發(fā)布時間：2018-05-10 17:50

  本文選題：TKA + PS型TKA�。� 參考：《第三軍醫(yī)大學》2017年碩士論文

【摘要】：背景我國已步入老齡化社會,膝關節(jié)骨性關節(jié)炎患者呈逐年增多趨勢,已將近5000萬人。隨著生物醫(yī)學、材料工程學、手術技術的不斷發(fā)展,全膝關節(jié)置換術(Total knee arthroplasty,TKA)已成為治療中、晚期膝關節(jié)骨性關節(jié)炎重要手段。后交叉韌帶為膝關節(jié)重要結(jié)構(gòu),對膝關節(jié)屈伸、旋轉(zhuǎn)等功能起到重要穩(wěn)定作用。隨著現(xiàn)代膝關節(jié)置換技術的發(fā)展,后交叉韌帶保留型膝關節(jié)假體(CR型假體)和后穩(wěn)定型膝關節(jié)假體(PS型假體)已成為主要的兩種假體設計使用類型,在長期的臨床治療及學術探討過程中,如何選擇假體始終是學者長期爭論的問題。術中能否完整保留后交叉韌帶,是術后發(fā)揮CR假體功能的重要前提。國內(nèi)骨科醫(yī)生大多選擇PS型TKA治療膝關節(jié)骨性關節(jié)炎,近幾年來,CR型TKA術式逐漸增多,CR型TKA是否適合國人膝關節(jié)生理解剖特點以及國人TKA術中保留PCL可行性成為本研究探討的重點。目的1、研究國人PS型TKA中,采取脛骨平臺0°后傾、9mm厚度截骨后,是否仍殘留部分PCL及其殘留量,探討國人PS型TKA中,影響PCL殘留量的影響因素;2、探討國人行CR型TKA的可行性、術中技術要領,并比較CR型TKA與PS型TKA術后臨床療效。方法1、選取2015年5月—2016年8月在第三軍醫(yī)大學附屬新橋醫(yī)院骨科進行的全膝關節(jié)置換術患者共36例,均為單膝患者,年齡范圍為52歲-75歲,身高145cm-173cm,男性、女性各18名。以上患者均簽署本研究知情同意書及手術同意書,對患者身高、性別、PCL保留比例、脛骨平臺截骨前后徑、內(nèi)外徑、脛骨長度進行數(shù)據(jù)收集,仔細收集術中截取脛骨平臺標本予以測量處理。PCL保留比例測量:將脛骨平臺截骨及殘余后交叉韌帶標本固定、脫鈣,取腱骨界面部位切片、染色,通過Auto CAD2014軟件分析PCL保留比例。2、選擇2015年5月-2016年5月,在接受單側(cè)PS型全膝關節(jié)置換的患者16例,共16膝,其中女性9例,男性7例,患者年齡55-75歲,平均65.1歲。接受單側(cè)CR型全膝關節(jié)置換的患者16例,共16膝,其中女性11例,男性5例,患者年齡58-73歲,平均65.0歲。以上患者均簽署本研究知情同意書及手術同意書。PS型TKA采取常規(guī)手術操作。本研究CR型TKA手術操作要領:經(jīng)過前期對PS型TKA脛骨平臺截骨術后PCL殘留量的研究,發(fā)現(xiàn)絕大部分患者在CR型TKA術中,脛骨平臺采取0°后傾、9mm截骨,PCL無法完整保留。故在施行CR型TKA中,本研究采取預留PCL骨島(采取克氏針行骨島周邊保護)、分次截骨(對骨島內(nèi)外側(cè)及前側(cè)分次截骨),在此過程中,始終保持PCL處于松弛狀態(tài),避免產(chǎn)生骨島骨折,脛骨平臺截骨后,常規(guī)行股骨髁截骨,采用自制工具檢測膝關節(jié)屈伸間隙平衡后,安裝假體,可有效降低反復使用試模測量屈伸間隙導致的骨島骨折發(fā)生率。采取VAS評分、AKS評分、WOMAC評分、膝關節(jié)活動度(ROM)、股骨髁后滾距離比較PS型TKA與CR型TKA術后臨床療效。結(jié)果1、身高是影響脛骨平臺內(nèi)外徑、前后徑大小、后交叉韌帶保留比例、脛骨長度大小主要因素,而性別對脛骨平臺內(nèi)外徑、前后徑、后交叉韌帶保留比例、脛骨長度無影響或者影響很小。身高、脛骨平臺前后徑、內(nèi)外徑、脛骨長度與PCL殘留比例存在著線性關系,呈正相關變化。本研究顯示,國人行TKA中,采取脛骨平臺0°后傾、9mm截骨時,身高低于171cm時,PCL保留比例在50%以下,普遍偏低。2、在本研究CR型TKA術中,采取預留PCL骨島(采取克氏針行骨島周邊保護)、分次截骨(對骨島內(nèi)外側(cè)及前側(cè)分次截骨)的方法實行脛骨平臺0°后傾、9mm截骨,術中2例患者出現(xiàn)骨島撕脫性骨折,改為PS型假體,其余14例患者完整保留PCL。術后3天CR型TKA患者在ROM、股骨髁后滾距離、VAS評分明顯優(yōu)于PS型TKA患者,患者滿意率提高,康復周期、平均住院日明顯縮短。術后3個月,CR型TKA與PS型TKA患者在AKS評分、WOMAC評分、VAS評分、ROM方面無明顯差異。結(jié)論身高是影響脛骨平臺內(nèi)外徑、前后徑大小、后交叉韌帶保留比例、脛骨長度大小主要因素,而性別對脛骨平臺內(nèi)外徑、前后徑、后交叉韌帶保留比例、脛骨長度無影響或者影響很小。身高、脛骨平臺前后徑、內(nèi)外徑、脛骨長度與PCL殘留比例存在著線性關系,呈正相關變化。本研究顯示,身高低于171cm的患者,當采取脛骨平臺0°后傾、9mm截骨時,PCL保留比例在50%以下,普遍偏低,術后殘留PCL不能發(fā)揮其正常生理功能。對于大部分擬行TKA的國人,身高普遍在170cm以下,若采取后交叉韌帶保留型TKA假體,手術難度、技術及時間要求增加,術中發(fā)生骨島撕脫骨折風險增加,后交叉韌帶保留成功率降低,臨時更改手術方案,改用PS型假體,本研究中采取預留PCL骨島(采取克氏針行骨島周邊保護)、分次截骨(對骨島內(nèi)外側(cè)及前側(cè)分次截骨),手術過程中,始終保持PCL處于松弛狀態(tài),使用自制工具檢測膝關節(jié)屈伸間隙平衡可有效降低反復使用試模測量屈伸間隙導致的骨島骨折發(fā)生率。雖然術后3天CR型TKA患者在ROM、股骨髁后滾距離、VAS評分明顯優(yōu)于PS型TKA患者(P0.05),患者滿意率提高、康復周期、平均住院日明顯縮短。然而術后3個月,CR型TKA與PS型TKA患者在AKS評分、WOMAC評分、VAS評分、ROM方面無明顯差異(P0.05)。故鑒于行TKA的大部分國人的身高普遍在170cm以下,術中采取脛骨平臺0°后傾、9mm截骨時,成功保留PCL,手術難度及技術要求高,增加手術時間,易發(fā)生骨島撕脫骨折,導致后交叉韌帶保留失敗,并且兩種類型假體行TKA后,遠期療效并無顯著差異(P0.05),大多數(shù)國人OA患者不宜行CR型TKA,需更加嚴格把握手術適應癥。
[Abstract]:Background our country has entered an aging society. The patients with osteoarthritis of the knee joint are increasing year by year, and nearly 50 million people. With the continuous development of biomedicine, material engineering and surgical technique, Total knee arthroplasty (TKA) has become an important means of advanced knee osteoarthritis in the treatment of advanced knee joint. As an important structure of the knee joint, it plays an important and stable role in the flexion, extension and rotation of the knee joint. With the development of modern knee replacement technology, the reserved knee prosthesis (CR type prosthesis) and the post stable knee joint prosthesis (PS type prosthesis) have become the main two types of prosthesis design and use in the long term clinical treatment and the development of the knee joint replacement technique. In the course of academic discussion, how to choose the prosthesis has always been a long argument for the scholars. Whether the posterior cruciate ligament is retained completely during the operation is an important prerequisite for the function of the CR prosthesis after the operation. Most of the doctors in the domestic Department of orthopedics choose PS TKA for the treatment of osteoarthritis of the knee joint. In recent years, the CR type TKA has gradually increased, and the CR TKA is suitable for the people of the country. The physiological and anatomical characteristics of the knee joint and the feasibility of retaining the PCL in Chinese TKA have become the focus of this study. 