和骨丢失---持续内翻---MCL挛缩---固定畸形---外侧软组织拉长后方关节囊挛缩膝内翻畸形病理改变SPORTSMEDICINE:LIGAMENTSANDCAPSULARRESTRAINTSINCADAVERKNEEE.Grood,F.Noyes,D.Butler,W.SuntayJ.BoneandJointSurg.,63A,1257-1269,Oct.1981inSprainedkneesMorelaxityinFlexionthaninExtensionIntroducestheconceptofPrimary&SecondarySofttissuesStabilizersRestrainingMoment%100500MCLACLAnt&MidPostPCLCapsulen=135mmJointOpeningMedialRestraints5°KneeFlexion57.414.87.717.525.2INVALGUSSTRESSPrimary:MCLbut….Midcapsule

Post.Capsule25%Whenyoubendthekneeat90°

V/VSTABILIZERS

INFLEXIONonceACL+PCLexcised

collateralligts&adjacentcapsulearenearlytheonlystabilizers后方关节囊挛缩TightposteriorcapsuleLoosecollateralligtReleaseinextensiontoacompletelysatisfactorydegreewillpossiblybeassociatedwithinstabilityinflexion出现内翻膝松解常见错误术前判断不全面要不要松解？术中松解部位不准确要松解哪里？不理解软组织松解后的影响内翻膝的股骨旋转可以影响曲屈稳定！我的内翻膝松解顺序不需要松解术中出现不平衡可能截骨导致的首先保证完全伸直去除后关节囊挛缩影响其次去骨赘MCL深层以次松解半膜肌后内侧角MCL浅层不松鹅足避免过度松解2023/12/19外翻膝中山三院病例随诊中山三院病例中山三院病例术后步态前后2023/12/19中山三院病例膝关节外侧解剖外侧副韧带屈、伸腘肌腱复合体屈、伸后外侧关节囊伸、屈髂胫束伸、屈外侧支持带腓肠肌外侧头伸弓形韧带股二头肌伸后交叉韧带屈、伸前外侧韧带上胫腓联合外侧肌间隔腓总神经外翻膝的病理骨关节

关节内发育外旋磨损髌股关节

关节外畸形创伤发育代谢重塑软组织

内侧有无松弛松弛程度

外侧挛缩程度神经病变如何选择松解方法-共识松解股二头肌NO后交叉韧带YES后外侧关节囊YESITBYES骨外翻角-过度纠正外旋-加大

2023/12/19如何选择松解方法？有争议

静态韧带动态腓肠肌外侧头

髂胫束？外侧副韧带？腘肌腱？

松解顺序？2023/12/19外翻膝松解后常见错误我的体会内侧入路内侧软组织保护暴露股骨外翻减少2-3度外翻，一般3-5度,垫块胫骨少量截骨4-6mm伸直位平衡后股骨前后截骨，选大一号假体，外旋加大，内侧5-7mm，外侧3-5mm胫骨外旋加大我的体会—松解顺序骨赘后方关节囊从股骨上清理粘连后交叉韧带彻底清除RanawatInside-outWhitesideITBPie-crustingInsallPie-crusting腘肌腱?外翻膝畸形来源关节内还是关节外理解外翻膝的病理变化MCL是决定性因素截骨可以影响下肢力线和关节间隙平衡如何能做外侧有效松解又能保持外侧曲屈稳定是成功的关键2023/12/19膑股关节并发症SubluxationDislocationimpingementpatellaclunkAnteriorkneepainFractureLooseningTendonruptureOsteonecrosisCase71yFemaleOA1yafterTKAX-RayCTIR:9°IR:11°Case71yFemaleOA1yafterTKASurgicaltechnique

The10commandmentsofthepatella摩西十诫Ⅰ:NointernalrotationPoortrackingandkinematicsMostcommonerrorLeadingtorevisionsurgery不要内旋MeasuredResectionTechnique

Bonelandmarks---3°ERtoPCA(后髁缺损)---PerpendiculartoApaxis

(滑车发育不良or严重髌股关节炎症)---ParalleltoTEA

(通髁线定位)GapBalancingTechniqueDependantonaperfecttibialcutVarustibialcut-femoralcomponentIRValgustibialcut-femoralcomponentERDependantonligamentousintegrityGapBalancingTechniqueligamentreleasesperformedinextensionmayhavealargereffectinflexionelevatethejointlinesHeesterbeek,ClinOrthopRelatRes,2009.

ChristianP,Arthroplasty,2013

GapBalancingTechniqueMRORGBPersonalexperienceⅡ：LateralizethecomponentsImprovespatellatrackingMedialpositioning

--createslateraltracking

--irritatesMCL

--increasestheQangle假体外置Ⅲ：Don’tover-sizethefemoralcomponentStuffsthePFjointStuffstheflexiongapCausespainandlossofmotion不要过度充填Ⅳ：Don’traisethejointlinePatellaBaja--increasecontactpressure--decreaseROM不要抬高关节线Ⅴ:Don’tincreasetheQangleAlignment：7°valgusorless>10°valguscanincreasetheQ-angleandtheriskofpatellarsubluxationordislocation不要增加Q角Ⅵ：GetadequateexposureCircumferentialdebridementofpatella--exposeinsertionofquadandpatellatendonRemoveosteophytes--Positionjigforasymmetricalcut暴露充分Ⅶ：MeasureandmedializeMeasurebeforecuttingTakemorefrommedialside--symmetricalLeave12mmofresidualbone髌骨内置PositionatthemedialedgeTrimexposedboneOvaldesignProvidesbettercoverageⅧ：Chooseasmaller,ratherthanalargerpatellacomponentAvoidincreasedthicknessAvoidoverhangingpolyToolargeexacerbatesmaltrackingToosmallmayallowboneovergrowth小髌骨Ⅸ:BalancethesofttissuesUsealessinvasiveapproach--mid-vastusorsub-vastusFollowthe“ruleofNOthumb”-takeslackoutofthequad-deflatetourniquetifneeded软组织平衡Beforedoingalateralrelease