广东省中医院二沙岛医院骨科 许树柴膝骨性关节炎(Knee Osteoarthritis)是指膝关节软骨出现原发或继发性退行性改变,并伴有软骨下骨质增生,从而使关节逐渐被破坏及产生畸形,影响膝关节功能的一种退行性疾病。疾病整个过程涉及关节软骨、软骨下骨、韧带、关节囊、滑膜及关节周围肌肉(图1)。它开始表现为膝关节软骨生化代谢的异常和结构上的损害,进而发生退行性改变,产生纤维化、缝隙、溃疡及整个关节面的缺损,导致关节疼痛和功能丧失。在超过50岁以上人群中,骨关节炎在导致长期残疾的疾病中仅次于心血管疾病排名第二。膝骨性关节炎的患病率女性较男性多见,尤其多见于中老年肥胖女性。女性发病多开始于40岁,男性50岁;其中55-60岁发病率最高,70岁以上发病率几乎达到80-90%。本病属中医的“痹症”、“骨痹”、“膝痹”等范畴。病因病理原发性膝骨关节炎的发病原因目前尚不清,可能为多因素作用的结果。 1.年龄:临床发现,本病的发生率随年龄的增长而上升,特别是到中老年期,患病率明显升高。可能与下列因素有关:(1)中年以后神经-肌肉功能逐渐减退,由于运动不协调而导致关节损伤。(2)随着年龄的增长,骨中无机盐的含量进行性增高,导致骨的弹性和韧性减低。同时供应关节的血流量减少,关节软骨因营养减少而变薄、基质减少、纤维化,使关节内负重分布发生改变,关节面及关节软骨易受损伤。(3)绝经前后的妇女,由于雌激素失衡而使骨质丢失增加,发生骨质疏松。 2.损伤和过度使用:是较为公认的原因之一。 3.肥胖:国外有人统计发现,37岁时超过标准体重20%的男性,其患原发性膝骨关节炎的危险性较标准体重者高1.5倍,而女性肥胖者患病的危险性较标准体重者高2.1倍。也可能与关节负重增大和肥胖引起的姿势、步态、运动习惯等有关。 4.遗传:许多继发性膝骨关节炎有明显的遗传倾向。 5.其他:如关节软骨基质的改变、骨内压升高等。在多种原因单独或共同作用下,膝骨性关节炎病理变化主要包括关节软骨变化、软骨下骨质改变、滑膜病变、肌肉的改变、细胞因子参与骨关节炎中作用等。关节软骨是膝骨性关节炎最早病变的部位。病理改变是主要是早期关节软骨表面的胶原纤维退化及后期软骨面的磨损,软骨间质的破坏不断发展而导致关节功能逐步丧失。其次就是软骨下骨的改变,骨关节炎时,软骨剥脱,软骨下骨质暴露,骨髓内血管和纤维组织增生,产生新骨,形成硬化层,硬化区在压应力作用下,骨质发生微骨折、坏死及囊性变,继而软骨边缘出现骨赘新生物,软骨下骨髓内骨质增生,囊肿形成。滑膜病变在膝骨关节炎进程中起重要作用。滑膜和关节囊在骨关节炎初期虽无变化,但后期剥脱的软骨附着在滑膜上,刺激滑膜增生肥大,关节滑膜受脱落软骨碎片的刺激而充血、水肿、增生、肥厚、滑液增多;肥大的滑膜或形成皱襞,嵌夹在关节间,造成关节交锁、滑膜卡压等引起滑膜炎。滑膜炎促使血管增生及释放大量炎性介质,进一步降解软骨,如此周而复始,造成恶性循环。 图片:微骨折技术(钻小而深的洞,有利于软骨修复) 与关节置换术临床表现与诊断膝骨关节炎主要表现为膝关节疼痛和功能障碍。关节疼痛在早期可仅表现活动时隐痛,随着患者病情的发展,疼痛逐渐加重,性质改变为胀痛,在上下楼、下蹲、起立时明显,严重时在静止状态也可有疼痛发作。有的表现为在行走过程关节腔内砾轧音、关节打空、绞索。有的表现为关节僵直。严重的膝骨关节炎患者还可伴有关节肿胀、周围水肿、肌肉萎缩等。关节功能障碍包括:关节僵硬,不稳,活动范围减少,步行能力下降等。关节僵硬是指经过休息,或长时间处于某一体位后,自觉活动不利,特别是起动困难,胶滞。不稳有伸膝支撑稳定力量减弱,和侧向不稳,表现为步态摇摆。屈伸活动范围减少常常由于膝关节疼痛肿胀,被迫轻度屈曲位以增加关节腔内容积,久之则腘绳肌痉挛,伸直受限。膝骨关节炎诊断多采用美国风湿病学会1995年的诊断标准:1.临床诊断标准①前月大多数时间内有膝痛。②有骨摩擦音。③晨僵<30min。④年龄≥38岁。⑤膝检查示骨性肥大。满足①②③④或①②⑤或①④⑤者可诊断为膝骨关节炎。 2.临床、实验室和放射学诊断标准(图2):①前月大多数时间内有膝痛。②X线片示关节边缘有骨赘。③关节液检查符合骨关节炎。④年龄≥40岁。⑤晨僵<30min。⑥关节活动时有骨响声。满足①②或①③⑤⑥或①④⑤⑥者可诊断为膝骨关节炎。本病需与风湿性关节炎、类风湿关节炎、膝关节非特异性滑膜炎、髌骨软化症、色素绒毛结节性滑膜炎等病相鉴别。风湿性关节炎有链球菌感染史,并常于再次接触链球菌感染而复发,也表现为游走性。活动期血沉增快,抗“O”阳性。X线检查多无异常发现。类风湿关节炎科发生于任何年龄,女性多于男性,游走性,晨僵现象,好发于四肢小关节,类风湿因子多为阳性,久发病例X光片常见关节骨质疏松及不同程度骨质破坏。膝关节非特异性滑膜炎表现为反复出现的膝关节积液,浮髌试验阳性。关节肿胀程度与疼痛不一致,肿胀常很严重,但关节疼痛相对较轻。X光片仅显示软组织肿胀。髌骨软化症亦属于退行性疾病,重点累计髌股关节,表现为上下楼梯、下蹲起身膝前疼痛,髌骨研磨试验阳性,髌骨内侧关节面常有压痛,X线髌骨轴位片可见髌股关节间隙狭窄,关节面不光滑。色素绒毛结节性滑膜炎多见于膝髋踝关节,表现为受累关节反复肿胀,全身无症状,血沉不快,X光早期仅可见软组织肿胀,晚期可见边缘骨性破坏,关节液穿刺暗红色或咖啡色。治 疗(一)辨证治疗1、瘀血阻滞型 代表方剂:身痛逐瘀汤加减。2、阳虚寒凝型 代表方剂:独活寄生汤加减。3、肾虚髓亏型 代表方剂:清骨散、知柏地黄丸。(二)中成药治疗辨证使用中成药。(三)中药外治法应用中医中药外治关节局部病变的相应部位,方法简便易行,无明显副作用,对减轻或缓解疼痛及改善关节的活动功能有良好的效果。中药熏洗:使用金桂外洗方(组成:半风荷60 入地金牛60 生川乌30 生草乌30 宽筋藤30 海桐皮30 大黄18 桂枝18),用于关节炎后期关节强直拘挛,疼痛麻木等。借助药力和热疗综合作用于患膝,改善局部血液循环,消除关节周围炎症。(四)针灸疗法可分为针刺法、灸法、刺络拔罐法、火针温灸拔罐法、水针穴位注射法等。(五)手法治疗1.轻度捏拿法:嘱患者仰卧位,患肢取中立位,如果膝关节不能完全伸直,应在膝关节窝处垫实,以稳定膝关节的位置,避免膝关节造成医源性损伤。术者站于患侧施术。捏拿从上至下,手法宜轻宜柔,频率不宜快,对骸骨上下缘、内外侧缘做顺理肌筋手法,以达宣通气血、舒筋活络、缓解痉挛的功效。2.抱膝按揉法;患者仰卧位,患肢屈曲约100度左右,术者迎患腿侧坐。双手掌部在患肢两侧相对环抱揉按,力量适中,由轻到重,速度不应快,以病人舒服为度。经约1分钟揉按后,术者立于思侧帮助患者进行膝关节伸屈活动,不可过于勉强,逐步加大伸屈幅度,经数次伸屈活动后,嘱患者尽量将膝关节伸直,术者扶按髌骨,沿髌股关节面做上下、左右慢慢按压推拉,研磨等手法。然后使患者尽量放松患肢,使患肢尽量伸直,如伸直不完全者,术者双手掌扶于膝关节使之徐涂加压使其伸直,然后再帮助患者练习屈曲活动。伸直和屈曲的程度因人而异,逐渐加大幅度。本法对髌股关节起到磨造作用,同时有舒筋活血、剥离粘连、消炎止痛、恢复关节功能等作用。3.运膝法:患者仰卧位,术者站于患侧,嘱患者屈髋、屈膝各90度,术者一手扶住膝关节固定患肢位置,另一手握住小腿下端,沿顺时针方向画圆。画团的幅度均由小到大,速度稍慢,力度和缓轻柔。然后再做逆时针旋转,要领同前。此手法旨在使小腿带动膝关节活动,有促进关节血液循环、缓解膝关节筋肌痉挛、松解膝关节周围粘连、恢复膝关节功能等作用。(六)功能锻炼1、股四头肌舒缩锻炼法:膝关节疼痛较重或关节积液时,多主张限制患肢活动或不负重活功,在疼痛能耐受的情况下,尽早行股四头肌舒缩锻炼。2、膝关节仲屈活动法:患者坐在床边,将膝置于床旁,然后尽量伸直膝关节,保持伸直位,有酸胀感时、缓促屈曲胶关节.反复进行锻炼。3、直腿抬高锻炼法:病人仰卧位,先屈膝关节并将股部拾起,然后伸直膝关节并保持列有酸胀感的屈曲膝关节反复进行锻炼。上述方法每日3—5次,循序渐进.直到正常行走。(七)西医治疗1.口服药物①对乙酰氨基酚;②NSAIDs;③阿片类药物等。2. 注射药①糖皮质激素:关节腔注射长效糖皮质激素可缓解疼痛、减少渗出。疗效持续数周至数月,但在同一关节不应反复注射,注射间隔时间不应短于4-6个月。②透明质酸(玻璃酸):非药物疗法和单纯止痛刺疗效不佳的膝关节OA可采用关节腔内拄射透明质酸(玻璃酸)类制剂治疗。对减轻关节疼痛、增加关节活动度、保护软骨均有效,治疗效果可持续数月。对轻中度的OA具有良好的疗效。每周1次膝关节腔内注射,4-6周为1个疗程。注射频率可以根据患者症状适当调整。③NSAIDs:肌肉注射起效快,胃肠道反应不明显。3. 局部外用药①NSAIDs:局部外用NSAIDs制剂,可减轻关节疼痛。不良反应小。②辣椒碱:辣椒碱乳剂可消耗局部感觉神经末梢的P物质.可减轻关节疼痛和压痛。4. 骨关节炎慢作用药(DMOAD)及软骨保护剂此类药物一般起效较慢,需治疗数周才见效,故称骨关节炎慢作用药。具有降低基质金属蛋白酶、胶原酶等活性的作用,既可抗炎、止痛,又可保护关节软骨,有延缓OA发展的作用。但目前尚未有公认的理想的药物,常用药物氨基葡萄糖、双醋瑞因、硫酸软骨素、双膦酸盐等可能有一定的作用。(八)手术治疗1. 关节镜清理手术手术适应证:症状明显,时间短,保守治疗不佳者,或明确有膝关节游离体。临床表现和X线片明确诊断为骨性关节炎,关节间隙狭窄不明显,关节力线排列基本正常,中度症状骨关节炎。关节镜清理术:涵盖了关节内冲洗、半月板成形,纤维化软骨清理,关节修整或打磨,部分滑膜切除,游离体摘除,滑膜皱襞成形,外侧支持带松解等术式。2. 自体骨软骨移植术(图3) 手术适应证:有症状的位于股骨关节面的全层软骨损伤,患者年龄介于15-55岁,软骨损伤为outbridge分级III-IV级,有学者建议病损范围<2CM2。病损≥2CM2 者,可以使用保存软骨活性的异体骨软骨移植。手术方法:(1)术前准备,完善膝关节MR检查确认病灶位置大小;确认手术适应症;(2)髌内缘弧形切口,屈曲暴露膝关节病灶,圆头磨钻打磨病灶,小环钻取出病灶骨质至软骨下骨15-25mm;(3)小环钻取非负重区软骨带软骨下骨相应长度的骨柱,植入软骨缺损区;(4)术后可马上进行全范围关节活动,需2-3周免负重,随后2周部分负重,30-40kg。 微创单髁置换术程序,仅仅置换1/3的软骨面 图 膝关节软骨损伤自体骨软骨移植; 软骨帽技术 ; 单髁置换技术 HTO膝关节周围截骨改变力线,延缓软骨退变3.胫骨高位截骨术 手术适应证:年龄<55岁,体形无肥胖,要求活动量大,术前活动度:屈曲达到90°,屈曲挛缩<15°,内翻<10°,单间室关节炎,膝关节稳定性好。 手术方法:外侧闭合胫骨高位截骨术(closed wedge high tibial osteotomy,CWO)取膝外侧纵行切口,切口位于腓骨小头与胫骨结节之中线,打开近端胫腓关节,近端截骨于关节面下2cm,平行于关节面进行,保留内侧部分骨皮质;远端斜行截骨按术前设计角度进行,外翻折顶,以Giebel槽式钢板固定。 内侧撑开胫骨高位截骨术(open wedge high tibial osteotomy,OWO)取膝内侧纵行切口,在X线透视下以修整的自体髂骨植骨,楔形骨块外缘高度5-13mm,另取部分碎骨植入截骨间隙以MAY解剖型钢板固定。术前设计截骨角度以患膝术后胫骨股骨角达到外翻9°。4.全膝关节置换手术适应证:老年人有膝关节疼痛、功能障碍,有或者无膝关节畸形,严重影响工作、生活,保守治疗无效。手术方法:⑴恰当的暴露关节;⑵假体大小应尽量符合原来的解剖直径,保证假体精确对位对线;⑶保证软组织平衡;⑷伸直间隙、屈膝间隙相等;⑸胫骨平台后倾0-10°;⑹股骨6°外翻截骨,垂直胫骨干截骨,胫骨平台中立位,平行踝关节运动轴;股骨假体适当外旋;⑺保持髌骨运动轨迹良好,无拇指试验阴性;⑻采用现代骨水泥,保证假体与骨之间稳妥的水泥界面;⑼采用鸡尾酒混合镇痛液关节腔周围浸润注射;⑽术后多模式镇痛,保证患者早起功能锻炼。 5.单髁置换术 手术适应证:单间室的骨关节炎或骨坏死; 放射学检查提示对侧间室可以保留且髌股关节未受累或只是轻度退变。术前至少有90°的活动度,屈曲挛缩小于5°,内翻畸形小于1O°,外翻畸形小于15°;病人休息时疼痛轻微;对于年龄较大,身体一般状况不良,不愿意行全膝置换时也可行单髁置换术。 手术方法:(Oxford 牛津单髁)屈膝位,取膝关节正中纵切口,髌骨内侧入路,暴露关节腔,检查前后交叉韧带是否完整,髌股关节面及内外侧间室关节面病变程度。如前后叉韧带不完整,髌股关节及外侧间室病变严重,可以考虑术中改为全膝关节置换。将内侧股骨髁、髁间窝和胫骨平台增生的骨赘切除,将内侧半月板切除。定位器定位后行股骨和胫骨截骨,术中保持力线0°或轻度内翻,截骨过程中避免损伤侧副韧带与交叉韧带。 然后进行试模测试,胫骨试模应能覆盖周围皮质骨。试模调试达到软组织平衡后,植入假体并骨水泥固定,术区脉冲冲洗, 留置负压引流管后。逐层依次缝合伤口。 预防与调理 提高目标人群对膝骨关节炎的认识,改善患者的生活方式,通过信息的交流,促进目标人群自愿采纳有利于健康的行为和生活方式,消除或减少膝骨关节炎的危险因素,从而预防疾病,使患者达到最佳的健康状态。适量运动,可保护关节,如游泳、打太极拳和步行等,尽量减少上下楼梯,以减轻膝关节的负荷。老年人多走路、晒太阳,不可过度负重;免受凉受潮、免久坐,尤其不宜长久屈膝大于 90°;肥胖病人应减肥,以减轻负重,避免过多下蹲,座椅位置升高,如厕时使用坐厕;天气变化时注意膝关节的保暖。总之注意保持健康的生活方式有利于膝骨关节炎的病情缓解和控制。预后与转归 膝骨关节炎患者首先出现膝关节疼痛,僵硬,随着病程的进展疼痛加重,伴有功能受限,畸形,下肢力线改变,关节活动范围减少,最终因疼痛,畸形,功能受限接受关节置换手术治疗。然而随着社会医疗保障的提高与普及,膝骨关节炎纳入慢病管理,很多患者在关节炎早期就得到了有效的治疗,减轻了痛苦,生活质量得到很好的改善。 古籍选读《素问脉要精微论》指出:“膝者,筋之府,屈伸不能,行则偻附,筋将惫矣”。《张氏医通》指出:“膝为筋之府……膝痛无有不因肝肾虚者,虚则风寒湿气袭之”。 倘若素体禀赋不足,或后天失养,内伤七情等导致正气虚弱,而风、寒、暑、湿、燥、火、痰、瘀等淫邪入侵,蕴积搏结于骨节而发生骨关节痹病。因此膝痹证病本在肝肾虚,病标在风寒湿阻,瘀血闭阻,属本虚标实之证。
广东省中医院二沙岛医院骨科--保膝治疗组 许树柴 黄泽鑫 陈伯建 刘洪亮胫骨高位截骨(HTO)术是个较老且成熟的手术。创伤后关节不稳和内侧间室过度负重引起的症状;老年病人失代偿性单间室性骨关节炎有内翻者,可通过外翻截骨来治疗。这两个群体的病例应分别予评价。几十年的临床研究证实,在年青有活力的,或相对年轻的人群截骨术能延缓退变的进行,比单髁膝关节置换和全膝关节置换术有较多的优势。现在,HTO又受到广泛重视,随着技术的改进及内固定材料的进步,效果更有提高。开放式截骨术(Opening Wedge Osteotomy)不须作腓骨截断,故手术比以前更准确,并发症更少。胫骨高位截骨是指截骨平面在胫骨结节以上,而不是在其以下。假若膝关节单髁骨性关节炎最初是由于机械因素所致,即由于胫骨关节力线改变过度负荷引起,它的治疗应包括力学原则,在合并有内翻畸形的内侧胫股关节骨关节炎时,应用截骨术改变内侧部份的过度负荷,使其转移到外侧部份,并使应力达到平衡。相反外翻畸形合并外侧胫股关节炎时,应行内翻截骨术,使其达到正常的外翻力线。截骨术的治疗原理除上述机械因素外,有作者以为,通过截骨,使骨关节的过高骨内压降低,使软骨下骨质的血运重建及增加关节的稳定性,这对退变关节的修复,症状缓解亦有重要作用。假若膝关节轴成异常,骨关节炎可先始于一侧(内侧或外侧),由于正常膝关节60~75%的负荷通过膝关节内侧,当步行下肢负重时,膝关节有一向外的摆动,使膝内侧部份负荷大大增加,故膝关节骨关节炎多先始于内侧,并多合并内翻畸形。其截骨术式有多钟,开放楔形截骨术是其杰出代表。随着内固定技术的发展,手术效果明显提高,以开放楔形截骨术防治力线不良所致骨性关节炎就被更多人接受。以图解说明开放楔形截骨术如下。 (部分内容From :Tibial & Femoral Opening Wedge Osteotomy System Surgical Technique,Arthrex Inc.)术前准备,作负重位全长下肢X-RAY片,测量截骨角度(有几种不同方法); 病例:46岁,M,滑雪运动员,多发韧带伤,内翻畸形,内侧关节炎,膝关节疼痛,开式截骨,纠正10度内翻;术后二月全负重行走,膝关节内侧疼痛缓解,膝关节稳定性改善(许树柴教授病例)。胫骨高位截骨术假若畸形矫正满意,而无技术并发症,其结果绝大多数是好的。大多术前疼痛明显缓解,步行能力提高,关节活动增加,因此中年或中年以下的患者无论是全膝关节置换或单髁置换都是应当慎重的。胫骨高位截骨术对活动能力减少的老人是一种与膝关节置换竞争的手术;胫骨高位截骨选择的对象年龄相对较轻,活动能力较强,并以单髁骨性关节炎为主。是一种充分利用膝关节健康软骨有利条件,使部分正在退变的软骨得到修复的手术,它可以减轻症状,延缓骨关节炎的进展,对60岁以下的患者是一种可免除或延缓关节置换的措施. 如下图的上行图片:Case 2男性,19岁,因发现右膝关节内翻、过伸畸形伴跛行5年(左侧膝关节也有类似畸形,暂时无症状)。于2006年7月就诊,其母亲也有类似病史。查体:右膝关节内翻畸形约15度,应力下过伸约20度,内翻及外翻时膝关节均有松动感,Lanchman试验(+)。无负重下X片示:右膝关节内翻畸形约15度,胫骨平台无后倾,倒呈前倾13o。膝关节MR示:右膝内侧股骨及胫骨软骨面已有缺损并囊性变。诊断:先天性膝关节内翻畸形(Blount病)。 术前X线可见右膝关节内翻畸形约15°,胫骨平台前倾畸形13°;术前膝关节MR示:右膝内侧胫、股骨骨软骨面已有缺损并囊性变 ; 应力位过伸畸形明显 术后6月X片示右膝内翻、前倾畸形已矫正,胫骨截骨处愈合,腓骨未愈合,但无症状。(许树柴教授随访10年以上病例)其他技术:弧形截骨,截骨后外支架固定,缓慢矫形等。(如上图的下面病例。)Case 3 19岁,胡**,膝关节内翻畸形,短缩3.7CM,弧形截骨,矫形术后等长,脊柱及肢体平衡,膝关节疼痛消失(许树柴教授病例)。
日前,在广东省卫生厅官方网站张榜公布了广东省人工髋、膝关节置换技术准入医疗机构名单。广东省中医院的二沙岛医院顺利通过专家评审,晋级成为广东省内首批78家人工关节置换技术准入单位之一。作为广东省首批认定具备可开展髋、膝关节置换两种手术资质的医院之一,我院的技术力量得到专家和同行的认可,标志着我院人工关节置换技术完全达到国家技术规范标准,迈入了全省先进行列。 省中医二沙岛医院骨科主任许树柴教授被广东省第一批认定同时具备髋、膝关节置换两种手术准入资格的专科医生。二沙岛医院骨科今后将进一步提高医疗技术和管理水平,加强随访服务,让更多关节疾病的患者享受到高质量的标准化的医疗服务。人工关节置换的医生必须要有严格的培训,如下图片可见国内外人工关节置换培训的证明款式。 这是许树柴教授参加欧洲人工关节中心德国ENDO-KLINIK医院;德国Bad Kreuznach医院,香港玛丽医院人工关节置换外科等的培训证明书部分。 人工膝关节置换术 这是2013年我本人参加的美国 Boston Adover 的人工膝关节置换及运动医学真实尸体操作培训所用的材料及场景,比中国的真正的手术的耗材,操作工具还多,还随手可得。 附件2第一批准予开展人工髋关节置换、人工膝关节置换技术临床应用的医师名单编号 姓名 单位 职称 髋/膝准入类别78林定坤广东省中医院主任医师人工髋关节置换、人工膝关节置换79曹学伟广东省中医院副主任医师人工髋关节置换、人工膝关节置换80许树柴广东省中医院主任医师人工髋关节置换、人工膝关节置换据悉,为规范人工髋/膝关节置换技术的临床应用,卫生部着手建立人工关节置换注册登记制度,自今年起,开始在全国各级具有人工关节置换手术准入资质的医院强制实施该制度。医院必须获得相关资质后才可以实施该项技术,这意味着人工关节置换技术准入门槛进一步提高,患者的权益得到保障。 见附件:关于公布第一批准予开展髋关节置换、膝关节置换技术临床应用医疗机构和医师名单的通知 2013-06-05 17:07:19广东省卫生厅 【办公室】粤卫办函〔2013〕127号各地级以上市卫生局、深圳市卫生和人口计划生育委员会,佛山市顺德区人口和卫生药品监督局,部属、省属驻穗医药院校附属医院及厅直属有关单位: 按照《卫生部办公厅关于印发人工髋关节置换技术管理规范(2012版)的通知》(卫办医政发〔2012〕68号)、《卫生部办公厅关于印发人工膝关节置换技术管理规范(2012版)的通知》(卫办医政发〔2012〕93号)要求,我厅组织了相关技术临床应用能力评审工作。经专家评审,准予广东省人民医院等78家医院开展人工关节置换诊疗技术临床应用(名单及相应技术项目见附件1);准予郑秋坚等345名医师开展人工关节置换诊疗技术临床应用(名单及相应技术项目见附件2)。 医院或医师开展人工关节置换技术自评达到上述规范要求,可向我厅申请准予临床应用。 特此通知。 附件: 1.第一批准予开展人工髋关节置换、人工膝关节置换技术临床应用的医疗机构名单 2.第一批准予开展人工髋关节置换、人工膝关节置换技术临床应用的医师名单广东省卫生厅办公室2013年5月16日
