膝关节置换术

来源:上海六院骨科欧阳元明欢迎分享本文，转载请保留出处！膝关节的结构和功能是人体关节中最复杂的部分之一，也是人体下肢重要的负重关节。如果膝关节出现问题会让行动出现不便，影响正常生活。而膝关节退行性骨关节病也是很大一部分老年人的常见骨科疾病。膝关节骨关节病的患者中女性为主要发病者。要治疗较为严重的膝关节骨关节病，人工膝关节置换术是其中比较有效的方法。治疗较为严重的膝关节骨关节病，人工膝关节置换术是其中比较有效的方法。膝关节置换术能够解除膝关节疼痛，较好改善膝关节功能，还能纠正膝关节畸形和让机体获得长期稳定的手术。膝关节置换术，并不是全部将膝关节进行置换处理，应该叫做“全膝关节表面置换术”，手术只是将患者关节表面被破坏的部分切除一层，再将同样厚度的人工关节面装在病变切除处的表面，尽最大力度恢复原来关节面的光滑平整。随着医学水平的不断进步，人工膝关节假体使用时间也能够维持更久。原先的膝关节假体只能维持10年到15年的时间，而现在的膝关节假体比较好的能够维持20年以上。当然，人工关节的使用寿命与医生的技术水平也有关系，经验丰富的医生安装的关节尺寸适中，位置准确，贴合紧密，这样的人工关节使用寿命相对于会更长一些。做完人工膝关节置换术以后应该如何护理呢？膝关节置换手术后护理也非常重要，护理主要包括疼痛护理、严密观察生命体征、引流管护理、预防下肢静脉血栓、预防感染。1.疼痛护理：术后回病房，密切观察病情变化，评估疼痛部位及性质，进行冰敷。2.严密观察生命体征：术后患者去枕平卧，膝后用一软枕将患肢垫高，密切监测血压、心律、氧饱和度，注意神、尿量等以便准确判断病情。3.引流管护理：妥善安置引流管，要固定好引流管，防止拉扯、扭曲、折叠，避免脱落，确保引流通畅，注意观察引流液体的性质、颜色及量。4.预防下肢深静脉血栓：适当进行下肢活动和训练，防止下肢深静脉血栓。5.预防感染：感染是膝关节镜术后较为严重的并发症，术后应严密观察患者体温变化，根据医嘱应用抗生素。保持切口清洁、干燥，严格无菌换药。一般来说，做完手术，根据据引流量情况，大多数患者术后48小时就可以拔除引流，2周左右可以拆线，同时复建。膝关节置换术后如何进行康复训练？1.踝泵运动：患者有节奏地进行踝关节的屈、伸活动，在屈曲位和背伸位各停留5秒钟。屈伸为1组，上下午各500组。2.股四头肌等长收缩：患者取仰卧位，绷紧大腿前方肌肉，将膝盖往下压紧床面，保持5-10秒，再缓慢放松，10个/组，上下午各2组。3.直腿抬高训练：患者取仰卧位，患侧下肢在伸膝状态下，将大腿抬离床面20~30公分，终末端保持5秒，再恢复至起始位，10个/组，上下午各2组。4.被动屈膝90°：患者取仰卧位，康复治疗师或家属一手握住患侧膝关节以维持髋关节稳定，另一手握住踝关节，双手同时往头顶方向推至髋膝关节屈曲，达到屈膝90°，再恢复至起始位，10个/组，上下午各2组。5.主动抱膝90°：患者取仰卧位，将大腿抬离开床面，双手抱住大腿，主动屈曲膝关节直至90°，再恢复至起始位，10个/组，上下午各2组。6.起身-坐-站转移训练：7.床边垂腿训练：患者取坐位，双腿在床边自然下垂，主动屈膝至最大角度后，可用健腿架在患腿上方，用力下压至最大角度，再缓慢放松，10个/组，上下午各2组。8.重心转移训练：患者取站立位，双脚与肩同宽，逐渐将重心由健腿转移至患腿，再将重心维持在正中，站立训练为5-10min/次，2-3次/天。9.提踵训练：患者取站立位，保持膝关节伸直，踮起脚尖直至后脚跟抬至最高点，保持5-10秒，再缓慢放松，10个/组，上下午各2组。10、扶拐步行训练：患者扶助行器进行步行训练，使用三点步态，即先出助行器，再迈患肢，后迈健肢，扶拐步行训练为10-15min/次，2-3次/天。11、上厕所训练：术后注意事项：1、避免摔倒、剧烈跳跃、急转急停；2、避免进行剧烈的竞技体育运动；3、避免过大负重及在负重情况下反复屈伸膝关节；4、保持体重，预防骨质疏松；5、扶单拐时需置于健康腿侧；6、术后注意预防和控制全身部位炎症的发生，防止造成人工关节感染；7、术后功能恢复期间需要服用止痛药4-6周，减少功能锻炼期间关节的肿胀疼痛；8、上下楼梯训练：上楼梯时健康腿在前，患者跟上；下楼梯时患肢在前，健康腿跟上。9、如果有拔牙、发热、出血或者有局部炎症需要使用抗菌素。10、术后1个月，患者需到医院进行复查，并且拍片检查患者膝关节功能恢复情况。欧阳元明（上海市第六人民医院骨科-关节外科主任医师，医学博士，博士研究生导师）上海交通大学医学院毕业，从事临床工作20多年，主攻关节外科。曾在韩国首尔，德国慕尼黑，加拿大及香港进修学习，掌握先进关节置换手术及关节镜技术。年均手术量1000台左右。擅长：1、人工膝关节、髋关节置换及假体感染松动翻修手术（骨关节炎、类风湿、痛风性关节炎、创伤性关节炎、强直性脊柱炎、骨质增生、骨刺、关节磨损、膝关节内、外翻畸形、股骨头坏死、先天性髋关节发育不良）；2、保膝，保髋、髋关节镜手术；3、关节镜微创治疗膝关节积液、滑膜炎，软骨损伤，半月板损伤、半月板撕裂、肩周炎、肩袖损伤；4、全肩、全肘关节置换；5、严重肘、膝、髋关节异位骨化关节僵硬松解手术。担任职务：担任中华医学会手外科分会委员，中华医学会上海分会手外科学会委员兼秘书，上海市运动医学关节微创学组成员，上海市中西医结合学会创伤专业青年委员，上海市科技专家库评审专家，亚太膝关节-关节镜-运动医学协会（APKASS）会员，国际期刊《FrontiersinNeuroscience》编委，美国期刊《orthopedics》主要审稿人。

大多数人听到“膝关节置换”，脑海里浮现出的场景是“把膝关节锯掉，换上一个人工的关节”。其实膝关节置换，全名叫膝关节表面置换。在我们膝关节的表面上有软骨，随着年龄增大，磨损增多，慢慢的软骨就磨掉了。磨掉了以后就会出现膝关节疼痛，尤其是行走负重和上下楼梯，爬山时疼痛会加重，休息后会好转，严重的可引起膝关节内外翻，就是“O”型腿和“X”型腿。膝关节置换就是针对这种软骨损伤严重，影响生活的人群。膝关节置换术是通过手术切除已经磨损破坏的关节面，使用人工生物材料（膝关节假体）来置换病变的的膝关节软骨，达到消除膝关节疼痛、矫正膝关节畸形、恢复下肢力线、重建膝关节功能的目的。01膝关节置换术适应症膝关节置换术的适应症主要为终末期膝骨关节炎、类风湿性关节炎、创伤性关节炎、强直性脊柱炎膝关节受累等。对于早期膝骨关节炎、类风湿性关节炎等，可采取减轻体重、佩戴护具、药物治疗、理疗、中西医结合治疗等方法，可有效改善关节症状，并减缓病情进展。然而，当出现关节间隙变窄或消失、关节畸形明显时，则保守治疗效果有限。此时，可选择膝关节置换手术，重建膝关节的功能，术后可早期功能锻炼，改善生活质量。02膝关节置换术的类型单髁关节置换术:单髁置换术主要针对单侧骨关节病，单髁置换手术是用人工关节垫片和软骨替代磨损的部位，属于保膝手术，适合单一间室出现磨损的患者，不会损伤前、后交叉韧带，可保持关节稳定性和本体感觉，相对会比较好，康复周期也会短。全膝关节置换术：全膝置换手术会破坏整个关节面，包括韧带，适合全关节严重退化后需要建立表面置换的患者。03膝关节置换术操作步骤1、备体位，消毒2、切开暴露关节，软组织处理3、股骨远端截骨4、股骨前后髁和斜面截骨（四合一截骨）5、胫骨近端截骨6、假体试模7、截骨面放置骨水泥并安装假体8、冲洗，逐层缝合，关闭切口——关注我们——

全膝关节置换治疗膝关节夏科氏关节病的中长期疗效（2024）Mid-toLong-TermResultsofTotalKneeArthroplastyforCharcotArthropathyoftheKnee OnoiY,MatsumotoT,NakanoN,TsubosakaM,KamenagaT,KurodaY,IshidaK,HayashiS,KurodaR.Mid-toLong-TermResultsofTotalKneeArthroplastyforCharcotArthropathyof theKnee[J].IndianJOrthop,2024,58(3):308-315. 转载文章的原链接1：https://pubmed.ncbi.nlm.nih.gov/38425826/ 转载文章的原链接2：https://link.springer.com/article/10.1007/s43465-023-01094-z AbstractBackground:Totalkneearthroplasty(TKA)forCharcotarthropathyofthekneeisconsideredcontroversialbecauseofitshighercomplicationratecomparedwiththatofTKAforosteoarthritis.Inthisstudy,weinvestigatedtheclinicaloutcomes,survivalrates,andcomplicationsofprimaryTKAforCharcotarthropathy.全膝关节置换术(TKA)治疗膝关节Charcot关节病被认为是有争议的，因为与骨关节炎的TKA相比，其并发症发生率更高。在这项研究中，我们调查了初次TKA治疗Charcot关节病的临床结果、生存率和并发症。 Methods:Weconductedaretrospectiveanalysisofninepatients(12knees)withCharcotarthropathywhounderwentTKA.Themeanageofthepatientswas63.9±9.4years(range,52-83years).Themostfrequentcausativediseasewasdiabetesmellitus(threepatients).Patients'clinicaloutcomes,includingthe2011KneeSocietyScoreandtherangeofmotion,werecomparedbetweenpreoperativeandthemostrecentpostoperativedata.The5-and10-yearsurvivalratesforasepticrevision,revisionduetoinfection,andcomplicationswereexamined.Themeanfollow-upperiodwas7.3±3.9years(range,3-14years).我们对9例Charcot关节病患者(12个膝关节)进行了全膝关节置换术的回顾性分析。患者平均年龄为63.9±9.4岁(52~83岁)。最常见的病因是糖尿病(3例)。患者的临床结果，包括2011年膝关节社会评分和活动范围，在术前和术后的最新数据之间进行比较。检查无菌翻修、感染翻修和并发症翻修的5年和10年生存率。平均随访时间7.3±3.9年(范围3~14年)。 Results:The2011KneeSocietyScoreandthekneeflexionanglesignificantlyimprovedafterTKAsurgery(P<0.05).The5-yearsurvivalratesforasepticrevision,revisionduetoinfection,andcomplicationswere100%,91.7%,and83.3%,respectively;the10-yearsurvivalratesfortheseparameterswerethesame.Onepatientunderwentrevisionforinsertreplacementduetoperiprostheticinfection,andtheotherpatienthadvarus/valgusinstabilityduetosofttissueloosening.TKA术后膝关节社会评分和膝关节屈曲角度均显著提高(P<0.05)。