1, in the study of Chinese human PS TKA, the influence factors of the residual amount of PCL and its residual amount remained after the tibial plateau was 0 degrees and the thickness of 9mm was cut, and the influence factors of the PCL residues in the PS type TKA of the Chinese people were discussed. 2, to explore the TKA CR TKA. The feasibility, technical essentials in the operation, and comparison of the clinical effect of CR type TKA and PS type TKA. Method 1, 36 cases of total knee arthroplasty in the Department of orthopedics, Xinqiao Hospital Affiliated to Third Military Medical University from May 2015 to August 2016 were selected, all were single knee patients, the age range was 52 years old -75 years, height 145cm-173cm, male and female 18. All the patients signed this research agreement and the surgical consent. The patient's height, sex, PCL retention ratio, the tibial plateau anterior and posterior diameter, the internal and external diameter, the length of the tibia were collected, and the tibial plateau specimens were collected carefully to measure the.PCL retention ratio: the tibial plateau osteotomy and the residual posterior cruciate ligament The specimens were fixed, decalcified, and the tendon bone interface was sliced and stained, and the PCL retention ratio was analyzed by Auto CAD2014 software. In May 2015 -2016 May, 16 patients received unilateral PS total knee replacement, including 16 knees, 9 women, 7 men, 55-75 years old and 65.1 years old. 16 cases, including 16 knees, 11 women, 5 men, 58-73 years old, average 65 years old. All the patients signed this study and the operation consent book.PS TKA to take routine operation. This study of CR type TKA operation essentials: after the early stage of the PS TKA tibial plateau osteotomy after the study of PCL residues, found the vast part In the patients with type CR TKA, the tibial plateau was tilting 0 degrees, 9mm osteotomy, and PCL could not be retained completely. Therefore, in the CR TKA, this study adopted the reservation of PCL bone island (with Kirschner needle on the periphery of the bone island) and the sub osteotomy (the osteotomy of the bone and the anterior and outer sides of the bone island). During this process, the PCL was kept in a relaxed state to avoid producing bone. After the island fracture and the tibial plateau osteotomy, the femoral condyle osteotomy was routinely carried out. After using the self-made tool to detect the balance of the knee joint and extension space, the prosthesis was installed, which could effectively reduce the incidence of bone island fracture caused by the flexion and extension clearance. The VAS score, the AKS score, the WOMAC score, the knee joint activity (ROM), and the femoral condyle roll distance were compared with PS The clinical efficacy of type TKA and type CR TKA after operation. Results 1, height is the influence of the internal and external diameter of tibial plateau, the size of the anterior and posterior diameter, the retention ratio of the posterior cruciate ligament, the main factor of the length of the tibia, and the proportion of the internal and external diameter of the tibial plateau, the back and back diameter, the posterior cruciate ligament, the length of the tibia, and the small influence of the tibia length, the height, and the tibial plateau diameter, the tibial plateau, and the diameter of the tibial plateau. There is a linear relationship between the diameter of the internal and external diameter, the length of tibia and the ratio of PCL residue, which shows a positive correlation. This study shows that in TKA, when the tibial plateau is 0 degrees back, and when the 9mm osteotomy is lower than 171cm, the retention ratio of PCL is below 50%, and it is generally low.2. In this study, the PCL bone island (Kirschner pin is used to take the bone island around the bone island). 