Total Knee Replacement 全膝关节置换 广州中医药大学附属广东省中医院二沙岛医院骨科 许树柴 李晓武 翻译并整理 If your knee is severely damaged by arthritis or injury, it may be hard for you to perform simple activities, such as walking or climbing stairs. You may even begin to feel pain while you are sitting or lying down. 如果你的膝关节因为关节炎或受伤而严重破坏,可能让你很难进行简单的活动,如走路或爬楼梯。你甚至开始感到疼痛即便你是坐着或躺着。If nonsurgical treatments like medications and using walking supports are no longer helpful, you may want to consider total knee replacement surgery. Joint replacement surgery is a safe and effective procedure to relieve pain, correct leg deformity, and help you resume normal activities. 如果像药物和使用助行支架等非手术治疗不能缓解症状,你可能要考虑行全膝关节置换手术。关节置换手术是一种安全有效的方法,能缓解疼痛,矫正畸形腿,并帮助你恢复正常活动。Knee replacement surgery was first performed in 1968. Since then, improvements in surgical materials and techniques have greatly increased its effectiveness. Total knee replacements are one of the most successful procedures in all of medicine. According to the Agency for Healthcare Research and Quality, more than 600,000 knee replacements are performed each year in the United States. 早在1968年,全膝关节就已经开展。此后,手术材料和技术的改进都大大增加了手术的有效性。全膝关节置换是医学界最成功的手术之一。根据美国医疗保健研究与质量局,在美国,每年有超过60万台膝关节置换手术。 Whether you have just begun exploring treatment options or have already decided to have total knee replacement surgery, this article will help you understand more about this valuable procedure. 无论你是刚刚开始探索治疗方案或已经决定要行全膝关节置换术,这篇文章将帮助您了解更多关于这个手术的过程。Anatomy 解剖 The knee is the largest joint in the body and having healthy knees is required to perform most everyday activities. 膝关节是人体最大的关节,健康的膝关节对于我们大多数的日常活动是必须的。The knee is made up of the lower end of the thighbone (femur), the upper end of the shinbone (tibia), and the kneecap (patella). The ends of these three bones where they touch are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily. 膝关节由股骨下端、胫骨的上端、还有髌骨组成。这三块骨头,他们彼此的接触面均覆盖着光滑的关节软骨,这样保护骨骼,并使骨头之间能够轻松移动。The menisci are located between the femur and tibia. These C-shaped wedges act as "shock absorbers" that cushion the joint. 半月板位于股骨和胫骨之间。C形的半月板可以充当“减震器”以缓冲关节受力。Large ligaments hold the femur and tibia together and provide stability. The long thigh muscles give the knee strength. 大的韧带连接股骨和胫骨并提供稳定性。大腿肌肉为膝关节提供力量。All remaining surfaces of the knee are covered by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage, reducing friction to nearly zero in a healthy knee. 膝关节的关节面覆盖有薄的、被称为滑膜的组织。在健康的膝关节,这种滑膜能分泌一些液体,可以润滑软骨,使关节摩擦力几乎为零。Normally, all of these components work in harmony. But disease or injury can disrupt this harmony, resulting in pain, muscle weakness, and reduced function. 通常情况下,各个组织的协调工作。但疾病或外伤可破坏这种关节,可导致疼痛、肌肉无力,并减少关节功能。Cause 病因The most common cause of chronic knee pain and disability is arthritis. Although there are many types of arthritis, most knee pain is caused by just three types: osteoa rthritis, rheumatoid arthritis, and post-traumatic arthritis. 慢性膝关节疼痛和功能障碍的最常见原因是关节炎。虽然有许多类型的关节炎,膝关节疼痛往往是由于骨关节炎、类风湿性关节炎和创伤后关节炎这三种类型造成的。· Osteoarthritis.This is an age-related "wear and tear" type of arthritis. It usually occurs in people 50 years of age and older, but may occur in younger people, too. The cartilage that cushions the bones of the knee softens and wears away. The bones then rub against one another, causing knee pain and stiffness.· 骨关节炎,这是一种与年龄有关的“磨损”类型的关节炎。通常发生在50岁及以上的患者,但也可发生于年轻人。缓冲关节受力的软骨软化和磨损。骨头相互摩擦,造成膝盖疼痛和僵硬。· Rheumatoid arthritis.This is a disease in which the synovial membrane that surrounds the joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most common form of a group of disorders termed "inflammatory arthritis."· 类风湿关节炎,这是一种围绕关节的滑膜发炎和增厚的疾病。这种慢性炎症可破坏软骨,并最终导致软骨丧失,关节疼痛和僵硬。类风湿性关节炎是“炎性关节炎”最常见的形式。· Post-traumatic arthritis.This can follow a serious knee injury. Fractures of the bones surrounding the knee or tears of the knee ligaments may damage the articular cartilage over time, causing knee pain and limiting knee function.· 创伤后关节炎,这可以发生在严重的膝关节损伤后。发生于膝关节的骨折、韧带损伤可以随着时间的推移,慢慢破坏关节软骨。导致膝关节疼痛、活动受限。 Description 概述 A knee replacement (also called knee arthroplasty) might be more accurately termed a knee "resurfacing" because only the surface of the bones are actually replaced 膝关节置换术,更准确地说应该是膝关节表面的置换,因为置换的只是骨头的表面。There are four basic steps to a knee replacement procedure. 膝关节置换术有四个基本步骤。· Prepare the bone.The damaged cartilage surfaces at the ends of the femur and tibia are removed along with a small amount of underlying bone.· 骨准备。去除股骨和胫骨最表层的已损坏的软骨。· Position the metal implants.The removed cartilage and bone is replaced with metal components that recreate the surface of the joint. These metal parts may be cemented or "press-fit" into the bone.· 植入金属假体。金属假体替换被去除的软骨和骨,重新组成关节的接触面。这些金属部件可以粘住或被打入骨头。· Resurface the patella.The undersurface of the patella (kneecap) is cut and resurfaced with a plastic button. Some surgeons do not resurface the patella, depending upon the case.· 修复髌骨。修剪并用用塑料扣修复髌骨的底面。一些医生在一些情况下不修复髌骨。· Insert a spacer.A medical-grade plastic spacer is inserted between the metal components to create a smooth gliding surface.· 插入垫片。在金属部件之间插来塑料垫片,创建一个更顺滑的表面。 Is Total Knee Replacement for You? 全膝置换术适应证 The decision to have total knee replacement surgery should be a cooperative one between you, your family, your family physician, and your orthopaedic surgeon. Your physician may refer you to an orthopaedic surgeon for a thorough evaluation to determine if you might benefit from this surgery. 是否行全膝关节置换术应该是由你、你的家人、你的家庭医生、和你的骨科医生共同决定的。医生可能会对你的身体进行彻底的评估,以确定你是否适合行该手术。 When Surgery Is Recommended 什么时候会建议行置换术?There are several reasons why your doctor may recommend knee replacement surgery. People who benefit from total knee replacement often have: 医生建议行膝关节置换术是有原因的,适合行置换术的人通常有以下问题:· Severe knee pain or stiffness that limits your everyday activities, including walking, climbing stairs, and getting in and out of chairs. You may find it hard to walk more than a few blocks without significant pain and you may need to use a cane or walker· Moderate or severe knee pain while resting, either day or night· Chronic knee inflammation and swelling that does not improve with rest or medications· Knee deformity — a bowing in or out of your knee· Failure to substantially improve with other treatments such as anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy, or other surgeries· 严重的膝关节疼痛或僵硬,限制你的日常活动,包括散步,爬楼梯,连坐椅子都受影响。你可能会觉得没有显著的疼痛也走不了多远,并且可能需要使用拐杖或助行器· 无论是白天还是夜晚休息时均可感到 中度或重度膝关节疼痛· 慢性膝关节炎症和肿胀,休息或药物均不能改善· 膝关节畸形 - 内翻和外翻等· 其他治疗,如消炎药,激素,润滑注射,物理疗法,或其他手术不能显着改善症状Candidates for Surgery手术适应的人群There are no absolute age or weight restrictions for total knee replacement surgery. 全膝关节置换手术没有绝对的年龄或体重限制。Recommendations for surgery are based on a patient's pain and disability, not age. Most patients who undergo total knee replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total knee replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis. 手术是根据病人的痛苦和功能障碍的情况而定的,而不是年龄。接受全膝关节置换术的患者大多是50岁至80岁,但骨科医生的评估因人而异。全膝关节置换已成功在所有年龄段完成,从患少年关节炎的年轻的少年到患退行性关节炎的老年患者。 Orthopaedic Evaluation 专科评估 An evaluation with an orthopaedic surgeon consists of several components: 骨科医生的手术评估包括:· A medical history.Your orthopaedic surgeon will gather information about your general health and ask you about the extent of your knee pain and your ability to function.· A physical examination.This will assess knee motion, stability, strength, and overall leg alignment.· X-rays.These images help to determine the extent of damage and deformity in your knee.· Other tests.Occasionally blood tests, or advanced imaging such as a magnetic resonance imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues of your knee.· 病史:医生将收集有关你的健康信息,并评估你的膝盖疼痛和功能障碍的程度。· 查体:这将评估膝关节的运动功能,稳定性,强度,和下肢力线等。· X射线:有助于确定你膝盖损伤和畸形的程度。· 可能需要的其他测试。有时候验血或先进的成像,如磁共振成像(MRI)扫描,可以用以确定膝盖的骨和软组织的状况。Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether total knee replacement is the best method to relieve your pain and improve your function. Other treatment options — including medications, injections, physical therapy, or other types of surgery — will also be considered and discussed. 医生将根据你的检查结果,讨论全膝关节置换是否是减轻你疼痛,改善你膝关节功能的最佳方法。其他的治疗方案 - 包括药物,注射,物理疗法,或其他类型的手术 - 也将被考虑和讨论。 In addition, your orthopaedic surgeon will explain the potential risks and complications of total knee replacement, including those related to the surgery itself and those that can occur over time after your surgery.此外,医生会解释全膝关节置换术潜在风险,包括与手术本身有关和可以发生在手术后的并发症。Deciding to Have Knee Replacement Surgery 决定行全膝关节置换术 Realistic Expectations 手术期望An important factor in deciding whether to have total knee replacement surgery is understanding what the procedure can and cannot do. 决定是否要行全膝关节置换手术的一个重要因素是要了解这个手术能给我们带来什么,不能带来什么。More than 90% of people who have total knee replacement surgery experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living. But total knee replacement will not allow you to do more than you could before you developed arthritis. 超过90%的行全膝关节置换手术的患者可以急剧减少膝关节疼痛并明显改善日常生活能力。但全膝关节置换不能使你的状况比在患关节炎前更好。With normal use and activity, every knee replacement implant begins to wear in its plastic spacer. Excessive activity or weight may speed up this normal wear and may cause the knee replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports for the rest of your life after surgery. 在正常使用和活动下,每个膝关节假体开始在其塑料垫片磨损。过度活动或重量过重可能加快这一过程,并可能导致膝关节假体松动,产生痛苦。所以,大多数骨科医生建议在你术后恢复的过程中,避免高强度的活动,如跑步,慢跑,跳跃,或其他高冲击力的运动。Realistic activities following total knee replacement include unlimited walking, swimming, golf, driving, light hiking, biking, ballroom dancing, and other low-impact sports. 全膝关节置换术后可以进行的活动包括散步,游泳,高尔夫,驾驶,轻远足,骑自行车,交谊舞等低强度运动。With appropriate activity modification, knee replacements can last for many years. 适当的活动可以使膝关节假体寿命维持很多年。 Possible Complications of Surgery 手术可能的并发症 The complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in fewer than 2% of patients. Major medical complications such as heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur, they can prolong or limit full recovery. 全膝关节置换术的并发症的发生率低。严重的并发症,诸如膝关节感染,发生率少于2%。其他主要的并发症,如心脏病发作或中风的发生就更低。慢性疾病可能会增加并发症的发生率。这种情况虽然少见,但当这些并发症发生,可以延长或限制你的恢复。Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.在手术前充分与你的医生讨论你的问题。Infection. Infection may occur in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement. 感染:感染可发生在伤口或假体周围,可以发生在医院或出院回家后。甚至可能发生在术后若干年。在伤口表面轻微的感染通常用抗生素治疗。重要的或深部感染,可能需要更进一步的手术和去除假体。任何在你身体的感染均能扩散到你置换的关节。Blood clots. Blood clots in the leg veins are the most common complication of knee replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program, which may include periodic elevation of your legs, lower leg exercises to increase circulation, support stockings, and medication to thin your blood. 血栓形成:膝关节置换手术最常见的并发症是下肢静脉栓塞。如果血栓脱落到达肺部,可危及生命。医生将制定一个预防方案,其中可能包括定期抬高你的腿,小腿练习以增加血液循环,弹力袜和用药物来预防血栓形成。Implant problems. Although implant designs and materials, as well as surgical techniques, continue to advance, implant surfaces may wear down and the components may loosen. Additionally, although an average of 115° of motion is generally anticipated after surgery, scarring of the knee can occasionally occur, and motion may be more limited, particularly in patients with limited motion before surgery. 假体问题。尽管假体的设计和材料,以及外科手术的技术发展很快,假体的表面可能会磨损和松动。此外,尽管术后膝关节的平均活动度可达到115°,由膝关节上的疤痕,可能导致膝关节活动受限,尤其是在术前就有活动受限的患者。Continued pain. A small number of patients continue to have pain after a knee replacement. This complication is rare, however, and the vast majority of patients experience excellent pain relief following knee replacement. 持续的疼痛。少数患者在术后有持续的疼痛。这种并发症是罕见的,绝大多数患者可以体验到膝关节置换带来的明显的疼痛减轻。Neurovascular injury. While rare, injury to the nerves or blood vessels around the knee can occur during surgery.神经血管损伤。膝关节周围神经或血管损伤罕见,可发生在手术过程中。 Preparing for Surgery 手术准备 Medical Evaluation 医学评估 If you decide to have total knee replacement surgery, your orthopaedic surgeon may ask you to schedule a complete physical examination with your family physician several weeks before the operation. