膝關(guān)節(jié)置換術(shù)

來源:上海六院骨科歐陽元明歡迎分享本文，轉(zhuǎn)載請保留出處！膝關(guān)節(jié)的結(jié)構(gòu)和功能是人體關(guān)節(jié)中最復(fù)雜的部分之一，也是人體下肢重要的負(fù)重關(guān)節(jié)。如果膝關(guān)節(jié)出現(xiàn)問題會讓行動出現(xiàn)不便，影響正常生活。而膝關(guān)節(jié)退行性骨關(guān)節(jié)病也是很大一部分老年人的常見骨科疾病。膝關(guān)節(jié)骨關(guān)節(jié)病的患者中女性為主要發(fā)病者。要治療較為嚴(yán)重的膝關(guān)節(jié)骨關(guān)節(jié)病，人工膝關(guān)節(jié)置換術(shù)是其中比較有效的方法。治療較為嚴(yán)重的膝關(guān)節(jié)骨關(guān)節(jié)病，人工膝關(guān)節(jié)置換術(shù)是其中比較有效的方法。膝關(guān)節(jié)置換術(shù)能夠解除膝關(guān)節(jié)疼痛，較好改善膝關(guān)節(jié)功能，還能糾正膝關(guān)節(jié)畸形和讓機(jī)體獲得長期穩(wěn)定的手術(shù)。膝關(guān)節(jié)置換術(shù)，并不是全部將膝關(guān)節(jié)進(jìn)行置換處理，應(yīng)該叫做“全膝關(guān)節(jié)表面置換術(shù)”，手術(shù)只是將患者關(guān)節(jié)表面被破壞的部分切除一層，再將同樣厚度的人工關(guān)節(jié)面裝在病變切除處的表面，盡最大力度恢復(fù)原來關(guān)節(jié)面的光滑平整。隨著醫(yī)學(xué)水平的不斷進(jìn)步，人工膝關(guān)節(jié)假體使用時間也能夠維持更久。原先的膝關(guān)節(jié)假體只能維持10年到15年的時間，而現(xiàn)在的膝關(guān)節(jié)假體比較好的能夠維持20年以上。當(dāng)然，人工關(guān)節(jié)的使用壽命與醫(yī)生的技術(shù)水平也有關(guān)系，經(jīng)驗豐富的醫(yī)生安裝的關(guān)節(jié)尺寸適中，位置準(zhǔn)確，貼合緊密，這樣的人工關(guān)節(jié)使用壽命相對于會更長一些。做完人工膝關(guān)節(jié)置換術(shù)以后應(yīng)該如何護(hù)理呢？膝關(guān)節(jié)置換手術(shù)后護(hù)理也非常重要，護(hù)理主要包括疼痛護(hù)理、嚴(yán)密觀察生命體征、引流管護(hù)理、預(yù)防下肢靜脈血栓、預(yù)防感染。1.疼痛護(hù)理：術(shù)后回病房，密切觀察病情變化，評估疼痛部位及性質(zhì)，進(jìn)行冰敷。2.嚴(yán)密觀察生命體征：術(shù)后患者去枕平臥，膝后用一軟枕將患肢墊高，密切監(jiān)測血壓、心律、氧飽和度，注意神、尿量等以便準(zhǔn)確判斷病情。3.引流管護(hù)理：妥善安置引流管，要固定好引流管，防止拉扯、扭曲、折疊，避免脫落，確保引流通暢，注意觀察引流液體的性質(zhì)、顏色及量。4.預(yù)防下肢深靜脈血栓：適當(dāng)進(jìn)行下肢活動和訓(xùn)練，防止下肢深靜脈血栓。5.預(yù)防感染：感染是膝關(guān)節(jié)鏡術(shù)后較為嚴(yán)重的并發(fā)癥，術(shù)后應(yīng)嚴(yán)密觀察患者體溫變化，根據(jù)醫(yī)囑應(yīng)用抗生素。保持切口清潔、干燥，嚴(yán)格無菌換藥。一般來說，做完手術(shù)，根據(jù)據(jù)引流量情況，大多數(shù)患者術(shù)后48小時就可以拔除引流，2周左右可以拆線，同時復(fù)建。膝關(guān)節(jié)置換術(shù)后如何進(jìn)行康復(fù)訓(xùn)練？1.踝泵運動：患者有節(jié)奏地進(jìn)行踝關(guān)節(jié)的屈、伸活動，在屈曲位和背伸位各停留5秒鐘。屈伸為1組，上下午各500組。2.股四頭肌等長收縮：患者取仰臥位，繃緊大腿前方肌肉，將膝蓋往下壓緊床面，保持5-10秒，再緩慢放松，10個/組，上下午各2組。3.直腿抬高訓(xùn)練：患者取仰臥位，患側(cè)下肢在伸膝狀態(tài)下，將大腿抬離床面20~30公分，終末端保持5秒，再恢復(fù)至起始位，10個/組，上下午各2組。4.被動屈膝90°：患者取仰臥位，康復(fù)治療師或家屬一手握住患側(cè)膝關(guān)節(jié)以維持髖關(guān)節(jié)穩(wěn)定，另一手握住踝關(guān)節(jié)，雙手同時往頭頂方向推至髖膝關(guān)節(jié)屈曲，達(dá)到屈膝90°，再恢復(fù)至起始位，10個/組，上下午各2組。5.