朱慶生 曹曉瑞 閆昭 王剛

. 述評(píng) Editorial .

人工關(guān)節(jié)置換要重視患者的術(shù)后感受與功能康復(fù)

朱慶生 曹曉瑞 閆昭 王剛

關(guān)節(jié)成形術(shù)，置換，髖；髖關(guān)節(jié)；關(guān)節(jié)成形術(shù)，置換，膝；人工膝關(guān)節(jié)；人工關(guān)節(jié)

近年來，人工關(guān)節(jié)置換在我國得到了廣泛地開展和普及，據(jù)不完全統(tǒng)計(jì)去年我國的髖、膝關(guān)節(jié)置換達(dá)到近 40 萬例，我國關(guān)節(jié)外科事業(yè)得到了長足的發(fā)展，很多關(guān)節(jié)病患者得到了及時(shí)治療，生活質(zhì)量得到大幅度改善和提高。由于我國關(guān)節(jié)置換外科開展較晚，各級(jí)醫(yī)院和從事關(guān)節(jié)外科置換的醫(yī)生水平參差不齊，因此部分患者的臨床結(jié)果不如預(yù)期。且近些年來人工關(guān)節(jié)置換領(lǐng)域新技術(shù)、新材料、新方法、新設(shè)計(jì)不斷涌現(xiàn)，這對(duì)關(guān)節(jié)外科醫(yī)生來說也是一個(gè)新的挑戰(zhàn)。只有不斷學(xué)習(xí)、了解該領(lǐng)域發(fā)展的動(dòng)態(tài)，方能更好地完成日常臨床工作的需要，使患者通過人工關(guān)節(jié)置換獲得更好的療效。

一、初次髖、膝關(guān)節(jié)置換

近些年來初次全髖關(guān)節(jié)主要熱議的話題是有關(guān)手術(shù)入路、短柄假體以及微創(chuàng)技術(shù)。直接前側(cè)入路 ( DAA )和 Super-Path 入路是近年來討論比較多的話題，其主要采用前方肌間隙入路，理論上不損傷任何肌肉組織完成全髖關(guān)節(jié)置換。其主要優(yōu)點(diǎn)是手術(shù)微創(chuàng)；避免后入路帶來的脫位風(fēng)險(xiǎn)；更有利于患者術(shù)后的加速康復(fù)。文獻(xiàn)報(bào)道 DAA 全髖置換可以最大程度地提高患者的滿意度、縮短住院時(shí)間、減少術(shù)后疼痛、實(shí)現(xiàn)加速康復(fù)[1-3]。有學(xué)者對(duì) 17 個(gè)研究，2302 例患者資料分析進(jìn)行了 DAA 入路和傳統(tǒng)后入路的比較，結(jié)果顯示在術(shù)后疼痛和加速康復(fù)上 DAA 入路優(yōu)于傳統(tǒng)后側(cè)入路，而在住院時(shí)間和脫位發(fā)生率上無證據(jù)顯示前者優(yōu)于后者[4]。DAA 技術(shù)有一定的學(xué)習(xí)曲線，早期會(huì)出現(xiàn)假體位置不良和術(shù)中出現(xiàn)骨折風(fēng)險(xiǎn)尤其是在股骨側(cè)[5]。在膝關(guān)節(jié)初次置換手術(shù)技術(shù)的精準(zhǔn)化為學(xué)者所關(guān)注，因此新型導(dǎo)航技術(shù)和機(jī)器人手術(shù)被引入臨床以提高操作的精準(zhǔn)化，從而改善臨床結(jié)果。Desseaux 等[6]研究顯示新型導(dǎo)航系統(tǒng)可以使 95% 的 TKA 患者在冠狀面獲得正確的力線和假體位置。Moon 等[7]結(jié)果顯示機(jī)器人輔助的全膝關(guān)節(jié)置換無論是在矢狀面和冠狀面均能顯示精確對(duì)線及假體安放。尤其是在股骨旋轉(zhuǎn)定位較常規(guī)方法更為準(zhǔn)確。在繼續(xù)關(guān)注髖膝關(guān)節(jié)置換的新型假體設(shè)計(jì)、新材料的開發(fā)與應(yīng)用、新方法和新技術(shù)臨床應(yīng)用，近年來關(guān)節(jié)外科界已經(jīng)關(guān)注到如何降低手術(shù)風(fēng)險(xiǎn)，提高手術(shù)效能，使患者最大獲利，因此關(guān)于人工髖膝關(guān)節(jié)置換術(shù)后圍手術(shù)期加速康復(fù) ( ERAS ) 的研究得到應(yīng)有的重視。全國已經(jīng)發(fā)布髖膝關(guān)節(jié)置換加速康復(fù)圍手術(shù)期系列專家共識(shí)，涉及疼痛管理、血液管理、睡眠管理等多學(xué)科領(lǐng)域。其目的是減輕患者圍手術(shù)期的疼痛、減少輸血或避免輸血、預(yù)防血栓等，獲得好的關(guān)節(jié)功能。