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such as a cardiologist, before the surgery. 如果你决定要全膝关节置换手术,骨科可能会要求你在手术前几个星期接受你的家庭医生一次完整的身体检查。这对于确保你身体可以接受手术和完成恢复过程的相当必要的。一些有慢性疾病,如心脏病的患者在术前需要专家对身体进行评估。 Tests 检查Several tests, such as blood and urine samples, and an electrocardiogram, may be needed to help your orthopaedic surgeon plan your surgery.一些检查,在骨科医生进行手术前需要进行,如血液和尿液的检测以及心电图等。 Medications 药物Tell your orthopaedic surgeon about the medications you are taking. He or she will tell you which medications you should stop taking and which you should continue to take before surgery.告诉你的骨科医生你正在服用的药物,医生会告诉你,在手术前,哪些你应该停止服用,哪些可以继续服用。 Dental Evaluation 牙科评估 Although the incidence of infection after knee replacement is very low, an infection can occur if bacteria enter your bloodstream. To reduce the risk of infection, major dental procedures (such as tooth extractions and periodontal work) should be completed before your total knee replacement surgery.虽然膝关节置换术后感染不常见,如果细菌进入你的血液,感染就可能发生。主要的牙科手术(如拔牙和牙周工作)应在你的膝关节置换手术前完成。 Urinary Evaluations 泌尿系评估People with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before undertaking knee replacement surgery.最近或经常有尿路感染的病史的患者在手术前应该有一个泌尿评价。有前列腺疾病的老年男性应在手术治疗前应完成必要的治疗。 Social Planning 社会生活计划Although you will be able to walk on crutches or a walker soon after surgery, you will need help for several weeks with such tasks as cooking, shopping, bathing, and doing laundry.虽然你可以在手术后不久靠拐杖或助行器走路,你还是需要几个星期的帮助,例如烹饪,购物,洗澡,洗衣等。If you live alone, your orthopaedic surgeon's office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at home. They also can help you arrange for a short stay in an extended care facility during your recovery, if this option works best for you.如果你独自生活,你的骨科医生办公室、社会工作者或者医院的出院处可以帮助你在家的时候得到他人的帮助。也可以根据你的需要在你术后的恢复过程把你暂时安排在一个有充分护理设施的地方。 Home Planning 家庭计划Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:一些改动可以让你的家在你的恢复过程中更轻松地进行导航。下列项目可以帮助你的日常活动:· Safety bars or a secure handrail in your shower or bath· 在你淋浴器或浴缸安装牢固的安全扶手或扶手· Secure handrails along your stairways· 所有楼梯都安装安全扶手· A stable chair for your early recovery with a firm seat cushion (and a height of 18 to 20 inches), a firm back, two arms, and a footstool for intermittent leg elevation· 你早期的康复需要一张有坚固的座垫的稳定的椅子(高度18到20寸),这张椅子要有一个坚定的靠背以及两个扶手,还要有一张凳子以便间歇地抬高腿。· A toilet seat riser with arms, if you have a low toilet· 如果你家厕所较低,可以安装一个扶手在马桶旁边· A stable shower bench or chair for bathing· 稳定的淋浴板凳或椅子洗澡· Removing all loose carpets and cords· 去除所有松动的地毯和线· A temporary living space on the same floor because walking up or down stairs will be more difficult during your early recovery· 在同一层楼有个临时的地方住,因为上下楼梯在你的早期康复期是特别困难的 Your Surgery 手术 Anesthesia 麻醉After admission, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anesthesia (you are awake but your body is numb from the waist down). The anesthesia team, with your input, will determine which type of anesthesia will be best for you. 入院后,你的麻醉团队成员将会对你进行评估。麻醉中最常见的类型是全身麻醉(你进入睡眠状态)或脊髓,硬膜外或区域神经阻滞麻醉(你是清醒的,但你的身体从腰部以下无感觉)。麻醉团队会根据你的具体情况决定麻醉的哪种类型是最适合你的。 Procedure 手术过程 The procedure itself takes approximately 1 to 2 hours. Your orthopaedic surgeon will remove the damaged cartilage and bone, and then position the new metal and plastic implants to restore the alignment and function of your knee. 该手术本身需要大约1到2小时。医生将取出损坏的软骨和骨,然后放置新的金属、塑料假体等来恢复你的膝盖的对齐方式和功能。After surgery, you will be moved to the recovery room, where you will remain for several hours while your recovery from anesthesia is monitored. After you wake up, you will be taken to your hospital room. 手术后,你将被送到恢复室,你会在那呆几个小时直到你从麻醉中恢复。当你醒来时,你会被带到你的病房。 Your Hospital Stay 住院期间You will most likely stay in the hospital for several days. 你很有可能要再医院住几天。 Pain Management 疼痛控制After surgery, you will feel some pain, but your surgeon and nurses will provide medication to make you feel as comfortable as possible. Pain management is an important part of your recovery. Walking and knee movement will begin soon after surgery, and when you feel less pain, you can start moving sooner and get your strength back more quickly. Talk with your surgeon if postoperative pain becomes a problem.手术后,你会感到有些疼痛,但你的医生和护士会提供药物让你感到尽可能舒适。疼痛控制是你恢复过程的一个重要组成部分。术后很快就可以开始活动关节,当你感到疼痛少的时候,你就可以开始活动得更快,并快速地恢复你的力量。如果术后疼痛难忍请与你的医生交谈。 Blood Clot Prevention 预防血栓 医生可能会使用多种措施以防止血栓形成,减少腿部肿胀。包括特殊的支持袜子,可充气的腿覆盖物(压缩靴),以及抗凝药。鼓励术后可立即进行足部和踝关节运动,以促进你腿部肌肉的血液循环,以帮助防止腿部肿胀和血栓形成。 Physical Therapy 物理治疗 大多数患者在术后第二天就开始运动他们的膝关节。理疗师会教你具体的练习方法以促进你的腿和膝关节恢复运动,使你在术后不久可以开始步行和其他日常活动。 为了恢复在你膝关节和腿部的活动,医生可能会使用一个膝关节支撑装置,慢慢地在床上移动你的膝关节。该装置被称为持续被动运动(CPM)运动机,通过抬高你的腿部预防肿胀,并通过活动你腿的肌肉改善血液循环。 Preventing Pneumonia 预防肺炎 术后早期的病人常会出现呼吸浅弱。这通常是由于麻醉、止痛药物、卧床时间增长的影响。这个浅弱呼吸可导致肺的部分塌陷(称为“肺不张”),它可以使患者易患肺炎。为了防止出现这种情况,经常深呼吸是很重要的措施。护士可以提供一个叫肺活量计的简单的呼吸装置来帮助你深呼吸。 Your Recovery at Home 家庭康复过程 你的手术成功与否在很大程度上取决于你在术后回家的最初几周是否按照医生的指示执行。 Wound Care 伤口护理 可能会有针或钉在你的膝关节前面的伤口或皮肤下缝合。术后几周后即可拆除。皮下的缝合不需要拆除。 避免让伤口湿润,直到它完全密封和干燥。您可以继续包扎伤口,以防止来自衣服或袜的刺激。 Diet 饮食 手术后的几个星期食欲减退是很常见。均衡的饮食,且经常有补铁,对于促进相应的组织愈合,恢复肌肉力量是很重要的。 Activity 活动锻炼 运动是家庭康复的重要组成部分,特别是在手术后的最初几个星期。在术后的3到6个星期内,你应该能够恢复最基本的日常活动。术后几个星期内晚上活动时疼痛是很常见的。 你的锻炼计划包括: 一个适当的活动计划可以慢慢地增加你身体的流动性,最初是在家,慢慢地延伸到户外。· 恢复正常的家庭活动,如坐,站立,和爬楼梯· 一天几次具体的锻炼以恢复运动和加强你的膝关节。你可能会在没有帮助的情况下完成练习,但你也可以在术后前几周有物理治疗师在家或在治疗中心帮你你很可能能够恢复驾驶,当你的膝关节活动度尚可,可以让你进入并舒适地坐在车上,当你的肌肉恢复使你能有足够的反应时间,制动和加速。大多数人可以在术后4到6周恢复驾驶。 Avoiding Problems After Surgery 预防术后问题 Blood Clot Prevention 预防血栓形成 仔细按照医生的指示做,以减少在恢复的最初几个星期内血栓发展的风险。医生可能会建议您继续服用在医院就开始服用的抗凝药。如果您发现以下任何征兆请立即通知你的医生。 警惕血栓形成的预兆,下肢血栓形成的预兆包括:小腿疼痛加重膝关节周围出现压痛或局部发红小腿、踝部及足部出现进行性疼痛 警惕肺栓塞形成的预兆,血栓脱落入肺的征兆包括:突然出现呼吸急促胸痛突然发作出现咳嗽导致的胸痛Preventing Infection 预防感染A common cause of infection following total knee replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around your knee replacement and cause an infection. 导致膝关节置换手术感染的常见因素是:在牙科手术,泌尿道感染或皮肤感染时细菌进入血液。这些细菌可以集聚在置换的关节周围导致感染。After your knee replacement, you must take preventive antibiotics before dental or surgical procedures that could allow bacteria to enter your bloodstream. 膝关节置换手术后,你必须在可能让细菌进入血液的牙科或其他外科手术前使用预防性抗生素。Warning signs of infection. Notify your doctor immediately if you develop any of the following signs of a possible knee replacement infection: 出现感染的征兆。如果您发现以下任何一个可能的膝关节置换感染的迹象请立即通知你的医生:· Persistent fever (higher than 100°F orally) · 持续发热(高于37.7℃)· Shaking chills· 寒战· Increasing redness, tenderness, or swelling of the knee wound· 膝关节伤口呈进行性发红,压痛或肿胀· Drainage from the knee wound· 伤口出现渗液· Increasing knee pain with both activity and rest· 活动和休息时均出现进行性疼痛 Avoiding Falls 预防跌倒 在手术后的最初的几个星期跌倒可能会损害你的新膝关节,并可能会导致需要进行更多的手术。在你的膝关节有足够强度和活动度之前,爬楼梯是特别危险的。你应该使用拐杖,助行器,或扶手或有人扶你,直到你提高你的平衡性、柔韧性和力量。你的骨科医生和理疗师会帮你选一些手术后可以帮助你的工具,并告诉你何时可以安全地停止使用这些工具。 Outcomes 术后情况及结果How Your New Knee Is Different 新关节会带来一些不适应 膝关节活动改善是全膝关节置换术的目标,但全部恢复是罕见的。术后膝关节的活动可以根据术前膝关节活动度来预测。大多数患者术后几乎可以完全伸直膝关节,并且可以充分屈曲膝关节以上下楼梯和进出车。有时候下跪是不舒服的,但是无害的。 大多数人会觉得切口周围的皮肤麻木。也可能会感到关节僵硬,特别是过度屈曲膝关节的时候。 大多数人在屈曲膝关节或走路时可以感觉到或听到金属和塑料假体的响声。这是正常的现象并且往往会随着时间的推移而减少,大多数患者觉得他们的疼痛和活动受限的情况予术前相比有所改善。 你的新膝关节在机场和一些建筑物的安检时会引起金属探测器报警。如果报警被激活,告诉安检员你曾行膝关节置换术。 Protecting Your Knee Replacement 保护你的新关节 术后确保你要做到以下几点:· 采取特殊的预防措施,以避免摔倒和受伤。如果你的腿骨折了,你可能需要更进一步的手术。· 确保您的牙医知道你刚行膝关节置换术。在任何牙科手术前你均需要使用抗生素。· 定期骨科复诊并进行常规随访检查和X光片,一年复查一次。 Extending the Life of Your Knee Implant 延长假体的寿命 目前,超过90%的现代全膝关节置换假体在术后15年仍然运作良好。术后按照医生的指示,注意保护你的新膝关节并保持身体健康,是你手术成功的重要因素。
(自主翻译及整理而来)Total Hip Replacement (1)全髋关节置换(中英对照)Whether you have just begun exploring treatment options or have already decided to undergo hip replacement surgery, this information will help you understand the benefits and limitations of total hip replacement. This article describes how a normal hip works, the causes of hip pain, what to expect from hip replacement surgery, and what exercises and activities will help restore your mobility and strength, and enable you to return to everyday activities.无论你是刚开始寻找治疗方案,或已经决定接受髋关节置换手术,本文将帮助您了解全髋关节置换术的优点和局限性。本文介绍了一个正常的髋关节在人体的作用、导致髋关节疼痛的原因、对于髋关节置换手术我们可以有什么期望以及什么样的练习和活动将助于恢复患者身体的活动性与力量,让患者回归社会活动。If your hip has been damaged by arthritis, a fracture, or other conditions, common activities such as walking or getting in and out of a chair may be painful and difficult. Your hip may be stiff, and it may be hard to put on your shoes and socks. You may even feel uncomfortable while resting如果你的髋关节因关节炎、骨折或其它原因而被破坏,诸如散步或起坐椅子等日常生活都可能导致疼痛和难以完成。你的髋关节僵硬,可能让你连你的鞋子、袜子拿起来都难。你甚至在休息的时候都会感觉到不舒服。.If medications, changes in your everyday activities, and the use of walking supports do not adequately help your symptoms, you may consider hip replacement surgery. Hip replacement surgery is a safe and effective procedure that can relieve your pain, increase motion, and help you get back to enjoying normal, everyday activities.如果药物治疗、生活习惯的改变以及一些辅助步行的工具不能充分地帮助你缓解症状,您可以考虑髋关节置换手术。髋关节置换手术是一种安全而有效的方法,它可以减轻你的痛苦,改善肢体活动,帮你重新享受正常的日常活动First performed in 1960, hip replacement surgery is one of the most successful operations in all of medicine. Since 1960, improvements in joint replacement surgical techniques and technology have greatly increased the effectiveness of total hip replacement. According to the Agency for Healthcare Research and Quality, more than 285,000 total hip replacements are performed each year in the United States.最早实践于1960年,髋关节置换手术是在当时医学上最成功的成就之一。自1960年以来,在关节置换手术的手法和技术的改进大大提高了全髋关节置换成效。据卫生保健研究质量局报道,在美国,每年有超过285,000台全髋关节置换手术。Anatomy解剖特点The hip is one of the body's largest joints. It is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).髋关节是人体最大的关节之一。这是一个球窝对接关节。窝是髋臼,属于是大骨盆骨的一部分。球是股骨头,是股骨(大腿骨)上端。The bone surfaces of the ball and socket are covered with articular cartilage, a smooth tissue that cushions the ends of the bones and enables them to move easily.球窝的骨表面覆盖的关节软骨,是一缓冲骨端的平滑组织,能使球窝能自由地移动。A thin tissue called synovial membrane surrounds the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost all friction during hip movement.滑膜是一些环绕在髋关节的薄组织。在一个健康的髋关节,滑膜可制造少量的液体润滑软骨,使髋关节运动过程中,几乎没有摩擦。Bands of tissue called ligaments (the hip capsule) connect the ball to the socket and provide stability to the joint.韧带(关节囊)把球和窝连接起来,并保证关节的稳定性。Common Causes of Hip Pain髋关节疼痛的常见原因The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease.慢性髋关节疼痛和功能障碍最常见的原因是关节炎。骨关节炎、类风湿性关节炎、创伤性关节炎是本病的最常见原因。· Osteoarthritis.This is an age-related "wear and tear" type of arthritis. It usually occurs in people 50 years of age and older and often in individuals with a family history of arthritis. The cartilage cushioning the bones of the hip wears away. The bones then rub against each other, causing hip pain and stiffness. Osteoarthritis may also be caused or accelerated by subtle irregularities in how the hip developed in childhood· 骨性关节炎,是一种与年龄有关的“磨损”类型的关节炎。它通常发生50岁及以上或有家族性关节炎病史人群。缓冲髋关节的骨头摩擦的软骨磨损。骨头互相摩擦,造成髋关节疼痛和僵硬。小孩髋关节正在发育,一些轻微的错的动作亦可导致或加重骨关节炎。· Rheumatoid arthritis.This is an autoimmune disease in which the synovial membrane becomes inflamed and thickened. This chronic inflammation can damage the cartilage, leading to pain and stiffness. Rheumatoid arthritis is the most common type of a group of disorders termed "inflammatory arthritis."· 类风湿性关节炎,是一种自身免疫性疾病,可出现滑膜发炎和增厚。这种慢性炎症能损伤的软骨,导致疼痛和僵硬。类风湿关节炎是“炎症性关节炎”中最常见的一组疾病类型。· Post-traumatic arthritis.This can follow a serious hip injury or fracture. The cartilage may become damaged and lead to hip pain and stiffness over time.· 创伤性关节炎,可以出现在一次严重的髋关节损伤或骨折。有可能损坏软骨,随着时间的推移,可出现髋关节疼痛和僵硬。· Avascular necrosis.An injury to the hip, such as a dislocation or fracture, may limit the blood supply to the femoral head. This is called avascular necrosis. The lack of blood may cause the surface of the bone to collapse, and arthritis will result. Some diseases can also cause avascular necrosis.· 股骨头缺血性坏死,一些髋关节的损伤,如髋关节脱位或骨折,可能会使股骨头的血液供应不足。这就是所谓的股骨头缺血性坏死。缺血可能使骨头表面收缩,导致关节炎。某些疾病也可以造成股骨头缺血性坏死· Childhood hip disease.Some infants and children have hip problems. Even though the problems are successfully treated during childhood, they may still cause arthritis later on in life. This happens because the hip may not grow normally, and the joint surfaces are affected.· 童年髋关节疾病,一些婴儿和儿童髋关节的问题。即使问题在儿童时期得到成功治疗,但在以后的生活,这些问题仍可以导致关节炎。这是因为髋关节可能无法正常生长,关节面被影响。A hip with osteoarthritis.Top of pageDescription概述In a total hip replacement (also called total hip arthroplasty), the damaged bone and cartilage is removed and replaced with prosthetic components.在全髋关节置换(也称为全髋关节造形术),受损的骨和软骨被移除,并用假体代替。· The damaged femoral head is removed and replaced with a metal stem that is placed into the hollow center of the femur. The femoral stem may be either cemented or "press fit" into the bone.· 损坏的股骨头被去除,并被放置到股骨髓腔的金属杆取代。股骨柄可以是用水泥或“打压”进入骨髓腔。· A metal or ceramic ball is placed on the upper part of the stem. This ball replaces the damaged femoral head that was removed.· 金属或陶瓷球位于在杆的上半部分。这个球取代损坏的股骨头。· The damaged cartilage surface of the socket (acetabulum) is removed and replaced with a metal socket. Screws or cement are sometimes used to hold the socket in place.· 髋臼受损软骨表面被移除,并用金属臼替换。螺钉或骨水泥有时用于固定髋臼。· A plastic, ceramic, or metal spacer is inserted between the new ball and the socket to allow for a smooth gliding surface.· 塑料、陶瓷或金属垫片插入假体股骨头和髋臼之间,可制造一个更顺滑的接触面。(Left)The individual components of a total hip replacement. (Center) The components merged into an implant. (Right) The implant as it fits into the hip.(左)全髋关节置换的各个组件。 (中间)各个部件组成一个完整髋关节假体。(右)假体吻合组成一个人工髋关节。Is Hip Replacement Surgery for You?髋关节置换手术适合你吗?The decision to have hip replacement surgery should be a cooperative one made by you, your family, your primary care doctor, and your orthopaedic surgeon. The process of making this decision typically begins with a referral by your doctor to an orthopaedic surgeon for an initial evaluation.决定做髋关节置换手术需要你、你的家人、你的初级保健医生及你的骨科医生达成共识。做出这个决定的过程中通常是从骨科医生的初步评估开始的。Candidates for Surgery手术适应症There are no absolute age or weight restrictions for total hip replacements.髋关节置换手术没有绝对的年龄或体重限制。Recommendations for surgery are based on a patient's pain and disability, not age. Most patients who undergo total hip replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total hip replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.手术的建议是根据病人的疼痛及功能的障碍,而不是年龄。接受全髋关节置换的患者大多是50岁至80,但骨科医生会根据病人各自的实际情况评估。全髋关节置换已在所有年龄段的患者取得成功,从患幼年型关节炎的年轻少年到患退行性关节炎的老年患者。When Surgery Is Recommended什么时候会建议行髋关节置换?There are several reasons why your doctor may recommend hip replacement surgery. People who benefit from hip replacement surgery often have:你的医生建议你行髋关节置换手术有很多原因。适合行髋关节置换的病人往往有:· Hip pain that limits everyday activities, such as walking or bending· 髋关节疼痛限制日常生活,比如走路和弯腰· Hip pain that continues while resting, either day or night· 无论白天、黑夜,休息时髋关节持续疼痛· Stiffness in a hip that limits the ability to move or lift the leg· 髋关节僵硬限制移动或抬腿的能力· Inadequate pain relief from anti-inflammatory drugs, physical therapy, or walking supports· 消炎止痛药、物理疗法、或步行支架不能缓解疼痛The Orthopaedic Evaluation骨科评价An evaluation with an orthopaedic surgeon consists of several components.骨科医师的评估包括以下几个部分。· Medical history.Your orthopaedic surgeon will gather information about your general health and ask questions about the extent of your hip pain and how it affects your ability to perform everyday activities.· 病史:骨科医生将收集有关你的健康信息,并询问你的髋关节疼痛的程度,以及它如何影响你进行日常活动的能力。· Physical examination.This will assess hip mobility, strength, and alignment.· 查体:检查髋关节的活动度、力量及关节的对合情况· X-rays.These images help to determine the extent of damage or deformity in your hip.· X光片:X光片图像有助于确定髋关节损伤或畸形的程度· Other tests.Occasionally other tests, such as a magnetic resonance imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues of your hip.· 其他检查:.其他检查如磁共振成像扫描(MRI),有时也可以根据需要来评估骨和臀部的软组织的状况。(Left)In this x-ray of a normal hip, the space between the ball and socket indicates healthy cartilage. (Right) This x-ray of an arthritic hip shows severe loss of joint space and bone spurs.(左)正常髋关节的X光片,球窝之间的空间有健康的软骨。 (右)有关节炎的髋关节X光片显示关节间隙变窄和骨刺。Deciding to Have Hip Replacement Surgery决定做全髋关节置换手术Talk With Your Doctor告诉你的医生Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether hip replacement surgery is the best method to relieve your pain and improve your mobility. Other treatment options — such as medications, physical therapy, or other types of surgery — also may be considered.你的骨科医生将评估你的检查结果,并讨论髋关节置换手术是否是减轻你的疼痛,改善你的关节活动性的最好方法。其他的治疗方案 - 如药物治疗,物理治疗,或其他类型的手术 - 也可以考虑。In addition, your orthopaedic surgeon will explain the potential risks and complications of hip replacement surgery, including those related to the surgery itself and those that can occur over time after your surgery.此外,你的骨科医生会解释潜在的髋关节置换手术的风险和并发症,包括术中和术后可能发生的情况。Never hesitate to ask your doctor questions when you do not understand. The more you know, the better you will be able to manage the changes that hip replacement surgery will make in your life.当你不懂时,永远要毫不犹豫地去问你的医生。你知道得越多,就越能使髋关节置换手术更好的改变你的生活。Realistic Expectations手术期望An important factor in deciding whether to have hip replacement surgery is understanding what the procedure can and cannot do. Most people who undergo hip replacement surgery experience a dramatic reduction of hip pain and a significant improvement in their ability to perform the common activities of daily living.决定是否行髋关节置换手术的一个重要因素是了解这个手术可以和不能做什么。大多数接受髋关节置换手术的患者可以很大程度的减少髋部疼痛,并使其日常生活的能力有显著改善。With normal use and activity, the material between the head and the socket of every hip replacement implant begins to wear. Excessive activity or being overweight may speed up this normal wear and cause the hip replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports在日常使用和活动中,头和髋臼之间植入的材料开始磨损。过度活动或超重可能加快这一正常磨损过程,导致髋关节假体松动,并产生疼痛。所以,大多数骨科医生建议避免高强度的活动,如跑步,慢跑,跳跃,或其他高强度运动.Realistic activities following total hip replacement include unlimited walking, swimming, golf, driving, hiking, biking, dancing, and other low-impact sports.全髋关节置换术后可以进行的活动包括散步,游泳,高尔夫,驾车,远足,骑自行车,跳舞,和其他低强度的运动。With appropriate activity modification, hip replacements can last for many years.适当的活动限制可使髋关节置换假体持续使用很多年。Preparing for Surgery手术准备Medical Evaluation医疗评估If you decide to have hip replacement surgery, your orthopaedic surgeon may ask you to have a complete physical examination by your primary care doctor before your surgical procedure. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such a cardiologist, before the surgery.如果你决定要行髋关节置换手术,你的骨科医生可能会在你的手术之前要求您通过您的主诊医生有一个完整的身体检查。这是为确保你身体足够承受手术并完成恢复过程。许多患者有心脏病等慢性疾病,也可以由专家进行评估,例如在手术前进行心脏评估。Tests术前检查Several tests, such as blood and urine samples, an electrocardiogram (EKG), and chest x-rays, may be needed to help plan your surgery.许多检查在手术前是必须的,例如血、尿常规,心电图还有胸片等Preparing Your Skin皮肤准备Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for treatment to improve your skin before surgery.你的皮肤手术前不应该有任何感染或过敏。如果有,请让您的骨科医生进行治疗,以在手术前改善你的皮肤。Blood Donations捐血You may be advised to donate your own blood prior to surgery. It will be stored in the event you need blood after surgery.建议你在手术前预先捐献自己的血液。术后需要血液方能用到。Medications药物Tell your orthopaedic surgeon about the medications you are taking. He or she or your primary care doctor will advise you which medications you should stop taking and which you can continue to take before surgery.告诉你的骨科医生你正在服用的药物,他或她,或您的主诊医生会告诉你,在手术前,哪些你应该停止服用,哪些可以继续服用。Weight Loss减肥If you are overweight, your doctor may ask you to lose some weight before surgery to minimize the stress on your new hip and possibly decrease the risks of surgery.如果你体重过重,你的医生可能会要求你在手术前要减减肥,以尽量减少对你的新髋关节的压力,并可减少手术的风险。Dental Evaluation牙科评估Although infections after hip replacement are not common, an infection can occur if bacteria enter your bloodstream. Because bacteria can enter the bloodstream during dental procedures, major dental procedures (such as tooth extractions and periodontal work) should be completed before your hip replacement surgery. Routine cleaning of your teeth should be delayed for several weeks after surgery.虽然髋关节置换术后感染不常见,如果细菌进入你的血液,感染就可能发生。因为细菌可以在牙科治疗过程进入血液,主要的牙科手术(如拔牙和牙周工作)应在你的髋关节置换手术前完成。你的牙齿日常清洁,应推迟在术后数周后进行。Urinary Evaluation泌尿系评估Individuals with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before having surgery.最近或经常有尿路感染的病史的患者在手术前应该有一个泌尿评价。有前列腺疾病的老年男性应在手术治疗前应完成必要的治疗。Social Planning社会生活计划Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry.虽然你可以在手术后不久靠拐杖或助行器走路,你还是需要几个星期的帮助,例如烹饪,购物,洗澡,洗衣等。If you live alone, your orthopaedic surgeon's office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home. A short stay in an extended care facility during your recovery after surgery also may be arranged.如果你独自生活,你的骨科医生办公室、社会工作者或者医院的出院处可以帮助你在家的时候得到他人的帮助。也可以在你术后的恢复过程把你暂时安排在一个有充分护理设施的地方。Home Planning家庭计划Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:一些改动可以让你的家在你的恢复过程中更轻松地进行导航。下列项目可以帮助你的日常活动:· Securely fastened safety bars or handrails in your shower or bath· 在你淋浴器或浴缸安装牢固的安全扶手或扶手· Secure handrails along all stairways· 所有楼梯都安装安全扶手· A stable chair for your early recovery with a firm seat cushion (that allows your knees to remain lower than your hips), a firm back, and two arms· 你早期的康复需要一张有坚固的座垫的稳定的椅子(让你的膝盖仍然维持在你的髋部以下),这张椅子要有一个坚定的靠背以及两个扶手。