骨關(guān)節(jié)外科

現(xiàn)代全踝關(guān)節(jié)置換的歷史、發(fā)展、進(jìn)展、未來方向，包括假體設(shè)計(jì)、適用證、手術(shù)方法、臨床效果、并發(fā)癥_現(xiàn)代全踝關(guān)節(jié)置換的評(píng)價(jià):敘述性回顧（2024）Anevaluationofthetotalanklereplacementinthemodernera:anarrativereview?ShaffreyI,HenryJ,DemetracopoulosC.Anevaluationofthetotalanklereplacementinthemodernera:anarrativereview[J].AnnTranslMed,2024,12(4):71.轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/39118953/轉(zhuǎn)載文章的原鏈接2：https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11304414/?AbstractBackgroundandObjectiveTotalanklereplacementhasbecomeanincreasinglypopularsurgicalprocedurefortreatmentofend-stageanklearthritis.Thoughanklearthrodesishashistoricallybeenconsideredthegoldstandardtreatment,advancementsinimplantdesign,functionaloutcomes,andsurvivorshiphavemadetotalanklereplacementacompellingalternative.Particularly,inthepast20years,totalanklereplacementhasundergonetremendousinnovation,andthefieldofresearchinthisprocedurecontinuestogrow.Inthisreview,weaimtosummarizethehistory,evolution,advancements,andfuturedirectionsoftotalanklereplacementasdescribedthroughimplantdesign,indications,surgicalprocedures,complications,andoutcomes.全踝關(guān)節(jié)置換術(shù)已成為治療終末期踝關(guān)節(jié)關(guān)節(jié)炎的一種日益流行的手術(shù)方法。雖然踝關(guān)節(jié)融合術(shù)歷來被認(rèn)為是金標(biāo)準(zhǔn)的治療方法，但隨著植入物設(shè)計(jì)、功能結(jié)果和生存率的提高，全踝關(guān)節(jié)置換術(shù)已成為一種令人信服的選擇。特別是在過去的20年里，全踝關(guān)節(jié)置換術(shù)經(jīng)歷了巨大的創(chuàng)新，該手術(shù)的研究領(lǐng)域也在不斷發(fā)展。在這篇綜述中，我們旨在總結(jié)全踝關(guān)節(jié)置換術(shù)的歷史、發(fā)展、進(jìn)展和未來方向，包括植入物設(shè)計(jì)、適應(yīng)癥、手術(shù)方法、并發(fā)癥和結(jié)果。?MethodsLiteraturesearcheswereconductedinPubMedtoidentifyrelevantarticlespublishedpriortoMarch2023usingthefollowingkeywords:“totalanklereplacement”,“totalanklearthroplasty”,and“totalankle”.在PubMed中檢索2023年3月之前發(fā)表的相關(guān)文章，檢索關(guān)鍵詞為:“全踝關(guān)節(jié)置換”、“全踝關(guān)節(jié)置換”和“全踝”。?KeyContentandFindingsTotalanklereplacementhasdemonstratedsignificantimprovementsinsurgicaltechnique,implantdesign,survivorship,andclinicalandfunctionaloutcomesinthemodernera.Theprocedurereportshighpatientsatisfaction,lowcomplicationrates,andimprovedfunctionalabilitiesthatchallengethecurrentgoldstandardtreatmentforanklearthritis.在現(xiàn)代，全踝關(guān)節(jié)置換術(shù)在手術(shù)技術(shù)、植入物設(shè)計(jì)、存活、臨床和功能結(jié)果方面都有顯著的改進(jìn)。該手術(shù)報(bào)告患者滿意度高，并發(fā)癥發(fā)生率低，并改善了功能，挑戰(zhàn)了目前治療踝關(guān)節(jié)關(guān)節(jié)炎的黃金標(biāo)準(zhǔn)。?ConclusionsThoughthereareareasofimprovementfortotalanklereplacement,theproceduredemonstratespromisingoutcomesforpatientswithend-stageanklearthritistoimprovepainandfunctionalabilities.Researchstudiescontinuetoexplorevariousthefacetsoftotalanklereplacement,includingoutcomes,riskfactors,noveltechniquesandmodalities,andcomplications,todirectfutureinnovationandtooptimizepatientresults.