Oxford 膝关节单髁置换

【笔记】⽜津（Oxford）单髁置换的⼿术步骤和原理在⽬前的膝关节炎中，有超过25％的膝关节⾻关节炎的病⼈膝关节前内侧⾻关节炎，对于这类患者，只需要部分置换膝关节就可以，膝关节内侧⾻关节炎（AMOA)是单髁置换（UKA）的适应症！当然单髁置换还要满⾜以下指征：1、疼痛明确位于内侧关节线，⽆泛化的疼痛，否则术后效果容易不佳。

膝内翻能被外翻应⼒纠正⾄中⽴位。

2、ACL应该完整，内侧副韧带完整。

外侧间室软⾻厚度要完整。

3、膝关节畸形：屈曲、内翻畸形⼩于10°，同时膝关节⾄少能屈曲到90-110 °。

4、髌股关节炎（PFJ）并⾮⼿术禁忌症。

外侧轻度不影响，外侧部分严重破坏，⾻磨损和纵⾏磨损沟不适合单髁置换。

5、所有炎症性关节炎均不适合单颗置换（感染、风湿、类风湿、痛风等）。

注意：即使已经打算做单颗置换，也要做好TKA的准备（韧带功能不全、类风湿、外侧间室破坏等）。

年龄、体重、负重、活动⽔平、是否存在软⾻钙质沉着症，均不再作为UKA的禁忌症。

简⽽⾔之：单髁置换患者选择标准：前内侧⾻关节炎（ＡＭＯＡ）；MCL功能正常；ＡＣＬ完好；外侧全层软⾻；可矫正的内翻畸形（最好⼩于５度）；固定屈曲畸形⼩于１５度。

单髁的适应症选择（积⽔潭黄野教授）⽜津单髁⼿术步骤及部分简要原理分析1､体位⼤腿应⽤⽌⾎带｡下肢固定架将腿悬空,髋关节屈曲30度,轻度外展,⼩腿⾃然下垂,膝关节可屈曲135度,⼀般⾄少110度｡2､⼿术切⼝及⼊路髌旁内侧切⼝,上端起⾃髌⾻内上缘,远端⾄关节线远3cm,⽌于胫⾻结节内侧缘｡(1)打开关节腔,切除部分髌下脂肪垫,以⽅便显露｡(2)去除股⾻髁内侧⾻赘,恢复内侧副韧带和关节囊的相对长度,允许膝内翻畸形被动矫正｡去除髁间窝的⾻赘,防⽌后期与前交叉韧带撞击,否则后期撞击会导致前交叉韧带损伤或疼痛｡(3)不允许对侧副韧带进⾏松解｡在进⾏截⾻之前,评价前交叉韧带､对侧胫股关节间室和髌股关节间室的状态｡3､胫⾻截⾻胫⾻截⾻前可先插⼊股⾻髓内定位杆｡从远端逆⾏插⼊股⾻髓腔,插⼊点是髁间窝前内⾓的前⽅1cm｡屈膝45°,应⽤钻和锥⼦进⾏开孔,插⼊髓内定位杆｡便于截⾻垂直截⾻参考⽅向,也可起拉钩作⽤｡应⽤⽜津⾻勺插⼊内侧间室判断关节软⾻磨损后关节间隙⼤⼩,⾻勺厚度分别为1mm､2mm､3mm｡(⼀般股⾻远端磨损,所以⾻勺前缘离股⾻远端2-3mm,可左右旋转20-30度合适｡)连接G形夹持器及胫⾻近端截⾻向导｡G 形夹持器分3mm和4mm,代表期望放置半⽉板衬垫厚度｡胫⾻截⾻使⽤髓外定位,截⾻向导远端固定于踝部,其轴线指向踝关节中⼼稍内侧｡截⾻向导在正侧⾯上都平⾏于胫⾻长轴,这样可保证7度后倾截⾻(截⾻板⾃带7度后倾)｡G型夹截⾻⼀般选择在胫⾻平台磨损最低处关节⾯下2-3mm,截⾻⾄少要获得6-7mm间隙｡内侧副韧带深层的远端附着点可作为截⾻深度的⼀个解剖标志｡胫⾻截⾻不⾜,术中可能需要反复截⾻; 截⾻平⾯太低,会导致间隙过⼤,甚⾄可能没有⾜够厚的半⽉板衬垫可供植⼊(最厚半⽉板衬垫为9mm),截⾻太多同时会造成胫⾻平台⽀撑减弱⽽容易出现⾻折｡原理:单髁半⽉板衬垫共7个型号(厚度3-9mm),胫⾻平台假体厚度为3mm,所以,最少截⾻为3+3mm=6mm,通常应⽤4mm胫⾻衬垫,(也就是G型夹4mm)所以⼀般⾄少截⾻7mm,即获得7mm 屈曲间隙｡