主動抱膝90°：患者取仰臥位，將大腿抬離開床面，雙手抱住大腿，主動屈曲膝關(guān)節(jié)直至90°，再恢復(fù)至起始位，10個/組，上下午各2組。6.起身-坐-站轉(zhuǎn)移訓(xùn)練：7.床邊垂腿訓(xùn)練：患者取坐位，雙腿在床邊自然下垂，主動屈膝至最大角度后，可用健腿架在患腿上方，用力下壓至最大角度，再緩慢放松，10個/組，上下午各2組。8.重心轉(zhuǎn)移訓(xùn)練：患者取站立位，雙腳與肩同寬，逐漸將重心由健腿轉(zhuǎn)移至患腿，再將重心維持在正中，站立訓(xùn)練為5-10min/次，2-3次/天。9.提踵訓(xùn)練：患者取站立位，保持膝關(guān)節(jié)伸直，踮起腳尖直至后腳跟抬至最高點，保持5-10秒，再緩慢放松，10個/組，上下午各2組。10、扶拐步行訓(xùn)練：患者扶助行器進(jìn)行步行訓(xùn)練，使用三點步態(tài)，即先出助行器，再邁患肢，后邁健肢，扶拐步行訓(xùn)練為10-15min/次，2-3次/天。11、上廁所訓(xùn)練：術(shù)后注意事項：1、避免摔倒、劇烈跳躍、急轉(zhuǎn)急停；2、避免進(jìn)行劇烈的競技體育運動；3、避免過大負(fù)重及在負(fù)重情況下反復(fù)屈伸膝關(guān)節(jié)；4、保持體重，預(yù)防骨質(zhì)疏松；5、扶單拐時需置于健康腿側(cè)；6、術(shù)后注意預(yù)防和控制全身部位炎癥的發(fā)生，防止造成人工關(guān)節(jié)感染；7、術(shù)后功能恢復(fù)期間需要服用止痛藥4-6周，減少功能鍛煉期間關(guān)節(jié)的腫脹疼痛；8、上下樓梯訓(xùn)練：上樓梯時健康腿在前，患者跟上；下樓梯時患肢在前，健康腿跟上。9、如果有拔牙、發(fā)熱、出血或者有局部炎癥需要使用抗菌素。10、術(shù)后1個月，患者需到醫(yī)院進(jìn)行復(fù)查，并且拍片檢查患者膝關(guān)節(jié)功能恢復(fù)情況。歐陽元明（上海市第六人民醫(yī)院骨科-關(guān)節(jié)外科主任醫(yī)師，醫(yī)學(xué)博士，博士研究生導(dǎo)師）上海交通大學(xué)醫(yī)學(xué)院畢業(yè)，從事臨床工作20多年，主攻關(guān)節(jié)外科。曾在韓國首爾，德國慕尼黑，加拿大及香港進(jìn)修學(xué)習(xí)，掌握先進(jìn)關(guān)節(jié)置換手術(shù)及關(guān)節(jié)鏡技術(shù)。年均手術(shù)量1000臺左右。擅長：1、人工膝關(guān)節(jié)、髖關(guān)節(jié)置換及假體感染松動翻修手術(shù)（骨關(guān)節(jié)炎、類風(fēng)濕、痛風(fēng)性關(guān)節(jié)炎、創(chuàng)傷性關(guān)節(jié)炎、強(qiáng)直性脊柱炎、骨質(zhì)增生、骨刺、關(guān)節(jié)磨損、膝關(guān)節(jié)內(nèi)、外翻畸形、股骨頭壞死、先天性髖關(guān)節(jié)發(fā)育不良）；2、保膝，保髖、髖關(guān)節(jié)鏡手術(shù)；3、關(guān)節(jié)鏡微創(chuàng)治療膝關(guān)節(jié)積液、滑膜炎，軟骨損傷，半月板損傷、半月板撕裂、肩周炎、肩袖損傷；4、全肩、全肘關(guān)節(jié)置換；5、嚴(yán)重肘、膝、髖關(guān)節(jié)異位骨化關(guān)節(jié)僵硬松解手術(shù)。擔(dān)任職務(wù)：擔(dān)任中華醫(yī)學(xué)會手外科分會委員，中華醫(yī)學(xué)會上海分會手外科學(xué)會委員兼秘書，上海市運動醫(yī)學(xué)關(guān)節(jié)微創(chuàng)學(xué)組成員，上海市中西醫(yī)結(jié)合學(xué)會創(chuàng)傷專業(yè)青年委員，上海市科技專家?guī)煸u審專家，亞太膝關(guān)節(jié)-關(guān)節(jié)鏡-運動醫(yī)學(xué)協(xié)會（APKASS）會員，國際期刊《FrontiersinNeuroscience》編委，美國期刊《orthopedics》主要審稿人。

