本文選題：膝關(guān)節(jié)骨性關(guān)節(jié)炎 + 膝關(guān)節(jié)內(nèi)側(cè)單間室置換手術(shù)��； 參考：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：背景:膝關(guān)節(jié)骨性關(guān)節(jié)炎是骨科常見疾病,骨性關(guān)節(jié)炎表現(xiàn)為關(guān)節(jié)軟骨磨損退變,骨質(zhì)增生導(dǎo)致骨贅形成�；颊咝凶咛弁�,關(guān)節(jié)間隙壓痛,對(duì)患者的生活及工作有極大的影響。在膝關(guān)節(jié)骨性關(guān)節(jié)炎的患者中,有大約30%的患者是膝關(guān)節(jié)前內(nèi)側(cè)間室骨性關(guān)節(jié)炎,針對(duì)這一類患者的治療手段較多,其中膝關(guān)節(jié)內(nèi)側(cè)單間室置換手術(shù)經(jīng)過長期的臨床隨訪,被證實(shí)是有效可靠的手術(shù)方式。但是術(shù)后部分患者會(huì)出現(xiàn)髕骨與股骨假體撞擊的問題,以及出現(xiàn)髕股關(guān)節(jié)炎的進(jìn)展,有研究顯示是術(shù)中對(duì)于股骨內(nèi)側(cè)髁切跡的錯(cuò)誤判斷,導(dǎo)致選擇了型號(hào)偏大的股骨假體,術(shù)后股骨假體的前緣與髕骨發(fā)生撞擊。膝關(guān)節(jié)單間室置換的長期并發(fā)癥還包括對(duì)側(cè)間室的骨關(guān)節(jié)炎進(jìn)展及假體無菌性松動(dòng),有學(xué)者提出膝關(guān)節(jié)內(nèi)翻的矯正角度應(yīng)控制在1°左右為佳,后傾的理想角度為7°,目前關(guān)于膝關(guān)節(jié)內(nèi)側(cè)單間室置換的文獻(xiàn)較多,但是關(guān)于股骨內(nèi)側(cè)髁切跡對(duì)股骨截骨及假體型號(hào)選擇的研究還為數(shù)較少。本研究通過使用三維重建成像技術(shù)模擬手術(shù)使用的股骨假體型號(hào),來實(shí)現(xiàn)每位患者的個(gè)體化截骨,達(dá)到準(zhǔn)確的選擇假體型號(hào)及安放假體位置,減少了髕骨撞擊等并發(fā)癥的發(fā)生。目的:本實(shí)驗(yàn)是選擇診斷為膝關(guān)節(jié)前內(nèi)側(cè)間室骨性關(guān)節(jié)炎的患者,術(shù)前常規(guī)做雙膝關(guān)節(jié)CT平掃+三維重建及膝關(guān)節(jié)正側(cè)位X線片。利用膝關(guān)節(jié)單髁假體模板模擬股骨假體放置位置,評(píng)估選擇合適的假體型號(hào),根據(jù)術(shù)前測量結(jié)果進(jìn)行精確的脛骨及股骨截骨,為臨床進(jìn)行單間室置換手術(shù)提供進(jìn)一步的手術(shù)操作依據(jù)及優(yōu)化手術(shù)技巧。方法:選取河北醫(yī)科大學(xué)第三醫(yī)院自2014年9月至2016年5月初次行膝關(guān)節(jié)內(nèi)側(cè)間室置換術(shù)的患者102例102膝(女性67例,男性35例,年齡50~73歲)。隨機(jī)分為兩組,常規(guī)手術(shù)組及個(gè)體化截骨組(CT測量組)。手術(shù)均由同一位主任醫(yī)師完成,個(gè)體化截骨組術(shù)前通過RadiAnt DICOM軟件在CT片及三維重建中測量,確定確切截骨方案及評(píng)估術(shù)中可能使用假體型號(hào)完成手術(shù);常規(guī)手術(shù)組沒有術(shù)前測量。術(shù)前所有患者常規(guī)掃描膝關(guān)節(jié)CT,然后對(duì)股骨進(jìn)行三維重建,在合適的CT矢狀位層面上,確定股骨遠(yuǎn)端骨性標(biāo)志點(diǎn):股骨內(nèi)側(cè)髁切跡最低點(diǎn)(A點(diǎn)),后髁最遠(yuǎn)點(diǎn)(B點(diǎn))。確定股骨長軸中軸線(f),經(jīng)過A、B兩點(diǎn)分別做f的平行線定義為a線和b線。a線與b線的最短距離定義為H。將每位患者使用的相應(yīng)假體前后徑(AP值)分別減去其測得的H值,得到相應(yīng)的數(shù)值定義為h值,h0的數(shù)據(jù)不計(jì)入統(tǒng)計(jì)分析,h≥0進(jìn)行統(tǒng)計(jì)分析。h≥0,意味著假體前緣超過了股骨內(nèi)側(cè)髁切跡,有可能造成術(shù)后髕骨與股骨假體撞擊。將單髁的股骨假體與三維重建圖像進(jìn)行模擬放置,評(píng)估假體的位置。兩組所有病例術(shù)前及術(shù)后均拍攝患者負(fù)重位雙下肢全長片及膝關(guān)節(jié)正側(cè)位。對(duì)X線片的脛骨后傾角度及膝關(guān)節(jié)內(nèi)翻角度進(jìn)行測量。評(píng)估兩組術(shù)后8周的膝關(guān)節(jié)活動(dòng)度、膝關(guān)節(jié)協(xié)會(huì)評(píng)分及視覺模擬評(píng)分的情況并進(jìn)行統(tǒng)計(jì)學(xué)分析。結(jié)果:所有患者中有髕骨撞擊的患者共5例,均出現(xiàn)在常規(guī)手術(shù)組,并且h≥3mm。髕股關(guān)節(jié)有癥狀(這些癥狀包括髕骨撞擊、膝前疼痛及上下樓疼痛或不適,Table 1、2)的患者15例,其中h≥0mm,常規(guī)手術(shù)組有7例,個(gè)體化截骨組有2例;h0的一共有6例,常規(guī)手術(shù)組及個(gè)體化截骨組個(gè)體化截骨組各3例。常規(guī)手術(shù)組與個(gè)體化截骨組術(shù)后的脛骨假體后傾角及膝關(guān)節(jié)內(nèi)翻角度無統(tǒng)計(jì)學(xué)差異;兩組術(shù)后的膝關(guān)節(jié)活動(dòng)度、膝關(guān)節(jié)協(xié)會(huì)評(píng)分及視覺模擬評(píng)分均存在統(tǒng)計(jì)學(xué)差異。結(jié)論:股骨假體前緣超過股骨內(nèi)側(cè)髁切跡3mm會(huì)產(chǎn)生髕骨與股骨假體撞擊的癥狀。術(shù)前進(jìn)行三維重建模擬假體型號(hào)的大小及假體放置的位置,有效的避免了因股骨假體型號(hào)選擇過大、股骨假體的過度旋前導(dǎo)致的假體前移和后髁截骨量過多所導(dǎo)致的髕骨撞擊的發(fā)生;避免了因股骨假體型號(hào)選擇過小,股骨假體的過度旋后所導(dǎo)致的股骨假體與聚乙烯襯墊撞擊的發(fā)生。因此在CT及三維重建影像下模擬手術(shù)截骨方案是非常重要的。股骨內(nèi)側(cè)髁切跡對(duì)于單髁置換術(shù)中假體的位置判斷有重要意義。