无菌翻修、感染翻修和并发症翻修的5年生存率分别为100%、91.7%和83.3%;这些参数的10年生存率是相同的。一名患者因假体周围感染接受假体置换翻修，另一名患者因软组织松动出现内翻/外翻不稳定。 Conclusions:Themid-tolong-termresultsofTKAforCharcotarthropathyweregenerallyfavorable.OurfindingsindicatethatTKAmaybeaviabletreatmentoptionforCharcotarthropathy.TKA治疗Charcot关节病的中长期结果通常是有利的。我们的研究结果表明TKA可能是治疗Charcot关节病的可行选择。 Keywords:Charcotarthropathy;Constrainedcondylarprosthesis;Neuropathicarthropathy;Rotatinghingeprosthesis;Survivalrates;Totalkneearthroplasty. IntroductionCharcotarthropathyisadegenerativeneuropathicarthropathythatleadstoseverejointdestructionandinstability,causedbyrepetitiveasymptomaticmicrotraumaduetodecreasedorabsentjointnociception[1].Theglobalincreaseintheincidenceofdiabetesmellitus(DM),themaincausativediseaseofCharcotarthropathy,isexpectedtoleadtoahigherprevalenceofCharcotarthropathy[2,3].BecauseofthenatureofCharcotarthropathy,patientsrarelycomplainofpainduringtheearlydeformitystagesandtypicallyseektreatmentonlyafterseveredeformity,instability,andgaitdisturbancehaveoccurred[4].ThismakesCharcotarthropathyoneofthemostdifficultconditionsfororthopaedicsurgeonstotreat.Charcot关节病是一种退行性神经性关节病，可导致严重的关节破坏和不稳定，由关节痛觉减少或缺失引起的重复性无症状微创伤引起[1]。糖尿病(DM)是Charcot关节病的主要致病疾病，随着全球糖尿病发病率的增加，预计将导致Charcot关节病的患病率升高[2,3]。由于Charcot关节病的性质，患者在早期畸形阶段很少主诉疼痛，通常只有在发生严重畸形、不稳定和步态障碍后才寻求治疗[4]。这使得Charcot关节病成为骨科医生最难治疗的疾病之一。Althoughtotalkneearthroplasty(TKA)forCharcotarthropathywaspreviouslynotrecommendedbecauseofitshighrateofcomplications,suchasperiprostheticinfection,fracture,anddislocation[5,6],severalrecentstudieshaveshowngoodshort-termclinicaloutcomeswithTKA[2,7].However,thereislimitedliteratureonthemid-tolong-termresultsofTKAforCharcotarthropathy[8,9],andimportantquestionsregardingsurvivalrates,potentialcomplications,andclinicaloutcomesofTKAremainunresolved.ThislackofinformationmaypreventpropermanagementofCharcotarthropathy.Therefore,weaimedtoreportthemid-tolong-termresultsofprimaryTKAforpatientswithCharcotarthropathy.尽管全膝关节置换术(TKA)治疗Charcot关节病之前不被推荐，因为其并发症发生率高，如假体周围感染、骨折和脱位[5,6]，但最近的几项研究表明，TKA的短期临床效果良好[2,7]。然而，关于TKA治疗Charcot关节病的中长期结果的文献有限[8,9]，TKA的生存率、潜在并发症和临床结果等重要问题仍未解决。这种信息的缺乏可能会妨碍对Charcot关节病的适当治疗。因此，我们的目的是报道原发性全膝关节置换术治疗Charcot关节病患者的中长期结果。MaterialsandMethodsPatientsThestudywasapprovedbytheInstitutionalReviewBoardofourinstitution(PermissionNo;1510),andwritteninformedconsentwasobtainedfromthepatients.Weconductedaretrospectiveanalysisof11consecutivepatientswithCharcotarthropathyofthekneewhounderwentprimaryTKAatourinstitutionbetweenAugust2008andMarch2020.TwopatientswereexcludedfromthestudybecausetheydiedwithinoneyearforreasonsunrelatedtoTKA.Theremainingninepatients(12knees),consistingoffourmenandfivewomenwithameanageof63.9 ± 9.4years(range,52–83years)atthetimeofTKA,wereenrolledinthestudy.NoneofthepatientshadundergonearthroscopicdebridementorotherkneesurgeriespriortotheTKAs.PriortoTKA,threepatientshadipsilateralanklejointfracturesandunderwentopenreductionandinternalfixation.TheCharcotarthropathy-causativeneuropathywasdiagnosedbyneurologistsusingnerveconductionstudies,electromyography,andclinicalevaluations.Orthopaedicsurgeonsverifiedthediagnosesbyphysicalexaminationandradiographicstudies,revealingfeaturescharacteristicofCharcotarthropathy,includingseveredeformity,instability,andrestrictedrangeofmotion.Theninepatientsincludedinthestudyhadavarietyofcausativediseases.Ofthese,DMwasthemostcommon(threepatients),withameanHbA1cof5.9 ± 0.2%(range,5.6–6.1%).Twopatientshadneurosyphilis,onehadCharcot-Marie-Toothdisease,onehadGuillain–Barresyndrome,onehadcervicalossificationoftheposteriorlongitudinalligament,andonehadmeningealaneurysm(Table1).Noneofthepatientswerelosttofollow-up,andthemeanfollow-upperiodwas7.3 ± 3.9years(range,3–14years).  Table1Patients’characteristics  OperativeProceduresAllsurgerieswereperformedbyseniorsurgeonswith> 15yearsofexperienceinTKAprocedures.Allpatientsreceivedgeneralanesthesiaandfemoral/sciaticnerveblockwith0.75%ropivacaine(40mL).Afterinflatingtheairtourniquetto250mmHg,thekneeswereexposedbymedialparapatellararthrotomy;osteotomywasperformedusingthemeasuredresectiontechnique.ALegacyconstrainedcondylarkneeprosthesis(LCCK;ZimmerBiomet,Warsaw,IN,USA)wasinsertedintenkneesandarotatinghingekneeprosthesis(RHK;ZimmerBiomet)wasinsertedintwokneespresentinghyperextension.Stemswereusedinboththefemurandtibiaforsevenknees;infourknees,thestemswereusedinthetibiaonly;inoneknee,nostemswereused,followingaprotocoltousestemsinfragilebones.Augmentationwasappliedtoreplacetibialbonedefectsof>5mmineightknees.Allthefemoralandtibialprostheseswerefixedwithcementafterpulsedlavage,drying,andpressurizationofthecement.Patellarresurfacingwasconductedinsevenkneeswithpatellardeformity.Afteralltheprostheseswereimplanted,lateralretinacularreleasewasneededinfourcasesofkneesbasedontheassessmentofpatellartracking.Duringsurgery,nocaseshadsofttissueinjuriessuchasmedialorlateralcollateralligamentsorpatellartendons(Table1). PostoperativeTherapyTheoperatedkneedidnotwearanybracefromthedayofsurgery.Fromthedayaftersurgery,allpatientswereallowedfullweight-bearingandbeganactivekneemotionexercises,alongwithquadriceps-strengtheningexercisesandstandingatthebedsideorwalkingwithcrutchesorawalkerunderthesupervisionofaphysicaltherapist.Onthe14thpostoperativeday,thewoundstitcheswereremoved.Nopatienthadanyinfectionorwounddehiscenceatthispoint.Twotofourweeksaftersurgery,patientsweredischargedfromthehospital,andphysicaltherapyattheoutpatientclinicwasconductedonceaweekforthreemonthsaftersurgery.Inadditiontotheinpatientrehabilitationprogram,outpatientrehabilitationfocusedonactivitiesofdailylivingexercisessuchasbathing,hillwalking,andstairclimbing,tailoredtoeachpatient'scondition.Forpostoperativeanalgesia,NSAIDswereadministeredupto1monthpostoperativelyandacetaminophenfrom1to3monthspostoperatively.AfterdiagnosisofosteoporosisbydualenergyX-rayabsorptiometry,patientsreceivedoraladministrationof35mgalendronateonceaweekand0.75µgeldecalcitoldaily. ClinicalandRadiographicEvaluationsClinicalandradiographicevaluationswereperformedforeachpatientpreoperatively,andat3-,6-,and12-monthspostoperatively,andannuallythereafter.The2011KneeSocietyScore(KSS)[10]wasrecordedandassessed.Therangeofmotion(ROM)wasmeasuredthreetimeseachusingagoniometerinthesupinepositionbyseveralseniorphysiotherapistswith> 5yearsofclinicalexperience.Duringradiographicevaluation,thefemorotibialangle(FTA)wasmeasuredinfull-lengthviewsofthelowerextremities,inthestandingposition.ThestageofCharcotarthropathywasclassifiedaccordingtotheKoshinoclassification[11].Prosthesislooseningwasassessedbycomponentsubsidence>2mmorbyacompleteradiolucentlinearoundthecomponent[12].Allradiographicevaluationswereindependentlyanalyzedbytwoinvestigators,whohad> 10yearsofclinicalexperienceandwerenotinvolvedintheoperations.11.Koshino,T.(1991).Stageclassifications,typesofjointdestruction,andbonescintigraphyinCharcotjointdisease.BulletinoftheHospitalforJointDiseasesOrthopaedicInstitute,51(2),205–217.12.Ewald,F.C.(1989).TheKneeSocietytotalkneearthroplastyroentgenographicevaluationandscoringsystem.ClinicalOrthopaedicsandRelatedResearch,248,9–12. StatisticalAnalysisAllvalueswerenormallydistributedandwereexpressedasmean ± standarddeviation(SD).AllstatisticalanalyseswereperformedusingthestatisticalsoftwareEZR(SaitamaMedicalCenter,JichiMedicalUniversity,Saitama,Japan)[13].Pairedttestswereusedtocomparethe2011KSSandROMbetweenpreoperativeandthemostrecentdata.Forpatientswhodiedorexperiencedrevisionsurgery,thevaluesatthepre-eventvisitwereconsideredthemostrecentdata.TheKaplan–Meiermethodwasusedtocreatesurvivalcurvesforrevisionandcomplications[14].StatisticalsignificancewassetatP < 0.05. ResultsClinicalOutcomesTheaveragepre-andpostoperative2011KSSandtheirsubscales,ROMs,andmobilityarepresentedinTable2.The2011KKS,allitssubscales,andkneeflexionanglesweresignificantlyimprovedfollowingsurgery(P < 0.05)(Table2).Preoperatively,noneofthepatientscouldwalkindependentlyandonlythreepatientscouldwalkwithasinglecane;however,postoperatively,threepatientswereabletowalkindependentlyandfivepatientscouldwalkwithasinglecane(Table2).   Table2Clinicaloutcomespre-andpost-operatively  RadiographicResultsAccordingtotheKoshinoclassification,twokneeshadstageII,and10kneeshadstageIIICharcotarthropathy(Table1).Preoperatively,theFTAofeightvaruskneeswas199.8 ± 11.1°(range,186–223°)andtheFTAoffourvalguskneeswas155.1 ± 5.4°(range,148–163°);postoperatively,theFTAimprovedto176.6 ± 3.7°(range,170–183°).Nocasesshowedcomponentsubsidence> 2mmorprogressiveradiolucentlinesaroundthefemoral,tibial,orpatellarcomponents(Figs.1,2).  Fig.1Radiographsofa61-year-oldmalewithKoshinoclassificationstageIIICharcotarthropathy(No.2inTable1)preoperatively(A,B),immediatelypostoperatively(C,D),andmostrecently,14yearspostoperatively(E,F)  Fig.2Radiographsofa74-year-oldfemalewithKoshinoclassificationstageIIICharcotarthropathy(No.4.1inTable1)preoperatively(A,B),immediatelypostoperatively(C,D),andmostrecently,5yearspostoperatively(E,F)  ImplantSurvival,Revisions,andComplicationsThesurvivalratesforasepticrevision,revisionduetoinfection,andcomplicationsarepresentedinFig.3.The5-yearsurvivalrateswere100%(12/12)forasepticrevision,91.7%(11/12)forrevisionduetoinfection,and83.3%(10/12)forcomplications.The10-yearsurvivalrateswerethesame.Only2outof12patientshadcomplicationsduringfollow-upperiod.  