大多數(shù)人聽到“膝關(guān)節(jié)置換”，腦海里浮現(xiàn)出的場景是“把膝關(guān)節(jié)鋸掉，換上一個人工的關(guān)節(jié)”。其實膝關(guān)節(jié)置換，全名叫膝關(guān)節(jié)表面置換。在我們膝關(guān)節(jié)的表面上有軟骨，隨著年齡增大，磨損增多，慢慢的軟骨就磨掉了。磨掉了以后就會出現(xiàn)膝關(guān)節(jié)疼痛，尤其是行走負(fù)重和上下樓梯，爬山時疼痛會加重，休息后會好轉(zhuǎn)，嚴(yán)重的可引起膝關(guān)節(jié)內(nèi)外翻，就是“O”型腿和“X”型腿。膝關(guān)節(jié)置換就是針對這種軟骨損傷嚴(yán)重，影響生活的人群。膝關(guān)節(jié)置換術(shù)是通過手術(shù)切除已經(jīng)磨損破壞的關(guān)節(jié)面，使用人工生物材料（膝關(guān)節(jié)假體）來置換病變的的膝關(guān)節(jié)軟骨，達(dá)到消除膝關(guān)節(jié)疼痛、矯正膝關(guān)節(jié)畸形、恢復(fù)下肢力線、重建膝關(guān)節(jié)功能的目的。01膝關(guān)節(jié)置換術(shù)適應(yīng)癥膝關(guān)節(jié)置換術(shù)的適應(yīng)癥主要為終末期膝骨關(guān)節(jié)炎、類風(fēng)濕性關(guān)節(jié)炎、創(chuàng)傷性關(guān)節(jié)炎、強(qiáng)直性脊柱炎膝關(guān)節(jié)受累等。對于早期膝骨關(guān)節(jié)炎、類風(fēng)濕性關(guān)節(jié)炎等，可采取減輕體重、佩戴護(hù)具、藥物治療、理療、中西醫(yī)結(jié)合治療等方法，可有效改善關(guān)節(jié)癥狀，并減緩病情進(jìn)展。然而，當(dāng)出現(xiàn)關(guān)節(jié)間隙變窄或消失、關(guān)節(jié)畸形明顯時，則保守治療效果有限。此時，可選擇膝關(guān)節(jié)置換手術(shù)，重建膝關(guān)節(jié)的功能，術(shù)后可早期功能鍛煉，改善生活質(zhì)量。02膝關(guān)節(jié)置換術(shù)的類型單髁關(guān)節(jié)置換術(shù):單髁置換術(shù)主要針對單側(cè)骨關(guān)節(jié)病，單髁置換手術(shù)是用人工關(guān)節(jié)墊片和軟骨替代磨損的部位，屬于保膝手術(shù)，適合單一間室出現(xiàn)磨損的患者，不會損傷前、后交叉韌帶，可保持關(guān)節(jié)穩(wěn)定性和本體感覺，相對會比較好，康復(fù)周期也會短。全膝關(guān)節(jié)置換術(shù)：全膝置換手術(shù)會破壞整個關(guān)節(jié)面，包括韌帶，適合全關(guān)節(jié)嚴(yán)重退化后需要建立表面置換的患者。03膝關(guān)節(jié)置換術(shù)操作步驟1、備體位，消毒2、切開暴露關(guān)節(jié)，軟組織處理3、股骨遠(yuǎn)端截骨4、股骨前后髁和斜面截骨（四合一截骨）5、脛骨近端截骨6、假體試模7、截骨面放置骨水泥并安裝假體8、沖洗，逐層縫合，關(guān)閉切口——關(guān)注我們——

全膝關(guān)節(jié)置換治療膝關(guān)節(jié)夏科氏關(guān)節(jié)病的中長期療效（2024）Mid-toLong-TermResultsofTotalKneeArthroplastyforCharcotArthropathyoftheKnee?OnoiY,MatsumotoT,NakanoN,TsubosakaM,KamenagaT,KurodaY,IshidaK,HayashiS,KurodaR.Mid-toLong-TermResultsofTotalKneeArthroplastyforCharcotArthropathyof?theKnee[J].IndianJOrthop,2024,58(3):308-315.?轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/38425826/?轉(zhuǎn)載文章的原鏈接2：https://link.springer.com/article/10.1007/s43465-023-01094-z?AbstractBackground:Totalkneearthroplasty(TKA)forCharcotarthropathyofthekneeisconsideredcontroversialbecauseofitshighercomplicationratecomparedwiththatofTKAforosteoarthritis.Inthisstudy,weinvestigatedtheclinicaloutcomes,survivalrates,andcomplicationsofprimaryTKAforCharcotarthropathy.全膝關(guān)節(jié)置換術(shù)(TKA)治療膝關(guān)節(jié)Charcot關(guān)節(jié)病被認(rèn)為是有爭議的，因為與骨關(guān)節(jié)炎的TKA相比，其并發(fā)癥發(fā)生率更高。在這項研究中，我們調(diào)查了初次TKA治療Charcot關(guān)節(jié)病的臨床結(jié)果、生存率和并發(fā)癥。?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).我們對9例Charcot關(guān)節(jié)病患者(12個膝關(guān)節(jié))進(jìn)行了全膝關(guān)節(jié)置換術(shù)的回顧性分析?；颊咂骄挲g為63.9±9.4歲(52~83歲)。最常見的病因是糖尿病(3例)?；颊叩呐R床結(jié)果，包括2011年膝關(guān)節(jié)社會評分和活動范圍，在術(shù)前和術(shù)后的最新數(shù)據(jù)之間進(jìn)行比較。檢查無菌翻修、感染翻修和并發(fā)癥翻修的5年和10年生存率。平均隨訪時間7.3±3.9年(范圍3~14年)。?Results:The2011KneeSocietyScoreandthekneeflexionanglesignificantlyimprovedafterTKAsurgery(P<0.05).The5-yearsurvivalratesforasepticrevision,revisionduetoinfection,andcomplicationswere100%,91.7%,and83.3%,respectively;the10-yearsurvivalratesfortheseparameterswerethesame.Onepatientunderwentrevisionforinsertreplacementduetoperiprostheticinfection,andtheotherpatienthadvarus/valgusinstabilityduetosofttissueloosening.TKA術(shù)后膝關(guān)節(jié)社會評分和膝關(guān)節(jié)屈曲角度均顯著提高(P<0.05)。無菌翻修、感染翻修和并發(fā)癥翻修的5年生存率分別為100%、91.7%和83.3%;這些參數(shù)的10年生存率是相同的。一名患者因假體周圍感染接受假體置換翻修，另一名患者因軟組織松動出現(xiàn)內(nèi)翻/外翻不穩(wěn)定。?Conclusions:Themid-tolong-termresultsofTKAforCharcotarthropathyweregenerallyfavorable.OurfindingsindicatethatTKAmaybeaviabletreatmentoptionforCharcotarthropathy.TKA治療Charcot關(guān)節(jié)病的中長期結(jié)果通常是有利的。我們的研究結(jié)果表明TKA可能是治療Charcot關(guān)節(jié)病的可行選擇。?Keywords:Charcotarthropathy;Constrainedcondylarprosthesis;Neuropathicarthropathy;Rotatinghingeprosthesis;Survivalrates;Totalkneearthroplasty.?IntroductionCharcotarthropathyisadegenerativeneuropathicarthropathythatleadstoseverejointdestructionandinstability,causedbyrepetitiveasymptomaticmicrotraumaduetodecreasedorabsentjointnociception[1].Theglobalincreaseintheincidenceofdiabetesmellitus(DM),themaincausativediseaseofCharcotarthropathy,isexpectedtoleadtoahigherprevalenceofCharcotarthropathy[2,3].BecauseofthenatureofCharcotarthropathy,patientsrarelycomplainofpainduringtheearlydeformitystagesandtypicallyseektreatmentonlyafterseveredeformity,instability,andgaitdisturbancehaveoccurred[4].ThismakesCharcotarthropathyoneofthemostdifficultconditionsfororthopaedicsurgeonstotreat.Charcot關(guān)節(jié)病是一種退行性神經(jīng)性關(guān)節(jié)病，可導(dǎo)致嚴(yán)重的關(guān)節(jié)破壞和不穩(wěn)定，由關(guān)節(jié)痛覺減少或缺失引起的重復(fù)性無癥狀微創(chuàng)傷引起[1]。