全踝关节置换术(PLUS 适应症禁忌症及手术步骤

TAR total ankle replacement TAA total ankle arthroplasty 全踝关节置换术（PLUS 适应症禁忌症及手术步骤）

[原创2010-11-30 12:59:59]

患者信息:M/66

术前诊断:OA ankle Rt.

治疗方案:TARA, Rt.

手术医师:professor Chu In Tak(St. Mary's hospital)

手术日期: 2010-11-30

手术体会：chu教授做踝关节置换手术非常熟练，术中几乎不要截骨定位器。入路是标准的前入路，他建议从胫前肌腱内侧入路，骨膜分离用手术刀而非骨膜剥离器，他认为这样损伤小。先在流行的踝关节假体有11种，他所用的假体是法国的Hintegra Sensitive假体，而在教科书上大部分都是讲解利用PE 假体，组件不同手术方式也有不同。

以上3图为术前X线表现

手术选择前正中切口

胫骨截骨定位器

截骨完成后

安装试模

安装试模后透视

胫骨假体组件标签

距骨假体组件标签

PE垫标签

术后拍片所见

术后到Catholic University图书馆查阅有关踝关节置换的内容，摘录如下：

假体组件Hintegra Sensitive Prosthesis

tibial component(CoCr)

talar component(CoCr)

Fixation screws(Titanium alloy)

intermediary sliding core(UHMW Polyethylene)

适应症Indications:

systemic caused arthritis of the ankle(eg. rheumatoid arthritis,hemochromatosis); primary arthritis(eg. degenerative disease);

secondary arthritis(eg. posttraumatic,infection,avascular necrosis);

salvage for failed total ankle replacement;

salvage for non-union and malunion of ankle arthrodesis.

禁忌症Contraindications:

relative controindications:

severe osteoporosis;

immunosuppressive therapy;

high demanding sport activities(eg.contact sports,jumping);

patients with a poor soft tissue envelope;

absolute contraindications:

active infection;

charcot neuroarthropathy;

neurologic disease of the lower extremities;

advanced peripheral vascular disease;

absence of distal leg muscular function

suspected or documented metal allery or intolerance;

avascular necrosis of the talus/tiba of more than1/2;

evere malalignment(if not surgically correctale);

severe instability;

diabetic syndrom

最常用的3种假体

although there are currently 11 different ankle implants being used throughout the world,attention in the united states has been focused on three second-generation ankle implant devices:

Buechel Pappas total ankle repalcement(Endotec, South Orange,NJ,USA)

Agility total ankle system (DePuy,Warsaw,IN,USA)

scandinavian total ankle replacement(STAR Waldemar-Link,Hamburg,Germany)

术前准备preoperative considerations:

instability of the ankle often accompanies hindfoot or tibiotalar deformity that necessitates repair or reconstruction of the lateral ligaments during implantation.

the condition of the soft tissues envelope is an important preoperative consideration that may influence complications.

preoperative evaluation of plain films,MRI, and CT scan can be used for evaluation of ankle deformity.

手术步骤Surgical technique

1.the patient is operated with spinal or general anesthesia;

2.the patient is placed on the operating table in the supine position with a sandbag placed under the ipsilateral hip;

3.a well-padded thigh tourniquet is used for hemostatic control;

4.the leg is surgically prepped and draped above the knee;

5.an anterior midline incision is centered over the ankle joint extending 10-13cm in length between the anterior tibial and extensor hallucis longus tendons;

6.the incision is carried through to the subcutaneous tissues, being careful to identify and protect the superficial peroneal nerve;

7.the extensor retinaculum is incised between the tendons of the anterior tibialis and the extensor hallucis longus;it is advisable to place a suture tag along the retinaculum on either side;

8.a deep incision is made through this space incising the ankle capsule down to the the tibial periosteum;

9.the osteophytes must be removed with bone cutters and rongeurs to expose the joint,next medial and lateral subperiosteal elevation provides exposure of the anterior ankle joint and the neck of the talus.the surgeon must be able to visualize the medial and lateral