Fig.3Kaplan–Meiercurvesofsurvivalratesforasepticrevision,revisionduetoinfection,andcomplications  Onepatientexperiencedaperiprostheticinfection4yearspostoperatively.Undergeneralanesthesia,thepolyethyleneinsertwasremoved,andthekneejointwasthoroughlydebridementandwashedwith9Lofsalinesolution.Thefemoralandtibialcomponentsshowednosepticlooseningandwerenotreplaced.Anewpolyethylenewasinsertedandthewoundwasclosed.Thedrainplacedinthekneejointwasremovedthedayaftersurgery.ThepathogenicbacteriawasE.coli,andthepatientwastreatedwithceftriaxoneintravenouslyfor6weekspostoperatively,followedbycefditorenpivoxilorallyfor6weeks.Noadditionalrevisionsurgerywasrequiredinthiscase.Theotherpatienthadcoronalplaneinstabilityduetosofttissueloosening1yearpostoperatively.Laterallooseningwassignificant,andalateralthrustwasobserved.Nolateralcollateralligamentinjurywasobservedduringsurgery,however,thesofttissuefragilitywasapparent,probablyduetoincreasedpostoperativeactivityandstress.Thepatientneededtowearahingedkneebracewhenwalking.Noneofthepatientsdevelopedpatellardislocation,periprostheticfracture,deepveinthrombosis,orpatellarcranksyndrome. DiscussionThemostimportantfindingofthisstudyisthatTKAwasgenerallyasafetreatmentoptionforCharcotarthropathyoftheknee.Clinicaloutcomesincluding2011KSSandROMweresignificantlyimprovedatthelastfollow-up,similartopreviousreports[7,8],andthemid-tolong-termsurvivalrateforasepticrevisioninthisstudywas100%.However,severalpostoperativecomplicationswereobserved.本研究最重要的发现是TKA通常是膝关节Charcot关节病的安全治疗选择。最后一次随访时，包括2011年KSS和ROM在内的临床结果均有显著改善，与既往报道相似[7,8]，本研究无菌翻修的中长期生存率为100%。然而，观察到一些术后并发症。SurvivalratesforasepticrevisionofTKAforCharcotarthropathyhavebeenreportedtobeexcellent,with100%atfiveyearsand88%attenyears[8],andourdatasupportthatresult.However,thepreviousreportshowedahighincidence(16%)ofperiprostheticinfections,whichoccurredatanaverageof3yearspostoperatively(range,1–6years)[8].Inourstudy,theincidenceofperiprostheticinfectionwasslightlylower,affecting1in12knees(8%).Charcotarthropathypatientsareoftenfrailduetotheirunderlyingdisease,andthefrailtyincreasestheincidenceofinfectionafterTKA[15].DM,themostcommondiseasecausativeofCharcotarthropathy,isalsorelatedtoahighincidenceofperiprostheticinfection[16].Inthisstudy,onecaseexperiencedpostoperativevarus/valgusinstability,whichwassimilarlyreportedinpreviousreportsandrequiredrevisionsurgeryinsomecases[6,9].However,thepatientdidnotneedrevisionsurgerybecauseofnosymptomsrelatedtotheinstabilitywithabrace.JointinstabilityisoneofthemostimportantcomplicationsinCharcotarthropathybecauseligamentouslaxityoftenoccursduetoadvancedjointdeformity.RemaininghyperextensionofthekneeafterTKAincreasestheriskofneurovascularinjuryandresidualkneepain.Insuchcases,itisimportanttochooseRHKtorestricttheextensormechanismandavoidrevisionsurgery[17,18],andthishingedprosthesiswasappliedfor2casesintheseriesofthestudy.据报道，无菌改良TKA治疗Charcot关节病的生存率非常好，5年生存率为100%，10年生存率为88%[8]，我们的数据支持这一结果。然而，先前的报道显示假体周围感染的发生率很高(16%)，平均发生在术后3年(范围1-6年)[8]。在我们的研究中，假体周围感染的发生率略低，影响12个膝关节中的1个(8%)。Charcot关节病患者往往因其基础疾病而身体虚弱，这种虚弱增加了TKA后感染的发生率[15]。DM是Charcot关节病最常见的病因，也与假体周围感染的高发有关[16]。在本研究中，1例患者出现了术后内翻/外翻不稳，这在之前的报道中也有类似的报道，在一些病例中需要进行翻修手术[6,9]。然而，由于没有与支具不稳定相关的症状，患者不需要翻修手术。关节不稳定是Charcot关节病最重要的并发症之一，因为晚期关节畸形常导致韧带松弛。全膝关节置换术后膝关节持续过伸会增加神经血管损伤和膝关节疼痛的风险。在这种情况下，选择RHK来限制伸肌机制，避免翻修手术是很重要的[17,18]，本系列研究中有2例使用了这种铰链式假体。InTKAforCharcotarthropathy,variousprostheseshavebeenused,includingcruciate-retaining(CR),posterior-stabilized(PS),LCCK,andRHK.Thechoiceofimplantsisstillamatterofdebate[19,20].Unrestrainedcomponents(e.g.,CR,PS)areofteninappropriateforCharcotarthropathy,becausetheycanleadtopostoperativejointinstabilityduetoseveredeformityandsoft-tissueimbalance[4,19].RHKshouldbeselectedcarefully,becauseexcessiverestraintcanincreasetheriskofasepticlooseningandperiprostheticfractures[18,20].Therefore,somesurgeonsconsiderthatLCCK,whichprovidesgoodstabilitywithminimalrestriction,istheoptimalprosthesisforCharcotarthropathy[7,8].Inourstudy,LCCKwasthepreferredprothesis,withRHKusedonlyinpatientspresentingwithkneehyperextension.Moreover,whenusingconstrainedcomponents,theuseoflongstemsisimportanttodistributetheincreasedstressonthebone[21,22].Inapreviousreport,16%ofCharcotarthropathypatientstreatedwithoutstemsdevelopedasepticlooseningwithin5years[4].Conversely,anotherstudyreportednocasesofasepticlooseningafterfiveyearsandonly6%after10yearsinpatientstreatedwithstems[8].Ofthepatientsincludedinourstudy,stemswereusedin92%ofcases,withnoneofthepatientsshowingasepticlooseningduringthefollow-upperiod.在Charcot关节病的TKA中，使用了各种假体，包括交叉关节保留(CR)、后稳定(PS)、LCCK和RHK。植入物的选择仍然是一个有争议的问题[19,20]。无约束假体(如CR、PS)通常不适合用于Charcot关节病，因为它们可能导致严重畸形和软组织失衡导致术后关节不稳定[4,19]。应谨慎选择RHK，因为过度约束会增加无菌性松动和假体周围骨折的风险[18,20]。因此，一些外科医生认为LCCK具有良好的稳定性和最小的限制，是治疗Charcot关节病的最佳假体[7,8]。在我们的研究中，LCCK是首选的假体，RHK仅用于出现膝关节过伸的患者。此外，当使用受限组件时，使用长柄对于分配骨上增加的应力很重要[21,22]。在先前的报道中，16%的Charcot关节病患者在5年内发生无菌性松动[4]。相反，另一项研究报告5年后没有无菌性松动病例，10年后只有6%的患者接受了茎干治疗[8]。在我们的研究中，92%的患者使用了支架，在随访期间没有患者出现无菌性松动。ManagementoflargebonedefectsinCharcotarthropathyisamajorconcern.Treatmentstrategiesforbonedefectsincludeautografts,allografts,metalaugmentation,andtantalumimplants[6,23].However,thebonestructureofCharcotarthropathyisveryweak,andevenifautologousorallogeneicboneisgraftedintothedefect,aboneunionisdifficulttoachieve[9,24].Therefore,inourcases,metalaugmentationwasusedtofillthebonedefect.Immediatelyaftersurgery,fullweightbearingwasallowed;however,nocasesresultedinlooseningorperiprostheticfractures.Charcot关节病大骨缺损的处理是一个主要问题。