糖尿病(DM)是Charcot關(guān)節(jié)病的主要致病疾病，隨著全球糖尿病發(fā)病率的增加，預(yù)計將導(dǎo)致Charcot關(guān)節(jié)病的患病率升高[2,3]。由于Charcot關(guān)節(jié)病的性質(zhì)，患者在早期畸形階段很少主訴疼痛，通常只有在發(fā)生嚴(yán)重畸形、不穩(wěn)定和步態(tài)障礙后才尋求治療[4]。這使得Charcot關(guān)節(jié)病成為骨科醫(yī)生最難治療的疾病之一。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.盡管全膝關(guān)節(jié)置換術(shù)(TKA)治療Charcot關(guān)節(jié)病之前不被推薦，因為其并發(fā)癥發(fā)生率高，如假體周圍感染、骨折和脫位[5,6]，但最近的幾項研究表明，TKA的短期臨床效果良好[2,7]。然而，關(guān)于TKA治療Charcot關(guān)節(jié)病的中長期結(jié)果的文獻(xiàn)有限[8,9]，TKA的生存率、潛在并發(fā)癥和臨床結(jié)果等重要問題仍未解決。這種信息的缺乏可能會妨礙對Charcot關(guān)節(jié)病的適當(dāng)治療。因此，我們的目的是報道原發(fā)性全膝關(guān)節(jié)置換術(shù)治療Charcot關(guān)節(jié)病患者的中長期結(jié)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??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.本研究最重要的發(fā)現(xiàn)是TKA通常是膝關(guān)節(jié)Charcot關(guān)節(jié)病的安全治療選擇。最后一次隨訪時，包括2011年KSS和ROM在內(nèi)的臨床結(jié)果均有顯著改善，與既往報道相似[7,8]，本研究無菌翻修的中長期生存率為100%。然而，觀察到一些術(shù)后并發(fā)癥。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.據(jù)報道，無菌改良TKA治療Charcot關(guān)節(jié)病的生存率非常好，5年生存率為100%，10年生存率為88%[8]，我們的數(shù)據(jù)支持這一結(jié)果。然而，先前的報道顯示假體周圍感染的發(fā)生率很高(16%)，平均發(fā)生在術(shù)后3年(范圍1-6年)[8]。在我們的研究中，假體周圍感染的發(fā)生率略低，影響12個膝關(guān)節(jié)中的1個(8%)。Charcot關(guān)節(jié)病患者往往因其基礎(chǔ)疾病而身體虛弱，這種虛弱增加了TKA后感染的發(fā)生率[15]。DM是Charcot關(guān)節(jié)病最常見的病因，也與假體周圍感染的高發(fā)有關(guān)[16]。在本研究中，1例患者出現(xiàn)了術(shù)后內(nèi)翻/外翻不穩(wěn)，這在之前的報道中也有類似的報道，在一些病例中需要進(jìn)行翻修手術(shù)[6,9]。然而，由于沒有與支具不穩(wěn)定相關(guān)的癥狀，患者不需要翻修手術(shù)。關(guān)節(jié)不穩(wěn)定是Charcot關(guān)節(jié)病最重要的并發(fā)癥之一，因為晚期關(guān)節(jié)畸形常導(dǎo)致韌帶松弛。全膝關(guān)節(jié)置換術(shù)后膝關(guān)節(jié)持續(xù)過伸會增加神經(jīng)血管損傷和膝關(guān)節(jié)疼痛的風(fēng)險。在這種情況下，選擇RHK來限制伸肌機(jī)制，避免翻修手術(shù)是很重要的[17,18]，本系列研究中有2例使用了這種鉸鏈?zhǔn)郊袤w。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關(guān)節(jié)病的TKA中，使用了各種假體，包括交叉關(guān)節(jié)保留(CR)、后穩(wěn)定(PS)、LCCK和RHK。植入物的選擇仍然是一個有爭議的問題[19,20]。無約束假體(如CR、PS)通常不適合用于Charcot關(guān)節(jié)病，因為它們可能導(dǎo)致嚴(yán)重畸形和軟組織失衡導(dǎo)致術(shù)后關(guān)節(jié)不穩(wěn)定[4,19]。應(yīng)謹(jǐn)慎選擇RHK，因為過度約束會增加無菌性松動和假體周圍骨折的風(fēng)險[18,20]。