全踝关节置换术PLUS适应症禁忌症及手术步骤Word文件下载.docx

全踝关节置换术PLUS适应症禁忌症及手术步骤Word文件下载.docx

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术前诊断:

OAankleRt.

治疗方案:

TARA,Rt.

手术医师:

professorChuInTak（St.Mary'

shospital）

手术日期:

2010-11-30

手术体会：

chu教授做踝关节置换手术非常熟练，术中几乎不要截骨定位器。

入路是标准的前入路，他建议从胫前肌腱内侧入路，骨膜分离用手术刀而非骨膜剥离器，他认为这样损伤小。

先在流行的踝关节假体有11种，他所用的假体是法国的HintegraSensitive假体，而在教科书上大部分都是讲解利用PE假体，组件不同手术方式也有不同。

以上3图为术前X线表现

手术选择前正中切口

胫骨截骨定位器

截骨完成后

安装试模

安装试模后透视

胫骨假体组件标签

距骨假体组件标签

PE垫标签

术后拍片所见

术后到CatholicUniversity图书馆查阅有关踝关节置换的内容，摘录如下：

假体组件HintegraSensitiveProsthesis

tibialcomponent（CoCr）

talarcomponent（CoCr）

Fixationscrews（Titaniumalloy）

intermediaryslidingcore（UHMWPolyethylene）

适应症Indications:

systemiccausedarthritisoftheankle（eg.rheumatoidarthritis,hemochromatosis）;

primaryarthritis（eg.degenerativedisease）;

secondaryarthritis（eg.posttraumatic,infection,avascularnecrosis）;

salvageforfailedtotalanklereplacement;

salvagefornon-unionandmalunionofanklearthrodesis.

禁忌症Contraindications:

relativecontroindications:

severeosteoporosis;

immunosuppressivetherapy;

highdemandingsportactivities（eg.contactsports,jumping）;

patientswithapoorsofttissueenvelope;

absolutecontraindications:

activeinfection;

charcotneuroarthropathy;

neurologicdiseaseofthelowerextremities;

advancedperipheralvasculardisease;

absenceofdistallegmuscularfunction

suspectedordocumentedmetalalleryorintolerance;

avascularnecrosisofthetalus/tibaofmorethan1/2;

everemalalignment（ifnotsurgicallycorrectale）;

severeinstability;

diabeticsyndrom

最常用的3种假体

althoughtherearecurrently11differentankleimplantsbeingusedthroughouttheworld,attentionintheunitedstateshasbeenfocusedonthreesecond-generationankleimplantdevices:

BuechelPappastotalanklerepalcement（Endotec,SouthOrange,NJ,USA）

Agilitytotalanklesystem（DePuy,Warsaw,IN,USA）

scandinaviantotalanklereplacement（STAR 

Waldemar-Link,Hamburg,Germany）

术前准备preoperativeconsiderations:

instabilityoftheankleoftenaccompanieshindfootortibiotalardeformitythatnecessitatesrepairorreconstructionofthelateralligamentsduringimplantation.

theconditionofthesofttissuesenvelopeisanimportantpreoperativeconsiderationthatmayinfluencecomplications.

preoperativeevaluationofplainfilms,MRI,andCTscancanbeusedforevaluationofankledeformity.

手术步骤Surgicaltechnique

1.thepatientisoperatedwithspinalorgeneralanesthesia;

2.thepatientisplacedontheoperatingtableinthesupinepositionwithasandbagplacedundertheipsilateralhip;

3.awell-paddedthightourniquetisusedforhemostaticcontrol;

4.thelegissurgicallypreppedanddrapedabovetheknee;

5.ananteriormidlineincisioniscenteredovertheanklejointextending10-13cminlengthbetweentheanteriortibialandextensorhallucislongustendons;

6.theincisioniscarriedthroughtothesubcutaneoustissues,beingcarefultoidentifyandprotectthesuperficialperonealnerve;

7.theextensorretinaculumisincisedbetweenthetendonsoftheanteriortibialisandtheextensorhallucislongus;

itisadvisabletoplaceasuturetagalongtheretinaculumoneitherside;

8.adeepincisionismadethroughthisspaceincisingtheanklecapsuledowntothethetibialperiosteum;

9.theosteophytesmustberemovedwithbonecuttersandrongeurstoexposethejoint,nextmedialandlateralsubperiostealelevationprovidesexposureoftheanterioranklejointandtheneckofthetalus.thesurgeonmustbeabletovisualizethemedialandlateralgutterandproximaltibialsurfaceapproximately4.0cmabovethelevelofthejoint.distallyexposuremustprovidevisualizationofthetalarbodyandneck;

10.tibialpreparation

11.preparationofthetalus.

ponentsizing.

13.finalcomponentimplantaton

14.closure:

afinalradiographicexamisperformedtoensurepropersizeandplacementofthecomponents.motionoftheanklejointisevaluatedagaintoassureadequatedorsiflexion.thewoundisclosedoverahemovacdrainusingnonabsorbableethibondsuturetoclosetheanklejointcapsuleandtheextensorretinaculum.absorbablesuturesareusedtoclosethesubcutaneouslayersandtheskinisclosedwith4-0nylonsutures;

15.thesurgicalsiteisinfiltratedwithplain,longactinglocalanesthesia;

16.afterasterilesurgicaldressingisplaced,awellpaddedbelowtheknessfiberglasssplintisplacedtomaintaintheanklejointat90degrees.

17.thetourniquetisreleasedandvascularstatusevaluated,thetourniquettimeshouldnotexceedtwohours.

术后处理：

石膏固定4周

第五周：

双拐部分负重，活动踝关节

第六周：

单拐部分负重

第七周：

不用拐杖负重