· A raised toilet seat· 一个加高的马桶座圈· A stable shower bench or chair for bathing· 稳定的淋浴板凳或椅子洗澡· A long-handled sponge and shower hose· 一个长柄的海绵和淋浴软管· A dressing stick, a sock aid, and a long-handled shoe horn for putting on and taking off shoes and socks without excessively bending your new hip· 量身定制的敷料、袜子援助和长柄鞋拔使你在穿脱鞋袜的时候不会过度弯曲你的新髋关节· A reacher that will allow you to grab objects without excessive bending of your hips· 一个让你可以在不过度弯曲你的新髋关节的情况下就可以拿东西的工具。· Firm pillows for your chairs, sofas, and car that enable you to sit with your knees lower than your hips· 你的椅子、沙发还有汽车需要坚固的枕头保持你的膝盖低于你的髋部。· Removal of all loose carpets and electrical cords from the areas where you walk in your home· 在你家里活动的区域去除所有松动的地毯和电线Set up a "recovery center" where you will spend most of your time. Things like the phone, television remote control, reading materials, and medications should all be within reach.成立一个“康复中心”,大部分时间你会在那里度过。如手机,电视机遥控器,阅读材料和药物都应该唾手可得。Your Surgery手术You will most likely be admitted to the hospital on the day of your surgery.你最有可能在你手术的那天被收入院。Anesthesia麻醉After admission, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anesthesia (you are awake but your body is numb from the waist down). The anesthesia team, with your input, will determine which type of anesthesia will be best for you.入院后,你的麻醉团队成员将会对你进行评估。麻醉中最常见的类型是全身麻醉(你进入睡眠状态)或脊髓,硬膜外或区域神经阻滞麻醉(你是清醒的,但你的身体从腰部以下无感觉)。麻醉团队会根据你的具体情况决定麻醉的哪种类型是最适合你的。Implant Components植入假体Many different types of designs and materials are currently used in artificial hip joints. All of them consist of two basic components: the ball component (made of highly polished strong metal or ceramic material) and the socket component (a durable cup of plastic, ceramic or metal, which may have an outer metal shell).许多不同类型的人工髋关节设计和材料在目前均有使用。所有这些由两个基本部分组成:球部件(由高度抛光的强的金属或陶瓷材料制成的)和柄部件(持久塑料杯,陶瓷或金属,也可以有外金属壳)。The prosthetic components may be "press fit" into the bone to allow your bone to grow onto the components or they may be cemented into place. The decision to press fit or to cement the components is based on a number of factors, such as the quality and strength of your bone. A combination of a cemented stem and a non-cemented socket may also be used.假体可能是被“压入”骨头并让你的骨在部件周围生长,也可以固定在那里。决定打压或用水泥固定基于许多因素,如您的骨的质量与强度。也可以使用水泥与非水泥混合的柄。Your orthopaedic surgeon will choose the type of prosthesis that best meets your needs.你的骨科医生会选择最符合您的需要的假体类型(Left)A standard non-cemented femoral component. (Center) A close-up of this component showing the porous surface for bone ingrowth. (Right) The femoral component and the acetabular component working together.(左)标准的非骨水泥股骨组件。(中)一个特写镜头显示这部分的多孔表面以便骨往里头生长。(右)股骨假体和髋臼组件一起工作。(Left)The acetabular component shows the plastic (polyethylene) liner inside the metal shell. (Right) The porous surface of this acetabular component allows for bone ingrowth.(左)有金属外壳的塑料(聚乙烯)衬里的髋臼假体。 (右)这髋臼假体的多孔表面允许骨长入。------待续(在本处搜寻,见本网)
广州中医药大学附属广东省中医院骨科 许树柴 翻译 续(1)Procedure手术过程Thesurgicalproceduretakesafewhours.Yourorthopaedicsurgeonwillremovethedamagedcartilageandboneandthenpositionnewmetal,plastic,orceramicimplantstorestorethealignmentandfunctionofyourhip.手术过程需要几个小时。你的骨科医生将取出损坏的软骨和骨,然后放置新的金属、塑料或陶瓷假体来恢复你的髋关节的对位和功能。X-raysbeforeandaftertotalhipreplacement.Inthiscase,non-cementedcomponentswereused.全髋术前和术后X光片。这里使用的非水泥型假体。Aftersurgery,youwillbemovedtotherecoveryroomwhereyouwillremainforseveralhourswhileyourrecoveryfromanesthesiaismonitored.Afteryouwakeup,youwillbetakentoyourhospitalroom.手术后,你将被送到恢复室,你会在那呆几个小时直到你从麻醉中恢复。当你醒来时,你会被带到你的病房。TopofpaYourStayintheHospital住院治疗Youwillmostlikelystayinthehospitalforafewdays.Toprotectyourhipduringearlyrecovery,apositioningsplint,suchasafoampillowplacedbetweenyourlegs,maybeused.你很可能会住在医院几天。为了在早期恢复的过程中保护你的髋关节,固定位置的工具,如海绵枕头,可以放在你的两腿之间。PainManagement疼痛控制Aftersurgery,youwillfeelsomepain,butyoursurgeonandnurseswillprovidemedicationtomakeyoufeelascomfortableaspossible.Painmanagementisanimportantpartofyourrecovery.Movementwillbeginsoonaftersurgery,andwhenyoufeellesspain,youcanstartmovingsoonerandgetyourstrengthbackmorequickly.Talkwithyoursurgeonifpostoperativepainbecomesaproblem.手术后,你会感到有些疼痛,但你的医生和护士会提供药物让你感到尽可能舒适。疼痛控制是你恢复过程的一个重要组成部分。术后很快就可以开始活动关节,当你感到疼痛少的时候,你就可以开始活动得更快,并快速地恢复你的力量。如果术后疼痛难忍请与你的医生交谈。PhysicalTherapy物理疗法Walkingandlightactivityareimportanttoyourrecoveryandwillbeginthedayoforthedayafteryoursurgery.Mostpatientswhoundergototalhipreplacementbeginstandingandwalkingwiththehelpofawalkingsupportandaphysicaltherapistthedayaftersurgery.Thephysicaltherapistwillteachyouspecificexercisestostrengthenyourhipandrestoremovementforwalkingandothernormaldailyactivities.散步和轻度活动对于你的恢复是很重要的,而且手术当天或术后的一天就可以进行。大多数接受全髋关节置换手术的患者在术后第一天能在助行器和物理治疗师的帮助下开始站立和走路。物理治疗师会教你具体的锻炼方法,以加强你的髋关节和恢复运动散步等日常活动。PreventingPneumonia预防肺炎Aspirometermeasurestheamountofairyoubreatheinandout.肺活量计测量你呼吸的进出量2011,ThinkstockItiscommonforpatientstohaveshallowbreathingintheearlypostoperativeperiod.Thisisusuallyduetotheeffectsofanesthesia,painmedications,andincreasedtimespentinbed.Thisshallowbreathingcanleadtoapartialcollapseofthelungs(termed"atelectasis")whichcanmakepatientssusceptibletopneumonia.Tohelppreventthis,itisimportanttotakefrequentdeepbreaths.Yournursemayprovideasimplebreathingapparatuscalledaspirometertoencourageyoutotakedeepbreaths.术后早期的病人常会出现呼吸浅弱。这通常是由于麻醉、止痛药物、卧床时间增长的影响。这个浅弱呼吸可导致肺的部分塌陷(称为“肺不张”),它可以使患者易患肺炎。为了防止出现这种情况,经常深呼吸是很重要的措施。护士可以提供一个叫肺活量计的简单的呼吸装置来鼓励你深呼吸。Recovery康复Thesuccessofyoursurgerywilldependinlargemeasureonhowwellyoufollowyourorthopaedicsurgeon'sinstructionsregardinghomecareduringthefirstfewweeksaftersurgery.您的手术的成功很大程度上取决于你在术后回家的最初的几个星期内是否按照你的骨科医生的指示进行康复。WoundCare伤口护理Youmayhavestitchesorstaplesrunningalongyourwoundorasuturebeneathyourskin.Thestitchesorstapleswillberemovedapproximately2weeksaftersurgery.可能会有针或钉在你的伤口或皮肤下缝合。术后约2周针或钉即可拆除。Avoidgettingthewoundwetuntilithasthoroughlysealedanddried.Youmaycontinuetobandagethewoundtopreventirritationfromclothingorsupportstockings.避免让伤口湿润,直到它完全密封和干燥。您可以继续包扎伤口,以防止来自衣服或袜的刺激。Diet饮食Somelossofappetiteiscommonforseveralweeksaftersurgery.Abalanceddiet,oftenwithanironsupplement,isimportanttopromotepropertissuehealingandrestoremusclestrength.Besuretodrinkplentyoffluids.手术后的几个星期食欲减退是很常见。均衡的饮食,且经常有补铁,对于促进相应的组织愈合,恢复肌肉力量是很重要的。一定要多喝水。Activity活动锻炼2011,ThinkstockExerciseisacriticalcomponentofhomecare,particularlyduringthefirstfewweeksaftersurgery.Youshouldbeabletoresumemostnormallightactivitiesofdailylivingwithin3to6weeksfollowingsurgery.Somediscomfortwithactivityandatnightiscommonforseveralweeks.运动是家庭康复的重要组成部分,特别是在手术后的最初几个星期。你应该能够恢复最基本的日常活动3至6个星期内手术。有些不适与活动,晚上是很常见的几个星期。Youractivityprogramshouldinclude:你的活动计划应该包括:·Agraduatedwalkingprogramtoslowlyincreaseyourmobility,initiallyinyourhomeandlateroutside一个适当的活动计划可以慢慢地增加你身体的流动性,最初是在家,慢慢地延伸到户外。·Resumingothernormalhouseholdactivities,suchassitting,standing,andclimbingstairs·恢复正常的家庭活动,如坐,站立,和爬楼梯·Specificexercisesseveraltimesadaytorestoremovementandstrengthenyourhip.Youprobablywillbeabletoperformtheexerciseswithouthelp,butyoumayhaveaphysicaltherapisthelpyouathomeorinatherapycenterthefirstfewweeksaftersurgery·一天几次具体的锻炼以恢复运动和加强你的髋关节。你可能会在没有帮助的情况下完成练习,但你也可以在术后前几周有物理治疗师在家或在治疗中心帮你TopofpagePossibleComplicationsofSurgery手术可能出现的并发症Thecomplicationratefollowinghipreplacementsurgeryislow.Seriouscomplications,suchasjointinfection,occurinlessthan2%ofpatients.Majormedicalcomplications,suchasheartattackorstroke,occurevenlessfrequently.However,chronicillnessesmayincreasethepotentialforcomplications.Althoughuncommon,whenthesecomplicationsoccurtheycanprolongorlimitfullrecovery.髋关节置换手术的并发症发生率较低。严重的并发症,诸如关节感染,发生率小于2%。主要的并发症,如心脏病发作或中风,发生率更低。然而,慢性疾病可能会增加并发症的发生率。这种情况虽然少见,但当这些并发症的发生可以延长或限制你的恢复期。Infection感染Infectionmayoccursuperficiallyinthewoundordeeparoundtheprosthesis.Itmayhappenwhileinthehospitalorafteryougohome.Itmayevenoccuryearslater.感染可能会发生在伤口表面或深部假体的周围。可以在你住院期间或回家之后发生,甚至有可能在几年后出现。Minorinfectionsofthewoundaregenerallytreatedwithantibiotics.Majorordeepinfectionsmayrequiremoresurgeryandremovaloftheprosthesis.Anyinfectioninyourbodycanspreadtoyourjointreplacement.伤口轻微感染的话,一般用抗生素治疗。重要的或深部感染,可能需要进一步手术治疗和去除假体。你身体任何部位的感染均能扩散到你置换的关节。BloodClots血栓Bloodclotsmayforminthelegveinsorpelvis.血栓可能形成于下肢静脉或骨盆。Bloodclotsinthelegveinsorpelvisarethemostcommoncomplicationofhipreplacementsurgery.Theseclotscanbelife-threateningiftheybreakfreeandtraveltoyourlungs.Yourorthopaedicsurgeonwilloutlineapreventionprogramwhichmayincludebloodthinningmedications,supporthose,inflatablelegcoverings,anklepumpexercises,andearlymobilization.下肢静脉或骨盆血栓形成是髋关节置换手术最常见的并发症。当这些血栓脱落并随血液进入肺,这将会危及生命。你的骨科医生将制定出一个预防方案,其中可能包括抗凝的药物,支架管,包裹腿部,踝部的练习,和早期活动。Leg-lengthInequality双下肢不等长Sometimesafterahipreplacement,onelegmayfeellongerorshorterthantheother.Yourorthopaedicsurgeonwillmakeeveryefforttomakeyourleglengthseven,butmaylengthenorshortenyourlegslightlyinordertomaximizethestabilityandbiomechanicsofthehip.Somepatientsmayfeelmorecomfortablewithashoeliftaftersurgery.有时髋关节置换术后会出现患肢与健肢不等长。你的骨科医生会尽一切努力使你的双下肢等长,但可能为了最大限度保持髋关节的稳定性和生物力学会延长或缩短你的患肢。有些患者可能会觉得在手术后患肢用鞋子垫高更舒服。Dislocation脱位Thisoccurswhentheballcomesoutofthesocket.Theriskfordislocationisgreatestinthefirstfewmonthsaftersurgerywhilethetissuesarehealing.Dislocationisuncommon.Iftheballdoescomeoutofthesocket,aclosedreductionusuallycanputitbackintoplacewithouttheneedformoresurgery.Insituationsinwhichthehipcontinuestodislocate,furthersurgerymaybenecessary.当球假体从臼杯脱出来时会发生脱位。脱位的风险最大是在手术后的几个月,这时组织正在逐渐愈合。脱位并不常见。如果发生脱位,闭合复位通常可以使之复位,而不需要手术。在髋关节反复脱位的情况下,可能需要进一步手术治疗。Hipimplantdislocation.髋关节假体脱位LooseningandImplantWear假体松动及磨损Overyears,thehipprosthesismaywearoutorloosen.Thisismostoftenduetoeverydayactivity.Itcanalsoresultfromabiologicthinningofthebonecalledosteolysis.Iflooseningispainful,asecondsurgerycalledarevisionmaybenecessary.若干年后,髋关节假体可能会磨损或松动。这是最常见的原因为日常的活动。它也可以导致从称为骨质溶解骨的生物变薄。如果松动是痛苦的,第二次手术被称为修正是必要的。OtherComplications其他并发症Nerveandbloodvesselinjury,bleeding,fracture,andstiffnesscanoccur.Inasmallnumberofpatients,somepaincancontinueornewpaincanoccuraftersurgery.Topofpage神经及血管损伤,出血,骨折,和关节僵硬均可能发生。在少数患者中,术后有些疼痛可能持续或出现新的疼痛。AvoidingProblemsAfterSurgery防止术后出现问题RecognizingtheSignsofaBloodClot要意识到血栓形成的征兆Followyourorthopaedicsurgeon'sinstructionscarefullytoreducetheriskofbloodclotsdevelopingduringthefirstseveralweeksofyourrecovery.Heorshemayrecommendthatyoucontinuetakingthebloodthinningmedicationyoustartedinthehospital.Notifyyourdoctorimmediatelyifyoudevelopanyofthefollowingwarningsigns.仔细按照你的骨科医生的指示做,以减少在恢复的最初几个星期内血栓发展的风险。医生可能会建议您继续服用在医院就开始服用的抗凝药。如果您发现以下任何征兆请立即通知你的医生。Warningsignsofbloodclots.Thewarningsignsofpossiblebloodclotinyourleginclude:警惕血栓形成的预兆,下肢血栓形成的预兆包括:·Paininyourcalfandlegthatisunrelatedtoyourincision·在你的小腿和脚出现与刀口无关的疼痛·Tendernessorrednessofyourcalf·在你的小腿出现压痛或发红·Swellingofyourthigh,calf,ankle,orfoot·你的大腿,小腿,脚踝或足部出现肿胀Warningsignsofpulmonaryembolism.Thewarningsignsthatabloodclothastraveledtoyourlunginclude:警惕肺栓塞形成的预兆,血栓脱落入肺的征兆包括:·Suddenshortnessofbreath·突然出现呼吸急促·Suddenonsetofchestpain·胸痛突然发作·Localizedchestpainwithcoughing·出现咳嗽导致的胸痛PreventingInfection预防感染Acommoncauseofinfectionfollowinghipreplacementsurgeryisfrombacteriathatenterthebloodstreamduringdentalprocedures,urinarytractinfections,orskininfections.导致髋关节置换手术感染的常见因素是:在牙科手术,泌尿道感染或皮肤感染时细菌进入血液。Followingyoursurgery,youmayneedtotakeantibioticspriortodentalwork,includingdentalcleanings,oranysurgicalprocedurethatcouldallowbacteriatoenteryourbloodstream.Formanypeoplewithjointreplacementsandnormalimmunesystems,theAmericanAcademyofOrthopaedicSurgeons(AAOS)recommendstakingpreventativeantibioticsbeforedentalwork.围手术期,你可能需要使用抗生素预先针对你的牙科问题,包括牙科洗牙,或任何可以让细菌进入你血液的牙科手术。有正常的免疫系统并要进行关节置换手术的病人,美国骨科医师学会(AAOS)建议在牙科工作之前使用预防性抗生素。Warningsignsofinfection.Notifyyourdoctorimmediatelyifyoudevelopanyofthefollowingsignsofapossiblehipreplacementinfection:出现感染的征兆。如果您发现以下任何一个可能的髋关节置换感染的迹象请立即通知你的医生:·Persistentfever(higherthan100°Forally)·持续发热(高于37.7℃)·Shakingchills·寒战·Increasingredness,tenderness,orswellingofthehipwound·伤口呈进行性发红,压痛或肿胀·Drainagefromthehipwound·伤口出现渗液·Increasinghippainwithbothactivityandrest·活动和休息时均出现进行性疼痛AvoidingFalls预防跌倒Afallduringthefirstfewweeksaftersurgerycandamageyournewhipandmayresultinaneedformoresurgery.Stairsareaparticularhazarduntilyourhipisstrongandmobile.Youshoulduseacane,crutches,awalker,orhandrailsorhavesomeonehelpyouuntilyouimproveyourbalance,flexibility,andstrength.在手术后的最初的几个星期跌倒可能会损害你的新髋关节,并可能会导致需要进行更多的手术。在你的髋关节有足够强度和活动度之前,爬楼梯是特别危险的。你应该使用拐杖,助行器,或扶手或有人扶你,直到你提高你的平衡性、柔韧性和力量。Yourorthopaedicsurgeonandphysicaltherapistwillhelpyoudecidewhichassistiveaideswillberequiredfollowingsurgery,andwhenthoseaidescansafelybediscontinued.你的骨科医生和理疗师会帮你选一些手术后可以帮助你的工具,这些工具可以安全地启动和停止。OtherPrecautions其它注意事项Toassureproperrecoveryandpreventdislocationoftheprosthesis,youmaybeaskedtotakespecialprecautions—usuallyforthefirst6weeksafterthesurgery:为了确保适当的恢复和防止假体脱位,您可能需要采取特殊的预防措施-通常是手术后6周内:2011,Thinkstock·Donotcrossyourlegs·不要盘腿·Donotbendyourhipsmorethanarightangle(90°)·不要弯曲你的髋部超过90°·Donotturnyourfeetexcessivelyinwardoroutward·不要过分外展或内收你的脚·Useapillowbetweenyourlegsatnightwhensleepinguntilyouareadvisedbyyourorthopaedicsurgeonthatyoucanremoveit·晚上睡觉时,在你的两腿之间放一个枕头,直到你的骨科医生同意将之拿走Yoursurgeonandphysicaltherapistwillgiveyoumoreinstructionspriortoyourdischargefromthehospital.您的骨科医生和理疗师会给你更多预防建议在你出院的时候。TopofpageOutcomes术后情况HowYourNewHipIsDifferent新关节会带来一些不适应Youmayfeelsomenumbnessintheskinaroundyourincision.Youalsomayfeelsomestiffness,particularlywithexcessivebending.Thesedifferencesoftendiminishwithtime,andmostpatientsfindtheseareminorcomparedwiththepainandlimitedfunctiontheyexperiencedpriortosurgery.你可能会觉得刀口周围的皮肤有些麻木。你也可能会觉得关节有些僵硬,特别是过度弯曲的时候。这些感觉往往随着时间的推移慢慢消失,大多数患者发现这些与他们经历的手术前的疼痛和功能受限相比较都是不起眼的。Yournewhipmayactivatemetaldetectorsrequiredforsecurityinairportsandsomebuildings.Tellthesecurityagentaboutyourhipreplacementifthealarmisactivated.Youmayaskyourorthopaedicsurgeonforacardconfirmingthatyouhaveanartificialhip.你的新髋关节在机场和一些建筑物的安检时会引起金属探测器报警。如果报警被激活,告诉安检员你曾行髋关节置换术。你可以向你的骨科医生要一张证明,证明你有一个人工髋关节。ProtectingYourHipReplacement保护你的新关节Therearemanythingsyoucandotoprotectyourhipreplacementandextendthelifeofyourhipimplant.保护你的新髋关节、延长你的髋关节假体的使用寿命,你可以做很多事情。·Participateinaregularlightexerciseprogramtomaintainproperstrengthandmobilityofyournewhip.·一个规律的轻度的锻炼计划可以帮助保持你的新髋关节有适当强度和流动性。·Takespecialprecautionstoavoidfallsandinjuries.Ifyoubreakaboneinyourleg,youmayrequiremoresurgery.·采取特殊的预防措施,以避免摔倒和受伤。如果你的腿骨折了,你可能需要更进一步的手术。·Makesureyourdentistknowsthatyouhaveahipreplacement.Youwillneedtotakeantibioticsbeforeanydentalprocedure.·确保您的牙医知道你刚行髋关节置换术。在任何牙科手术前你均需要使用抗生素。·Seeyourorthopaedicsurgeonperiodicallyforroutinefollow-upexaminationsandx-rays,evenifyourhipreplacementseemstobedoingfine.·定期骨科复诊并进行常规随访检查和X光片,即使你的新髋关节看似没问题。AAOSdoesnotendorseanytreatments,procedures,products,orphysiciansreferencedherein.Thisinformationisprovidedasaneducationalserviceandisnotintendedtoserveasmedicaladvice.Anyoneseekingspecificorthopaedicadviceorassistanceshouldconsulthisorherorthopaedicsurgeon,orlocateoneinyourareathroughtheAAOS"FindanOrthopaedist"programonthiswebsite. AAOS不推荐任何治疗方法,程序,产品或医生。提供此信息只作为一种培训服务,不作为医疗建议。任何寻求具体骨科咨询或援助,应咨询自己的骨科医生,或者在您的区域在本网站通过AAOS“找到一个骨科医生”为您解答。
广州中医药大学附属广东省中医院骨科 许树柴主任 翻译整理MeniscalTears半月板撕裂Yourkneeisthelargestjointinyourbodyandoneofthemostcomplex.Becauseyouuseitsomuch,itisvulnerabletoinjury.Becauseitismadeupofsomanyparts,manydifferentthingscangowrong.膝关节是在身体最大和最复杂的一个关节。因为我们经常使用膝关节,故很容易受伤。它构成复杂,故很多部位很容易损坏。Meniscaltearsareamongthemostcommonkneeinjuries.Athletes,particularlythosewhoplaycontactsports,areatriskformeniscaltears.However,anyoneatanyagecantearameniscus.Whenpeopletalkabouttorncartilageintheknee,theyareusuallyreferringtoatornmeniscus.半月板撕裂是最常见的膝关节损伤之一。运动员,特别是那些身体接触较多的运动,很容易导致半月板撕裂。然而,任何人在任何年龄均可发生半月板撕裂。当人们谈论膝盖的软骨撕裂,他们通常指的是半月板撕裂。AnatomyThreebonesmeettoformyourkneejoint:yourthighbone(femur),shinbone(tibia),andkneecap(patella).膝关节涵盖三块相邻的骨:股骨(大腿骨),胫骨,以及膝盖骨(髌骨)。Twowedge-shapedpiecesofcartilageactas"shockabsorbers"betweenyourthighboneandshinbone.Thesearecalledmeniscus.Theyaretoughandrubberytohelpcushionthejointandkeepitstable.两个楔形软骨在股骨和胫骨之间作为“减震器”。称为半月板。他们是坚韧和质软的,可以帮助缓解关节受力和保持稳定。TopofpageDescription特点Meniscitearindifferentways.Tearsarenotedbyhowtheylook,aswellaswherethetearoccursinthemeniscus.Commontearsincludelongitudinal,parrot-beak,flap,buckethandle,andmixed/complex.半月板撕裂的方式不同。半月板撕裂通常可以从外形看得出来具体撕裂部位。常见的撕裂包括纵裂、斜裂、层裂、提篮样和混合/复杂撕裂。Sports-relatedmeniscaltearsoftenoccuralongwithotherkneeinjuries,suchasanteriorcruciateligamenttears.与体育相关的半月板撕裂经常发生与其他膝关节损伤一起发生,如前十字韧带撕裂。Cause半月板撕裂的原因Suddenmeniscaltearsoftenhappenduringsports.Playersmaysquatandtwisttheknee,causingatear.Directcontact,likeatackle,issometimesinvolved.突如其来的半月板撕裂经常发生在运动损伤。运动员在蹲下和扭曲膝盖时可以造成撕裂。直接接触,例如铲球的动作,亦可以导致撕裂。Olderpeoplearemorelikelytohavedegenerativemeniscaltears.Cartilageweakensandwearsthinovertime.Aged,worntissueismorepronetotears.Justanawkwardtwistwhengettingupfromachairmaybeenoughtocauseatear,ifthemeniscihaveweakenedwithage.年纪大的人更容易有退行性半月板撕裂。随着时间的推移,软骨慢慢减弱变薄,老的、破旧的组织更容易撕裂。如果半月板已经随着年龄的增长老化,只是从椅子站起来,可能就足以造成撕裂,。Symptoms症状Youmightfeela"pop"whenyoutearameniscus.Mostpeoplecanstillwalkontheirinjuredknee.Manyathleteskeepplayingwithatear.Over2to3days,yourkneewillgraduallybecomemorestiffandswollen.Themostcommonsymptomsofmeniscaltearare:你可能会觉得“啪”的一声当你撕裂半月板的时候。大多数人受伤后还是可以走路的。许多运动员即使半月板撕裂依然继续运动。超过2~3天,你的膝关节会逐渐变得更加僵硬和肿胀。半月板撕裂的最常见的症状是:·Pain 疼痛·Stiffnessandswelling 关节僵硬和肿胀·Catchingorlockingofyourknee 关节交锁·Thesensationofyourknee"givingway" 关节松动感·Youarenotabletomoveyourkneethroughitsfullrangeofmotion·活动受限Withouttreatment,apieceofmeniscusmaycomelooseanddriftintothejoint.Thiscancauseyourkneetoslip,poporlock.如果不进行治疗,半月板可能会松动和漂移进入关节腔。这可能会导致你的膝关节不稳或交锁。DoctorExamination 检查PhysicalExaminationandPatientHistory 查体及病史Afterdiscussingyoursymptomsandmedicalhistory,yourdoctorwillexamineyourknee.Heorshewillcheckfortendernessalongthejointlinewherethemeniscussits.Thisoftensignalsatear.了解你的症状和病史后,医生会检查你的膝关节。他会沿着关节的半月板检查压痛。压痛部位往往就是撕裂部位。OneofthemaintestsformeniscaltearsistheMcMurraytest.Yourdoctorwillbendyourknee,thenstraightenandrotateit.Thisputstensiononatornmeniscus.Ifyouhaveameniscaltear,thismovementwillcauseaclickingsound.Yourkneewillclickeachtimeyourdoctordoesthetest.麦氏征是最重要的半月板撕裂的检查之一。医生弯曲你的膝盖,然后伸直和旋转。这使得撕裂的半月板紧张。如果你有半月板撕裂,这个动作将导致关节有响声。每次医生检查时你的膝关节都会响。ImagingTests 影像学检查 Becauseotherkneeproblemscausesimilarsymptoms,yourdoctormayorderimagingteststohelpconfirmthediagnosis.因为其他的膝关节问题可以导致类似的症状,医生可能会要求影像学检查,以帮助明确诊断。X-rays.AlthoughX-raysdonotshowmeniscaltears,theymayshowothercausesofkneepain,suchasosteoarthritis.X射线:虽然X射线不显示半月板撕裂,但可以显示出膝盖疼痛其他原因,例如骨关节炎。Magneticresonanceimaging(MRI).Thisstudycancreatebetterimagesofthesofttissuesofyourkneejoint.磁共振成像(MRI)。这项检查可以更好地显示你的膝盖关节的软组织。Treatment治疗Howyourorthopaedicsurgeontreatsyourtearwilldependonthetypeoftearyouhave,itssize,andlocation.医生会根据你撕裂的类型、大小和具体位置来决定你的治疗方案。Theoutsideone-thirdofthemeniscushasarichbloodsupply.Atearinthis"red"zonemayhealonitsown,orcanoftenberepairedwithsurgery.Alongitudinaltearisanexampleofthiskindoftear.半月板的外三分之一具有丰富的血液供应。在这个“红”区,半月板撕裂可能可以自愈,亦可以进行手术修复。纵向撕裂就是这种撕裂的一个例子。Incontrast,theinnertwo-thirdsofthemeniscuslacksabloodsupply.Withoutnutrientsfromblood,tearsinthis"white"zonecannotheal.Thesecomplextearsareofteninthin,worncartilage.Becausethepiecescannotgrowbacktogether,tearsinthiszoneareusuallysurgicallytrimmedaway.与此相反,半月板的内三分之二缺乏血液供应。因为缺乏血液的供应,在这个“白”区内的撕裂不能愈合。这些复杂的撕裂往往发生在薄的、磨损的地方。由于这两块不能重新生长起来,在这个区域内撕裂通常需要手术削去。Alongwiththetypeoftearyouhave,yourage,activitylevel,andanyrelatedinjurieswillfactorintoyourtreatmentplan.你撕裂的类型、年龄、活动量以及任何与损伤相关的因素都将成为你治疗计划的参考。NonsurgicalTreatment 非手术治疗Ifyourtearissmallandontheouteredgeofthemeniscus,itmaynotrequiresurgicalrepair.Aslongasyoursymptomsdonotpersistandyourkneeisstable,nonsurgicaltreatmentmaybeallyouneed.如果你撕裂的范围小,并在半月板的外侧缘,可能不需要手术修复。只要你的症状没有持续,你的膝关节是稳定的,非手术治疗可能是你所需要的。RICE.TheRICEprotocoliseffectiveformostsports-relatedinjuries.RICEstandsforRest,Ice,Compression,andElevation.RICE。RICE原则对于大多数运动相关的损害是有效的。RICE表示休息、冰敷、加压包扎和抬高患肢。·Rest.Takeabreakfromtheactivitythatcausedtheinjury.Yourdoctormayrecommendthatyouusecrutchestoavoidputtingweightonyourleg.·休息。损伤后停止活动,进行休息。医生可能会建议您使用拐杖避免患肢负重。·Ice.Usecoldpacksfor20minutesatatime,severaltimesaday.Donotapplyicedirectlytotheskin.·冰敷。用冰袋冷敷20分钟,每天数次。不要直接在皮肤上敷冰。·Compression.Topreventadditionalswellingandbloodloss,wearanelasticcompressionbandage.·加压包扎。为了避免额外的肿胀和出血,用的弹性压缩绷带加压包扎。·Elevation.Toreduceswelling,reclinewhenyourest,andputyourleguphigherthanyourheart.·抬高患肢。为了减轻肿胀,当你休息把你的腿抬起比你的心脏高。Non-steroidalanti-inflammatorymedicines.Drugslikeaspirinandibuprofenreducepainandswelling.非甾体抗炎药物。如阿司匹林和布洛芬等药物减轻疼痛和肿胀。SurgicalTreatmen手术治疗tIfyoursymptomspersistwithnonsurgicaltreatment,yourdoctormaysuggestarthroscopicsurgery.经非手术治疗后,如果你的症状扔持续存在,医生可能会建议关节镜手术。Procedure.Kneearthroscopyisoneofthemostcommonlyperformedsurgicalprocedures.Init,aminiaturecameraisinsertedthroughasmallincision.Thisprovidesaclearviewoftheinsideoftheknee.Yourorthopaedicsurgeoninsertsminiaturesurgicalinstrumentsthroughothersmallincisionstotrimorrepairthetear.手术:膝关节镜手术是最常见的外科手术之一。在这里面,一个微型摄像头通过一个小切口插入。提供膝关节的内部的清晰视图。骨科医生通过其他的小切口插入微型手术器械修整或修复撕裂的半月板。Rehabilitation.Aftersurgery,yourdoctormayputyourkneeinacastorbracetokeepitfrommoving.康复:术后,医生可能会在你的膝关节上石膏或支具以制动。Oncetheinitialhealingiscomplete,yourdoctorwillprescriberehabilitationexercises.Regularexercisetorestoreyourkneemobilityandstrengthisnecessary.Youwillstartwithexercisestoimproveyourrangeofmotion.Strengtheningexerciseswillgraduallybeaddedtoyourrehabilitationplan.一旦最初的治疗完成后,医生会开始叫你进行康复锻炼。有规律的锻炼对于恢复你的膝关节流动性和强度是必要的。你将开始练习使你的运动范围增大。您的康复计划将包括加强功能锻炼。Forthemostpart,rehabilitationcanbecarriedoutathome,althoughyourdoctormayrecommendphysicaltherapy.在大多数情况下,虽然医生可能会建议物理治疗,康复亦可以在家里进行。Recovery 预后Meniscaltearsareextremelycommonkneeinjuries.Withproperdiagnosis,treatment,andrehabilitation,patientsoftenreturntotheirpre-injuryabilities.半月板撕裂是非常常见的膝关节损伤。有了正确的诊断,治疗和康复,患者一般可以恢复到受伤前的功能。