前内侧⾻关节炎患者通常股⾻后髁软⾻没有磨损,所以选择屈曲时测量准确可靠｡因为前侧软⾻和⾻磨损较重,所以不可以选择前侧关节⾯下7mm,⽽是选择磨损最深处关节⾯下2-3mm,此处为保守截⾻,可能正好,亦可能偏少｡先进⾏垂直截⾻,截⾻贴近前交叉韧带⽌点内侧,尽量靠近胫⾻髁间嵴,但注意不要损伤交叉韧带,靠近股⾻内侧髁外侧缘,指向股⾻头⽅向,⽬前多采⽤髂前上棘或偏内侧｡(股⾻头⽅向术中难确定)避免出现摆锯后⼿抬⾼,以免后⽅截⾻过深损伤胫⾻平台后⽅⽪质｡为判断⽅便,可先⾏插⼊股⾻髓内杆｡⽤窄锯⽚对胫⾻进⾏⽔平截⾻,应⽤⾻⼑撬起截⾻块并取出,截⾻块通常表现为经典的前内侧⾻关节炎特征｡残余半⽉板此时可以去除｡胫⾻截⾻时,⽤“Z”字形拉钩置于内侧保护内侧副韧带｡4､股⾻截⾻股⾻截⾻包括股⾻后髁截⾻和股⾻远端研磨截⾻,前者是建⽴股⾻假体后髁安装间隙,后者则是建⽴伸直间隙｡股⾻髓内定位杆从远端逆⾏插⼊股⾻髓腔,⽤连接杆连接髓内杆和股⾻钻孔向导｡然后在股⾻髁远端相继钻两个直径4mm和6mm的孔｡股⾻髁远端钻孔要保证在股⾻髁中⼼(或中间1/3)｡股⾻假体外侧边放置位置要与胫⾻假体位置⼀致,⽽未必是放在股⾻髁原始中⼼线位置,理论上,如果胫⾻假体安放准确,股⾻假体应紧靠中⼼线外侧｡(冠状⾯上假体轴线平⾏于⼒线轴,⽮状⾯上假体中⼼杆<钻孔⽅向>平⾏于股⾻长轴｡可接受10度轴线旋转｡)放⼊股⾻后髁截⾻向导,⽤窄锯⽚对后髁截⾻,此时应⽤“Z”形拉钩保护内侧副韧带｡截⾻厚度应该等于假体厚度（约6-7mm，与假体型号有关）｡插⼊0号研磨栓,应⽤磨钻对股⾻远端进⾏研磨｡取出所有拉钩,放⼊股⾻和胫⾻试模｡屈膝90°位置,插⼊塑料测厚器测量屈曲间隙｡屈膝20°,应⽤⾦属测厚器测量伸直间隙｡塑料测厚器⼤⼩(屈曲间隙) 减去⾦属测厚器⼤⼩(伸直间隙) 即为需要进⾏进⼀步研磨的厚度(研磨量=屈曲间隙-伸直间隙)mm,即研磨栓型号,通过股⾻远端进⼀步研磨即可实现屈伸间隙平衡｡再次评估屈伸间隙｡如果伸直间隙仍⼩于屈曲间隙,则需要使⽤研磨钻继续对股⾻远端截⾻,每次按1mm递增使⽤研磨栓｡此步骤完成后,屈伸间隙平衡既已完成｡研磨栓分0-7号,两侧栓柄⼀样长,长度区别主要在于中间颈领的厚度,0号颈领最厚,1号⽐0号薄1mm,相当于多磨1mm,2号⽐0号薄2mm,相当于多磨2mm,以此类推｡0号相当于建⽴研磨0点,如果屈膝间隙⽐伸直间隙宽3mm,则选择3号研磨栓研磨,即股⾻远端多研磨3mm｡为何屈曲间隙⼤于伸直间隙?因为0号研磨后,股⾻假体的安放使股⾻远端磨损⾯和假体关节⾯之间的距离约5mm,相当于伸直间隙⽐原来减⼩了5mm,所以需要进⼀步研磨处理｡需进⼀步研磨的厚度即屈伸间隙测量的差值,也就是对应研磨栓的号码(如3mm=3号)｡为何选择在屈曲90 度和20度测量?正常膝关节伸直时,内外侧韧带的都被拉紧,内外侧间室都⽆法撑开｡屈曲20度时,内外侧⼤约可撑开1mm｡屈曲90度时,外侧间隙增加到7mm,⽽内侧间室约2mm,也就是说内侧间室在屈曲20度到90的之间没有显著增加｡胫⾻前内侧关节炎患者, 后关节囊挛缩,在伸直时,关节囊紧张使得关节间隙变窄,测得的并⾮真正的伸直间隙,⽽是要⼩,在屈曲20度时,关节囊松弛,所以测得更准确｡因此,选择20度作为伸直间隙进⾏评估｡屈曲90度时，股⾻髁后关节⾯软⾻相对正常，未被磨损，此时的关节线接近未磨损时的关节线，只要接⾻厚度等于股⾻假体厚度，获得的关节线就与原始关节线相⼀致。