雖然全踝關(guān)節(jié)置換術(shù)有改進(jìn)的地方，但該手術(shù)對終末期踝關(guān)節(jié)關(guān)節(jié)炎患者改善疼痛和功能能力的效果很有希望。研究繼續(xù)探索全踝關(guān)節(jié)置換術(shù)的各個(gè)方面，包括結(jié)果、風(fēng)險(xiǎn)因素、新技術(shù)和模式以及并發(fā)癥，以指導(dǎo)未來的創(chuàng)新并優(yōu)化患者的結(jié)果。?Keywords:Totalanklereplacement(TAR),totalanklearthroplasty(TAA),anklearthritis?IntroductionTotalanklereplacement(TAR)hasundergonetremendousdevelopmentssinceitsinception50yearsago.Inthemodernera,therehasbeenimmensegrowthinannualvolumes,increasingby564%between2005to2017(1),asindicationsforsurgeryexpand,surgicaltechniquesrefine,andoutcomesimprove.Concurrently,theliteraturesurroundinganklereplacementcontinuestoevolveasnewinsightsanddiscoveriesarepublished.Atthistime,thefieldofTARhasintroduceditsfourthgenerationofimplants,increaseditssurgicalindications,improveditsimplantsurvivorship,minimizeditscomplications,anddevelopednewtechnologyaimedtooptimizepatientoutcomes.全踝置換術(shù)(TAR)自50年前問世以來，經(jīng)歷了巨大的發(fā)展。在現(xiàn)代，隨著手術(shù)適應(yīng)癥的擴(kuò)大、手術(shù)技術(shù)的改進(jìn)和結(jié)果的改善，年交易量有了巨大的增長，2005年至2017年增長了564%(1)。同時(shí)，隨著新的見解和發(fā)現(xiàn)的發(fā)表，關(guān)于踝關(guān)節(jié)置換術(shù)的文獻(xiàn)也在不斷發(fā)展。此時(shí)，TAR領(lǐng)域已經(jīng)推出了第四代植入物，增加了手術(shù)指征，提高了植入物的存活率，最大限度地減少了并發(fā)癥，并開發(fā)了旨在優(yōu)化患者預(yù)后的新技術(shù)。ThisreviewaimstosummarizethecurrentknowledgeofTARasdescribedthroughitsevolution,improvements,andfuturedirections.WepresentthisarticleinaccordancewiththeNarrativeReviewreportingchecklist.這篇綜述的目的是通過TAR的演變、改進(jìn)和未來方向來總結(jié)目前對其的了解。我們按照敘述性評(píng)論報(bào)告清單來呈現(xiàn)這篇文章。?MethodsWereviewedtheresultsofclinicalstudiesandmeta-analysesofTARspresentedonPubMed.Thesearticlesincludedtopicsaboutthehistory,indications,surgicaltechnique,complications,outcomes,andfutureofTARs,aswellascomparativestudiesbetweenTARsandanklearthrodesis.Thesearticleswereidentifiedusingthefollowingkeywords:“totalanklereplacement”,“totalanklearthroplasty”,and“totalankle”(Table1).??Table1ThesearchstrategysummaryItems????????SpecificationDateofsearch??March1,2023DatabasesandothersourcessearchedPubMedSearchtermsused?????Totalanklereplacement,totalanklearthroplasty,andtotalankleTimeframe???????EnglishabstractsandarticlesbeforeMarch2023Inclusioncriteria???????EnglishabstractsandarticlesSelectionprocess??????LiteraturesearchwasconductedbyI.S.Finalapprovalofliteraturesearchwasconductedbyallauthors??DiscussionHistoryPriortotheintroductionofanklereplacements,theonlyoperativetreatmentoptionforend-stageanklearthritiswasanklearthrodesis,consideredthe‘gold-standard’treatment.Thoughtheresultsofanklearthrodesiswereshowntoachievegoodclinicaloutcomesandhighsatisfactionscores,concernsaboutcomplicationsandfunctionaloutcomesstillexisted(2,3).Namely,anklearthrodesishadcomplicationswithnonunion,malunion,andinfectionfollowingsurgery,withlimitedsalvageoptions(4).Furthermore,patientswithanklearthrodesisexperienceddecreasedsagittalplanemotioninthehindfoot,slower,asymmetricalgait,andultimately,degenerativearthritischangesinadjacentjoints(5-7).Theseshortcomingsinanklearthrodesispromptedexplorationinalternativetreatmentoptions,includingjointreplacement.在引入踝關(guān)節(jié)置換術(shù)之前，終末期踝關(guān)節(jié)關(guān)節(jié)炎的唯一手術(shù)治療選擇是踝關(guān)節(jié)融合術(shù)，被認(rèn)為是“金標(biāo)準(zhǔn)”治療。盡管踝關(guān)節(jié)融合術(shù)的臨床效果良好，滿意度較高，但對并發(fā)癥和功能結(jié)局的擔(dān)憂仍然存在(2,3)。也就是說，踝關(guān)節(jié)融合術(shù)有術(shù)后不愈合、不愈合和感染等并發(fā)癥，且挽救選擇有限(4)。此外，踝關(guān)節(jié)融合術(shù)患者后足矢狀面運(yùn)動(dòng)減少，步態(tài)變慢、不對稱，最終相鄰關(guān)節(jié)發(fā)生退行性關(guān)節(jié)炎變化(5-7)。踝關(guān)節(jié)融合術(shù)的這些缺點(diǎn)促使人們探索包括關(guān)節(jié)置換術(shù)在內(nèi)的替代治療方案。?FirstgenerationThefirstgenerationofTARimplants,developedinthe1970s,featuredavarietyofdesignsthatattemptedtomimicthesuccessfulfeaturesofhipandkneearthroplasty.Thoughtherewaswidevariabilityinprosthesisdesigns,thebasicmodelofthisgenerationfeaturedatwo-partsystemwithapolyethyleneconcavearticularcomponentandaconvexcobaltchromemetalcomponent.Thisgenerationhadbothconstrainedandunconstrainedsystems,eachwiththeirownramificationscontributingtohighfailureratesandunsatisfactoryoutcomes.Constrainedsystemslimitedthedissipationofstressesbetweenthecontactsurfaces,contributingtohighratesofloosening;unconstrainedsystemsplacedincreasedstressesonthesurroundingligamentsoftheankle,leadingtoproblemsofmalalignment(8,9).Moreover,thisearlygenerationofimplantsusedcementedfixationandrequiredextensiveboneresectiontoproperlypositionthecomponent.Thisfirstgenerationofimplantsencounteredseveralissues:highratesofloosening(between29–90%at10years),lowsatisfactionscores,andpoorsurvivorship(8-11).Thepoorresultsassociatedwiththeimplantsofthisgenerationledtothecompleteabandonmentofthesedesigns.Nonetheless,thisgenerationofferedimmenseinsightforimprovementsinthefuturegenerationsofimplants,includingconsiderationsaboutminimizingbonyresection,balancingsofttissue,anddecreasingshearstressforces(10,12).20世紀(jì)70年代開發(fā)的第一代TAR植入物具有多種設(shè)計(jì)，試圖模仿髖關(guān)節(jié)和膝關(guān)節(jié)置換術(shù)的成功特征。雖然假體設(shè)計(jì)有很大的可變性，但這一代的基本模型具有兩部分系統(tǒng)，其中包括聚乙烯凹關(guān)節(jié)組件和凸鈷鉻金屬組件。這一代既有受約束的系統(tǒng)，也有不受約束的系統(tǒng)，每個(gè)系統(tǒng)都有自己的分支，導(dǎo)致高失敗率和令人不滿意的結(jié)果。