因此，一些外科醫(yī)生認(rèn)為LCCK具有良好的穩(wěn)定性和最小的限制，是治療Charcot關(guān)節(jié)病的最佳假體[7,8]。在我們的研究中，LCCK是首選的假體，RHK僅用于出現(xiàn)膝關(guān)節(jié)過伸的患者。此外，當(dāng)使用受限組件時，使用長柄對于分配骨上增加的應(yīng)力很重要[21,22]。在先前的報道中，16%的Charcot關(guān)節(jié)病患者在5年內(nèi)發(fā)生無菌性松動[4]。相反，另一項研究報告5年后沒有無菌性松動病例，10年后只有6%的患者接受了莖干治療[8]。在我們的研究中，92%的患者使用了支架，在隨訪期間沒有患者出現(xiàn)無菌性松動。ManagementoflargebonedefectsinCharcotarthropathyisamajorconcern.Treatmentstrategiesforbonedefectsincludeautografts,allografts,metalaugmentation,andtantalumimplants[6,23].However,thebonestructureofCharcotarthropathyisveryweak,andevenifautologousorallogeneicboneisgraftedintothedefect,aboneunionisdifficulttoachieve[9,24].Therefore,inourcases,metalaugmentationwasusedtofillthebonedefect.Immediatelyaftersurgery,fullweightbearingwasallowed;however,nocasesresultedinlooseningorperiprostheticfractures.Charcot關(guān)節(jié)病大骨缺損的處理是一個主要問題。骨缺損的治療策略包括自體移植物、同種異體移植物、金屬隆胸和鉭植入物[6,23]。然而，Charcot關(guān)節(jié)病的骨結(jié)構(gòu)非常薄弱，即使將自體或異體骨移植到缺損處，也難以實現(xiàn)骨愈合[9,24]。因此，在我們的病例中，我們使用金屬隆胸來填充骨缺損。手術(shù)后立即允許完全負(fù)重;然而，沒有病例導(dǎo)致松動或假體周圍骨折。Thisstudyhadsomelimitations.First,itwasaretrospectivecaseserieswithalimitednumberofpatients.Thislimitedtheabilitytoperformsubgroupanalysisbasedoncausativedisease,Charcotstage,orimplanttype.Toperformsubgroupanalysis,alargernumberofpatientsisneeded.Second,alongerfollow-upperiodisdesirabletoaccuratelyevaluatetheefficacyoftheTKAprocedureinCharcotarthropathy.這項研究有一些局限性。首先，這是一個回顧性病例系列，患者數(shù)量有限。這限制了基于病因、Charcot分期或植入物類型進(jìn)行亞組分析的能力。為了進(jìn)行亞組分析，需要更多的患者。其次，為了準(zhǔn)確評估TKA手術(shù)治療Charcot關(guān)節(jié)病的療效，需要更長的隨訪期。Inconclusion,ourmid-tolong-termresultsofTKAforCharcotarthropathyweregenerallyfavorable.Patientsinthisstudyachieveddefiniteimprovementinkneepain,function,andmobility,andthe5-and10-yearsurvivalratesforasepticrevisionwereexcellent.Therefore,TKAmaybeaviabletreatmentoptionforCharcotarthropathywhilethecomplicationssuchasperiprostheticinfectionandinstabilityshouldbekeptinmind.總之，TKA治療Charcot關(guān)節(jié)病的中長期結(jié)果總體上是有利的。在這項研究中，患者在膝關(guān)節(jié)疼痛、功能和活動方面得到了明確的改善，無菌翻修術(shù)的5年和10年生存率非常好。因此，TKA可能是Charcot關(guān)節(jié)病的一種可行的治療選擇，但應(yīng)注意假體周圍感染和不穩(wěn)定等并發(fā)癥。