Oxford第三代单髁系统治疗单纯膝关节内侧间室骨关节炎患者的初期疗效王磊;沈伟中;蒋忠;骆园【摘要】Objective:To investigate early effects of unicompartmental knee arthroplasty ( UKA) in treatment of single anterio-medialis compartmental arthrosis, in order to provide a clinical evidence to the clinical treatment of this disease. Methods:23patients (23 knees) diagnosed with single anteriomedialis compartmental arthrosis and undergone UKA were retrospectively analyzed. These pa-tients were followed up and evaluated from the skin incision length, time of operation, amount of bleeds, postoperative VAS score, ac-tive straight-leg raise time, average stay, range of motion at 1 year postoperatively, postoperative HSS scores at 1 year and latest follow-up. Results:Total 23 patients obtained complete follow-up, and no infections, vascular nerve injury, and postoperative liner dislo-cations occurred. 1 case suffered from total knee revision due to bone cement loosening, and 2 cases reported a residual pain, which was not severe and could be tolerable. The statistical analysis showed that compared with related TKA reports, UKA had obvious ad-vantages in skin incision length, amount of bleeds, postoperative VAS score, active straight-leg raise time and average stay. Conclu-sions:UKA can retain the health compartments and normal ligament structure but only reconstruct the damaged compartment in order to promote the recovery of knee joint function and can obtain satisfied early therapeutic effect in carefullyselected patients with less trau-ma, rapid recovery and high satisfaction.%目的：：探讨采用膝关节单髁置换系统( UKA)治疗单纯膝关节内侧间室骨关节炎患者的初期临床疗效,为临床治疗单纯膝关节内侧间室骨关节炎方案选择提供依据。

牛津活动平台单髁置换术治疗晚期膝关节自发性骨坏死的疗效分析.发布时间：2023-04-25T11:48:27.255Z 来源：《医师在线》2022年12月24期作者：黎文勇李朝晖蓝国波罗真陈啟源[导读]牛津活动平台单髁置换术治疗晚期膝关节自发性骨坏死的疗效分析黎文勇 李朝晖 蓝国波 罗真 陈啟源（佛山复星禅诚医院关节外科；广东佛山528000）【摘要】目的：探讨牛津活动平台单髁置换术治疗晚期膝关节自发性骨坏死的疗效。

方法：选取佛山复星禅诚医院2019年6月～2020年6月收治的30例晚期膝关节自发性骨坏死患者，按数字随机表法分组，各15例。

对照组接受全膝关节置换术治疗，观察组则采用牛津活动平台单髁置换术治疗，对比两组疗效及相关指标变化。

结果：治疗前两组VAS、KSS评分和ROM比较无显著差异（P＞0.05），治疗后3月和6月两组VAS评分较治疗前显著降低且观察组下降程度高于对照组（P＜0.05）；治疗后1月、3月和6月两组KSS评分较治疗前提高且观察组各时段KSS评分高于对照组（P＜0.05）；疗后1月、3月和6月两组ROM较治疗前显著上升且观察组上升幅度高于对照组（P＜0.05）。

结论：在晚期膝关节自发性骨坏死中以牛津活动平台单髁置换术治疗可以改善患者膝关节功能，减轻膝痛和提高关节活动度，值得应用。

【关键词】牛津活动平台；单髁置换术；膝关节自发性骨坏死；晚期【中图分类号】R684.3Analysis of the curative effect of Oxford platform unicondylar replacement on spontaneous osteonecrosis ofthe knee【Abstract】Objective: To explore the curative effect of Oxford mobile platform unicondylar replacement surgery on spontaneous osteonecrosis of late knee joint. Methods: Thirty patients with spontaneous osteonecrosis of the knee who were admitted to the Foshan Fosun Chancheng Hospital from June 2019 to June 2020 were selected and grouped according to the numerical random table method, 15 cases each. The control group received total knee arthroplasty, while the study group received Oxford platform unicondylar arthroplasty, comparing the efficacy and related index changes between the two groups. Results: There was no significant difference in VAS, KSS scores and ROM between the two groups before treatment (P>0.05). The VAS scores of the two groups were significantly lower than those before treatment in 3 and 6 months after treatment and the decrease in the study group was higher than that in the control group (P<0.05). 0.05); The KSS scores of the two groups were higher than those before the treatment in January, March and June after treatment and the KSS scores of the study group were higher than those of the control group at each time period (P<0.05); the two groups were in January, March and June after treatment ROM increased significantly than before treatment and the increase in the study group was higher than that in the control group (P<0.05). Conclusion: In the late stage of spontaneous osteonecrosis of the knee joint, the Oxford mobile platform unicondylar replacement surgery can improve the patient's knee function, reduce knee pain and improve joint mobility, which is worthy of application.[Keywords] Oxford platform; unicondylar replacement; spontaneous osteonecrosis of the knee; late膝关节自发性骨坏死（spontaneous osteonecrosis of the knee, SONK）是一种常见的骨坏死疾病，具有发病率高和致残率高的特点，晚期SONK多表现为关节活动受限和持续肿胀，若不及时干预治疗，很容易导致关节发生退行性病变，进而影响患者日常生活能力[1-2]。