二、髖、膝關(guān)節(jié)翻修

雖然初次髖膝關(guān)節(jié)置換已經(jīng)取得很大成功，但每年仍有部分患者因種種原因需要做翻修手術(shù)。導(dǎo)致初次髖膝關(guān)節(jié)置換失敗的主要原因?yàn)闊o菌松動(dòng)、聚乙烯磨損導(dǎo)致的骨溶解、感染、關(guān)節(jié)不穩(wěn)、假體周圍骨折等[8-11]。無論是髖關(guān)節(jié)翻修還是膝關(guān)節(jié)翻修，最困難的還是嚴(yán)重缺損的處理。

在髖關(guān)節(jié)翻修中股骨側(cè)假體選擇以非骨水泥假體為主，對(duì) Paprosky type I 和 II 缺損如果遠(yuǎn)端固定 ＞ 4 cm及髓腔直徑 ＜ 19 mm 者，可選用廣泛涂層假體[12-14]，而錐形柄的臨床結(jié)果優(yōu)于圓柱狀柄。 當(dāng)股骨髓腔遠(yuǎn)近端缺損不一，如 Paprosky type IIIA 和 IIIB 缺損，組配假體是非常好的選擇，它能夠滿足遠(yuǎn)近端很好地固定和調(diào)整肢體長度[15]，而且能夠獲得遠(yuǎn)期骨整合并提高假體的長期生存率，降低遠(yuǎn)期失敗率[16-17]。盡管組配柄也能用于 Paprosky type IV 缺損的重建，但異體骨植骨加上骨水泥柄或非骨水泥柄即 ( APCs ) 技術(shù)仍然是選擇之一[18]。