骨缺损的治疗策略包括自体移植物、同种异体移植物、金属隆胸和钽植入物[6,23]。然而，Charcot关节病的骨结构非常薄弱，即使将自体或异体骨移植到缺损处，也难以实现骨愈合[9,24]。因此，在我们的病例中，我们使用金属隆胸来填充骨缺损。手术后立即允许完全负重;然而，没有病例导致松动或假体周围骨折。Thisstudyhadsomelimitations.First,itwasaretrospectivecaseserieswithalimitednumberofpatients.Thislimitedtheabilitytoperformsubgroupanalysisbasedoncausativedisease,Charcotstage,orimplanttype.Toperformsubgroupanalysis,alargernumberofpatientsisneeded.Second,alongerfollow-upperiodisdesirabletoaccuratelyevaluatetheefficacyoftheTKAprocedureinCharcotarthropathy.这项研究有一些局限性。首先，这是一个回顾性病例系列，患者数量有限。这限制了基于病因、Charcot分期或植入物类型进行亚组分析的能力。为了进行亚组分析，需要更多的患者。其次，为了准确评估TKA手术治疗Charcot关节病的疗效，需要更长的随访期。Inconclusion,ourmid-tolong-termresultsofTKAforCharcotarthropathyweregenerallyfavorable.Patientsinthisstudyachieveddefiniteimprovementinkneepain,function,andmobility,andthe5-and10-yearsurvivalratesforasepticrevisionwereexcellent.Therefore,TKAmaybeaviabletreatmentoptionforCharcotarthropathywhilethecomplicationssuchasperiprostheticinfectionandinstabilityshouldbekeptinmind.总之，TKA治疗Charcot关节病的中长期结果总体上是有利的。在这项研究中，患者在膝关节疼痛、功能和活动方面得到了明确的改善，无菌翻修术的5年和10年生存率非常好。因此，TKA可能是Charcot关节病的一种可行的治疗选择，但应注意假体周围感染和不稳定等并发症。

膝关节冠状面对线CPAK分类系统_不是所有的膝关节、全膝关节置换都是一样的（2024）Notallkneesarethesame MacDessiSJ,vandeGraafVA,WoodJA,Griffiths-JonesW,BellemansJ,ChenDB.Notallkneesarethesame[J].BoneJointJ,2024,106-B(6):525-531. 转载文章的原链接1：https://pubmed-ncbi-nlm-nih-gov-443.vpnm.ccmu.edu.cn/38821506/ 转载文章的原链接2：https://boneandjoint.org.uk/Article/10.1302/0301-620X.106B6.BJJ-2023-1292.R1 AbstractTheaimofmechanicalalignmentintotalkneearthroplastyistoalignallkneesintoafixedneutralposition,eventhoughnotallkneesarethesame.Asaresult,mechanicalalignmentoftenaltersapatient’sconstitutionalalignmentandjointlineobliquity,resultinginsoft-tissueimbalance.ThisannotationprovidesanoverviewofhowtheCoronalPlaneAlignmentoftheKnee(CPAK)classificationcanbeusedtopredictimbalancewithmechanicalalignment,andthenofferspracticalguidanceforbonebalancing,minimizingtheneedforsoft-tissuereleases.全膝关节置换术中的机械对线的目的是将所有膝关节对线到一个固定的中立位置，尽管并非所有膝关节都相同。因此，机械对线通常会改变患者的固有对线和关节线倾斜度，导致软组织失衡。本文概述了如何使用“膝关节冠状面对线（CPAK）”分类来预测机械对线引起的失衡，并提供了实用的指导，以平衡骨骼，减少对软组织释放的需要。 IntroductionIrrespectiveofthealignmentstrategyusedwhenundertakingtotalkneearthroplasty(TKA),surgeonsmustcontendwiththefactthatnotallkneesarethesame.InmechanicallyalignedTKA,balancingisusuallyperformedfollowingcompletionofthebonycutsandassessmentofthelaxityofthesoft-tissues.1Thelong-standingapproachforachievingbalanced“gaps”hasbeenbyreleasingorlengtheningligamentousandcapsularstructures,therebyalteringtheirinherentphysiologicalfunction.1,2Withagreateracceptancethatligamentsdonotcontract,3andthatimbalanceresultsfromsurgicalalterationstothepatient’sconstitutionalalignment,4amorenuancedapproachwith“bonebalancing”hasbeensuggested.5Bonebalancingmodifiesthealignmentbybiasingbonyresectionstowardsamoreconstitutionalorientation,therebymaintainingtheirfunctionandreducingthenecessityforsoft-tissuereleases.BonebalancingusinganinitialmechanicalalignmentplanrepresentsoneendofthespectrumofTKAalignmentstrategies,withunrestrictedkinematicalignmentattheother.6-10Subtlechangesofalignmentupto3°fromaneutralmechanicalaxisareoftenenoughtoimproveimbalance,andstillconsideredsafeforsurgeonswhowanttomaintainalignmentwithinthismoretraditionalwindow.11,12Restoringtheknee’sconstitutionalalignmentismorelikelytoachievesoft-tissuebalancecomparedwithusingmechanicalalignmentforallpatients.13,14TheCoronalPlaneAlignmentoftheKnee(CPAK)classificationisawidelyadoptedandpragmaticsystemthatoffersaframeworktounderstandtherelationshipbetweenthenativelowerlimbalignmentandjointlineobliquity(JLO)tothesoft-tissuebalance.14CPAKdefinesninekneephenotypesbasedonconstitutionalalignmentoftheknee,incorporatingthearithmetichip-knee-ankleangle(aHKA)andthejointlineobliquity.Inthisinstructionalreview,weusetheCPAKclassificationtounderstandwhynotallkneesarethesameintermsofimbalancewhenperformingmechanicallyalignedTKA.EachCPAKtypewillbeintroducedbasedonitsprimaryradiologicalandmorphologicalcharacteristics.AlterationstoconstitutionalalignmentthatresultwhenperformingmechanicallyalignedTKAwillbepresentedforeachCPAKtype,alongwiththeanticipatedchallengeswithbalance.Formostsurgeonswhousemechanicalalignment,andforthosewhohavenowadoptedanindividualizedapproach,understandingtheseconceptsisimportantforappreciatingwhyalignmentmatters. RadiologicalassessmentPreoperativelonglegimagingthatallowsforassessmentofthemechanicalaxisisobtainedusingplainradiographswithdigitalstitching,biplanarimagingorwhole-legCTimaging.Thelateraldistalfemoralangle(LDFA)ismeasuredasthelateralanglesubtendedbythemechanicalaxisofthefemurandthearticularlinetangentialtothedistalfemoralarticularsurface.Themedialproximaltibialangle(MPTA)ismeasuredasthemedialanglesubtendedbythemechanicalaxisofthetibiaandthearticularlinetangentialtotheproximaltibialarticularsurface(Figure1).Apartfromhighlightinglossofjointspace,shortradiographsofthekneeareofnovalueintheassessmentofconstitutionalalignment,andthereforeoftheindividual’skneephenotype.15,16  Fig.1Longlegstandingradiographsshowingthemechanicalaxesofthefemurandtibia.Therightkneeshowsmeasurementofconstitutionalalignmentinanarthritickneeusingthearithmetichip-knee-ankleangle(aHKA)algorithm.Theleftnormalkneeshowsmeasurementofthethemechanicalhip-knee-ankleangle(mHKA).LDFA,lateraldistalfemoralangle;MA,mechanicalaxis;MPTA,medialproximaltibialangle.  