ACLInjury:DoesItRequireSurgery? 广州二沙岛医院骨科 许树柴 教授 下面的文章提供了深入了解治疗前交叉韧带损伤的信息。前交叉韧带损伤,提供了一个很好的介绍主题,并建议在此阅读文章。 (如图所示: 前交叉韧带损伤及磁共振所示,手术中所见,韧带供体,术中及术后图片)Theinformationthatfollowsincludesthedetailsofanteriorcruciateligament(ACL)anatomyandthepathophysiologyofanACLtear,treatmentoptionsforACLinjuriesalongwithadescriptionofACLsurgicaltechniquesandrehabilitation,potentialcomplications,andoutcomes.Theinformationisintendedtoassistthepatientinmakingthebest-informeddecisionpossibleregardingthemanagementofACLinjury. 后面的信息包括前十字韧带(ACL)解剖和ACL撕裂的病理生理,ACL的手术技术和康复,潜在的并发症和结果并说明治疗方案的细节。该信息旨在帮助病人作出有关ACL损伤时的最明智的决定。Anatomy解剖Thebonestructureofthekneejointisformedbythefemur,thetibia,andthepatella.TheACLisoneofthefourmainligamentswithinthekneethatconnectthefemurtothetibia. 膝关节的骨骼结构是由股骨,胫骨和髌骨形成。前交叉韧带是膝关节内股骨连接到胫骨的四个主要韧带之一。Thekneeisessentiallyahingedjointthatisheldtogetherbythemedialcollateral(MCL),lateralcollateral(LCL),anteriorcruciate(ACL)andposteriorcruciate(PCL)ligaments.TheACLrunsdiagonallyinthemiddleoftheknee,preventingthetibiafromslidingoutinfrontofthefemur,aswellasprovidingrotationalstabilitytotheknee. 膝关节的韧带是由内侧副(MCL),外侧副(LCL),前十字(ACL)和后交叉(PCL)韧带构成。ACL的斜行在膝盖的中间,防止胫骨从在股骨的前面滑出,以及提供膝关节的旋转稳定性。Theweight-bearingsurfaceofthekneeiscoveredbyalayerofarticularcartilage.Oneithersideofthejoint,betweenthecartilagesurfacesofthefemurandtibia,arethemedialmeniscusandlateralmeniscus.Themenisciactasshockabsorbersandworkwiththecartilagetoreducethestressesbetweenthetibiaandthefemur. 膝关节的负重表面覆盖着一层关节软骨。在关节的两侧,股骨和胫骨的软骨表面之间,是内侧半月板和外侧半月板。半月板充当减震器,并与软骨一起减少胫骨和股骨之间的应力。Description概述Theanteriorcruciateligament(ACL)isoneofthemostcommonlyinjuredligamentsoftheknee.TheincidenceofACLinjuriesiscurrentlyestimatedatapproximately200,000annually,with100,000ACLreconstructionsperformedeachyear.Ingeneral,theincidenceofACLinjuryishigherinpeoplewhoparticipateinhigh-risksports,suchasbasketball,football,skiing,andsoccer. 前十字韧带(ACL)是膝关节的最容易受伤的一条韧带。ACL损伤的发病率目前每年估计约为200,000。其中约有100000人行前十字韧带重建术。一般情况下,ACL损伤的发病率在参加高风险运动,如篮球,足球,滑雪,和足球的人中更高。Approximately50percentofACLinjuriesoccurincombinationwithdamagetothemeniscus,articularcartilage,orotherligaments.Additionally,patientsmayhavebruisesofthebonebeneaththecartilagesurface.Thesemaybeseenonamagneticresonanceimaging(MRI)scanandmayindicateinjurytotheoverlyingarticularcartilage. 约50%的ACL损伤患者合并有半月板、关节软骨、或其他韧带的损伤。此外,患者可能有骨的损伤。这些均可以在磁共振成像(MRI)扫描下看到,并可以看到损伤的关节软骨(Left)ArthroscopicpictureofthenormalACL.(Right)ArthroscopicpictureoftornACL[yellowstar].(左)关节镜下正常的ACL。(右)关节镜下前十字韧带撕裂[黄星]。Cause原因Itisestimatedthat70percentofACLinjuriesoccurthroughnon-contactmechanismswhile30percentresultfromdirectcontactwithanotherplayerorobject. 据统计,70%的ACL损伤,通过非接触式的机制发生,另外30%是直接与别人或物体碰撞的结果。 Themechanismofinjuryisoftenassociatedwithdecelerationcoupledwithcutting,pivotingorsidesteppingmaneuvers,awkwardlandingsor"outofcontrol"play. 损伤的机制往往发生在减速时的切割、旋转或回避动作,无意识踩地或滑到亦可导致。SeveralstudieshaveshownthatfemaleathleteshaveahigherincidenceofACLinjurythanmaleathletesincertainsports.Ithasbeenproposedthatthisisduetodifferencesinphysicalconditioning,muscularstrength,andneuromuscularcontrol.Otherhypothesizedcausesofthisgender-relateddifferenceinACLinjuryratesincludepelvisandlowerextremity(leg)alignment,increasedligamentouslaxity,andtheeffectsofestrogenonligamentproperties. 一些研究表明,女性运动员ACL损伤的发生率高于男性运动员。有人提出,这是由于在身体协调,肌肉力量和神经肌肉控制的差异所致。其它认为ACL损伤率存在性别差异的假设原因包括骨盆和下肢(小腿)力线,韧带松弛,还有雌激素对韧带性能的影响。Immediatelyaftertheinjury,patientsusuallyexperiencepainandswellingandthekneefeelsunstable.WithinafewhoursafteranewACLinjury,patientsoftenhavealargeamountofkneeswelling,alossoffullrangeofmotion,painortendernessalongthejointlineanddiscomfortwhilewalking. 损伤后,患者通常会感觉疼痛和肿胀,膝关节不稳定感。在ACL损伤后数小时内,患者往往出现膝关节肿胀,活动受限,疼痛或沿关节线出现压痛以及走路出现不适。DoctorExamination检查 WhenapatientwithanACLinjuryisinitiallyseenforevaluationintheclinic,thedoctormayorderX-raystolookforanypossiblefractures.Heorshemayalsoorderamagneticresonanceimaging(MRI)scantoevaluatetheACLandtocheckforevidenceofinjurytootherkneeligaments,meniscuscartilage,orarticularcartilage. 当前交叉韧带损伤的患者最初来就诊,医生可能会要求X线来排除可能的骨折。医生也可能要求行磁共振成像(MRI)扫描,以评估ACL和检查有无伤到其他膝关节韧带、半月板或关节软骨。Inadditiontoperformingspecialtestsforidentifyingmeniscustearsandinjurytootherligamentsoftheknee,thephysicianwilloftenperformtheLachman'stesttoseeiftheACLisintact. 除了执行特殊检查确定半月板撕裂和膝关节韧带损伤等,医生会经常进行Lachman's试验,看看ACL是否完整的。深静脉血栓形成IftheACListorn,theexaminerwillfeelincreasedforward(upwardoranterior)movementofthetibiainrelationtothefemur(especiallywhencomparedtothenormalleg)andasoft,mushyendpoint(becausetheACListorn)whenthismovementends. 如果ACL撕裂,检查者会感觉到胫骨相对于股骨向前移动增加(尤其是在与正常的腿对比),亦可检查到软性终止点GettingBackintheGame:UnderstandingtheImpactsofTreatmentOptionsforACLTears(http://anationinmotion.org/value/ACL/)AnothertestforACLinjuryisthepivotshifttest.Lachman'sTestvideo(AAOS)Lachman'sTestvideo(AAOS)(http://orthoinfo.aaos.org/acl_video/KneeLigamentVideoLachmans.avi)Inthistest,iftheACListorn,thetibiawillstartforwardwhenthekneeisfullystraightandthenwillshiftbackintothecorrectpositioninrelationtothefemurwhenthekneeisbentpast30degrees. 另一种检查ACL损伤是抽屉试验。在这个检查中,如果ACL断裂,膝关节完全伸直时胫骨相对于股骨将开始前移,相当于膝盖弯曲近30度时的位置。 Lachman'sTestvideo(UMN)(http://www.sportsdoc.umn.edu/Clinical_Folder/Knee_Folder/Knee_Exam/lachmans.htm)NaturalHistory 疾病自然史 ThenaturalhistoryofanACLinjurywithoutsurgicalinterventionvariesfrompatienttopatientanddependsonthepatient'sactivitylevel,degreeofinjuryandinstabilitysymptoms. ACL损伤是否需行手术干预因人而异,取决于患者的活动水平,损伤和不稳定的症状程度。TheprognosisforapartiallytornACLisoftenfavorable,withtherecoveryandrehabilitationperiodusuallyatleastthreemonths.However,somepatientswithpartialACLtearsmaystillhaveinstabilitysymptoms.Closeclinicalfollow-upandacompletecourseofphysicaltherapyhelpsidentifythosepatientswithunstablekneesduetopartialACLtears. 局部十字韧带撕裂愈合后往往是有用的,恢复和康复期通常至少三个月。然而,一些患者局部ACL撕裂还是可能有不稳定的症状。密切的临床随访和一个完整的理疗过程有助于识别那些患者因局部ACL撕裂而不稳定的膝关节。 CompleteACLruptureshaveamuchlessfavorableoutcome.AfteracompleteACLtear,somepatientsareunabletoparticipateincuttingorpivoting-typesports,whileothershaveinstabilityduringevennormalactivities,suchaswalking.Therearesomerareindividualswhocanparticipateinsportswithoutanysymptomsofinstability.Thisvariabilityisrelatedtotheseverityoftheoriginalkneeinjury,aswellasthephysicaldemandsofthepatient. ACL完全断裂,有一个更坏结果。前交叉韧带完全断裂后,一些患者无法完成伸曲或旋转活动,连日常的活动,如散步等都有不稳定。有极少数人可以参加运动而且没有任何不稳定的症状。这种差异跟膝关节损伤的严重程度,以及患者的生理情况有关。 AbouthalfofACLinjuriesoccurincombinationwithdamagetothemeniscus,articularcartilageorotherligaments.SecondarydamagemayoccurinpatientswhohaverepeatedepisodesofinstabilityduetoACLinjury.Withchronicinstability,upto90percentofpatientswillhavemeniscusdamagewhenreassessed10ormoreyearsaftertheinitialinjury.Similarly,theprevalenceofarticularcartilagelesionsincreasesupto70percentinpatientswhohavea10-year-oldACLdeficiency. 大约有一半前交叉韧带损伤同时伴有半月板、关节软骨或其他韧带的损伤。继发性损害可发生在因前交叉韧带损伤而导致反复出现关节不稳定。在慢性不稳定的患者中,高达90%的比例在10年或10年多后会有半月板的损伤。同样,70%有10年前交叉韧带损伤的患者会出现关节软骨病变。TopofpageNonsurgicalTreatment非手术疗法 Innonsurgicaltreatment,progressivephysicaltherapyandrehabilitationcanrestorethekneetoaconditionclosetoitspre-injurystateandeducatethepatientonhowtopreventinstability. Thismaybesupplementedwiththeuseofahingedkneebrace.However,manypeoplewhochoosenottohavesurgerymayexperiencesecondaryinjurytothekneeduetorepetitiveinstabilityepisodes. 在非手术治疗中,进行物理治疗及康复可以让膝关节恢复接近其受伤前的状态,并教导患者如何预防关节不稳定。这可能需要使用铰链式护膝。然而,很多选择非手术治疗的患者可能会因为反复出现的膝关节不稳定发生继发性的膝关节损伤。Surgicaltreatmentisusuallyadvisedindealingwithcombinedinjuries(ACLtearsincombinationwithotherinjuriesintheknee).However,decidingagainstsurgeryisreasonableforselectpatients.NonsurgicalmanagementofisolatedACLtearsislikelytobesuccessfulormaybeindicatedinpatients:有合并伤时(ACL撕裂合并膝关节其他损伤),通常会建议手术治疗。然而,对于一些病人来说,不主张手术治疗。非手术治疗ACL撕裂是有可能成功也可能在病人中证实的,以下是非手术疗法的适应证:·Withpartialtearsandnoinstabilitysymptoms39·局部撕裂并没有关节不稳定的症状·Withcompletetearsandnosymptomsofkneeinstabilityduringlow-demandsportswhoarewillingtogiveuphigh-demandsports·完全断裂,但没有膝关节不稳定症状,只需要低强度的膝关节活动,对于高强度的活动没要求。·Whodolightmanualworkorlivesedentarylifestyles·从事轻体力工作或久坐的生活方式·Whosegrowthplatesarestillopen(children)· 仍处于生长阶段的(小孩) 手术治疗 前交叉韧带撕裂通常不用缝线来缝,因为修复的ACL一般都被证明是失败,因此,十字韧带撕裂,通常通过替换由肌腱制作的替代韧带来治疗。常用来取代该ACL的移植物包括:·髌骨肌腱(自体肌腱)·腘绳肌肌腱·股四头肌肌腱· 移植(取自尸体)髌腱,跟腱,半腱肌、股薄肌或胫后肌腱。 前交叉韧带重建术治疗的患者有82%到95%的成功率。出现经常性的不稳定和移植失败的概率大约为8%。 前交叉韧带重建手术的目的是为了防止出现关节不稳定和还原撕裂韧带的功能,建立稳定的膝关节。这允许患者恢复运动。在决定支持或反对前交叉韧带重建手术时,病人必须考虑到一些问题。 PatientConsiderations 患者注意事项 积极工作的成年患者,包括参与体育运动,或需要旋转、移动和重体力劳动的患者,建议手术治疗。这包括以前被排除在考虑前交叉韧带手术范围之外老年患者。是否考虑手术治疗,要根据活动要求而不是年龄。 对于年幼的儿童或青少年前交叉韧带撕裂,早期ACL重建可能会对生长产生损害的风险,从而导致骨骼生长的问题。医生可以延迟ACL手术直到小孩接近骨骼成熟或可以改进ACL手术技术,以减少生长损伤的风险 如果患者的十字韧带撕裂并有显著的功能不稳定且有继发性膝关节损害的高风险,则应考虑韧带重建。 经常可以看到前交叉韧带损伤合并半月板(50%)、关节软骨(30%)、侧副韧带(30%)、关节囊或上述的组合损伤。该“不和谐损伤群”,经常出现在足球运动员和滑雪者,同时有ACL、MCL及内侧半月板的损伤 对于合并伤,手术治疗可能是必要的,一般会产生更好的结果。在前交叉韧带合并半月板撕裂的患者中,50%的半月板撕裂是可修复的,并且可以愈合更好。 髌骨肌腱--髌韧带。取患者髌腱的中间三分之一,伴随着来自胫骨和髌骨的骨块的髌骨肌腱。偶尔会被一些医生称为前交叉韧带重建的“金标准”,经常推荐用于高要求的运动员和工作不需要经常跪地的病人。 在比较髌韧带和肌腱移植重建ACL的研究中,移植失败率较低的是髌腱组(1.9%对4.9%)。此外,大多数研究表明,髌韧带重建ACL在术后的膝关节松弛度的相关检查中(Lachman's试验、抽屉试验和仪表测试)有相同或更好的结果。然而,自体髌腱移植有术后髌股关节疼痛发生率较高(髌骨后面痛)及其他问题 取髌骨肌腱的缺陷是:·术后髌骨后方疼痛·跪地的时候疼痛·术后关节僵硬的风险略微增加·低度髌骨骨折风险 腘绳肌腱。膝盖内侧的半腱肌肌腱被用于建立腘绳肌腱并行ACL重建。一些医生使用一个额外的肌腱,股薄肌腱,它连接在膝盖以下的同一个区域。这将创建一个两或四股肌腱移植。相对于髌腱移植,腘绳肌腱移植的支持者声称该移植相关问题较少:·更少的问题,术后膝前疼痛或膝盖疼痛少·减少术后僵硬问题·切口较小·恢复更快 移植物功能可能在强度和在骨隧道的稳定性方面较差,因为没有骨块。已经有研究在腘绳肌腱是否在手术后更容易被拉伸从而会导致关节松弛的问题上取得结果。最近,一些研究已经证明腘绳肌腱的力量会逐渐减弱。 也有一些迹象表明,拥有的10度以上的固有韧带松弛,膝关节过伸患者可能增加术后肌腱移植物松弛的风险。因此,一些医生建议这些患者采用髌腱自体移植 此外,由于内侧腿筋经常提供针对外翻应力和不稳定动态支持,一些医生认为慢性或残留内侧副韧带松弛(2级或以上)的患者,可能是使用自己的半腱肌和股薄肌腱为ACL移植物的一个禁忌症 股四头肌肌腱。股四头肌肌腱经常被用于那些行ACL重建术失败的患者。从膝盖的上端的中间三分之一取患者的股四头肌腱和小骨块。这就可以满足更高和更重的病人的要求。因为只有一个骨块在一侧,稳定性没有髌腱移植物好。术后容易出现膝前痛和较低风险会出现髌骨骨折。患者可能会发生切口不愈合。 