膝關(guān)節(jié)置換術(shù)

微創(chuàng)切口單髁膝關(guān)節(jié)置換術(shù)（UKA）作為膝關(guān)節(jié)置換手術(shù)的一類特殊形式，越來越多的被應(yīng)用在膝關(guān)節(jié)退行性變的晚期功能重建。UKA具有創(chuàng)傷小、并發(fā)癥少，術(shù)后關(guān)節(jié)功能恢復(fù)快等優(yōu)點，同時通過保留交叉韌帶，不改變關(guān)節(jié)的穩(wěn)定性，保留了患者的本體感覺。因此，患者術(shù)后膝關(guān)節(jié)運動很接近正常膝關(guān)節(jié)運動學(xué)。此點區(qū)別于切除了交叉韌帶的全膝關(guān)節(jié)置換，是一種保膝手術(shù)，因此患者術(shù)后恢復(fù)要比傳統(tǒng)的膝關(guān)節(jié)置換手術(shù)快得多。在臨床工作中發(fā)現(xiàn)很多患者在做完UKA手術(shù)后疼痛緩解的很快，下地走路也很好，但不太敢進(jìn)行進(jìn)一步的功能鍛煉。因此在本文中，我將闡述單髁手術(shù)后患者進(jìn)行功能鍛煉的方法。術(shù)后當(dāng)天：術(shù)后當(dāng)天患者從麻醉反應(yīng)中逐漸恢復(fù)，此時膝關(guān)節(jié)已經(jīng)可以進(jìn)行自主的輕度的屈伸活動，此時我們并不要求馬上下地，而是以舒適的姿勢進(jìn)行少量的屈伸活動，同時建議患者將患側(cè)的膝關(guān)節(jié)輕度抬高，適度彎曲以減輕腫脹。此時由于有術(shù)中鎮(zhèn)痛藥物的應(yīng)用，多數(shù)患者不會感覺疼痛，所以可以正常進(jìn)流質(zhì)飲食，飲水并在家人攙扶下下地去洗手間等活動，均不受影響。切勿保持一個固定姿勢而不敢活動，這樣會造成膝關(guān)節(jié)僵硬不適。術(shù)后第1天：第一天早晨在早餐后，醫(yī)生會打開手術(shù)敷貼對創(chuàng)口進(jìn)行換藥處置，同時會繼續(xù)使用繃帶將膝關(guān)節(jié)進(jìn)行適當(dāng)加壓包扎以減少滲出。在第一天上午建議患者使用助行器進(jìn)行適當(dāng)行走，時間為10-20分鐘為宜，此時并不需要膝關(guān)節(jié)過度彎曲，坐在床邊將膝關(guān)節(jié)自然下垂即可，此時我們依然以最舒適的姿勢活動，切勿行走過多而導(dǎo)致腫脹。術(shù)后第2-4天：此時患者膝關(guān)節(jié)的活動量可以適當(dāng)加大，包括屈膝已經(jīng)可以很輕松的達(dá)到90度，下地行走的穩(wěn)定感更好，創(chuàng)面一般不需要再加壓包扎，如愈合良好，沒有明顯的滲出與腫脹，則已經(jīng)可以出院回家了。此時的功能鍛煉應(yīng)該逐漸加量，每天可以行走半小時-1小時左右，出院后需要定期換藥，如果有腫脹發(fā)生，是正常的現(xiàn)象，需要每天冰敷2-3次，以及踝泵運動，非常有利于消腫。術(shù)后1周：此時多數(shù)患者還有有輕度的疼痛感，主要與局部愈合過程中產(chǎn)生的反應(yīng)有關(guān)，建議口服的鎮(zhèn)痛藥，如西樂葆，安康信等可以每天口服，對鎮(zhèn)痛效果好，同時注重腿部力量練習(xí)，如直抬腿，走樓梯等都非常適合。鎮(zhèn)痛藥物的服用根據(jù)不同人的疼痛反應(yīng)，一般可以持續(xù)到術(shù)后1個月左右。術(shù)后2周：此時，創(chuàng)面正常可以拆線了，拆線后預(yù)示著我們的活動量需要進(jìn)一步加大，應(yīng)當(dāng)達(dá)到正?；顒恿康?0%-60%，尤其應(yīng)當(dāng)注重股四頭肌力量的練習(xí)，每天堅持進(jìn)行直抬腿運動，每天可以行走半小時以上。術(shù)后2周-2個月：在這個階段，患者應(yīng)當(dāng)大膽的嘗試下蹲和盤腿等動作。尤其坐便更加不受任何影響，這個期間膝關(guān)節(jié)的活動量應(yīng)當(dāng)達(dá)到正常的70%-80%，尤其要調(diào)整好心態(tài)，輕度的疼痛不必過度擔(dān)心，正常的加大鍛煉量，只有關(guān)節(jié)活動開了，以后才能真正不疼。并且可以嘗試脫離助歩器行走。術(shù)后2個月-半年：此時，需要第一次復(fù)查我們的膝關(guān)節(jié)，建議到門診進(jìn)行X光片的拍攝和肢體功能的檢查。同時我會再次對今后的生活與活動進(jìn)行一定的專業(yè)指導(dǎo)。最后還要強調(diào)，手術(shù)后不要忘記補鈣，服用改善骨質(zhì)疏松的藥物與食物。請您記住，好的關(guān)節(jié)需要好的骨骼來支撐，這樣才能用的更長久。

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——

功能對線、運動對線、力學(xué)對線等對線技術(shù)的核心理念_MAKO機械臂系統(tǒng)在全膝關(guān)節(jié)置換術(shù)中具有功能對線的間隙平衡新技術(shù)的初步研究（2024）AnewgapbalancingtechniquewithfunctionalalignmentintotalkneearthroplastyusingtheMAKOroboticarmsystem:apreliminarystudy?TsaiHK,BaoZ,WuD,HanJ,JiangQ,XuZ.AnewgapbalancingtechniquewithfunctionalalignmentintotalkneearthroplastyusingtheMAKOroboticarmsystem:apreliminarystudy[J].BMCSurg,2024,24(1):232.?轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/39143535/轉(zhuǎn)載文章的原鏈接2：https://bmcsurg.biomedcentral.com/articles/10.1186/s12893-024-02524-x?AbstractBackgroundGaptensionisanimportantfactorinfluencingtheclinicaloutcomesoftotalkneearthroplasty(TKA).Traditionalmechanicalalignment(MA)placesimportanceonneutralalignmentandoftenrequiresadditionalsofttissuereleases,whichmayberelatedtopatientdissatisfaction.Conversely,thefunctionalalignmentrequireslesssofttissuereleasetoachievegapbalance.Conventionalgaptensioninstrumentspresentseveralshortcomingsinpractice.TheaimofthisstudyistointroduceanewgapbalancingtechniquewithFAusingthemodifiedspacer-basedgaptoolandtheMAKOroboticarmsystem.間隙張力是影響全膝關(guān)節(jié)置換術(shù)(TKA)臨床療效的重要因素。傳統(tǒng)的機械對線(MA)重視中性對線，通常需要額外的軟組織松解，這可能與患者的不滿意有關(guān)。相反，功能性對線需要較少的軟組織松解來達(dá)到間隙平衡。傳統(tǒng)的間隙張力儀在實際應(yīng)用中存在一些不足。本研究的目的是引入一種新的間隙平衡技術(shù)，該技術(shù)使用改進(jìn)的基于間隔器的間隙工具和MAKO機械臂系統(tǒng)。?MethodsAtotalof22consecutivepatientsunderwentprimaryTKAusingtheMAKOroboticarmsystem.Thegaptensionwasassessedandadjustedwiththemodifiedspacer-basedgaptool改進(jìn)的基于墊片的間隙工具duringtheoperation.Patientsatisfactionwasevaluatedpost-operativelywitha5-pointLikertscale.Clinicaloutcomesincludinglowerlimbalignment,KneeSocietyScore(KSS)andWesternOntarioandMcMasterUniversitiesArthritisIndex(WOMAC)wererecordedbeforesurgery,3monthsand1yearaftersurgery.?ResultsTherangeofmotion(ROM)wassignificantlyincreased(p?