0 degree posterior tibial plateau tilting, 9mm osteotomy, 2 cases of bone island avulsion fracture, changed into PS type prosthesis, and the remaining 14 cases of CR TKA patients at ROM and femoral condyle roll distance, VAS score was obviously superior to PS type TKA patients in the other 14 cases. 3 months after operation, there was no significant difference in AKS score, WOMAC score, VAS score and ROM in the patients with type CR TKA and PS TKA. Conclusion the height of the tibial plateau is influenced by the internal and external diameter of the tibial plateau, the size of the posterior cruciate ligament, the main factor of the length of the tibia, and the gender of the tibial plateau. Internal and external diameter, front and back diameter, posterior cruciate ligament retention ratio, tibial length has no influence or small impact. Height, tibial plateau diameter, internal and external diameter, the length of tibia and PCL residual ratio has a linear relationship, and there is a positive correlation. This study shows that people with height below 171cm, when the tibial plateau is 0 degrees back, 9mm osteotomy, PCL retention ratio The cases are below 50%, generally low and the residual PCL can not perform normal physiological function after operation. For most of the people who do TKA, the height is generally below 170cm. If the posterior cruciate ligament is reserved for the reserved TKA prosthesis, the operation difficulty, the technical and time requirements are increased, the risk of bone island avulsion fracture is increased in the operation, and the posterior cruciate ligament has a successful rate drop. In this study, the PCL bone island was reserved (with Kirschner's needle on the periphery of bone island) and sub osteotomy (partial osteotomy of the lateral and anterior side of the bone island). During the operation, the PCL was kept in a relaxed state, and the balance of the flexion and extension gap of the knee joint could be effectively reduced repeatedly by using the self-made tool in this study. The incidence of bone island fracture caused by the flexion and extension gap was measured with a test model. Although the CR TKA patients were at ROM and the femoral condyle roll distance on the 3 day after operation, the VAS score was obviously better than that of the PS TKA patients (P0.05). The satisfaction rate of the patients was improved, the recovery cycle was significantly shortened. However, 3 months after the operation, CR type TKA and PS TKA were scored in AKS score There is no significant difference in ROM (P0.05). Therefore, in view of the height of the majority of the people in TKA is generally below 170cm, the tibial plateau is 0 degrees behind, and when the 9mm osteotomy is taken, the PCL is successfully retained, the operation difficulty and the technical requirement are high, the operation time is increased, the bone island avulsion is easy to take place, the posterior cruciate ligament is failed, and the two types of prosthesis are made. After TKA, there was no significant difference in long-term efficacy (P0.05). Most Chinese OA patients were not suitable for CR TKA.

【學位授予單位】：第三軍醫(yī)大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R687.4

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