全踝關(guān)節(jié)置換術(shù)(PLUS 適應(yīng)癥禁忌癥及手術(shù)步驟.doc

TAR total ankle replacement TAA total ankle arthroplasty 全踝關(guān)節(jié)置換術(shù)（PLUS 適應(yīng)癥禁忌癥及手術(shù)步驟） 原創(chuàng) 2010-11-30 12:59:59 患者信息:M/66術(shù)前診斷:OA ankle Rt.治療方案:TARA, Rt.手術(shù)醫(yī)師:professor Chu In Tak(St. Marys hospital)手術(shù)日期: 2010-11-30手術(shù)體會(huì)：chu教授做踝關(guān)節(jié)置換手術(shù)非常熟練，術(shù)中幾乎不要截骨定位器。入路是標(biāo)準(zhǔn)的前入路，他建議從脛前肌腱內(nèi)側(cè)入路，骨膜分離用手術(shù)刀而非骨膜剝離器，他認(rèn)為這樣損傷小。先在流行的踝關(guān)節(jié)假體有11種，他所用的假體是法國(guó)的Hintegra Sensitive假體，而在教科書上大部分都是講解利用PE假體，組件不同手術(shù)方式也有不同。以上3圖為術(shù)前X線表現(xiàn) 手術(shù)選擇前正中切口脛骨截骨定位器截骨完成后安裝試模安裝試模后透視脛骨假體組件標(biāo)簽距骨假體組件標(biāo)簽PE墊標(biāo)簽術(shù)后拍片所見(jiàn)術(shù)后到Catholic University圖書館查閱有關(guān)踝關(guān)節(jié)置換的內(nèi)容，摘錄如下：假體組件Hintegra Sensitive Prosthesistibial component(CoCr)talar component(CoCr)Fixation screws(Titanium alloy)intermediary sliding core(UHMW Polyethylene)適應(yīng)癥Indications:systemic caused arthritis of the ankle(eg. rheumatoid arthritis,hemochromatosis);primary arthritis(eg. degenerative disease);secondary arthritis(eg. posttraumatic,infection,avascular necrosis);salvage for failed total ankle replacement;salvage for non-union and malunion of ankle arthrodesis.禁忌癥Contraindications:relative controindications: severe osteoporosis;immunosuppressive therapy;high demanding sport activities(eg.contact sports,jumping);patients with a poor soft tissue envelope;absolute contraindications: active infection;charcot neuroarthropathy;neurologic disease of the lower extremities;advanced peripheral vascular disease;absence of distal leg muscular functionsuspected or documented metal allery or intolerance;avascular necrosis of the talus/tiba of more than1/2;evere malalignment(if not surgically correctale);severe instability;diabetic syndrom最常用的3種假體although there are currently 11 different ankle implants being used throughout the world,attention in the united states has been focused on three second-generation ankle implant devices:Buechel Pappas total ankle repalcement(Endotec, South Orange,NJ,USA)Agility total ankle system (DePuy,Warsaw,IN,USA)scandinavian total ankle replacement(STAR Waldemar-Link,Hamburg,Germany)術(shù)前準(zhǔn)備 preoperative considerations:instability of the ankle often accompanies hindfoot or tibiotalar deformity that necessitates repair or reconstruction of the lateral ligaments during implantation.the condition of the soft tissues envelope is an important preoperative consideration that may influence complications.preoperative evaluation of plain films,MRI, and CT scan can be used for evaluation of ankle deformity.手術(shù)步驟 Surgical technique1.the patient is operated with spinal or general anesthesia;2.the patient is placed on the operating table in the supine position with a sandbag placed under the ipsilateral hip;3.a well-padded thigh tourniquet is used for hemostatic control;4.the leg is surgically prepped and draped above the knee;5.an anterior midline incision is centered over the ankle joint extending 10-13cm in length between the anterior tibial and extensor hallucis longus tendons;6.the incision is carried through to the subcutaneous tissues, being careful to identify and protect the superficial peroneal nerve;7.the extensor retinaculum is incised between the tendons of the anterior tibialis and the extensor hallucis longus;it is advisable to place a suture tag along the retinaculum on either side;8.a deep incision is made through this space incising the ankle capsule down to the the tibial periosteum;9.the osteophytes must be removed with bone cutters and rongeurs to expose the joint,next medial and lateral subperiosteal elevation provides exposure of the anterior ankle joint and the neck of the talus.the surgeon must be able to visualize the medial and lateral gutter and proximal tibial surface approximately 4.0 cm above the level of the joint.distally exposure must provide visualization of the talar body and neck;10.tibial preparation11.preparation of the ponent sizing.13.final component implantaton14.closure:a final radiographic exam is performed to ensure proper size and placement of the components.motion of the ankle joint is evaluated again to assure adequate dorsiflexion.the wound is closed over a hemovac drain using nonabsorbable ethibond suture to close the ankle joint capsule and the extensor retinaculum.absorbable sutures are used to close the subcutaneous layers and the skin is closed with 4-0 nylon sutures;15. the surgical site is infiltrated with plain, long acting local anesthesia;16.after a sterile surgical dressing is placed, a well padded below the kness