同种异体移植物:同种异体移植物是从尸体取移植物,现正变得越来越流行,这些移植可用于曾行前交叉韧带手术失败的患者,也可用于修复或重建一个以上的膝盖韧带的患者。使用同种异体移植组织的优点包括消除从病人身体取腱所造成的疼痛,减少手术时间和更小的切口。髌腱移植允许在胫骨和股骨隧道用螺钉固定。 然而,异体移植会增加感染的风险,包括病毒传播(艾滋病毒和丙型肝炎),尽管有仔细筛查和处理。一些死亡的病例跟来自同种异体组织的细菌感染有关(因不当采购及杀菌技术),促使我们改善同种异体移植组织的测试和处理技术。在调查研究过程中也出现了相互矛盾的结果,同种异体移植物是否更容易被拉伸而导致术后关节松弛。 最近发表的文献指出用同种异体肌腱完成ACL重建有更高的失败率。据报道在年轻、活跃的,行异体腱ACL重建后返回高强度体育活动的患者中,失败率介乎23%至34.4%。相对的,自体移植失败率介乎5%至10%。 这样高的失败率的原因是不清楚的。这可能是由于移植物材料性质(灭菌过程,移植物供体年龄,移植物的储存)。但也可能是由于运动员的不明智的早期恢复,因为过快地恢复到运动中,在体育活动中,移植物不能满足生理需要。在这方面进一步的研究表明,目前仍在进行。 SurgicalProcedure 手术过程 在任何手术治疗之前,患者通常需要行物理治疗。膝关节僵硬,肿胀,活动受限的病人在前交叉韧带重建术后恢复运动可有显著的问题,一般需要三个或更多个星期的时间恢复活动范围。我们还建议,对一些损伤的韧带进行修复,并使之在前交叉韧带重建术前愈合。 病人,医生和麻醉师选择手术麻醉方式。患者可能受益于腿的神经麻醉,减少手术后疼痛。该手术通常开始于患膝的检查,而病人由于麻醉的效果很放松。最终检查ACL撕破,也检查膝关节其它韧带松弛,可能需要手术时进行修复或术后处理。 如果检查明显表明前交叉韧带撕裂,则开始取腱(用于自体移植)或解冻(用于同种异体移植物)取与病人相符大小的移植物。 移植物准备好后,医生会将一个关节镜插进入关节内。小(1厘米)的切口在膝盖的前部插入关节镜和器械,然后医生检查膝关节的情况。先修复损伤的半月板和软骨,然后消除断裂的前交叉韧带。 最常见的前交叉韧带重建术,在胫骨和股骨钻隧道用于放置ACL移植物使之与原撕裂的前交叉韧带在几乎相同的位置上。然后用长针通过胫骨隧道传递,向上通过股骨隧道,然后穿过所述大腿的皮肤。移植物和缝合线沿着长针向上穿过胫骨隧道,然后向上进入股骨隧道拉入位置。移植物在张力下及使用界面螺钉、加标垫片、柱或钉固定到位。用来保持移植物固定不会移动。 在此手术技术的变化包括“两切口”,“过度的顶部”和“双包”类型的ACL重建术,这些新技术可能由于不同的医生或特殊情况下选择不同(改良前交叉韧带重建术,开放生长板)。 在手术完成之前,医生将测试移植物,以确保它具有良好的张力,确认膝盖有充分的活动范围,并进行测试,如Lachman's试验,以评估移植物的稳定性。然后关闭皮肤并敷料加压包扎(或许还有术后支具和冷疗设备,这取决于医生的偏好)。患者通常会在手术当天回家。手术并发症 感染:据报道,前交叉韧带重建术后有0.2%到0.48%的感染几率。也出现几个与感染来自因不当采购和杀菌技术被细菌污染的同种异体组织的死亡病例病毒传播:同种异体移植物有使包括艾滋病毒和丙型肝炎等病毒传播的风险,尽管仔细筛查和处理。获得HIV感染的同种异体骨移植供体的机率小于百万分之一。出血,肢体麻木:罕见的风险包括由急性损伤导致的腘动脉出血(总发病率是0.01%)。下肢麻痹或无力。大腿的外侧部分切口旁麻木的情况并不常见,这可能是暂时的或永久血栓:下肢静脉血栓形成是一个潜在的威胁生命的并发症。血栓可能在血液中脱落并行进到肺部,引起肺栓塞或到大脑,引起中风。据报道,此并发症发生率约0.12%。关节不稳定:重建的韧带的破裂或拉伸或落后的手术技术可导致术后关节不稳定(据报告,发生率在2.5%到34%之间)关节僵硬:膝关节僵硬或无法活动发生率据报道为5%到25%伸膝不能 ;髌腱的断裂(髌骨肌腱自体移植)或髌骨骨折(髌腱或股四头肌腱自体移植)可能是在取腱的部位发生。骨垢线受损:在年幼的儿童或青少年的ACL撕裂中,早期ACL重建术造成骨垢线的损伤有一定的风险,从而导致骨骼生长出现问题。ACL手术可以推迟到孩子的骨骼接近成熟。另外,外科医生可以通过改良ACL重建的技术以降低生长板损伤的风险。髌骨疼痛:使用髌骨肌腱的前交叉韧带重建术后髌骨疼痛是特别常见的。髌骨后方疼痛的发病率在4%到56%之间,而跪痛的发生率可高达42%。 术后恢复 物理治疗是成功的ACL手术的重要组成部分,手术后立即开始功能锻炼。大多数ACL重建手术的成功取决于病人以严谨态度接受物理治疗。随着新的手术技术和较强的移植物固定的出现,物理治疗仍然可以加速你的康复过程。 术后注意事项: 在手术后的10~14天内,伤口保持清洁和干燥,早期重点放在恢复到完全伸直膝关节和恢复股四头肌控制的能力上。膝关节经常接受冰敷以减少肿胀和疼痛。医生可能会决定术后使用支具以及可以调整活动范围的机器。负重状态(使用拐杖保持患肢部分或全部负重)也是由术后出现的损伤情况及医生的偏好决定的。 康复: 前交叉韧带重建手术的康复目标包括减少膝关节肿胀,保持膝盖的流动性,防止膝关节疼痛等问题,恢复膝关节的活动度,以及加强股四头肌和腘绳肌的力量。 病人可以恢复运动,如果不再有疼痛或肿胀,并已经达到正常的膝关节活动度,而且肌肉力量,耐力以及退的功能已经完全恢复。 患者的平衡能力和腿部的控制也必须通过功能锻炼恢复神经肌肉控制。通常需要四到六个月。成功的前交叉韧带重建术后,当你回归运动后带一个功能支具是非常没有必要的,但有些病人可能会感到戴着支具会更有安全感。
PosteriorCruciateLigamentInjuries后交叉韧带损伤 广州中医药大学附属广东省中医院二沙岛医院骨科 许树柴 翻译整理Theposteriorcruciateligamentislocatedinthebackoftheknee.Itisoneofseveralligamentsthatconnectthefemur(thighbone)tothetibia(shinbone).Theposteriorcruciateligamentkeepsthetibiafrommovingbackwardstoofar.后交叉韧带位于膝盖的后面。它是众多连接股骨和胫骨韧带中其中一条。其功能为防止胫骨过度向后移动。Aninjurytotheposteriorcruciateligamentrequiresapowerfulforce.Acommoncauseofinjuryisabentkneehittingadashboardinacaraccidentorafootballplayerfallingonakneethatisbent.致后交叉韧带损伤一般是受到暴力冲击。损伤的常见原因包括车祸时膝盖撞击到仪表盘,或者是足球运动员摔倒时膝盖着地。Anatomy解剖学Twobonesmeettoformyourkneejoint:yourthighbone(femur)andshinbone(tibia).Yourkneecapsitsinfrontofthejointtoprovidesomeprotection.股骨和胫骨共同结合形成膝关节。髌骨位于在膝关节的前方,可以保护膝关节。Bonesareconnectedtootherbonesbyligaments.Therearefourprimaryligamentsinyourknee.Theyactlikestrongropestoholdthebonestogetherandkeepyourkneestable.韧带能够维持骨头之间的联系。膝关节周围主要有四条韧带。这四条主要的韧带如同结实的绳索锁住你的骨头,以保持你的膝关节的稳定。Collateralligaments.Thesearefoundonthesidesofyourknee.Themedialcollateralligamentisontheinsideandthelateralcollateralligamentisontheoutside.Theycontrolthesidewaysmotionofyourkneeandbraceitagainstunusualmovement.侧副韧带侧副韧带位于膝关节的侧面。内侧副韧带位于膝关节的内侧边,外侧副韧带位于膝关节的外侧边。它们的主要功能为控制膝关节的横向移动,阻止其不寻常的移动。Cruciateligaments.Thesearefoundinsideyourkneejoint.Theycrosseachothertoforman"X"withtheanteriorcruciateligamentinfrontandtheposteriorcruciateligamentinback.Thecruciateligamentscontrolthebackandforthmotionofyourknee.交叉韧带交叉韧带位于膝关节的里面。其中前交叉韧带位于前方,后交叉韧带位于后方,它们共同交叉形成一个“X”形。交叉韧带的主要功能为控制膝关节的前后移动。Theposteriorcruciateligamentkeepstheshinbonefrommovingbackwardstoofar.Itisstrongerthantheanteriorcruciateligamentandisinjuredlessoften.Theposteriorcruciateligamenthastwopartsthatblendintoonestructurethatisaboutthesizeofaperson'slittlefinger.后交叉韧带可以防止胫骨过度向后方移动。它比前交叉韧带更加坚韧,且不容易损伤。后交叉韧带由两部分组成,其尺寸大小大概与成人的小指大小一样。 小于14.5岁未成年人后交叉韧带损伤另有操作指南 Description描述Injuriestotheposteriorcruciateligamentarenotascommonasotherkneeligamentinjuries.Infact,theyareoftensubtleandmoredifficulttoevaluatethanotherligamentinjuriesintheknee.相对其他膝关节韧带来说,后交叉韧带的损伤没那么常见。事实上,后交叉韧带的损伤往往比较细微,相对膝关节其他韧带更加难以评估。Manytimesaposteriorcruciateligamentinjuryoccursalongwithinjuriestootherstructuresinthekneesuchascartilage,otherligaments,andbone.许多时候后交叉韧带的损伤常常伴有膝关节其他部位的损伤,包括软骨损伤,其他韧带的损伤,或者是骨头的损伤。Injuredligamentsareconsidered"sprains"andaregradedonaseverityscale.韧带损伤往往与“扭伤”有关,根据其损伤严重程度可分为三个等级。Grade1Sprains.TheligamentismildlydamagedinaGrade1Sprain.Ithasbeenslightlystretched,butisstillabletohelpkeepthekneejointstable.一级扭伤。韧带轻微损伤,轻度的拉伸,但仍然能保持膝关节稳定。Grade2Sprains.AGrade2Sprainstretchestheligamenttothepointwhereitbecomesloose.Thisisoftenreferredtoasapartialtearoftheligament.二级扭伤。韧带损伤,中度的拉伸,使它变得松弛。此时通常被称为韧带部分撕裂。Grade3Sprains.Thistypeofsprainismostcommonlyreferredtoasacompletetearoftheligament.Theligamenthasbeensplitintotwopieces,andthekneejointisunstable.三级扭伤。韧带三级扭伤通常被称为韧带断裂。损伤的韧带断成两部分,此时膝关节十分不稳定。Posteriorcruciateligamenttearstendtobepartialtearswiththepotentialtohealontheirown.Peoplewhohaveinjuredjusttheirposteriorcruciateligamentsareusuallyabletoreturntosportswithoutkneestabilityproblems.后交叉韧带部分损伤后,有潜在的自我愈合能力。如果患者仅仅是后交叉韧带损伤,他们通常能够再次投入运动,并且膝关节不会出现不稳定。Cause原因Aninjurytotheposteriorcruciateligamentcanhappenmanyways.Ittypicallyrequiresapowerfulforce.导致后交叉韧带的损伤原因有很多,通常情况下是遭到了暴力冲击。·Adirectblowtothefrontoftheknee(suchasabentkneehittingadashboardinacarcrash,orafallontoabentkneeinsports)·膝关节前方受到直接暴力(例如车祸时膝盖撞击到仪表盘,或者是运动时不慎摔倒致膝盖着地)·Pullingorstretchingtheligament(suchasinatwistingorhyperextensioninjury)·韧带受到牵拉力或者是拉伸力(例如扭伤或者过度伸展)·Simplemisstep·失足Symptoms症状Thetypicalsymptomsofaposteriorcruciateligamentinjuryare:后交叉韧带损伤典型的症状有:·Painwithswellingthatoccurssteadilyandquicklyaftertheinjury·损伤后迅速、持续出现疼痛、肿胀·Swellingthatmakesthekneestiffandmaycausealimp·膝关节僵硬,可能同时伴有跛行·Difficultywalking·行走困难·Thekneefeelsunstable,likeitmay"giveout"·膝关节不稳定,乏力DoctorExamination医生检查Duringyourfirstvisit,yourdoctorwilltalktoyouaboutyoursymptomsandmedicalhistory.第一次看诊时,医生将会详细询问你的症状以及病史。Duringthephysicalexamination,yourdoctorwillcheckallthestructuresofyourinjuredknee,andcomparethemtoyournon-injuredknee.Yourinjuredkneemayappeartosagbackwardswhenbent.Itmightslidebackwardstoofar,particularlywhenitisbentbeyonda90°angle.OthertestswhichmayhelpyourdoctorconfirmyourdiagnosisincludeX-raysandmagneticresonanceimaging(MRI).Itispossible,however,forthesepicturestoappearnormal,especiallyiftheinjuryoccurredmorethan3monthsbeforethetests.做体格检查时,医生将会检查患侧和健侧膝关节的所有部位,并做出对比。当患侧膝关节弯曲时,可能会出现胫骨向后方倾斜,特别是当弯曲的角度大于90°时,胫骨可能会向后方过度移动。除了体格检查之外,其它辅助检查包括X片和MRI可以帮助医生明确诊断。然而,如果后交叉韧带损伤的时间已经超过三个月,影像显现出来的图像也有可能提示是正常的。X-rays.Althoughtheywillnotshowanyinjurytoyourposteriorcruciateligament,X-rayscanshowwhethertheligamenttoreoffapieceofbonewhenitwasinjured.Thisiscalledanavulsionfracture.X片。尽管X片显示不了后交叉韧带的损伤,但是能够提示是否由韧带撕脱所引起的骨折,通常我们会把这种类型的骨折称之为撕脱骨折。MRI.Thisstudycreatesbetterimagesofsofttissuesliketheposteriorcruciateligament.MRI。MRI能够更清楚地显示出软组织,其中包括后交叉韧带。Treatment治疗 NonsurgicalTreatment非手术治疗Ifyouhaveinjuredjustyourposteriorcruciateligament,yourinjurymayhealquitewellwithoutsurgeryYourdoctormayrecommendsimple,nonsurgicaloptions.如果你仅仅是后交叉韧带损伤,即使没有采取手术治疗,它也可以愈合得很好。所以医生可能会建议采取简单,非手术的治疗方法。RICE.Whenyouarefirstinjured,theRICEmethod-rest,ice,gentlecompressionandelevation—canhelpspeedyourrecovery.RICE治疗。当你第一次损伤时,采用RICE治疗方法可以更加快速地帮助你恢复。RICE治疗方法由四个步骤组成,分别是休息,冰敷,轻微地加压以及抬高下肢。Immobilization.Yourdoctormayrecommendabracetopreventyourkneefrommoving.Tofurtherprotectyourknee,youmaybegivencrutchestokeepyoufromputtingweightonyourleg.制动。医生会对患侧膝关节进行制动以防止它随意移动。为了更妥善地保护患侧膝关节,医生会建议患者使用拐杖,以减轻其负重。Physicaltherapy.Astheswellinggoesdown,acarefulrehabilitationprogramisstarted.Specificexerciseswillrestorefunctiontoyourkneeandstrengthenthelegmusclesthatsupportit.Strengtheningthemusclesinthefrontofyourthigh(quadriceps)hasbeenshowntobeakeyfactorinasuccessfulrecovery.物理治疗。当肿胀消退时,可以开始进行康复锻炼。定期的锻炼将会恢复患侧膝关节的功能以及加强其肌肉的力量。加强股骨前方肌群的肌力已经被认为是成功康复的一个重要因素。 SurgicalTreatment手术治疗Yourdoctormayrecommendsurgeryifyouhavecombinedinjuries.Forexample,ifyouhavedislocatedyourkneeandtornmultipleligamentsincludingtheposteriorcruciateligament,surgeryisalmostalwaysnecessary.如果你存在多部位的损伤,医生可能会建议你进行手术治疗。举个例子,假如你的膝关节脱位了,同时伴有后交叉韧带在内的多条韧带损伤,此时必须进行手术治疗。Rebuildingtheligament.Becausesewingtheligamentendsbacktogetherdoesnotusuallyheal,atornposteriorcruciateligamentmustberebuilt.Yourdoctorwillreplaceyourtornligamentwithatissuegraft.Thisgraftistakenfromanotherpartofyourbody,orfromanotherhumandonor(cadaver).Itcantakeseveralmonthsforthegrafttohealintoyourbone.重建韧带。后交叉韧带断裂必须进行重建。这是因为韧带断裂末端即使缝合在一起,通常很难愈合。此时医生将会移植一段组织来代替断裂的韧带。这些组织可以来源于患者身体上的其他部位,也可以来源于他人的捐赠。但要使这些移植的组织成功长到骨头上大概需要几个月的时间。Procedure.Surgerytorebuildaposteriorcruciateligamentisdonewithanarthroscopeusingsmallincisions.Arthroscopicsurgeryislessinvasive.Thebenefitsoflessinvasivetechniquesincludelesspainfromsurgery,lesstimespentinthehospital,andquickerrecoverytimes.手术步骤。操作关节镜进行后交叉韧带重建术,只需一个小切口,具有创伤小的特点。这种微创技术的优势在于不仅可以减少患者痛苦,同时可以减少手术时间以及使患者快速康复。Surgicalprocedurestorepairposteriorcruciateligamentscontinuetoimprove.Moreadvancedtechniqueshelppatientsresumeawiderrangeofactivitiesafterrehabilitation.目前后交叉韧带修复手术在不断地进行改良之后,涌现出越来越多的先进技术,帮助患者康复后可以进行更多的运动。 Rehabilitation康复Whetheryourtreatmentinvolvessurgeryornot,rehabilitationplaysavitalroleingettingyoubacktoyourdailyactivities.Aphysicaltherapyprogramwillhelpyouregainkneestrengthandmotion.Ifyouhadsurgery,physicaltherapywillbegin1to4weeksafteryourprocedure.无论你是否选择手术治疗,康复锻炼都扮演着十分重要的角色。它能够让你重新回到日常生活中。而进行物理治疗将会帮助你恢复膝关节的力量和活动。如果你选择手术治疗,物理治疗将会在手术后1到4周内进行。Howlongittakesyoutorecoverfromaposteriorcruciateligamentinjurywilldependontheseverityofyourinjury.Combinedinjuriesoftenhaveaslowrecovery,butmostpatientsdowellovertime.后交叉韧带损伤的康复时间决定于其损伤的严重程度。通常情况下多部位的损伤康复时间较为漫长,但大多数患者的恢复情况都很好。Ifyourinjuryrequiressurgery,itmaybeseveralweeksbeforeyoureturntoadeskjob-perhapsmonthsifyourjobrequiresalotofactivity.Fullrecoverytypicallyrequires6to12months.如果你的伤势急需手术治疗,那可能需要休息几个星期后才能回到办公室工作。如果是属于高强度工作,则可能需要休息几个月。一般来说,整个康复过程需要六到十二个月。Althoughitisaslowprocess,yourcommitmenttotherapyisthemostimportantfactorinreturningtoalltheactivitiesyouenjoy.尽管这个过程很漫长,然而为了回归一切你喜欢的活动,最重要的因素是你需要配合治疗。