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骨科在线
关节置换术的演变与最新发展
发布时间:2010/3/19 打印 关闭

关节置换术的演变与最新发展
􁇬                    马偕纪念医院、马偕医学院董事长黄俊雄医师医师//教授教授
John CharnleyJohn Charnley
* John Charnley 将骨水泥
使用于人工髋关节置换并获得良好的结果(1958)
*  全身各部位之关节置换术
风起云涌,尤其膝关节的置换更是各方人士积极投入研发的项目。
History
1861 Fergusson-Resection arthroplasty􀞼
1863 Vernevil-Interpositional arthroplasty
1920s & 1930s Campbell-Free fascial transplant 􀳯􀙙
1940 Campbel-Metallic mold
1950s Walldius & Shiers-Hinged implants
1971 Gunston-Minimally constrained total knee
1974 Insall-Total condylar
1980 Hungerford-PCA porous coating

Type of Knee Prosthesis
1. Total constrained
2. 2. Non-constrained
3. Semiconstrained

Total Constrained Prosthesis
Walldius Hinge Constrained type (1951)
--Permitted flexion-extension i the sagittal plane only and that did not require ligaments for stability􀁦
Guyper (1976)
Spherocentric(Kaufer and Matthews,1973 )
--No patellar resurfacing
--Permit rotation and flexion

Non--constrained Prosthesis
Gunston polycentric (1969) from Mayo Clinic
--Referred to as “femoral rollback” and multiple instant centers of rotation

Semiconstrained Prosthesis
Anatomic knee replacement (Townly, 1973)
--Bicruciate retaine
--All PE tibial component
--No keel to intrude into the tbia for fixation both cruciate ligaments retention
--Dished tibial contours are apparen

Total Condyle
Total Condylar cruciate sacrificed (1974)
--John Insall and Ranawat from hospital for special surgery

John Insall (2-5 years follow-up)
--It is apparent that none of the prosthesis replacing the knee joint offer results approaching the excellence of total hip replacement in terms of either relief of pain or improvement in function.
--THIS IS NO LONGER TRUE WITH REGARD TO THE “ TOTAL CONDYLAR PROSTHESIS”.

The instrument of Total Condylar
Very simple
Only 3 cutting Jig

Technique Demanded
Prof. T.L. Huang (黃登亮教授)

Clinical Result of Total Condylar Knee Arthroplasty
Orthopaedic annual meeting in 1982
--3 months To 3 years follow u
--Excellence and good results: 92% in 52 case

Survivorship
From 1979 to 1984
126 primary Total Condylar knee arthroplasties were done in 103 patients
--All polyethylene 96.4%
--metal-backed 88.4%

We recommend the use of the cost-effective (150,000 ~ 160,000 NT) and durable APT for a primary TKA, particularly in Asians with a relatively low weight,and in patients who are relatively inactive, especially the elderly.

Metal backing design
1970’s: Peter Walker
1982: Mono-block design (not modulus)

Particle disease or bone cement disease in THR developed in 1970’s

PCA(porous coated anatomic) knee
Designed by Funger Ford (John Hopkins) in (1981)

The instrument of PCA
Instrument supply and technician help from company (Howmedica)
Complicated instrument for accurate cutting
--Jig guid
--Cutting guid

Cement Fixation
Insisted on cement fixation

New Jersey Low Contact Stress (LCS) Mobile Bearing Knee
Designed by Buechel and Pappas in 1970!ˉs
Be introduced to Mackay Memorial Hospital (1985 Dec.)

Long Term Results of Low Contact Stress
Mobile Bearing Knee Replacement:
A 10 to15 yrs Survivorship Analysis
Chun-Hsiung Huang,MD;
Mackay Memorial Hospital
Clinical Orthopaedics and Related
Research (416) 1-6, 2003

Survivorship
Our study (LCS at 15 yrs)
Meniscal bearing:             83 %
Rotating platform:          92.1%
Overall mobile bearing: 88.1%
Not better than fixed bearing survival rates!

The incidence of osteolysis
80 revision TKR were done between 1995 ~ 1998.
--Group A: 34 mobile bearing knee
--Group B: 46 fixed bearing knee
The incidence of osteolysis
--Mobile bearing (47%)
--Fixed bearing knees (13%)
--P<0.05

Polyethylene Particles
More fine phagocytosable polyethylene particles were generated in LCS mobile bearing knee.

Controversy for Fixed or Mobile Bearing knees
--Low Contact Stress (LCS) mobile bearing prosthesis was design to provide congruity and mobility.
--However, we concluded that LCS knees could not demonstrate better long term performance demonstrate better long term performance.
--The mobile bearing knees were at increased risk for osteolysis in our series.
--Whether by SEM or Light-Scattering, we illustrate that the debris size of mobile model is smaller than fixed models.

Miller-Galante Knee
1987 MG I (Zimmer)
其后因塑料片太薄设计不良,尤其是髋骨组件很快就磨损破裂而被淘汰,不久M/G-I也改善而有M/G-II
Tricon Knee
其它在台湾也曾经盛行的Tricon很快被淘汰
其后各欧美大厂的产品纷纷引进台湾,百家争鸣,盛况空前

United Total Knee System

New Trends
Unicondylar  Arthroplasty
High-flex TKA
Minimally Invasive Solution
Navigation System

Unicondylar Arthroplasty

Berger et al. CORR, 367, 50-60, 1999
--10-yrs follow-up: 98
--Argenson et al. JBJS, 84-A, 2235-39,2002
--10-yrs follow-up:94%
A modern unicompartmental knee is a valid alternative for patients with unicompartmental tibiofemoral noninflammatory disease.

Several Designs
MOBILE BEARING

Several Designs
FIXED BEARING

Typical Example
Unicondylar Replacement

OUR CASE
High-flex TKA
2002 High-flex knee (Nexgen)

LPS--Flex Design

Minimally Invasive Solution

Minimally Invasive Solution

Minimally Invasive TKA
better mechanical femorotibial alignment
decreased blood loss
shorter hospital stays
increased range of motion

Minimally Invasive TKA
However, the minimally invasive surgery group had more complications and more radiographic outliers. (Mondanelli et al.)
Reducing exposure will make appropriate alignment more difficult to obtain, especially for the occasional knee surgeon, with a resultant increase in technical errors. (Laskin et al.)

Navigation System
成功大学医学中心的杨后佑医师自2002年将电脑导航系统技术引进国内并运用在人工膝关节手术。

Valgus / Varus stress

Navigation system can help surgeon perform correct alignment in varus/valgus and flexion/extension.
However, using this novel facilities can not avoid internal/external malrotation.

internal/external rotational asymmetric wear was only found in fixed-bearing knee and did not occur in LCS-r knee.
the axial rotation occurs as designers of mobile-bearing knees intended

Although the mobile bearing design tended to produce smaller debris (Huang C.H et al., JOR, 2002), the advantages of spontaneous adjustment of malrotation and better wear resistance in this design were clinically validated.

Rotating-platform mobile bearing knee was effectively provide spontaneous adjustment of malrotation, and therefore can be a good way to solve this problem.


Thank you for your patience!

来源:《常见骨科伤病400问》 作者:刘沂


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