[Abstract]:Background: osteoarthritis of the knee is a common disease in the Department of orthopedics. Osteoarthritis is manifested by osteoarthritis of the articular cartilage and osteophyte formation caused by hyperosteogeny. The patient's walking pain and joint space pressure pain have a great influence on the life and work of the patients. In the patients with osteoarthritis of the knee, about 30% of the patients are the anterior medial knee joint. There are many methods of treatment for this type of patients. The medial single compartment replacement of the knee is proved to be an effective and reliable operation after a long period of clinical follow-up. However, some patients will have the problem of patellar and femoral prosthesis and the progress of patellofemoral arthritis. It is a misjudgement of the medial condyle notch of the femur during the operation, resulting in the selection of a large femoral prosthesis. The anterior margin of the femoral prosthesis is impacted by the patella. The long-term complications of the single compartment replacement of the knee include the progress of the osteoarthritis of the lateral compartment and the aseptic loosening of the prosthesis, and some scholars have proposed the correction angle of the knee varus. The best angle of control is about 1 degrees, and the ideal angle of posterior inclination is 7 degrees. There are many literatures about the replacement of the medial single compartment of the knee joint, but the study of the selection of the femoral osteotomy and the type of prosthesis of the femoral medial condyle is still less. The individualized osteotomy of each patient has achieved an accurate selection of the type of prosthesis and the position of the prosthesis to reduce the occurrence of the patellar impact. Objective: this experiment was to select the patients who were diagnosed as the medial anterior chamber osteoarthritis of the knee joint with CT plain and three-dimensional reconstruction of the knee joint and the lateral X-ray of the knee joint before operation. A single condyle prosthesis template was used to simulate the placement of the femoral prosthesis. The appropriate model of the prosthesis was selected. The precise tibial and femur osteotomy was carried out according to the preoperative measurement results. The surgical technique was provided for the clinical single room replacement and the surgical technique was optimized. Method: the Third Hospital of Hebei Medical University was selected from 2014. From September to early May 2016, 102 patients with 102 knees (67 females, 35 males, 50~73 years old) were randomly divided into two groups, the routine operation group and the individual osteotomy group (CT measurement group). The operation was performed by the same chief physician. The individual osteotomy group was performed by RadiAnt DICOM software in CT and 3 D before the operation. In the reconstruction, the exact osteotomy scheme and the possible use of the prosthesis were evaluated during the operation. There was no preoperative measurement in the routine operation group. All the patients before the operation were routinely scanned on the knee joint CT, then the three-dimensional reconstruction of the femur, and the distal femur condyle notch point was determined at the appropriate CT sagittal level: the lowest point of the medial femoral condyle. (A point), the farthest point of the posterior condyle (B point). Determine the axis axis (f) of the long axis of the femur. After A, the parallel lines of F are defined as the shortest distance between the a line and the B line.A line and the B line. The corresponding values of the corresponding prosthesis diameter (AP value) used by each patient are subtracted, and the corresponding values are defined as the values. The data are not included in the statistics. Analysis, H > 0, the statistical analysis of.H > 0, means that the anterior margin of the prosthesis exceeds the medial femoral condyle incisor, which may result in the impact of the patellar and femoral prosthesis. The femoral prosthesis of the single condyle and the three-dimensional reconstruction image are simulated and the position of the prosthesis is evaluated. All cases of all cases in the two groups are taken to take the full length of the lower limbs before and after the operation. The knee joint lateral position. The tibial posterior angle of the X-ray and the angle of the knee joint were measured. The knee joint activity, the knee association score and the visual analogue score of the two groups were evaluated at 8 weeks after operation, and the results were statistically analyzed. Results: all the patients with patellar impact were 5 cases in the routine operation group, and H The symptoms of the patellar joint (including the patellar joint, including the patellar impact, the pain of the knee and the pain or discomfort of the upper and lower floors, and discomfort, Table 1,2) were 15 cases, of which h was more than 0mm, 7 in the routine operation group, 2 in the individual osteotomy group, 6 in the total of H0 and 3 in the individual osteotomy group of the routine operation group and the individualized osteotomy group, and the routine operation group and the individualized section. There was no statistical difference between the tibial prosthesis and the knee varus angle after the operation of the bone group. There were statistical differences between the two groups of the knee joint activity, the knee association score and the visual analogue score. Conclusion: the 3mm of the femoral prosthesis ahead of the femoral medial condyle can produce the symptoms of the patellar and femoral prosthesis. The reconstruction of the size of the simulated prosthesis and the position of the prosthesis can effectively avoid the occurrence of the patellar impact caused by the excessive selection of the femoral prosthesis, the overrotation of the femoral prosthesis and the excessive posterior condyle osteotomy, and the avoidance of the excessive selection of the femoral prosthesis caused by the excessive rotation of the femoral prosthesis. The femoral prosthesis is impacted by the polyethylene liner. Therefore, it is very important to simulate the surgical osteotomy scheme under the CT and 3D reconstruction images. The medial femoral condyle notch is of great significance to the position of the prosthesis during the single condylar replacement.

【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.4

【參考文獻(xiàn)】

相關(guān)期刊論文 前1條

1 張炅;馮建民;;單髁膝關(guān)節(jié)置換的臨床應(yīng)用進(jìn)展[J];中華關(guān)節(jié)外科雜志(電子版);2013年04期

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本文編號(hào)：1891186