髖臼側(cè)的重建仍然以非骨水泥重建為主，但近些年來由于材料學(xué)的進(jìn)步，多孔材料表面處理的髖臼假體 ( 被稱之為第二代涂層技術(shù) ) 給髖臼側(cè)翻修帶來了更多的選擇。如 Regenerex Revision Acetabular Shells ( Biomet )，Pinnacle Revision Acetabular Cup System ( DePuy )，Tritanium Acetabular Shell ( Stryker ) Trabecular Metal Revision Shell ( Zimmer ) 等對(duì)包容性缺損和少量的邊緣結(jié)構(gòu)性缺損如 Paprosky type I 和 II 缺損都能有很好的重建效果[19-23]。對(duì)嚴(yán)重的髖臼缺損如 Paprosky IIIA 和 IIIB 型缺損，常常會(huì)使用 Augment + 多孔髖臼杯、Cage、Cup-Cage 等方法重建[24-27]。對(duì)一些極端病例，Paprosky 分型仍不能包括其內(nèi)的嚴(yán)重骨缺損 3 D 打印技術(shù)和個(gè)體定制假體也越來越多的應(yīng)用在髖臼假體的重建。但這種個(gè)體化制造的假體是否能夠完全匹配并充填真正的骨缺損區(qū)域，則受較多因素的影響。其中術(shù)中見到的和清創(chuàng)后的實(shí)際骨缺損狀況與術(shù)前評(píng)估的缺損有較大的差別，且價(jià)格昂貴，但仍不失為一種解決方案[28]。膝關(guān)節(jié)翻修的挑戰(zhàn)來自對(duì)有軟組織和骨缺損的翻修關(guān)節(jié)如何獲得穩(wěn)定和良好的功能？對(duì)膝關(guān)節(jié)翻修中骨缺損的處理無論是股骨側(cè)和 ( 或 ) 脛骨側(cè)其主要方法是包容性缺損采用金屬 cone，而非包容性缺損可采用金屬墊塊充填缺損，而對(duì)韌帶失衡難以重建者則宜選擇半限制性假體或全限制性假體，如果采用全限制性假體，旋轉(zhuǎn)鉸鏈?zhǔn)较ゼ袤w ( PHK ) 應(yīng)是不錯(cuò)的選擇。翻修假體的固定通常有三種模式即非骨水泥固定、混合固定 ( 假體用骨水泥，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 例膝關(guān)節(jié)翻修，隨訪 5 ～ 10 年，其假體生存率達(dá) 98%。Gofton等[30]報(bào)道 91 例混合固定的膝翻修患者平均隨訪 8.6 年，假體生存率達(dá) 95%。但混合固定需要宿主骨有足夠的骨量[31]。近些年來，多孔材料表面處理的新型假體和骨缺損的金屬充填快的應(yīng)用使得膝關(guān)節(jié)翻修假體的固定模式同樣發(fā)生了改變。MBT 是袖套與骨界面非骨水泥固定，假體和袖套采用錐度鎖定的固定機(jī)制。而 TM cone 則是 cone 與骨界面非骨水泥固定，假體與 cone 之間采用骨水泥固定。兩者在臨床上均取得了良好的療效。有學(xué)者回顧比較了 TM cone 與大塊異體骨植骨重建骨缺損的研究，結(jié)果顯示 TM cone 的遠(yuǎn)期假體生存率及感染發(fā)生率遠(yuǎn)低于后者[32]。Derome[33]結(jié)果顯示 TM cone 充填干骺端缺損，可獲得長期生物固定，其效果穩(wěn)定、可靠且并發(fā)癥發(fā)生率低。Bugler[34]報(bào)告采用干骺短袖套重建 AORI 分型 I ～ III 型缺損，短期隨訪獲得滿意療效。其主要優(yōu)點(diǎn)是操作簡單，固定牢固，無論是影像學(xué)和功能結(jié)果都很滿意。膝關(guān)節(jié)翻修要面臨的另外一個(gè)難題就是軟組織失能，特別是韌帶失能，假體的限制性設(shè)計(jì)在一定程度解決了大部分問題。限制性假體包括部分限制性假體 ( 髁限制假體 CCK ) 和全限制性假體 ( 鉸鏈膝或旋轉(zhuǎn)鉸鏈膝 RHK )。Kim[35]報(bào)道了 97例 ( 114 膝 ) 10 年 CCK 隨訪結(jié)果，其假體存留率高達(dá) 96%。Jones[36]報(bào)告 65 例 RHK 翻修病例，其中期隨訪結(jié)果優(yōu)良，但他強(qiáng)調(diào) RHK 的指征是韌帶安全失能伴有大量骨缺損的病例。

目前，人工關(guān)節(jié)置換外科在我國仍處于理論知識(shí)、手術(shù)技術(shù)的學(xué)習(xí)提高階段。但學(xué)界已經(jīng)開始關(guān)注圍手術(shù)期的處理，也更加重視關(guān)節(jié)置換后的康復(fù)問題。人工關(guān)節(jié)置換，要想獲得滿意的臨床效果，臨床醫(yī)師不僅要重視手術(shù)結(jié)果，更要重視患者的術(shù)后感受、重視患者術(shù)后的功能康復(fù)問題。

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( 本文編輯：李貴存 )

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，第四軍醫(yī)大學(xué)西京醫(yī)院骨科

2016-11-25 )