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。

生物膜相關(guān)性全膝關(guān)節(jié)置換感染:預(yù)防、診斷和治療(2024)BiofilmRelatedTotalKneeArthroplastyInfection:Prevention,DiagnosisandTreatment?Rodriguez-MerchanEC.BiofilmRelatedTotalKneeArthroplastyInfection:Prevention,DiagnosisandTreatment[J].ArchBoneJtSurg,2024,12(7):531-534.轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/39070877/轉(zhuǎn)載文章的原鏈接2：https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11283302/?AbstractBiofilmrelatedimplantinfectionisundoubtedlyarelevantchallengeinTKAwithourcomprehensionsteadilyprogressingandnovelmanagementapproachesbeingdeveloped.Theaimofthisarticlewastoreviewthemostimportantadvancesinapproachestocombatinfectionsduetobiofilm-formingbacteriainTKA.Themainconclusionswerethefollowing:1)FundamentalmanagementtechniquesforinfectedTKAincludeopenDAIR(debridement,antibiotics,andimplantretention),andoneandtwo-stagerevisionTKA;2)Continuouslocalantibioticperfusion(CLAP)appearstodiminishtheriskofPJI;3)RestraintofquorumsensingseemstoavertPJIafterTKA;4)ArecentinvitrostudyshowedpromisingresultsinthepreventionandmanagementofPJIafterTKAusingPMMA[poly(methylmethacrylate甲基丙烯酸甲酯)]loadedwithupto100mgofrifampin.生物膜相關(guān)的種植體感染無疑是TKA的一個相關(guān)挑戰(zhàn)，我們的理解正在穩(wěn)步進(jìn)步，新的管理方法正在開發(fā)中。本文的目的是回顧在TKA生物膜形成細(xì)菌感染的治療方法的最重要的進(jìn)展。主要結(jié)論如下:1)感染TKA的基本管理技術(shù)包括開放式DAIR(清創(chuàng)、抗生素和植入物保留)和一期和二期翻修TKA;2)持續(xù)局部抗生素灌注(CLAP)似乎可以降低PJI的風(fēng)險;3)群體感應(yīng)的抑制似乎可以避免TKA后的PJI;4)最近的一項體外研究顯示，使用PMMA[聚(甲基丙烯酸甲酯甲基丙烯酸甲酯)]加載多達(dá)100毫克的利福平，在TKA后PJI的預(yù)防和管理方面有希望的結(jié)果。?KeyWords:Biofilms,Diagnosis,Periprostheticjointinfection,Prevention,Totalkneearthroplasty,Treatment?IntroductionTKAisthetreatmentofchoiceforindividualswithsevereosteoarthritisofthekneeandintensepain.OveronemillionTKAsarecarriedouteveryyeargloballywithupto143%growthbyyear2050forecast.1ArecentclinicalstudyshowedthatkneePJIswereprincipallyattributedtoinfectionwithST59methicillin-resistantStaphylococcusaureus(MRSA)andrisingtrendsforinfectionwithST8andotherSTtypesofMRSAsinPJIindividualswerefoundfrom2016to2019.TheidentificationofMRSAgenotypesinPJIsmightbeusefulforthetreatmentofPJIs.2Forthepurposesofthisreview,on1January2024abibliographicsearchwasperformedonPubMedutilizingthesearchstring:[biofilmtotalkneearthroplasty],resultingin123articles,ofwhich20paperswerefinallyanalyzedbecausetheyweredirectlyrelatedtonovelstrategiestopreventandtreatbiofilm-formingbacteriaonTKAandwerepublishedin2022,2023and2024.?MainbodyCurrentDiagnosticandTreatmentMethodsRecentpublicationsonthediagnosisofPJIinTKAareshownin[Table1].3-11inacomputertomography(CT)-basedcadaverstudyitwasshownthatcementremovalofpolymethylmethacrylate(PMMA)usingultrasoundswasnearlyfull.12??Table1RecentpublicationsonthediagnosisofPJIinTKAAUTHORS[REFERENCE]?YEAR?????FINDINGSTsikopoulosetal32022??????Inthismeta-analysisnodifferencewasfoundbetweenthesonicationandchemical-basedbiofilmdislodgmentmethods.Rodriguez-Merchan42022?Thesonicationtechniqueprovedtobereliable.Itssensitivityandspecificityweregreaterthanconventionalculturesoftheperiprosthetictissue.PolyethylenelinerssonicationhasbeenpublishedtobeenoughfordiagnosisofPJIFisheretal52022?????ProteomicprofilingutilizingasmallproteinpanelwasabletomakeadistinctionbetweenPJIandnon-infectiousarthroplastyfailuresonicatesamplesandrenderedabettercomprehensionoftheimmuneresponseduringTKAfailure.Azadetal62022???????ThisstudyshowedthattheclinicalsensitivityoftheInvestigationalUseOnly(IUO)BioFireJointInfection(JI)Panelwasexcellentforon-panelbacteria.However,overallsensitivityforPJIdiagnosiswaslowduetotheabsenceofStaphylococcusepidermidis.Flurinetal72022Thisstudyanalyzedtheaccuracyofa16SrRNA(rRNA)gene-basedPCRfollowedbySangersequencingand/ortargetedmetagenomicsequencingapproach(tMGS)carriedoutonsynovialfluidforPJIdiagnosis.Itwasfoundthatthesequencing-basedmethodwasnotbetterthatculturefordiagnosisofPJI,butproducedpositiveresultsinsomeculture-negativesamples.Hongetal82023??????The16SribosomalRNA(rRNA)gene-basedtargetedmetagenomicsequencing(tNGS)methodhasshownsimilarperformancecharacteristicsthanshotgunmetagenomicsequencing(sNGS)forPJIbacteriarecognitioninsonicatefluidfromfailedTKAsinculture-negativecases.Brooksetal92023????Implantsurfaceculture(ISC)successfullyrecognizedbacterialgrowthwithhighsensitivitywhilealsodisclosingthatbiofilmgrowthwasusuallylocalizedtoparticularlocations.Dragoetal102023???Theantibiofilmpre-treatmentofsynovialfluidswithdithiotreitol(DTT)demonstratedthecapacitytoraisethesensitivityofmicrobiologicalexaminationinthesynovialfluidofindividualswithPJI.Fisheretal112023???Inapilotstudyproteomicprofilingofsonicatefluidutilizingliquidchromatography-tandemmassspectrometry(LC-MS/MS)wasabletodistinguishbetweenS.aureusPJIandnon-infectedarthroplastyfailure.?OpenDAIR(debridementantibioticimplantretention)Arecentstudyhassuggestedthatdebridementantibioticpearlsandretentionoftheimplant(DAPRI)couldbeagoodalternativetotheDAIRtechnique.13?One-stagerevisionTKA(rTKA)AccordingtoJietal(2022)one-stagerTKAusingintraarticularinfusionofantibioticscandiminishbiofilmformation.14?Two-stagerTKAIn2023Shichmanetalanalyzedthecharacteristicsof90individualswhohavehadrecurrentinfectionaftertwo-stagerTKAforPJI.Themostfrequentpathogendetectedwascoagulase-negativeStaphylococci.Persistenceofbacteriawasseenin14(22.2%)ofrecurrentPJIs.Almostonethirdoftheindividualsattainedinfectioncontrolaftertreatmentofafailedtwo-stagerTKAduetoPJI.15?StrategiestoReduceRiskofInfectionHowtodecreasetheriskofPJIbefore,duringandaftersurgeryisshownin[Table2].Inastudy,eightindividualsaccomplishedresolutionoftheinfectionusingcontinuouslocalantibioticperfusion(CLAP)andintravenousantibiotics.ThestudysuggestedthatCLAPcanbeausefulmanagementalternativeforPJIafterTKA.16??Table2FactstokeepinmindtoreducetheriskofPJIbefore,duringandafterTKA?Table2.Continued?PREOPERATIVEPHASEBodymassindex(BMI)oflessthan35OptimizationofdietGoodlevelsofhemoglobinandfructosamineStopsmokingMRSA(methicillin-resistantStaphylococcusaureus)nasalscreening?INTRAOPERATIVEPHASEAppropriateantibioticprophylaxisAdequatefluidresuscitationSkinpreparationwithbetadineandchlorhexidineIrrigationwithdilutedpovidoneiodinesolutionAdministrationoftranexamicacidUtilizationofmonofilamentbarbedtriclosan-coatedsuturesfortheclosureofsofttissues?POSTOPERATIVEPHASEEarlyPJIinfectionmustbesuspectedwhenerythrocytesedimentationrate(ESR),C-reactiveprotein(CRP),D-dimer,andinterleukin(IL)-6arenotnormal6weeksaftertheprocedure?NovelTechniquestoPreventandTreatPJIQuorumsensing(QS)canreducebacterialvirulence.Infact,inhibitionofbacterialcommunicationwithsodiumsalicylate(NaSa)水楊酸鈉hasshowntobeeffective.17Asystematicreviewandmeta-analysisstatedthatrifampin利福平seemedtoconferaprotectiveeffect.ThismanagementeffectwasparticularlypronouncedinthecontextofrTKA.18ArecentinvitrostudyshowedpromisingresultsinthepreventionandmanagementofPJIafterTKAusingPMMAloadedwithupto100mgofrifampin.19InaclinicalstudyonPJIwithcoagulase-negativeStaphylococcusaureus凝固酶陰性的金黃色葡萄球菌itwasfoundthatthesuccessratewas47%at1-yearfollow-up.OpenDAIRhadthehigherfailurerate(60%).Two-stagerTKAhada46.7%failurerate.20?ConclusionEssentialtreatmentapproachesforinfectedTKAincludeOpenDAIRandoneandtwo-stagerTKA;continuouslocalantibioticperfusion(CLAP)seemstoreducetheriskofPJI;restraintofQS(imsteadofquorumsensing)appearstoavertPJIafterTKA;arecentinvitrostudyhasshownpromisingresultsinthepreventionandtreatmentofPJIafterTKAusingPMMAloadedwithupto100mgofrifampin.感染TKA的基本治療方法包括開放式DAIR和一期和二期rTKA;持續(xù)局部抗生素灌注(CLAP)似乎可以降低PJI的風(fēng)險;抑制QS(而不是群體感應(yīng))似乎可以避免TKA后的PJI;最近的一項體外研究顯示，使用含有高達(dá)100毫克利福平的PMMA在TKA后預(yù)防和治療PJI方面有希望的結(jié)果。

全膝關(guān)節(jié)置換術(shù)后股骨遠(yuǎn)端假體周圍骨折的治療(2020)TheTreatmentofPeriprostheticDistalFemoralFracturesAfterTotalKneeReplacement?QuinziDA,ChildsS,LipofJS,SoinSP,RicciardiBF.TheTreatmentofPeriprostheticDistalFemoralFracturesAfterTotalKneeReplacement:ACriticalAnalysisReview[J].JBJSRev,2020,8(9):e2000003.轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/33151645/轉(zhuǎn)載文章的原鏈接2：https://journals.lww.com/jbjsreviews/abstract/2020/09000/the_treatment_of_periprosthetic_distal_femoral.5.aspx?Abstract??Periprostheticdistalfemoralfractureaftertotalkneearthroplastycarriessubstantialmorbidityandmortalityregardlessoffixationtechnique.??Surgicaltreatmentisfavoredinmostpatientscomparedwithconservativetherapybecauseofhighratesofnonunion,malunion,andreoperationaftercastingorbracing.??Internalfixationtechniquesincludingretrogradeintramedullarynailingandlockedplatingarefavoredforsurgicaltreatmentinmostfractureswhenbonestockinthedistalfragmentallowsforappropriatefixation.??Inthesettingofdeficientdistalfemoralbonestockorfemoralcomponentloosening,revisionarthroplastywithdistalfemoralreplacementisthefavoredtechnique.??Furtherstudieswithregardtotheuseofintramedullarynailing,lockedplating,anddistalfemoralreplacementarenecessarytorefinetheindicationsforeachtechniqueandtodefinetheuseofcombinationsofthesefixationtechniques.無論采用何種固定技術(shù)，全膝關(guān)節(jié)置換術(shù)后股骨遠(yuǎn)端假體周圍骨折的發(fā)病率和死亡率都很高。與保守治療相比，手術(shù)治療在大多數(shù)患者中更受青睞，因為手術(shù)治療的不愈合、不愈合率高，并且在鑄造或支具后再次手術(shù)。內(nèi)固定技術(shù)包括逆行髓內(nèi)釘和鎖定鋼板，在大多數(shù)骨折的手術(shù)治療中，當(dāng)遠(yuǎn)端碎片的骨量允許適當(dāng)?shù)墓潭〞r，首選內(nèi)固定技術(shù)。在股骨遠(yuǎn)端骨缺損或股骨假體松動的情況下，股骨遠(yuǎn)端置換術(shù)的翻修關(guān)節(jié)成形術(shù)是首選的技術(shù)。有必要進(jìn)一步研究髓內(nèi)釘、鎖定鋼板和股骨遠(yuǎn)端置換術(shù)的應(yīng)用，以完善每種技術(shù)的適應(yīng)癥，并確定這些固定技術(shù)的組合使用。?EpidemiologyPeriprostheticfractureisoneofthemostcommoncomplicationsaftertotalkneearthroplasty,withratesof0.3%to3.5%inthefirst4yearsafterthesurgicalprocedure1,2.Periprostheticsupracondylardistalfemoralfractureisthemostcommontypeofperiprostheticfractureaftertotalkneearthroplasty3.Thesefracturestypicallyoccuringeriatricpatientswithosteoporosis,withameanageof.70yearsandanincidenceoffemalepatientsof.70%inmoststudies4-6.Thesefracturesresultinsubstantialmortalityandmorbidity,withstudiesshowingamortalityrateofapproximately15%at1yearafterthesurgicalprocedure4,5.Despiteadvancesinimplantdesignandknowledgeoffracturemanagement,subsequentratesoflossofambulatoryindependence,needforsurgicalfixation,andpostoperativecomplicationsallremainhighinthispatientpopulation.Changesinfracturefixationdevicesandtotalkneereplacementdesign,particularlytheintercondylarbox,havechangedthewaythesefracturesaremanagedinthepast2decades;however,thereisstillconsiderablecontroversyastotheoptimalmethodstoaddresstheseinjuries.Thepurposeofourcriticalanalysisreviewwastopresentthecurrentconceptsoffracturefixationandprostheticreplacementmethodsforperiprostheticdistalfemoralfractureandprovideevidence-basedrecommendationsontheirmanagement.?ClassificationAnumberofclassificationsystemshavebeenutilizedtostandardizethedescriptionofperiprostheticdistalfemoralfractures,andmoststudieshaveutilizedclassificationsbySuetal.,RorabeckandTaylor,ortheOTA/AOtodescribethesefractures(TableI)7,8.Themostimportantconceptsfromtheseclassificationsystemswithregardtothetreatmentofthesefracturesarethepresenceofdisplacementorcomminution,theamountandqualityofavailablebonestockinthedistalfragment,andthepresenceofawell-fixedorloosefemoralcomponent.??TABLEICommonClassificationSystemstoDescribePeriprostheticDistalFemoralFractureAfterTKA7.SuET,KubiakEN,DewalH,HiebertR,DiCesarePE.Aproposedclassificationofsupracondylarfemurfracturesabovetotalkneearthroplasties.JArthroplasty.2006Apr;21(3):405-8.?NonoperativeManagementNonoperativemanagementofperiprostheticdistalfemoralfracturesiscurrentlyreservedfornondisplacedfracturesinotherwisenonambulatorypatients,thoseunsuitableforanesthesia,orthosewithwound-healingriskfactorstoogreattoundergoasurgicalprocedure9.Fracturesinthiscohortofpatientsmaybeduetofallsorevenlower-energyeventssuchastransfersassistedbystafforfamilymembers.Nonoperativemanagementmaybeundertakenwiththeuseofahingedkneebraceorcasting.Patientswhoundergoacourseofnonoperativemanagementmustbecloselyfollowedradiographicallytoensurethatthefracturedoesnothaveprogressivedisplacement,whichcanresultinskincompromise,andcloseclinicalfollow-upisnecessarytodecreasethelikelihoodofskinbreakdownorulcerationbeneaththeimmobilizationdevice.Historicalstudiesofnonoperativemanagementforperiprostheticdistalfemoralfracturesconsistedofcastingorfunctionalbracingwithorwithouttractionorclosedreduction9-11.Despitetheadvantagesofavoidingasurgicalprocedurewithnonoperativemanagement,nonunionsoccurinupto12%to40%ofcases,andhighratesofsubsequentsurgicalproceduresofbetween15%and30%havebeenreportedwithnonoperativetreatment,includingforimplant-relatedcomplicationsrequiringprostheticexchange,malunion,andnonunion,whichisgreaterthanformodernmethodsofinternalfixation9-12.Additionally,theclosedreductionofdisplacedfracturesresultsinhighratesofmalunion,particularlyinvarusalignment,whichoccurredinthemajorityofpatientstreatedwiththismethod9,11.Eveninthesettingofaminimallydisplacedfracture,nonoperativetreatmentcanresultinanincreasedriskofarthrofibrosis,withmanypatientslosingrangeofmotionaftertreatmentandhavingprogressivedisplacementovertime13.Giventheserisksandpoorresultsfromstudiesofnonoperativemanagement,mostpatientsundergosurgicalfixationfortheseinjuries.?OperativeTreatmentOperativetreatmentremainstheprimarymethodoftreatingperiprostheticdistalfemoralfracturesinthesettingofTKA.Theaimsofoperativemanagement,comparedwithnonoperativetreatmentwithcastingorbracing,aretoallowforearlymobilizationandtopreventlatedisplacement.Internalfixationremainsthemostcommonmethodofsurgicaltreatment,andexternalfixationisrarelyusedinthesettingofclosedfracturesbecauseoftheriskofinfectionandtheneedforkneejointimmobilization.Advancesinimplanttechnologyandapplicationofinternalfixationprincipleshaveimprovedtheoverallmanagementofthisfracturepattern14.Bothplate-and-screwconstructsand/orintramedullarynailconstructshavebeenusedwithvaryingdegreesofsuccess.?Plate-and-ScrewFixationOpenreductionandinternalfixation(ORIF)withplate-and-screwfixationhasbecomeroutineinthemanagementofperiprostheticdistalfemoralfractures.Earlierstudiessuccessfullyutilizedconventionalplatingtechniquesconsistingmostlyoffixed-angledevicesordynamiccondylarscrewstoimproveunionrates,toreducetheincidenceofmalunion,andtoacceleratetheadvancementofpost-treatmentambulatorystatuscomparedwithconservativetreatment13.Despitethisadvance,ratesoffailurewithconventionalfixationoccurredbetween7%and15%ofcases15.Additionally,ahighincidenceofbone-graftingwasneededwithconventionalplating(.50%insomeseries),andconventionalplatingneededmoreextensilesurgicalapproachescomparedwiththelessinvasiveapproachesachievablewithnewerplatedesigns15,16.BecauseoftheelderlypatientpopulationandpoorbonequalityproximaltoaTKR,internalfixationtechniquesthatareanalternativetoconventionalplatinghavebeensoughtinrecentyears.Thedevelopmentoflockingplatesallowedforaminimallyinvasiveapplicationofafixed-angleconstructforthedistalfragmentwithmanypointsoffixation,whichwasanimprovementoverpreexistingfractureplates(Fig.1)14,15.Additionally,lockedplatesallowedforbothrigidandbridgingtechniquesforthemetaphysealordiaphysealfracturecomponentandcanbeplacedutilizingminimallyinvasive,soft-tissue-sparingtechniques,although,inosteoporoticbonewithextensivecomminution,abridgingconstructismostsuccessful14,17,18.Thesurgicaltechniquecandictatewhethertheload-bearingconstructwillprovideabsoluteorrelativestabilitybasedonthetypeofscrews(lockingcomparedwithnonlocking),thespreadofscrews,andadjunctstotheplatesuchaslagscrewsandcables.Furthermore,inosteoporoticbone,lockingscrewoptionscanimprovefixationcomparedwithnonlockingscrewsandcanallowtheindirectreductionofthemetaphyseal-diaphysealjunctionandperiarticularfragments.Plate-and-screwconstructsalsohavetheabilitytobridgethefemur,decreasingthechanceofastress-riserbetweenipsilateraltotalhipreplacementstemsandsupracondylardistalfemoralfractures19.Inaddition,inverydistalfractures(e.g.,SuTypeIII),dual-platingconstructscanalsobeconsideredformorerigidfixationandearlymobilization20.??Fig.1Figs.1-Athrough1-ERadiographsshowingthemanagementofaSuType-Iperiprostheticdistalfemoralfracturewithalockedplate:preoperativeanteroposterior(Fig.1-A)andlateral(Fig.1-B)viewsandpostoperativeanteroposteriorviews(Figs.1-Cand1-D)andlateralview(Fig.1-E).??IntramedullaryNailFixationAnotheroptionfortreatingperiprostheticdistalfemoralfracturesisintramedullaryfixationwithantegradeorretrogradeintramedullarynail.Retrogradeintramedullarynailsareusedmorefrequentlybecausetheyhavemorereliablefixationinthedistalfemoralsegmentcomparedwithantegradenailswithlimiteddistallockingoptionsandscrewspread21.Theindicationforaretrogradeintramedullarynailinthissettingisawell-fixedimplantwithanopenboxthatwillaccommodateanappropriatestartingpointandnoipsilateraltotalhipreplacement(Fig.2).Comparedwiththeload-bearinglockingandnonlockingplates,theload-sharingintramedullarynailallowsforsecondarybone-healingthroughcallusformationandearlyweight-bearinginlength-stablefracturepatterns13.Otherbenefitsofretrogradeintramedullarynailsincludelimitedsurgicalexposure,minimalsoft-tissuestripping,andrelativeeaseofplacement21.Theuseofthistechniqueisrestrictedonthebasisofthepatient’spreexistingimplantdesignandpresenceofanipsilateraltotalhipreplacement21,22.Kneereplacementcomponentswithaclosedboxorposteriornotcharenotcompatiblewithretrogradeintramedullarynails,althoughmostmodernimplantshaveopen-boxdesigns23.InaSawbonesmodeltosimulateaperiprostheticfractureinatotalkneereplacement,itwastechnicallyfeasibletoplacethemajorityofretrogradeintramedullarynaildesignsthroughmanyofthemostcommonlyusedtotalkneereplacementdesigns;however,thisoftenresultedinexcessforceneededforinsertionanddamagetothenailasitpassesthroughtheimplantbox24.Additionally,mosttotalkneereplacementdesignsresultinnailinsertioninamoreposteriorstartingpointthaninanativekneeduetotheprostheticdesign,whichcarriesariskofanteriorcorticalperforationandextensiondeformity,whichishigherincruciate-retainingdesignscomparedwithposteriorstabilizeddesigns22,24.Pelfortetal.founda23%incidenceofanextensiondeformityof.10°withtheuseofretrogradeintramedullarynailsforperiprostheticdistalfemoralfractures;however,thisdidnotaffectradiographicunion,totalkneereplacementloosening,orpatient-reportedfunctioncomparedwiththosewithoutthisdeformityataminimumfollow-upof4years25.Anotherdisadvantageofretrogradeintramedullarynailsisachievingadequatefixationinfracturesdistaltotheanteriorflangeofthefemoralimplant.Thismaybedifficultwitharetrogradeintramedullarynailduetomorelimitedscrewoptions,andatleast2lockedscrewsshouldbeusedinthedistalfragmenttoreducetheriskofnonunionandimplantfailure26,27.??Fig.2Figs.2-Athrough2-DRadiographsshowingthemanagementofaSuType-Iperiprostheticdistalfemoralfracturewitharetrogradeintramedullarynail:preoperativeanteroposterior(Fig.2-A)andlateral(Fig.2-B)viewsandpostoperativeanteroposterior(Fig.2-C)andlateral(Fig.2-D)views.??CombinedIntramedullaryNailandPlate-and-ScrewConstructsRecently,increasedinterestincombinedlockingplateandintramedullaryfixationtechniquesbyeithercorticalallograftornail-platecombinationconstructshavebeenproposed.Biomechanicalstudieshavesuggestedthatalockedplatewithsupplementalintramedullaryfixationmayhavehighertorsionalstiffnessandlessmicromotionthanotherconstructs(Fig.3)28.LiporaceandYoonpreviouslypublishedtheirrecommendedstep-by-steptechniqueforimplementingthenail-platecombinationstrategyinfracturesmeetingsurgicalcriteria29.Theprocedureisinitiatedbyplacementofaretrogradeintramedullarynailthroughamidline,lateralparapatellarapproachwithsubluxationofthepatellaofsplittingthepatellartendon.Thishelpstorestorethetypicalrecurvatumdeformityandestablishfracturelength,alignment,androtation.Next,thelateralplatelengthisdeterminedwithfluoroscopicassistance,withtheproximalendstoppingatthebaseofthelessertrochanter.Platesareplacedviathetypicalsubmusculartechniqueusingthesamedistalincisionusedfornailplacement.Afterappropriateplatepositioning,distallockedscrewsarethenplaced,wheretypically1ofthevariableanglescrewscanbeinterlockedintothenail,unitizingthedistalportionoftheconstruct.Inselectpatients,surgeonscanchoosetobendtheproximalportionoftheplatetoallowforplacementofnonlockingscrewsintothefemoralneck,whichserveasbothprophylacticfixationaswellasplatereductionaids29??Fig.3Figs.3-Athrough3-DRadiographsshowingthemanagementofaSuType-IIperiprostheticdistalfemoralfracturewithacombinationofalockedplatewithanintramedullarynail:preoperativeanteroposteriorview(Fig.3-A)andpostoperativeanteroposteriorviews(Figs.3-Band3-C)andlateralview(Fig.3-D).??Thesuggestedbenefitofnail-platecombinationcomparedwithsingle-implantconstructsisearlierreturntoweight-bearingandmobilizationforhighlycomminutedlength-unstablefracturepatternsthattraditionallywouldbetreatedwithlockedplatingandprotectedweight-bearing30,31.Althoughadvantageousinpreventingmorbidityassociatedwithprolongedperiodsoflimitedweight-bearing,theprocedureexposespatientstoextendedsurgicaltimeandcost.Thereisarelativepaucityofliteratureregardingthistreatmentalgorithm;however,itremainsanexcitingprospectforpatientsappropriateforandamenabletofixation30,31?DistalFemoralReplacementProstheticreplacementisanothersurgicaloptionforperiprostheticdistalfemoralfractures.Theseinjuriestypicallyoccurinolder,medicallycomplexpatientswhoareunabletotolerateprolongedbedrestorweight-bearingrestrictions.Thetreatmentofthesepatientswithrevisionarthroplastyordistalfemoralreplacementhasbeenproposedtoallowearlymobilizationandweight-bearingwithouttheneedforbone-healing,whichmaybeadvantageousinthispatientpopulation.Limited,smallcaseserieshavedescribedrevisionarthroplastywithalong-stemtotalkneearthroplastyrevisioncomponentwithoutfemoralresection,whichmaybeanoptioninthesettingofaloosecomponentandpreservedcollateralligaments18.Mostcasesofarthroplastyforperiprostheticdistalfemoralfracturesinvolvedistalfemoralreplacement,whichconsistsoftheresectionoftheentiresupracondylarfemurproximaltothefracturesiteandreplacementwithahingedtotalkneeprosthesis(Fig.4).Inpriorstudies,authorshaverecommendeddistalfemoralreplacementinthesettingofperiprostheticdistalfemoralfracturesinthepresenceofseverelycompromisedbonequality,osteolysisorlooseningofthefemoralcomponent,lossoftheintegrityofthecollateralligaments,periprostheticfractureinthepresenceofarevisionfemoralcomponentorpreviousdistalfemoralreplacement,anddeficientdistalfemoralbonestock(typicallySuType-IIIfractures)32.Thebenefitsofadistalfemoralreplacementincludetheimmediaterestorationoflower-extremityalignmentandstability,relativelyshortoperativetimes,andimmediateweight-bearingwithlessrestriction33-38.Additionally,distalfemoralreplacementinthispopulationavoidsconcernsofmalunionornon-unionsecondarytoimpairedhealing.Concernsaboutdistalfemoralreplacementincludehighimplantcost,riskofimplantfailure,extensormechanismcomplications,andsoft-tissuecompromiseincludingperiprostheticjointinfection32-38.??Fig.4Figs.4-Athrough4-DRadiographsshowingthemanagementofaSuType-IIIperiprostheticdistalfemoralfracturewithadistalfemoralreplacement:preoperativeanteroposterior(Fig.4-A)andlateral(Fig.4-B)viewsandpostoperativeanteroposterior(Fig.4-C)andlateral(Fig.4-D)views.??Distalfemoralreplacementisperformedthroughasimilarapproachtotheindexsurgicalprocedure,typicallyanextensilemidlineoroccasionallylateral-basedincision.Thefemurandtibiaaresubperiosteallyexposedtotheleveloftheintendedresection.Theapproximatelengthofthedistalpartofthefemurtoberesectedismeasuredandismatchedtoanavailable,appropriateimplantlength.Implantsizingcanbeapproximatedbytheexplantedtibialcomponentandfemoralresection.Femoralrotationcanbechallengingtoreproduceandcanbeestimatedtomatchtheexistingimplantifthefracturecanbeapproximatedanatomicallyorcanbeestimatedtobedirectlyanteriortothelineaaspera.Thedistalfemoralcomponentandboneareremovedenblocifpossible,takingcaretomaintainasubperiostealdissectionposteriorlytoavoidneurovascularinjury.Theresidualproximalpartofthefemurisosteotomizedperpendiculartotheshaftandisreamedtoaccommodatetheappropriatestemsizeandfixationtype39.Thetibiaisexposedandthepreexistingimplantisremoved,preservingasmuchboneaspossible.Thetibiaispreparedaccordingtotheimplanttechnique.Theuseofcementlessdesignscomparedwithcementedstemsiscontroversial,withstudiessuggestingoverallsimilarintermediate-termsurvivorshipinthesettingofnononcologicreconstructionbutincreasedratesofearlyasepticlooseningonthefemoralsidewithcementlessdesigns,especiallyinthesettingofoncologicreconstruction40-42.NewercementlessimplantdesignssuchastheCompressCompliantPre-Stressimplant(Biomet),whichrelyoncompressionatthesiteofthefemoralresection,mayimprovetheoutcomesofcementlessfixation,butneedmorestudieswithlonger-termfollow-up43.Appropriatetrialsareplacedwithafocusonreproducingintraoperativelengthbasedonmaintainingappropriatesoft-tissuetensionwhileavoidingexcessivelengtheningtoavoidstressonneurovascularstructuresandoptimizingpatellartracking.?OutcomesofSurgicalTreatmentLockedPlateOutcomesutilizinglockedplatinghavebeenlargelypositiveandthesehavebecomefavoredoverconventionalplatingtechniques.Studiesoflockedplatinghavedemonstratedhighunionrateswithconsistentlylowercomplications,includingtheneedforrepeatsurgicalintervention,comparedwithconventionalplatingtechniquesandnonoperativetreatment12-14,30,44-51.Conventionalplatingshouldbelimitedtocaseswithsimplefracturepatternsandgoodbonestockproximalanddistaltothefracturesite,suchasinthesettingofasimplelateralormedialcondyleperioperativefracture.Systematicreviewsofperiprostheticdistalfemoralfracturestreatedwithlockedplatinghaveshownnonunionratesof5%to13%andmalunionratesofaround5%followingperiprostheticdistalfemoralfractures12,44,52.Theredoesnotappeartobeadifferenceinunionratesbetweendifferentlockedplatedesignswithregardtopolyaxialcomparedwithmonoaxiallockingscrews48.ArandomizedcontrolledtrialcomparedtheoutcomesofORIFwithpolyaxialandmonoaxiallockingscrewsinperiarticularlockingplatesandfoundnodifferenceintheunionratesutilizingthese2differentconstructsandcitedrespectoflocalfracturebiologyandAOprinciplesasbeingmoreimportantfactorsrelatedtounion48.Evenwithsuccessfulfractureunion,periprostheticdistalfemoralfracturescarrysubstantialmorbidityandmortalityforpatientsinadditiontolossoffunctionalindependence.Oneofthemostdevastatingcomplicationsthatoccursafterlockedplatingofperiprostheticdistalfemoralfracturesisdeepinfection,whichoccursinupto5%ofcases12,52.Mortalityrateshavebeenreportedtobeupto15%to25%after6months,andahigherCharlsonComorbidityIndexandolderageareassociatedwithahigherrateofmortality50,53,54.Postoperativelossorimpairmentofambulatorystatusisalsocommonafterlockedplatingforperiprostheticdistalfemoralfractures,withupto30%ofpreviouslyambulatorypatientsincreasingtheirneedforassistivedevicescomparedwiththeirpreoperativestatus,andthemajorityofpatientsrequiringsometypeofassistivedeviceafterthesurgicalprocedure5,54.?IntramedullaryNailWithregardtoretrogradeintramedullarynails,asimilarlyhighrateofsuccesshasbeenshowninselectpatternsandanaccommodatingtotalkneeimplant.Whencomparedwithconventionalplating,retrogradeintramedullarynailsappeartohavesuperiorratesofunionandlowerratesofreoperation.Herreraetal.conductedasystematicreviewof415casesofdistalfemoralperiprostheticfractureandfoundarelativeriskreductionof87%fornonunionand70%fortheneedforarevisionsurgicalprocedurewithretrogradeintramedullarynailscomparedwithtraditionalnonlockedplatingmethods(1.5%withretrogradeintramedullarynailscomparedwith12%withconventionplatingnonunionrate)12.Intramedullaryfixationrequireslesssurgicaldissectionandsoft-tissuestripping,whichmayprovideanadvantagewithregardtoinfectionrates.Therateofdeepinfectionwaslowwiththeuseofretrogradeintramedullarynailscomparedwiththatwithotherplatingtechniques(0%in65casescomparedwith5.7%withconventionalplating)12.Whencomparingretrogradeintramedullarynailswithlockedplating,moststudieshavenotconsistentlyfoundsignificantdifferencesinunionrateandreoperations12,14,44,49,52,55,56.Intheirsystematicreviewof719fractures,Ristevskietal.notedthatbothretrogradeintramedullarynailsandlockedplatingofferedadvantagesovernonoperativemanagement,andnosignificantdifferencebetweenthe2withregardtonon-unionratesortheneedforsecondarysurgicalprocedures,althoughatrendtowardimprovedunionrateswithretrogradeintramedullarynailswasfound44.Incontrast,therateofmalunionwassignificantlyincreasedwiththeuseofretrogradeintramedullarynails(16%)comparedwithlockedplates(8%)44.Inasystematicreview,Ebraheimetal.foundthatoverallunionratesweresimilarbetweenlockedplatesandretrogradeintramedullarynails,withoverallhealingratesof87%comparedwith84%inRorabeckandTaylortype-IIfractures52.Overallcomplicationswerehigherwithretrogradeintramedullarynails,withincreasedratesofmalunioncomparedwithlockedplates52.Infectionrateswere1%intheretrogradeintramedullarynailgroupcomparedwith4%intheconventionalplatinggroupinRorabeckandTaylortype-IIfractures52.Houetal.,intheircohortof52patients,foundasimilartimetounionof3.7monthsforretrogradeintramedullarynailscomparedwith4.0monthsforlockedplatingandnodifferenceinunionrates50.Inanothersystemicreview,Shinetal.foundsimilarratesofnonunionandmalunioninbothretrogradeintramedullarynailsandlockedplating49.?CombinedLockedPlateandIntramedullaryFixationAugmentationofplatefixationwithintramedullarystructuralallograftorintramedullarynailfixationhasshownfavorableresultsinlimitedstudies.Christetal.reportedonacohortof40patientswithperiprostheticdistalfemoralfracturestreatedwithORIFwithorwithoutendostealaugmentationwithfibularstrutallograft.Theyfoundahighrateofunionof94%,withnodifferenceinratesofunionwhencomparingthosewhoreceivedfibularallograftwiththosewhodidnot57.Hussainetal.reportedontheirseriesof9patientstreatedwitharetrogradeintramedullarynailandsoft-tissue-preservinglaterallockingplate(withoutinterfragmentarycompressionscrews,cables,orbone-grafting)withimmediatepostoperativeweight-bearing.Intheircohort,allpatientsachievedunionatameanof20weekswithoutareturntotheoperatingroomforasecondaryprocedure30.Althoughthesecasereportsandthesurgicaltechniquehavebeenreportedintheliterature,long-termoutcomesstudiescomparingnail-platecompositewithsinglesurgicaltechniquesarenotyetavailable31,45.Nevertheless,itremainsanintriguingandexcitingtechniqueforaskilledsurgeon.?DistalFemoralReplacementMoststudiesexaminingoutcomesofdistalfemoralreplacementperformedinthesettingofperiprostheticdistalfemoralfractureshavesmallpatientnumbers,withmostseriesincluding,20patients,multiplenononcologicindicationsfordistalfemoralreplacementwithinthestudy,andawiderangeofreportedoutcomeswithshort-termfollow-up32-39,58-65.Distalfemoralreplacementissuccessfulatrelievingpainandreestablishingkneerangeofmotionconsistentlyacrossstudies;however,functionaloutcomeshaveawidereportedrange.Moststudieshaveshowngoodrestorationofkneerangeofmotion(consistentlyachievinga90°to105°arcofmotion),appropriatepainrelief,KneeSocietyclinicalscoresof71to91points,andmeanOxfordkneescoresof22to27points(range,4to40points)4,32,33,36,58,59,61,64.Importantly,morbidityandmortalityofpatientswithperiprostheticdistalfemoralfracturesshouldnotbeoverlooked,especiallyinthesettingoffailure.Similartostudiesutilizinglockedplates,recentstudieshaveshown1-yearmortalityratesbetween