人工关节置换要重视患者的术后感受与功能康复

朱庆生 曹晓瑞 闫昭 王刚

. 述评 Editorial .

人工关节置换要重视患者的术后感受与功能康复

朱庆生 曹晓瑞 闫昭 王刚

关节成形术，置换，髋；髋关节；关节成形术，置换，膝；人工膝关节；人工关节

近年来，人工关节置换在我国得到了广泛地开展和普及，据不完全统计去年我国的髋、膝关节置换达到近 40 万例，我国关节外科事业得到了长足的发展，很多关节病患者得到了及时治疗，生活质量得到大幅度改善和提高。由于我国关节置换外科开展较晚，各级医院和从事关节外科置换的医生水平参差不齐，因此部分患者的临床结果不如预期。且近些年来人工关节置换领域新技术、新材料、新方法、新设计不断涌现，这对关节外科医生来说也是一个新的挑战。只有不断学习、了解该领域发展的动态，方能更好地完成日常临床工作的需要，使患者通过人工关节置换获得更好的疗效。

一、初次髋、膝关节置换

近些年来初次全髋关节主要热议的话题是有关手术入路、短柄假体以及微创技术。直接前侧入路 ( DAA )和 Super-Path 入路是近年来讨论比较多的话题，其主要采用前方肌间隙入路，理论上不损伤任何肌肉组织完成全髋关节置换。其主要优点是手术微创；避免后入路带来的脱位风险；更有利于患者术后的加速康复。文献报道 DAA 全髋置换可以最大程度地提高患者的满意度、缩短住院时间、减少术后疼痛、实现加速康复[1-3]。有学者对 17 个研究，2302 例患者资料分析进行了 DAA 入路和传统后入路的比较，结果显示在术后疼痛和加速康复上 DAA 入路优于传统后侧入路，而在住院时间和脱位发生率上无证据显示前者优于后者[4]。DAA 技术有一定的学习曲线，早期会出现假体位置不良和术中出现骨折风险尤其是在股骨侧[5]。在膝关节初次置换手术技术的精准化为学者所关注，因此新型导航技术和机器人手术被引入临床以提高操作的精准化，从而改善临床结果。Desseaux 等[6]研究显示新型导航系统可以使 95% 的 TKA 患者在冠状面获得正确的力线和假体位置。Moon 等[7]结果显示机器人辅助的全膝关节置换无论是在矢状面和冠状面均能显示精确对线及假体安放。尤其是在股骨旋转定位较常规方法更为准确。在继续关注髋膝关节置换的新型假体设计、新材料的开发与应用、新方法和新技术临床应用，近年来关节外科界已经关注到如何降低手术风险，提高手术效能，使患者最大获利，因此关于人工髋膝关节置换术后围手术期加速康复 ( ERAS ) 的研究得到应有的重视。全国已经发布髋膝关节置换加速康复围手术期系列专家共识，涉及疼痛管理、血液管理、睡眠管理等多学科领域。其目的是减轻患者围手术期的疼痛、减少输血或避免输血、预防血栓等，获得好的关节功能。

二、髋、膝关节翻修

虽然初次髋膝关节置换已经取得很大成功，但每年仍有部分患者因种种原因需要做翻修手术。导致初次髋膝关节置换失败的主要原因为无菌松动、聚乙烯磨损导致的骨溶解、感染、关节不稳、假体周围骨折等[8-11]。无论是髋关节翻修还是膝关节翻修，最困难的还是严重缺损的处理。

在髋关节翻修中股骨侧假体选择以非骨水泥假体为主，对 Paprosky type I 和 II 缺损如果远端固定 ＞ 4 cm及髓腔直径 ＜ 19 mm 者，可选用广泛涂层假体[12-14]，而锥形柄的临床结果优于圆柱状柄。 当股骨髓腔远近端缺损不一，如 Paprosky type IIIA 和 IIIB 缺损，组配假体是非常好的选择，它能够满足远近端很好地固定和调整肢体长度[15]，而且能够获得远期骨整合并提高假体的长期生存率，降低远期失败率[16-17]。尽管组配柄也能用于 Paprosky type IV 缺损的重建，但异体骨植骨加上骨水泥柄或非骨水泥柄即 ( APCs ) 技术仍然是选择之一[18]。