TheconstitutionalcoronalalignmentiscalculatedusingtheequationaHKA=MPTA–LDFA,andtheconstitutionaljointlineobliquity(JLO)usingtheequationJLO=MPTA+LDFA.TheboundariesforconstitutionalalignmentofthelowerlimbusingtheaHKAarevarus<-2°,neutral-2°to+2°inclusive,andvalgus>2°.TheboundariesforconstitutionalJLOareapexdistal<177°,neutral177°to183°,andapexproximal>183°.TheCPAKtypeisthendeterminedbasedontheseboundaries(Figure2).  Fig.2TheCoronalPlaneAlignmentoftheKnee(CPAK)classificationwithboundaries.aHKA,arithmetichip-knee-ankle;JLO,jointlineobliquity.  DatafrompreviousstudiessupportthedescriptionsofeachCPAKtypediscussedhere.Alignmentcharacteristicsarederivedfromasampleof500kneesin250healthyadults,agedbetween20and27years(SupplementaryTablei);13soft-tissuelaxitydataarederivedfromasampleof137kneescomparingbalancebetweendifferentalignmentstrategies(SupplementaryTableii);17andloadsensordataarederivedfromasampleof138kneescomparingcompartmentalloadsbetweenalignmentstrategies(SupplementaryTableiii).4Inthisannotation,onlyCPAKTypesItoVIarediscussed,asmanyauthorshaveshownthatTypesVIItoIXarerareinthegeneralpopulation.14,18-23FortheLDFAandMPTA,wecharacterizeorientationas“neutral”if≤1°from90°;“mild”if>1°and≤2°from90°;“moderate”if>2°and≤4°from90°;and“significant”if>4°from90°.DescriptiveradiologicalmeasurementsandschematicphenotypictraitsarepresentedforeachCPAKtypeandforchangestoJLO.Alterationsinconstitutionalalignment,nativefemoraljointlineanatomy,lateralfemoralcolumnlength,andtheirsequelaearesummarizedinTableI.  TableI.TheimplicationsofmechanicalalignmentbasedonCoronalPlaneAlignmentoftheKneetype.CPAK,CoronalPlaneAlignmentoftheKnee;MA,mechanicalalignment;N/A,notapplicable.  CPAKTypeIThekneesin133ofthesampleofhealthyindividuals(26.6%)wereCPAKTypeI.ThisisthemostprevalentphenotypeinAsianandIndianpatientsundergoingTKA,andisthemostcommonvarusphenotypeglobally.18,19,23Thistypeischaracterizedbysignificantproximaltibialvarusandmilddistalfemoralvalgus,resultinginavarusaHKAandanapexdistalJLO.TheimplicationsformechanicalalignmentareshowninFigure3a.MehanicalalignmentwithCPAKTypeIkneesresultsinconsiderabletightnessoftheMCLduetotheshiftinaHKAfromvarustoneutral.Asthemagnitudeofchangeincreases,sodoesthelikelihoodoflateralcondylarlift-off,asignalofmajorimbalance.TheMCListightinbothextensionandflexion.Commonly,surgeonspartiallyorcompletelyreleasetheMCLinanattempttoachievebalance,butsecondaryincompetenceoftheMCLmayresultfromreleasingthiscriticalstructure.Alterationofconstitutionalvarustoneutralwillincreasethelengthoftheleg,andincreasetheneedforathickerpolyethyleneinserttocompensatefortheartificialincreaseinmedialgapheight.24AstheprimarycharacteristicofTypeIistibialvarus,avarustibialrecutwithmechanicalalignmentmayberequiredtoachievebalanceinbothextensionandflexion.  Fig.3Illustrationofsoft-tissueimbalanceinCoronalPlaneAlignmentoftheKnee(CPAK)TypesItoVI,showinghowmechanicalalignment(MA)altersconstitutionalalignmentandjointlineobliquity.a)MAwithCPAKTypeI.Theredwedgehighlightssignificanttibialvarus,andtheredarrowindicateselevationofthemedialjointline.b)MAwithCPAKTypeII.Thegreenwedgeshighlightmoderatefemoralvalgusandmoderatetibialvarus.Theredarrowindicateselevationofthemedialjointline,andtheorangearrowindicatesdistalizationofthelateralfemoralcolumn.c)MAwithCPAKTypeIII.Theredwedgeshighlightssignificantfemoralvalgus,andtheorangearrowindicatesdistalizationofthelateralfemoralcolumn.d)MAwithCPAKTypeIV.Thegreenwedgeindicatesmoderatetibialvarus.Theredarrowhighlightselevationofthemedialjointline.e)MAwithCPAKTypeV.f)MAwithCPAKTypeVI.Thegreenwedgehighlightsmoderatefemoralvalgusandtheorangearrowindicatesdistalizationofthelateralfemoralcolumn.aHKA,arithmetichip-knee-ankleangle;JLO,jointlineobliquity.  