5.8%and33%59,60,63.Complicationsofdistalfemoralreplacementincludingperiprostheticfracture,asepticloosening,extensormechanismcomplications,andperiprostheticjointinfectionhavebeenreportedin15%to30%ofcasesoverashort-termtointermediate-termfollow-upperiodinmostseriesfornononcologicindications35-37,39,58-65.Becauseofsmallstudysizesindistalfemoralreplacementforperiprostheticdistalfemoralfractures,complicationratesvarydependingonthestudy.Periprostheticfracturehasbeenreportedwitharateof1%to18%andiscommonlyassociatedwiththefragilenatureoftheseelderlypatients,manyofwhommeetthefragilityfractureclassificationbasedonWorldHealthOrganizationcriteria58.Infectioninthesettingofdistalfemoralreplacementhasbeenattributedtosoft-tissuecompromisefrompriorsurgicalprocedures,moreextensiveexposures,longeroperativetimes,andhigherpatientcomorbidityprofiles62.Infectionrateshavebeenreportedtobeaslowas0%to10%andashighas20%insomeseries,althoughthisriskishighestfordistalfemoralreplacementinthesettingofasepticlooseningorpreviousperiprostheticjointinfection36,61-63,65.Asepticlooseningisariskforprostheticreplacementbutnotforplatefixation.Wylesetal.foundthatthatthecumulativerateofasepticlooseningafterdistalfemoralreplacementforperiprostheticdistalfemoralfractureswas10%at5yearsdespitethelow-demandpopulationthattypicallyundergoesthisprocedureforperiprostheticdistalfemoralfractures63.Shorterstemlengthcomparedwithtotalconstructlengthmayincreasethisrisk63.Patellofemoralcomplicationsreportedafterdistalfemoralreplacementareincreasedcomparedwithconventionaltotalkneearthroplastyandincludeinstabilityormaltracking,patellarimpingement,andfracture.Carefulattentiontofemoralandtibialcomponentrotationandlateralsoft-tissuereleasewhennecessaryareimportanttoreducemaltracking,whichmayoccurin.10%to15%ofpatientsundergoingdistalfemoralreplacement66-69.Patellabajaiscommonafterdistalfemoralreplacementandmayleadtoprostheticimpingement,althoughitmaynothaveasubstantialeffectonfunctionaloutcomes68,69.Treatmentofthepatellaindistalfemoralreplacementhasnotbeenextensivelyinvestigated;however,Etchebehereetal.didnotfindadifferenceinpatellofemoralcomplicationsoranteriorkneepainwithunresurfacedcomparedwithresurfacedpatellaeafterdistalfemoralreplacementforbenignormalignantbonetumors,withsimilarratesofanteriorkneepain(around25%ofpatients)67.Theroleofpatellectomyisnotclearfrompreviousliterature,althoughitremainsasalvageoptionforcasesinwhichthepatellacannotberesurfacedoralignedappropriately.?LockedPlateComparedwithDistalFemoralReplacementComparingtheoutcomesoflockedplatingwiththoseofdistalfemoralreplacement,nonrandomizedretrospectivecohortstudieshaverevealednoconsistentchangesinpostoperativemobilitystatus,similarreoperationrates,andsimilar90and365-daymortalityrates,regardlessoftreatment4,34,66,70-73.Overall,regardlessofthetreatmentmodality,ageatthetimeoftheinjuryismorepredictiveoffunctionalstatusthandistalfemoralreplacementcomparedwithORIF,withpatients.85yearsofagehavingtheworstfunctionaloutcomes72.Furthermore,withregardtocost,patientsmanagedwithdistalfemoralreplacementcomparedwithfixationwithlockedplatingorretrogradeintramedullarynailshadasimilartotalcost,astheincreasedcostofthedistalfemoralreplacementimplantwasbalancedbythedecreasedoveralllengthofstaythatthesepatientsexperienced74.Recently,Darrithetal.foundhigherKneeSocietyfunctionalscoreswithORIF;however,therewasahigheroverallincidenceofrevisionsinthiscohortcomparedwithdistalfemoralreplacement66.Thebenefitsofdistalfemoralreplacementincludeimmediateweight-bearingandlessrestrictedmobilizationalongwithappropriatepainreliefandkneerangeofmotion.Despitethis,distalfemoralreplacementisacomplexsurgicaloptionthatposesuniquerisks,causingmanysurgeonstolabelitasasalvagedevice.Complicationratesarerelativelysimilarbetweenthe2groups;nonunionormalunionandinfectionweremorecommoninORIF,andinfection,patellofemoralcomplications,andasepticlooseningweremorecommonindistalfemoralreplacement4,34,54,66,70-73,75.UnlikeafailedORIF,whichcanbesalvagedwithdistalfemoralreplacement,afaileddistalfemoralreplacementcanbedifficulttosalvage,withincreasingbonelossduringrepeatoperationsandsubstantialsoft-tissuecompromiseinthesettingofinfection.Asaresult,webelievethatthecurrentevidencesupportsdistalfemoralreplacementprimarilyforelderly,sedentarypatientsandfracturesthatprecludeinternalfixation,includingcaseswithalooseimplantorminimaldistalperiprostheticbonestock61.?ConclusionsPeriprostheticdistalfemoralfracturescarrysubstantialmorbidityandmortalityregardlessoffixationtechnique.OurrecommendationsforcarearesummarizedinTableII.Surgicaltreatmentisfavoredinmostpatientscomparedwithnonoperativetherapybecauseofhighratesofnonunion,malunion,andreoperationaftercastingorbracing.Internalfixationtechniquesincludingretrogradeintramedullarynailsandlockedplatingarefavoredforthesurgicaltreatmentofmostfractureswhenthebonestockinthedistalfragmentallowsforappropriatefixation.Inthesettingofdeficientdistalfemoralbonestockorimplantloosening,revisionarthroplastywithdistalfemoralreplacementisthefavoredtechnique.Furtherstudieswithregardtotheuseofretrogradeintramedullarynails,lockedplating,ordistalfemoralreplacementarenecessarytorefinetheindicationsforeachtechniqueandtodefinetheuseofcombinationsofthesefixationtechniques.無論采用何種固定技術(shù)，股骨遠(yuǎn)端假體周圍骨折的發(fā)病率和死亡率都很高。表二總結(jié)了我們的護(hù)理建議。與非手術(shù)治療相比，手術(shù)治療在大多數(shù)患者中更受青睞，因為手術(shù)治療的不愈合、不愈合率高，而且在鑄造或支具后再手術(shù)的幾率也高。內(nèi)固定技術(shù)包括逆行髓內(nèi)釘和鎖定鋼板，在大多數(shù)骨折的手術(shù)治療中，當(dāng)遠(yuǎn)端碎片的骨量允許適當(dāng)?shù)墓潭〞r，首選內(nèi)固定技術(shù)。在股骨遠(yuǎn)端骨缺損或假體松動的情況下，股骨遠(yuǎn)端置換術(shù)的翻修關(guān)節(jié)成形術(shù)是首選的技術(shù)。有必要進(jìn)一步研究逆行髓內(nèi)釘、鎖定鋼板或股骨遠(yuǎn)端置換術(shù)的使用，以完善每種技術(shù)的適應(yīng)癥，并確定這些固定技術(shù)的組合使用。??TABLEIIRecommendationsforManagementofPeriprostheticDistalFemoralFracturesAfterTotalKneeArthroplastyAccordingtoWright76,gradeAindicatesgoodevidence(Level-Istudieswithconsistentfindings)fororagainstrecommendingintervention;gradeB,fairevidence(Level-IIorIIIstudieswithconsistentfindings)fororagainstrecommendingintervention;gradeC,poor-qualityevidence(Level-IVorVstudieswithconsistentfindings)fororagainstrecommendingintervention;andgradeI,insufficientorconflictingevidencenotallowingarecommendationfororagainstintervention.