髋臼侧的重建仍然以非骨水泥重建为主，但近些年来由于材料学的进步，多孔材料表面处理的髋臼假体 ( 被称之为第二代涂层技术 ) 给髋臼侧翻修带来了更多的选择。如 Regenerex Revision Acetabular Shells ( Biomet )，Pinnacle Revision Acetabular Cup System ( DePuy )，Tritanium Acetabular Shell ( Stryker ) Trabecular Metal Revision Shell ( Zimmer ) 等对包容性缺损和少量的边缘结构性缺损如 Paprosky type I 和 II 缺损都能有很好的重建效果[19-23]。对严重的髋臼缺损如 Paprosky IIIA 和 IIIB 型缺损，常常会使用 Augment + 多孔髋臼杯、Cage、Cup-Cage 等方法重建[24-27]。对一些极端病例，Paprosky 分型仍不能包括其内的严重骨缺损 3 D 打印技术和个体定制假体也越来越多的应用在髋臼假体的重建。但这种个体化制造的假体是否能够完全匹配并充填真正的骨缺损区域，则受较多因素的影响。其中术中见到的和清创后的实际骨缺损状况与术前评估的缺损有较大的差别，且价格昂贵，但仍不失为一种解决方案[28]。膝关节翻修的挑战来自对有软组织和骨缺损的翻修关节如何获得稳定和良好的功能？对膝关节翻修中骨缺损的处理无论是股骨侧和 ( 或 ) 胫骨侧其主要方法是包容性缺损采用金属 cone，而非包容性缺损可采用金属垫块充填缺损，而对韧带失衡难以重建者则宜选择半限制性假体或全限制性假体，如果采用全限制性假体，旋转铰链式膝假体 ( PHK ) 应是不错的选择。翻修假体的固定通常有三种模式即非骨水泥固定、混合固定 ( 假体用骨水泥，柄用非骨水泥固定 ) 和骨水泥固定。Whiteside[29]采用非骨水泥固定方式行 110 例膝关节翻修，随访 5 ～ 10 年，其假体生存率达 98%。Gofton等[30]报道 91 例混合固定的膝翻修患者平均随访 8.6 年，假体生存率达 95%。但混合固定需要宿主骨有足够的骨量[31]。近些年来，多孔材料表面处理的新型假体和骨缺损的金属充填快的应用使得膝关节翻修假体的固定模式同样发生了改变。MBT 是袖套与骨界面非骨水泥固定，假体和袖套采用锥度锁定的固定机制。而 TM cone 则是 cone 与骨界面非骨水泥固定，假体与 cone 之间采用骨水泥固定。两者在临床上均取得了良好的疗效。有学者回顾比较了 TM cone 与大块异体骨植骨重建骨缺损的研究，结果显示 TM cone 的远期假体生存率及感染发生率远低于后者[32]。Derome[33]结果显示 TM cone 充填干骺端缺损，可获得长期生物固定，其效果稳定、可靠且并发症发生率低。Bugler[34]报告采用干骺短袖套重建 AORI 分型 I ～ III 型缺损，短期随访获得满意疗效。其主要优点是操作简单，固定牢固，无论是影像学和功能结果都很满意。膝关节翻修要面临的另外一个难题就是软组织失能，特别是韧带失能，假体的限制性设计在一定程度解决了大部分问题。限制性假体包括部分限制性假体 ( 髁限制假体 CCK ) 和全限制性假体 ( 铰链膝或旋转铰链膝 RHK )。Kim[35]报道了 97例 ( 114 膝 ) 10 年 CCK 随访结果，其假体存留率高达 96%。Jones[36]报告 65 例 RHK 翻修病例，其中期随访结果优良，但他强调 RHK 的指征是韧带安全失能伴有大量骨缺损的病例。

目前，人工关节置换外科在我国仍处于理论知识、手术技术的学习提高阶段。但学界已经开始关注围手术期的处理，也更加重视关节置换后的康复问题。人工关节置换，要想获得满意的临床效果，临床医师不仅要重视手术结果，更要重视患者的术后感受、重视患者术后的功能康复问题。

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( 本文编辑：李贵存 )

Highlights of hip and knee arthroplasty: feelings of postoperative patients and functional rehabilitation

ZHU Qing-sheng, CAO Xiao-rui, YAN Zhao, WANG Gang.
Department of Orthopedics, Xijing Hospital, the fourth Military Medical University, Xi’an, Shanxi, 710032, PRC

Minimally invasive approach for primary total hip arthroplasty ( THA ), including direct anterior approach ( DAA ) and Super-Path approach, has become popular with orthopaedic community.Theoretically there is no damage to the muscles through anterior intermuscular space approach.The main advantages are minimally invasive procedures, avoidance of the risk of hip dislocation via the posterior approach and acceleration of the course of convalescence.The precision of techniques in primary total knee arthroplasty ( TKA ) has been focused on by scholars.In order to improve the accuracy of operation and clinical outcomes, new navigation technology and computer-assisted TKA have been implemented.Bone stock reconstruction in THA and TKA revision surgery is one of the biggest challenges for surgeons.Femoral and acetabular prostheses are usually uncemented in THA revision surgery.Currently, with the development of materialogy, the problem of serious bone loss in THA and TKA revision surgery has been solved with the appearance of acetabular prostheses made of porous materials ( also called coating technology of the 2nd generation ) and metal blocks.As for the reconstruction of ligament imbalance, semiconstrained prostheses or fully constrained prostheses can be chosen.If fully constrained prostheses are used, the prostheses designed on the rotation platform are preferred.To acquire satisfactory clinical outcomes in hip and knee arthroplasty, the surgeons should pay attention to not only surgical results, but also feelings of postoperative patients and functional rehabilitation.

Arthroplasty, replacement, hip; Hip joint; Arthroplasty, replacement, knee; Knee prosthesis; Joint prosthesis

10.3969/j.issn.2095-252X.2016.12.001

R687.4

710032 西安，第四军医大学西京医院骨科

2016-11-25 )