专题教程：固定垫片单髁置换术手术技巧

涂意辉

同济大学附属杨浦医院关节外科主任，博士、主任医师、博士生导师，美国田纳西大学、英国牛津大学访问学者，《中国骨质疏松杂志》、《生物骨科材料临床研究杂志》编委、《中国组织工程研究》审稿专家，中国老年学会骨质疏松委员会常委，中国医师协会骨科医师分会委员，中国康复医学会骨与关节及风湿病专业委员会专家委员，上海市中西医结合学会创伤医学委员会常务委员，上海市中西医结合学会关节病委员会委员，上海市医师协会骨科分会关节工作组组员，国家、上海市科技奖评审专家，2017年上海市“五一劳动奖章”，国家发明专利5项、实用新型专利13项。

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UKA的适应证和禁忌证

• 内侧、外侧UKA手术适应症类似，包括单间室OA、骨坏死、创伤性关节炎 Unicompartmental  arthritis, Osteonecrosis, Post-traumatic arthritis (√)

• 类风湿关节炎不适合行UKA  Rheumatoid arthritis (×)

• 另外一个间室狭窄明显则为UKA的绝对禁忌证 Not limited to one compartment arthritis (×)

• 应力位下间隙狭窄固定，无法纠正，也应视为手术禁忌Fixed narrow deformity not corrected on stressed films (×) 

• 超过10°的固定屈曲畸形 Fixed flexion deformity >10°(×) 

• 非骨对骨Not bone on bone in involved compartment (×) 

• 韧带严重受损 Absent or several damaged ACL（MCL or PCL)(×)

St Georg Sled 

手术操作技术(以内侧UKA为例)

术前动力位检查 Preoperative varus and valgus examination by fluoroscopy

体位

髋关节屈曲70°Hip flexed to about 70° 

切口 

切口髌骨上极至关节线下3厘米 From above the pole of the patella to a point 3cm distal to the joint line  

剔除骨赘

剔除股骨髁边缘骨赘 Moving large osteophytes from the margin of the femoral condyle  and from both margins and root of the intercondylar notch

胫骨截骨

根据拟选择试模型号标记截骨的宽度和厚度  Marking  the point of width and thickness of the osteotomy according to the proposed model number.

根据标记截骨  Osteotomy is performed according to the markers

胫骨试模测试

测试屈曲间隙和选择胫骨假体 Measuring the flexion and chosing the tibial component with the appropriate width  

股骨侧处理

标记伸直线  Making full extension line 

除去关节软骨  Removing the femoral  cartilage by oscillating  blade

  

股骨定位和测试

股骨假体定位在胫骨平台中点的运动轨迹  Femoral prosthesis is positioned to contact in the centre of the tibial plateau

股骨假体完全覆盖股骨髁  Drill guide cover the femoral condyle  in deep flexion and extend up to but not significantly beyond the  extension line

股骨侧处理

钻固定孔   Drilling the fixation holes 

试模复位

试模复位   The trial sled prosthesis is placed on the prepared femoral condyle

胫骨侧处理

胫骨开槽   The bony structure is displaced, compressed by  the chisel 

试模复位

试模复位 The tibial trial prosthesis is put into place with slight valgus loading

屈伸间隙测试

屈伸间隙平衡 The knee is moved through its entire range of motion to check the balance of the flexion and extension and the natural tension of the ligaments is restored

  

假体安装

膝关节屈曲胫骨外旋有利于胫骨假体安装   To facilitate tibial prosthesis placement, the knee is flexed and the tibia is externally rotated

股骨假体先于胫骨假体安装 The femoral prosthesis was installed prior to the tibia prosthesis

关闭切口 

关闭切口 Closing the incision

术后检查 

术后检查  Postoperative examination by fluoroscopy  

手术操作要点

股骨髁截骨避免股骨假体过屈，避免发生髌骨撞击 Avoid excessive flexion of the femoral component, Prevent patella impingement

股骨髁截骨避免股骨假体过伸，避免发生髌骨弹跳 Avoid excessive extending of the femoral component，Prevent patella bounce

假体置入后必须反复伸屈检查  Repeatly test the patella movement trace

避免残存骨赘导致假体撞击  Avoid impingement

胫骨截骨 Tibial osteotomy

• 截骨应比较保守Osteotomy should be conservative

• 胫骨垂直截骨内旋5-10°（screw-home机制）（外侧UKA）   5 to 10°internal rotation of the sagital tibial cut

• 截骨深度5-7mm The osteotomy depth was 5-7mm

胫骨截骨 tibial osteotomy

• 最佳胫骨后倾角度是5-7°optimal tibial slope is 5-7°

• 超过7°UKA失败率增加 more failure when slope is beyond 7°

如何解决？How to do?

• 避免过度矫正冠状面畸形 Avoid overcorrection of coronal deformity

• 推荐轻度矫正不足 Slight undercorrection

• 内侧UKA保留轻度内翻 1 to 3°of  varus

• 外侧UKA保留轻度外翻  3 to 5°of  valgus

UKA的手术并发症

典型病例1（内侧UKA ）case 1

典型病例2（外侧UKA）  case 2

髌股轨迹  Patellofemoral track