膝關(guān)節(jié)冠狀面對線CPAK分類系統(tǒng)_不是所有的膝關(guān)節(jié)、全膝關(guān)節(jié)置換都是一樣的（2024）Notallkneesarethesame?MacDessiSJ,vandeGraafVA,WoodJA,Griffiths-JonesW,BellemansJ,ChenDB.Notallkneesarethesame[J].BoneJointJ,2024,106-B(6):525-531.?轉(zhuǎn)載文章的原鏈接1：https://pubmed-ncbi-nlm-nih-gov-443.vpnm.ccmu.edu.cn/38821506/?轉(zhuǎn)載文章的原鏈接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.全膝關(guān)節(jié)置換術(shù)中的機(jī)械對線的目的是將所有膝關(guān)節(jié)對線到一個固定的中立位置，盡管并非所有膝關(guān)節(jié)都相同。因此，機(jī)械對線通常會改變患者的固有對線和關(guān)節(jié)線傾斜度，導(dǎo)致軟組織失衡。本文概述了如何使用“膝關(guān)節(jié)冠狀面對線（CPAK）”分類來預(yù)測機(jī)械對線引起的失衡，并提供了實用的指導(dǎo)，以平衡骨骼，減少對軟組織釋放的需要。?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.在本綜述中，采用“膝關(guān)節(jié)冠狀面排列（CPAK）”分類來增強(qiáng)我們對在機(jī)械對線全膝關(guān)節(jié)置換術(shù)中考慮軟組織失衡時為何并非所有膝關(guān)節(jié)都相同的理解?；趯γ课换颊擢毺谻PAK類型的理解，可以實施骨平衡干預(yù)措施，以避免不必要的軟組織釋放。這些概念可能對有興趣采用更個性化對齊策略的外科醫(yī)生有所幫助，而不是為所有患者設(shè)定固定的機(jī)械對線目標(biāo)。

單髁置換UKA的適應(yīng)癥從初級階段的UKA到現(xiàn)在，UKA的適應(yīng)癥一直在擴(kuò)大，禁忌癥越來越少。以前認(rèn)為年齡、肥胖、髕股關(guān)節(jié)損傷等都屬于UKA的禁忌癥。隨著科學(xué)技術(shù)的發(fā)展，UKA材料和設(shè)計不斷改進(jìn)，目前公認(rèn)的UKA最佳適應(yīng)癥包括：1、前內(nèi)側(cè)骨關(guān)節(jié)炎（AMOA），股骨內(nèi)側(cè)髁或脛骨內(nèi)側(cè)平臺骨壞死2、前交叉韌帶ACL完好、內(nèi)側(cè)副韌帶MCL功能完好3、外側(cè)軟骨正?；蜉p微退4、內(nèi)翻畸形<15°，屈膝畸形<15°，膝關(guān)節(jié)可主動屈曲≥90°UKA的禁忌癥目前對于UKA的禁忌癥，多數(shù)并沒有科學(xué)試驗數(shù)據(jù)的直接依據(jù)，而只是絕大多數(shù)專家學(xué)者根據(jù)臨床經(jīng)驗做出的符合一般規(guī)律的推斷。主要包括：1、ACL、MCL缺失或嚴(yán)重?fù)p傷2、關(guān)節(jié)內(nèi)畸形不能被手動矯正3、屈膝畸形>15°，麻醉下膝關(guān)節(jié)被動屈曲<100°4、外側(cè)間室軟骨缺損5、炎癥性關(guān)節(jié)炎（類風(fēng)濕性關(guān)節(jié)炎、化膿性關(guān)節(jié)炎、色絨炎等）

單間室膝關(guān)節(jié)置換出現(xiàn)于20世紀(jì)50年代，在當(dāng)時處于初級階段的UKA，因假體材料、設(shè)計、技術(shù)等客觀原因的制約，UKA適應(yīng)癥很窄而禁忌癥很廣。目前臨床臨床上應(yīng)用的UKA假體主要有活動平臺（MB）和固定平臺（FB）兩種。1、MB-UKAMB-UKA?可使膝關(guān)節(jié)的運動更接近自然生物力學(xué)且磨損率低，但易發(fā)生墊片脫位及假體撞擊等并發(fā)癥。襯墊脫位與內(nèi)側(cè)副韌帶碰撞目前MB-UKA的主要代表是Oxford牛津單髁假體，MB-UKA可以使膝關(guān)節(jié)的運動更近似于正常的人體膝關(guān)節(jié)，減少脛股關(guān)節(jié)面的接觸應(yīng)力，降低墊片的磨損。實現(xiàn)MB-UKA更佳生物力學(xué)表現(xiàn)的前提是假體的精準(zhǔn)置入，故對術(shù)者的手術(shù)技術(shù)要求更高，學(xué)習(xí)曲線更長，且存在一定的墊片脫位發(fā)生率。2、FB-UKAFB-UKA較穩(wěn)定，無脫位風(fēng)險，并發(fā)癥少但磨損率高。FB-UKA主要有ZUK假體和LinkSled假體，手術(shù)技術(shù)相對簡單，精準(zhǔn)度要求相對低，但由于固定平臺的假體設(shè)計限制了負(fù)荷分散效能，活動時關(guān)節(jié)面的受力不能完全均勻分配，導(dǎo)致假體邊緣負(fù)荷過重，可能會增加聚乙烯墊片下表面磨損的發(fā)生，故更適合于一些韌帶松弛及活動量要求低的患肢。目前國內(nèi)外文獻(xiàn)對兩者的孰優(yōu)孰劣尚未形成統(tǒng)一標(biāo)準(zhǔn)。