CPAKTypeIIThekneesof205ofthehealthyindividuals(41.0%)wereCPAKTypeII.Thisisthemostcommonkneephenotypeglobally.14,22Thistypeischaracterizedbymoderateproximaltibialvarusandmoderatedistalfemoralvalgus,resultinginaneutralaHKAandanapexdistalJLO.TheimplicationsformechanicalalignmentareshowninFigure3b.MechanicallyalignedTKAspecificallyaddressesCPAKTypeIIphenotypiccharacteristics.Asneutralconstitutionalalignmentismaintained,soft-tissuebalanceinextensionisusuallynotaltered.Furthermore,byapplyingexternalrotationtothefemoralcomponent,imbalanceinflexionisunlikely.The“anatomicalalignment”methodattemptedtoreplicateTypeIIbyrecreatinganapexdistalJLO,25butimprecisecuttingguidesresultedinthistechniquebeingabandoned.ThefollowingkinematicalterationsrequireconsiderationinCPAKTypeII.Thenativefemoraljointlineisraisedmediallythroughoutthearcofmotion,apotentialcauseofmid-flexioninstability.26Thelateralfemoralcolumnislengthened(distalized)inextensionandflexion.Ithasbeensuggestedthatthismayleadtoincreasedpatellofemoralretinaculartightnessinflexionbylateraldistalfemoralprostheticoverstuffing,27particularlyinkneeswithveryobliquejointlinessuchasthoseof≤170°.Theneedforsoft-tissuebalancingwithCPAKTypeIIisminimal. CPAKTypeIIIThekneesof47ofthehealthyindividuals(9.4%)wereCPAKTypeIII.Thistypeisthemostcommonvalgusphenotypeandischaracterizedbyconsiderabledistalfemoralvalgusandmildproximaltibialvarus,resultinginavalgusaHKAandapexdistalJLO.TheimplicationsformechanicalalignmentareshowninFigure3c.Imbalancewithmechanicalalignmentoccursinextensionandtoalesserextentinflexion,astheaHKAisshiftedfromvalgustoneutral.Thedegreeoflateraltightnessisdependentontwovariables:themagnitudeofaHKArelativetothechangeprescribedbymechanicalalignment;andthevariabilityinconstitutionallaxityofthelateralsiderelativetomediallaxity.Inmanyknees,increasedconstitutionallaterallaxity,whichisfurtherincreasedafterresectionofthecruciateligaments,28–30cancompensateforthisshiftinaHKAandreducetheneedforlateralbalancing.However,inourexperience,whenpatientshaveanaHKAof≥5°,soft-tissueimbalanceinevitablyresults.AstheprimarycharacteristicofCPAKTypeIIIissignificantfemoralvalgus,adistalfemoralvalgusrecutmayberequiredtoachievebalanceinextension. CPAKTypeIVThekneesof21ofthehealthyindividuals(4.2%)wereCPAKTypeIV,whichisararervarusphenotype,characterizedbymoderateproximaltibialvarusandmilddistalfemoralvarus,resultinginavarusaHKAandneutralJLO.TheimplicationsformechanicalalignmentareshowninFigure3d.AswithTypeI,therewillbeMCLtightnessinCPAKTypeIVwithmechanicallyalignedTKA.However,thistightnessismoreprominentinextensionthanflexion.14AsthemajoranatomicalcharacteristicinCPAKTypeIVistibialvarus,avarustibialrecutmayberequiredtorestorebalanceinbothextensionandflexion,althoughanadditionalvarusfemoralrecutcanbeconsidered. CPAKTypeVThekneesof77ofthehealthyindividuals(15.4%)wereCPAKTypeV,whichisthetargetinmechanicallyalignedTKA.Thistypeischaracterizedbyneutraldistalfemoralandneutralproximaltibialanatomy,resultinginaneutralaHKAandneutralJLO.TheimplicationsformechanicalalignmentareshowninFigure3e.NobalancinginterventionsareusuallynecessaryforCPAKTypeVwithmechanicalalignment.However,unlikeCPAKTypeIIknees,thetibialjointlineisnotchanged,andsurgeonsshouldevaluatewhethertheroutine3°externalrotationofthefemoralcomponentisneeded. CPAKTypeVIThekneesof16ofthehealthyindividuals(3.2%)wereCPAKTypeVI.Thistypemakesupapproximatelyone-quarterofallvalgusknees,andischaracterizedbymoderatedistalfemoralvalgusandmildproximaltibialvalgus,resultinginavalgusaHKAandneutralJLO.TheimplicationsformechanicalalignmentareshowninFigure3f.ComparedwithCPAKTypeIII,constitutionalvalgusiscontributedtobyfemoralvalgusand,toalesserextent,tibialvalgus.Thisresultsinaneutraljointlineobliquity.Soft-tissueimbalanceismostpronouncedinextension.14AsthemaincharacteristicofTypeVIisfemoralvalgus,avalgusfemoralrecutmayberequiredifthereismarkedlateraltightnessinextension.Ifthereremainssomeimbalance,orwhenfemoralrecutsarepreferablyavoided,areleaseoftheposterolateralcapsular(arcuate)complex,withorwithouttheposteriorbandoftheiliotibialband,maybeconsidered.31 DiscussionThisinstructionalannotationpresentsamethod,basedonconstitutionalalignment,forunderstandingandpredictingthesoft-tissueimbalancethatoftenresultswhenundertakingmechanicallyalignedTKA.Itprovidesclear,alignment-drivenreasoningbasedondeviationstocommonCPAKphenotypes.Imbalancesaremostprofoundinconstitutionalvarusknees,TypesIandIV.However,constitutionalvalgusknees,TypesIIIandVI,alsopresentintraoperativechallenges.Theabilitytounderstandthelikelihoodofencounteringimbalancepriorto,andduring,surgeryisempowering.Theconceptscanalsobeusedbythosewhouseagap-balancingapproachwithconventionalcuttingguides,astheystreamlinetheworkflowofbothtibial-andfemoral-basedtechniques.Mostimportantly,notallkneesarethesame,andtherewillbemuchvariationbetweenindividuals,evenwithineachCPAKtype.Thus,onepatientwithaTypeIIkneemayhaveaLDFAof88°andMPTAof88°,anothermayhaveaLDFAof84°andMPTAof83°.Treatingbothkneeswiththesamemechanicallyalignedresectionsislikelytobringaboutdifferentkinematicresults.Or,whenapatientwithaTypeIkneewithanaHKAof-3°mayonlyrequirea2°varusrecutinordertoobtainabalancedknee,another,alsowithaTypeIknee,butanaHKAof-7°,isunlikelytobebalancedwithasmallvaruscorrectionfrommechanicalalignment.Furthermore,CPAKisaclassificationsystemtodescribephenotypesandisnotgranularenoughtoprovideacomprehensivebreakdownofhowbalancingshouldbeexecutedwhenperformingmechanicallyalignedTKA.Furthermore,itisnotonlytheconstitutionalalignmentbutalsotheconstitutionallaxitythatdeterminesthebalanceofaTKA.Nativelaxitiesarehighlyvariableinboththecoronal(extensionandflexion)andsagittalplanes.32-35Thus,akneecanhaveitsconstitutionalalignmentperfectlyrestored,asinunrestrictedkinematicalignment,butstillhaveunbalancedgaps.17,36TargetingbalancedcoronalandsagittalgapsremainsamajorgoalinTKAandisthecornerstoneofthefunctionalalignmenttechnique.17,36,37However,theoptimalbalance,includingwhetherrectangularortrapezoidalconstitutionalgapsshouldbethenewtarget,remainspoorlydefined.Surgeonsmustcontinuetousetheirclinicalacumentoassesseachkneeonitsmerits,applyingtheknowledgeofoutcomesdeterminedbyphenotype,tooptimizealignmentandbalance.Conventionalcuttingguideswithmechanicalalignmenthavealsobeenreportedtohaveprecisionerrorsof>3°in30%ofcases,38withhalfofthosecasespotentiallydeviatingintomorethan3°varus(15%)andhalfintomorethan3°valgus(another15%).Forexample,ifasurgeonaimingformechanicalalignmentusingconventionalinstrumentsunintentionallyalterstheHKAofakneethathas5°ofconstitutionalvarusto≥4°ofmechanicalvalgus,thiscouldresultinaprofoundchangeinalignmentof9°,thetypeofsituationthatcouldoccurin1in6(15%)ofmechanicallyalignedTKAsundertakenusingconventionalcuttingguides.SeveretightnessoftheMCLwillresultinlateralcondylarlift-off.TheonlywaytocorrectthisimbalanceistoreleasetheMCLfromitstibialinsertion.Thiswillresultinanincreaseinbothmedialflexionandextensiongaps,thesubsequentneedforathickerpolyethyleneinsert,andaneteffectoflengtheningthelimb.24CorrectiontowardsamorevarusphenotypeispreferredtoacompletereleaseoftheMCL.Theinherentlimitationsofconventionalcuttingguidesarethattheydonotallowquantificationorvalidationoftheanglesofresectionorthefinalalignmentofthelimb.Aswegraduallyshifttowardsmorepersonalizedoperationsforourpatients,itishopedthatthisannotationwillencouragesurgeonstoconsidereachpatient’suniqueCPAKtype.This,inpart,maymaketheoutcomesofTKAmorepredictable,reducingtheneedforsoft-tissuereleaseswhileusingadjustmentsinalignmenttorestorethenativebalanceoftheknee. Takehomemessage-Inthisreview,theCoronalPlaneAlignmentoftheKnee(CPAK)classificationisusedtoenhanceourunderstandingofwhynotallkneesarethesamewhenconsideringsoft-tissueimbalanceinmechanicallyalignedtotalkneearthroplasty.-Bonebalancinginterventionsbasedonanunderstandingofeachpatient’suniqueCPAKtypecanbeusedtoavoidunnecessarysoft-tissuereleases.-Theseconceptsmaybeconsideredbysurgeonsinterestedinamoreindividualizedalignmentstrategy,insteadofafixedmechanicalalignmenttargetforallpatients.在本综述中，采用“膝关节冠状面排列（CPAK）”分类来增强我们对在机械对线全膝关节置换术中考虑软组织失衡时为何并非所有膝关节都相同的理解。基于对每位患者独特CPAK类型的理解，可以实施骨平衡干预措施，以避免不必要的软组织释放。这些概念可能对有兴趣采用更个性化对齐策略的外科医生有所帮助，而不是为所有患者设定固定的机械对线目标。

单髁置换UKA的适应症从初级阶段的UKA到现在，UKA的适应症一直在扩大，禁忌症越来越少。以前认为年龄、肥胖、髌股关节损伤等都属于UKA的禁忌症。随着科学技术的发展，UKA材料和设计不断改进，目前公认的UKA最佳适应症包括：1、前内侧骨关节炎（AMOA），股骨内侧髁或胫骨内侧平台骨坏死2、前交叉韧带ACL完好、内侧副韧带MCL功能完好3、外侧软骨正常或轻微退4、内翻畸形<15°，屈膝畸形<15°，膝关节可主动屈曲≥90°UKA的禁忌症目前对于UKA的禁忌症，多数并没有科学试验数据的直接依据，而只是绝大多数专家学者根据临床经验做出的符合一般规律的推断。主要包括：1、ACL、MCL缺失或严重损伤2、关节内畸形不能被手动矫正3、屈膝畸形>15°，麻醉下膝关节被动屈曲<100°4、外侧间室软骨缺损5、炎症性关节炎（类风湿性关节炎、化脓性关节炎、色绒炎等）

单间室膝关节置换出现于20世纪50年代，在当时处于初级阶段的UKA，因假体材料、设计、技术等客观原因的制约，UKA适应症很窄而禁忌症很广。目前临床临床上应用的UKA假体主要有活动平台（MB）和固定平台（FB）两种。1、MB-UKAMB-UKA 可使膝关节的运动更接近自然生物力学且磨损率低，但易发生垫片脱位及假体撞击等并发症。衬垫脱位与内侧副韧带碰撞目前MB-UKA的主要代表是Oxford牛津单髁假体，MB-UKA可以使膝关节的运动更近似于正常的人体膝关节，减少胫股关节面的接触应力，降低垫片的磨损。实现MB-UKA更佳生物力学表现的前提是假体的精准置入，故对术者的手术技术要求更高，学习曲线更长，且存在一定的垫片脱位发生率。2、FB-UKAFB-UKA较稳定，无脱位风险，并发症少但磨损率高。FB-UKA主要有ZUK假体和LinkSled假体，手术技术相对简单，精准度要求相对低，但由于固定平台的假体设计限制了负荷分散效能，活动时关节面的受力不能完全均匀分配，导致假体边缘负荷过重，可能会增加聚乙烯垫片下表面磨损的发生，故更适合于一些韧带松弛及活动量要求低的患肢。目前国内外文献对两者的孰优孰劣尚未形成统一标准。

很多亲爱的患者咨询我，膝关节退变，药物治疗效果不理想，已经到了关节置换的程度，但是不知道做单髁置换术（UKA）还是全膝关节置换（TKA）。其实，能回答这个问题的专业医师都很少，患者来说，不清楚怎么选择是很正常的。膝关节外伤、感染、老化等原因导致关节疼痛，正规的治疗需要进行以下几个阶梯，一般不能马上选择开刀。以下四个步骤是目前最权威的治疗方案：基础治疗，药物治疗，修复性治疗，重建治疗，分别对应不同病情阶段的关节炎患者。也就是说，症状轻中度的，都不需要置换关节，到了终末期的膝关节炎，可以选择关节镜或者关节置换的治疗方案。其中关节置换针对的是所有其他方法都不奏效的患者。那么，什么是单髁置换术呢。单髁是对应全膝置换而言的“相对微创”的手术，对于膝关节单侧症状的，且符合适应证的患者，推荐选择单髁置换术（具体适应症比较专业，患者有兴趣的可以咨询您的医生，不再赘述）。单髁置换术相对来说，可以保留更多的骨量（手术截取的骨头少），所以，中年左右的、活动量大的患者可以考虑单髁置换术。单髁置换术涉及的专业知识较多，选择合适的假体、选择固定平台还是活动平台，都是需要仔细考虑的问题。作为一种保膝的手段，单髁置换术的并发症发生率和病死率相对全膝置换低。但是需要注意的是，单髁置换术不宜扩大适应症，否则会带来灾难性的后果，不仅不能缓解患者的疼痛，反而增加了费用和翻修的风险。全膝关节置换术几乎是关节炎的最终治疗方法。对其他干预措施都无效的患者，无奈之下只能选择做全膝关节置换术。纠结于选择单髁还是全膝置换，不能建立在是不是微创的角度上片面解释，解决问题才是最重要的，各种手术都有自己的优点和局限性。绝不能搜点资料就对号入座。术式的选择，这中间的评估过程比较复杂，建议咨询关节外科的专业医师。本人热忱欢迎广大患者来咨询关于关节置换的选择问题，希望为您解答疑惑。

女性，68岁，因为关节磨损变形走路困难就诊。给予行膝关节置换，争得病人的同意，愿意作为科普给大家做示教。术后8个月走路样子术后8个月晨练术后八个月晨练。良好的适应症，熟练的手术技术，乐观积极的心态，努力的康复锻炼，造就良好的手术效果。

选择膝关节镜、膝关节置换手术的患者术前一般都是因为各种疾病造成了在关节活动时出现严重的疼痛。而为了避免疼痛的发生，只能减少关节的活动。久而久之，造成膝关节周围肌肉组织力量减弱、肌肉萎缩、周围韧带组织粘连，整个关节就像一部锈住的机器，失去了正常运动的能力。为了恢复正常的活动能力，术后正确的康复锻炼来恢复膝关节的活动度和力量是十分重要的。①股四头肌+踝泵运动练习-增加您的大腿肌肉力量。尽量伸直您的膝关节勾住脚踝，每次持续30到60秒。在30分钟内重复左右腿交叉各15次，这样的动作，然后休息30分钟，一直重复练习直到您感觉大腿肌肉很疲惫。建议每天早中晚3组，每组30次。