????當(dāng)前，由于各種原因引起的晚期膝關(guān)節(jié)疾患已成為造成中老年人致殘的主要原因。而人工膝關(guān)節(jié)置換是目前在全球廣泛開展的一項治療晚期膝關(guān)節(jié)疾患的手術(shù)方式，是緩解關(guān)節(jié)疼痛和恢復(fù)功能的有效手段。1、人工膝關(guān)節(jié)置換是什么樣的手術(shù)?需要截掉整個膝關(guān)節(jié)嗎？????想要了解人工膝關(guān)節(jié)置換，需要先了解膝關(guān)節(jié)的結(jié)構(gòu)。膝關(guān)節(jié)是人體最大且最復(fù)雜的關(guān)節(jié)。膝關(guān)節(jié)的主要結(jié)構(gòu)包括股骨下端、脛骨上端、及髕骨關(guān)節(jié)面。當(dāng)膝關(guān)節(jié)由于各種原因,如晚期膝骨關(guān)節(jié)炎、類風(fēng)濕關(guān)節(jié)炎等，導(dǎo)致關(guān)節(jié)顯著破壞，并出現(xiàn)疼痛、活動障礙等癥狀，通過藥物、理療等手段醫(yī)治無效時，則可以考慮接受人工膝關(guān)節(jié)置換手術(shù)。?圖1膝關(guān)節(jié)骨關(guān)節(jié)炎晚期，關(guān)節(jié)間隙變窄，骨贅形成????人工膝關(guān)節(jié)置換，又稱為“人工膝關(guān)節(jié)表面置換”、“膝關(guān)節(jié)表面置換術(shù)”，通常指全膝關(guān)節(jié)置換。顧名思義，即用人工的膝關(guān)節(jié)表面（又稱“假體”）替換掉人自身“壞掉”的膝關(guān)節(jié)表面。手術(shù)醫(yī)生在術(shù)中會去掉病人自身已經(jīng)嚴(yán)重磨損的關(guān)節(jié)表面軟骨及部分軟骨下骨，再使用特殊的“膠水”——骨水泥，使假體與病人自身的股骨和脛骨可靠地固定在一起（目前也有非骨水泥型的人工膝關(guān)節(jié)，但尚未廣泛推廣使用）。2.?人工關(guān)節(jié)是什么材料做的？可以用一輩子嗎？????目前人工膝關(guān)節(jié)的材料多為鈷鉻鉬合金和高分子聚乙烯襯墊制作。????人工關(guān)節(jié)作為一種器官替代物，就像人體本身的膝關(guān)節(jié)一樣，必然存在磨損的問題。目前的人工假體使用壽命一般為20年左右。不過這只是一個估算的使用壽命，對于每個個體而言，假體的使用壽命還與體重、日?；顒恿俊⒏腥就鈧榷喾N因素有關(guān)。當(dāng)假體出現(xiàn)嚴(yán)重磨損或松動時，則需要進(jìn)行“膝關(guān)節(jié)翻修手術(shù)”，再次更換新的假體。?圖2膝關(guān)節(jié)人工關(guān)節(jié)假體3、什么是全膝關(guān)節(jié)置換？什么是單髁置換？有什么區(qū)別？????全膝關(guān)節(jié)置換術(shù)和單髁置換術(shù)與都是治療膝關(guān)節(jié)退變、炎癥、損傷導(dǎo)致的疼痛的絕佳手段，目前仍然是治療諸如骨性關(guān)節(jié)炎、類風(fēng)濕性關(guān)節(jié)炎、創(chuàng)傷性關(guān)節(jié)炎等的“金標(biāo)準(zhǔn)”。但是，這兩種手術(shù)方式有其獨有的特點。????把膝關(guān)節(jié)比作房屋結(jié)構(gòu)，人體的膝關(guān)節(jié)共有3個房間，分別是內(nèi)側(cè)間室、外側(cè)間室和髕股間室。單髁置換術(shù)只處理1個有問題的房間，如內(nèi)側(cè)或外側(cè)間室，而對于另外2個相對正常的間室保留原狀；而全膝置換術(shù)是處理所有的3個房間。????主刀醫(yī)生會根據(jù)患者的具體病情選擇做全膝置換或者單髁置換術(shù)，以及選用最合適的人工關(guān)節(jié)假體。?圖3全膝關(guān)節(jié)置換和單髁置換的區(qū)別?圖4全膝關(guān)節(jié)置換術(shù)前術(shù)后X線（站立位全長片和正側(cè)位）?圖5單髁置換術(shù)后X線（站立位全長片和正側(cè)位）4、做了手術(shù)多久以后可以走路？????一般而言，術(shù)后第一天會復(fù)查膝關(guān)節(jié)X線片，如無特殊情況可在醫(yī)生或護(hù)士的指導(dǎo)下下床活動。但要恢復(fù)到正常的步態(tài)或膝關(guān)節(jié)功能狀態(tài)，則需要一個系統(tǒng)規(guī)范的術(shù)后康復(fù)鍛煉過程，包括膝關(guān)節(jié)屈伸活動度鍛煉、下肢肌力鍛煉、踝泵動作等一系列簡單但是需要患者堅持進(jìn)行的康復(fù)活動。?圖6術(shù)后第一天患者助行器輔助下步態(tài)訓(xùn)練????如今溫州醫(yī)科大學(xué)附屬第一醫(yī)院按照浙江省醫(yī)療保障局要求，已全面執(zhí)行人工關(guān)節(jié)國家?guī)Я坎少徴?，假體費用下降約80%。從2023年開始，我院關(guān)節(jié)外科收治的關(guān)節(jié)置換患者都將能享受這一惠民政策。