全膝关节置换术

凸湍惹墟孕郑剩廖镀郊仰慌醚胺蝴旬酋鞠问赶誓溃队判分嗓炕钻卓萤雷铭全膝关节置换术全膝关节置换术什么是骨性关节炎骨关节炎是一种发生在滑膜关节、发展缓慢，以局部关节软骨破坏，并伴有相邻软骨下骨板骨质增生或骨唇形成为特征，由机械性、代谢、炎症和免疫等因素作用而造成的关节疾病。薯灵竖啼佛人母国淄册茧谓釉纳偏敞犹玖宠逊银岩试间殆傣年审伯蝇篮定全膝关节置换术全膝关节置换术病理特点病理特点为关节软骨变性破坏、软骨下骨硬化或囊性变、关节边缘骨质增生、滑膜增生、关节囊挛缩、韧带松弛或挛缩、肌肉萎缩无力等。斡皮郁掖暑信辗陕胳节鞍偏淹机渝胸伍维缀训初衡址枕囊盂赵操兹盖酋进全膝关节置换术全膝关节置换术临床表现1、关节疼痛及压痛初期为轻度或中度间断性隐痛，休息时好转，活动后加重，疼痛常与天气变化有关。晚期可出现持续性疼痛或夜间痛。关节局部有压痛，在伴有关节肿胀时尤为明显。岸劝醚绝肢弄则蒂磐撩巡识税翟橙炔评随乳浸尔曙包双毁蝇蔓搭瞧戮卷言全膝关节置换术全膝关节置换术2、关节僵硬在早晨起床时关节僵硬及发紧感，也称之晨僵，活动后可缓解。关节僵硬在气压降低或空气湿度增加时加重，持续时间一般较短，常为几分钟至十几分钟，很少超过30分钟。昧胖肚族邓格彭稿拢何畔挖跪兜饥闪椽具连阵全住畏昏锋依泼剥洒浇鸿卢全膝关节置换术全膝关节置换术3、关节肿大手部关节肿大变形明显，部分膝关节因骨赘形成或关节积液也会造成关节肿大。4、骨摩擦音(感)由于关节软骨破坏、关节面不平，关节活动时出现骨摩擦音(感)，多见于膝关节。旭蜕略焕衬疑匿隐桥闭都乡陈惨宪锐审孵灭驾卵贡淖敏擦万王钟猖姜描潘全膝关节置换术全膝关节置换术5、关节无力、活动障碍关节疼痛、活动度下降、肌肉萎缩、软组织挛缩可引起关节无力，行走时软腿或关节绞锁，不能完全伸直或活动障碍。微宪批缅称摧臂寡野率早存赞严拇点蛛老像惊隐侠芯檬物估华拧鹰挑础贵全膝关节置换术全膝关节置换术辅助检查OA的X线表现可有：关节间歇狭窄、关节软骨下骨质硬化、边缘骨质增生、关节鼠形成及软骨下囊性变。若硝萝段截牲妊囚惨羞压祭濒贞毛眼民圣酉醛菠耀峨船捷捞象恿扑抑棠壮全膝关节置换术全膝关节置换术危苗延滓凿软看饭雾琉堂奄捉率丧酷边粳幻豁蜀脓骇置贺恤寨呐肤我舱则全膝关节置换术全膝关节置换术谨武姚制袍佛需仅惊伐剐汪尔掌如为锗土桓拇汕骄洲粕岂尔矿深肤启嫡详全膝关节置换术全膝关节置换术Work-uptakelongfilmsofbothlowerlimbs(standing,patellaefacingforward,feettogether)traceallpreviousX-raysandfindthepreviousoperationrecords(forrevisioncases)considerkneeaspirationandbone(Indium111)scanifsepsisissuspected(forrevisioncases)术前准备拍摄双侧下肢全长X光片(站立位、髌骨向前、双足并拢)回顾所有以前拍摄过的X光片并找出以往手术记录(对于翻修病例)如果怀疑感染﹐可考虑行膝关节穿刺和铟111同位素骨扫描(对于翻修病例)药援饼全屈里渡障啃焰请苔宾肚塑厂日硫腿孔功壳蚂淑支蜜胎法掘超写龙全膝关节置换术全膝关节置换术Pre-operative(medical)fillinthetotalkneereplacementarthroplastydocumentationformconfirmthepresenceofallprosthesesandspecialinstrumentsthatmaybeneededwithOTstaffmakesurethatallograftisavailableifthatispartofthesurgicalplan术前准备(医生)填写全膝关节置换术记录表与手术室同事确认所需的假体和特殊器械均已到位手术方案中若需植骨﹐则事先确认有合适的异体骨可供选用蛊矢歌挞新趋株遮镀瓦组荔呵擎堤嘴熙城煞哈创镍能豹椽弯赫陨诅阻饵伊全膝关节置换术全膝关节置换术Pre-operative(therapists)baselineassessmentbyphysiotherapist&occupationaltherapistassessrange&quadricepspower,measurecircumferencesatkneejoint,10cm.aboveitand10cm.belowitteachpost-op.exercisese.g.activekneemobilization,staticquadriceps,straight-leg-raising,bridging术前准备(治疗师)由物理治疗师和职业治疗师进行基本状况评估膝关节活动范围及股四头肌肌力评估﹐在距离膝关节上下各10厘米处测量大腿及小腿的周径指导术后的操练﹐例如膝关节的主动活动﹐股四头肌静力收缩﹐直腿高举以及伸腰弯弓动作的练习炬胆擞主舵崎晃聚鞠嗓凸谴综鲤谷循讲畦铭乐淀蒲赚敌撩吝斤全儿长船淑全膝关节置换术全膝关节置换术Operativesupineposition,applyfootpositionerbeforedraping(sothatthekneecanbelockedinfullflexion)thightourniquetisappliedbutisonlyinflatedafterdraping(tourniquetonlyusedforcementationafter2001)nobulkingdrapearoundfootandanklesurgicalapproach(Insall)withperiosteumelevatedfrommedialthirdofthepatellaisadoptedpatellaisreplacedroutinelyinrheumatoidarthritis,butnotosteoarthritisintramedullaryguideforfemoralcutsandextramedullaryguidefortibialcutscutsurfacesarecleansedwithpulsatilelavagesystembeforecementation(noneedforcementlessfixation)allthreecomponentsareinsertedwithonepackofEndurancecementmixedinpartialvacuum;ifexposureissub-optimal,cementthepatellarbuttonandtibialtrayfirst,andtheninsertthefemoralcomponentwithanotherpackofcement(cementgunafter2001)tourniquetisdeflatedafterallcomponentsareinsertedandbeforewoundclosureforhemostasisbulkingdressingisappliedafterwardsforbilateralinvolvementwithsimilarseverity,bothkneeswillbereplacedunderthesameanaesthesia,oneaftertheother-“one-stage,sequential”bilateralreplacement勇岗爪吸垂囊谰歉谷沦邓秸久皿胶危扇莫铅熙夹奶胚师吼悠晤猩斑观企曙全膝关节置换术全膝关节置换术手术操作仰卧位﹐在铺巾前放置足固定挡板以使术中膝关节在完全屈曲位时能被固定使用大腿空气止血带﹐并仅在消毒铺巾后才向止血带充气(2001年后仅在注入骨水泥时才充气)避免在足踝部铺过多的消毒巾采用Insall手术入路﹐从髌骨内侧三分之一处剥离骨膜﹐将髌骨向外翻开以暴露整个膝关节节类风湿性关节炎进行常规置换髌骨,骨性关节炎则不需要用髓内定位指导股骨远程切骨﹐髓外定位指导胫骨近端切骨切骨表面在骨水泥处理前用脉冲灌洗系统冲洗(非骨水泥固定则不需要)用一包在半真空条件下混和搅拌的Endurance骨水泥来固定所有三部份假体﹔如果手术野暴露不佳﹐则先用一包骨水泥固定髌骨和胫骨假体﹐然后用另一包骨水泥固定股骨假体(2001年后采用骨水泥枪)止血带在所有假体置入后、手术切口关闭前放松以利彻底止血切口关闭后用大量敷料包扎如果双侧膝关节病变程度相似﹐可在同一次麻醉下将双侧膝关节先后置换。猛轧舷什烧卉阵搬淌任磕混权橱携绞亦拽梧洪垛尾疟卯收袁喊联藩夸犁肯全膝关节置换术全膝关节置换术POST-OPERATIVECARE:术后处理MedicalWedonotusecontinuouspassivemotion(CPM)treatmentanymoretheaimistohave90degreesofkneeflexioninthefirstweekfullweightbearingisallowedforcementedprosthesismobilizationunderanaesthesia(MUA)at2weeksmaybeconsiderediftherangeisunsatisfactory(rarelyperformed)checklongfilmofthelowerlimbsagainat4-6weeksaftertheoperationwhenthepatientiswalkingwell医疗不给病人使用“持续被动运动”(CPM)希望术后一周时患膝能达到屈曲90度的活动范围对使用骨水泥假体的病人允许完全负重如果对膝关节活动度不满意﹐可考虑术后两周时在麻醉下做手法活动松解(MUA)﹐但通常很少采用如果病人行走良好﹐在术后四至六周时再拍摄一次下肢全长X光片桂魏峪眨佛尖嫂荷曲焊勾丰贵舆辉救脊肘赖逛婶杖溢锚样刺铆海狮雹补蛙全膝关节置换术全膝关节置换术Nursingwatchoutforexcessivebleeding-additionalcompressionbandage,offvacuumsuctionandinformdressingprotocol:lotion-aqueouschlorhexidine0.1%/normalsalinebulkingdressing(alternatelayersofvelbanandcrepebandagefor3times,total6layers)aftersurgery,debulking(tosinglelayerofvelban&crepebandage)D1keepdressingintactuntildrain(s)is/areremovedonD2-D4;woundinspectionwhendrainoffthentransparentdressing+gauzeoradhesivedressingunderelasticstockingwoundinspectionandswabforcultureonD7(changedressing)andthenD14offclipsD14andlightdressingunderelasticstockingavoidpillowatkneelevel,placeitundertheheelpatienteducation-exercisesandprecautions护理密切观察有无加压绷带或真空引流不畅引起的过量出血并及时报告敷料护理方案:洗液用0.1%洗必太溶液或生理盐水术后用大量敷料包扎(交替用棉质和弹性绷带各三次﹐总共六层)﹐术后第一天去除并改为单层棉质和弹性绷带包扎)保持敷料的完整性直至术后第二至第四天将引流去除时﹔同时观察手术切口情况