很多親愛的患者咨詢我，膝關(guān)節(jié)退變，藥物治療效果不理想，已經(jīng)到了關(guān)節(jié)置換的程度，但是不知道做單髁置換術(shù)（UKA）還是全膝關(guān)節(jié)置換（TKA）。其實，能回答這個問題的專業(yè)醫(yī)師都很少，患者來說，不清楚怎么選擇是很正常的。膝關(guān)節(jié)外傷、感染、老化等原因?qū)е玛P(guān)節(jié)疼痛，正規(guī)的治療需要進(jìn)行以下幾個階梯，一般不能馬上選擇開刀。以下四個步驟是目前最權(quán)威的治療方案：基礎(chǔ)治療，藥物治療，修復(fù)性治療，重建治療，分別對應(yīng)不同病情階段的關(guān)節(jié)炎患者。也就是說，癥狀輕中度的，都不需要置換關(guān)節(jié)，到了終末期的膝關(guān)節(jié)炎，可以選擇關(guān)節(jié)鏡或者關(guān)節(jié)置換的治療方案。其中關(guān)節(jié)置換針對的是所有其他方法都不奏效的患者。那么，什么是單髁置換術(shù)呢。單髁是對應(yīng)全膝置換而言的“相對微創(chuàng)”的手術(shù)，對于膝關(guān)節(jié)單側(cè)癥狀的，且符合適應(yīng)證的患者，推薦選擇單髁置換術(shù)（具體適應(yīng)癥比較專業(yè)，患者有興趣的可以咨詢您的醫(yī)生，不再贅述）。單髁置換術(shù)相對來說，可以保留更多的骨量（手術(shù)截取的骨頭少），所以，中年左右的、活動量大的患者可以考慮單髁置換術(shù)。單髁置換術(shù)涉及的專業(yè)知識較多，選擇合適的假體、選擇固定平臺還是活動平臺，都是需要仔細(xì)考慮的問題。作為一種保膝的手段，單髁置換術(shù)的并發(fā)癥發(fā)生率和病死率相對全膝置換低。但是需要注意的是，單髁置換術(shù)不宜擴(kuò)大適應(yīng)癥，否則會帶來災(zāi)難性的后果，不僅不能緩解患者的疼痛，反而增加了費用和翻修的風(fēng)險。全膝關(guān)節(jié)置換術(shù)幾乎是關(guān)節(jié)炎的最終治療方法。對其他干預(yù)措施都無效的患者，無奈之下只能選擇做全膝關(guān)節(jié)置換術(shù)。糾結(jié)于選擇單髁還是全膝置換，不能建立在是不是微創(chuàng)的角度上片面解釋，解決問題才是最重要的，各種手術(shù)都有自己的優(yōu)點和局限性。絕不能搜點資料就對號入座。術(shù)式的選擇，這中間的評估過程比較復(fù)雜，建議咨詢關(guān)節(jié)外科的專業(yè)醫(yī)師。本人熱忱歡迎廣大患者來咨詢關(guān)于關(guān)節(jié)置換的選擇問題，希望為您解答疑惑。

女性，68歲，因為關(guān)節(jié)磨損變形走路困難就診。給予行膝關(guān)節(jié)置換，爭得病人的同意，愿意作為科普給大家做示教。術(shù)后8個月走路樣子術(shù)后8個月晨練術(shù)后八個月晨練。良好的適應(yīng)癥，熟練的手術(shù)技術(shù)，樂觀積極的心態(tài)，努力的康復(fù)鍛煉，造就良好的手術(shù)效果。

選擇膝關(guān)節(jié)鏡、膝關(guān)節(jié)置換手術(shù)的患者術(shù)前一般都是因為各種疾病造成了在關(guān)節(jié)活動時出現(xiàn)嚴(yán)重的疼痛。而為了避免疼痛的發(fā)生，只能減少關(guān)節(jié)的活動。久而久之，造成膝關(guān)節(jié)周圍肌肉組織力量減弱、肌肉萎縮、周圍韌帶組織粘連，整個關(guān)節(jié)就像一部銹住的機(jī)器，失去了正常運動的能力。為了恢復(fù)正常的活動能力，術(shù)后正確的康復(fù)鍛煉來恢復(fù)膝關(guān)節(jié)的活動度和力量是十分重要的。①股四頭肌+踝泵運動練習(xí)-增加您的大腿肌肉力量。盡量伸直您的膝關(guān)節(jié)勾住腳踝，每次持續(xù)30到60秒。在30分鐘內(nèi)重復(fù)左右腿交叉各15次，這樣的動作，然后休息30分鐘，一直重復(fù)練習(xí)直到您感覺大腿肌肉很疲憊。建議每天早中晚3組，每組30次。