約束系統(tǒng)限制了接觸面之間應(yīng)力的消散，導(dǎo)致高松動(dòng)率;無約束系統(tǒng)增加了踝關(guān)節(jié)周圍韌帶的壓力，導(dǎo)致了錯(cuò)位問題(8,9)。此外，早期的植入物使用骨水泥固定，需要廣泛的骨切除來正確定位組件。第一代植入物遇到了幾個(gè)問題:高松動(dòng)率(10年在29-90%之間)、低滿意度評(píng)分和低生存率(8-11)。與這一代植入物相關(guān)的不良結(jié)果導(dǎo)致了這些設(shè)計(jì)的完全放棄。盡管如此，這一代為未來幾代植入物的改進(jìn)提供了巨大的見解，包括考慮最小化骨切除，平衡軟組織和減少剪切應(yīng)力(10,12)。?SecondgenerationThesecondgenerationofTARwasintroducedtothemarketinthemid-1980s,incorporatingnovelimplantfeaturesthatattemptedtoaddresstheshortcomingsofthepreviousgeneration.Pooroutcomesattributedtocementedfixationandlargeboneresectioninthefirstgenerationledtoatransitiontowardscementlessimplantsinthesecondgeneration.Inaddition,thesedesignsfeaturedporous-coatedmetallictibialimplantsintendedtostimulateosseousintegrationanddecreasehighratesofloosening.第二代TAR于20世紀(jì)80年代中期引入市場，結(jié)合了新穎的植入物特征，試圖解決上一代的缺點(diǎn)。第一代骨水泥固定和大骨切除的不良結(jié)果導(dǎo)致第二代骨水泥植入物的過渡。此外，這些設(shè)計(jì)的特點(diǎn)是多孔涂層金屬脛骨植入物旨在刺激骨整合和降低高松動(dòng)率。Inthepreviousgeneration,bothhighlyconstrainedandhighlyunconstraineddesignswereassociatedwithalitanyofcomplications.Learningfromthisinsight,thesecondgenerationofTARdevelopedtwocategoriesofimplants,fixed-bearingandmobile-bearing,thathopedtomitigatepreviousshortcomings.Fixed-bearingimplantsconsistofatibial,talar,andfixedpolyethylenecomponent,thatfunctionasatwo-componentimplant.Incontrast,mobile-bearingimplantsfeaturethesamethreecomponents(tibia,talus,andpolyethylene),butimplementanunconstrainedpolyethyleneinsertthatcanarticulatebetweenthetibialandtalarcomponents(11,13,14).Fixed-bearingimplantshavehigherconstraintthanmobile-bearing,whichallowsforgreaterstability,butalsoincreasestheriskofimplantloosening.Thoughmobile-bearingimplantshaveminimalconstraintacrossthepolyethyleneinserttodecreaseloadstress,therearestillconcernsaboutpolyethylenewear,instability,andtranslation.Outcomeswerestilllargelyvariableinthesecond-generationdesigns.Inonemeta-analysisof1,105secondgenerationTARs,theaveragesurvivorshipacross7implantswas90%at5years,thoughsurvivorshiprangedbetween68%to100%acrossdifferentstudies(13).Further,thisgenerationcitedresidualissueswithimplantsubsidence,residualpain,andlimitedrangeofmotion(13).在上一代，高度約束和高度不約束的設(shè)計(jì)都伴隨著一連串的復(fù)雜問題。從這一見解中學(xué)習(xí)，第二代TAR開發(fā)了兩類植入物，固定軸承和移動(dòng)軸承，希望減輕以前的缺點(diǎn)。固定軸承植入物包括脛骨、距骨和固定聚乙烯組件，其功能為雙組件植入物。相比之下，移動(dòng)軸承植入物具有相同的三個(gè)組件(脛骨、距骨和聚乙烯)，但實(shí)現(xiàn)了可以在脛骨和距骨組件之間鉸接的不受約束的聚乙烯插入物(11,13,14)。固定軸承植入物比移動(dòng)軸承具有更高的約束，允許更大的穩(wěn)定性，但也增加了植入物松動(dòng)的風(fēng)險(xiǎn)。雖然移動(dòng)軸承植入物在聚乙烯插入物上具有最小的約束以降低載荷應(yīng)力，但仍然存在聚乙烯磨損、不穩(wěn)定和易動(dòng)的問題。在第二代設(shè)計(jì)中，結(jié)果仍然很大程度上是可變的。在一項(xiàng)對1105例第二代TARs的薈萃分析中，7種植入物的5年平均生存率為90%，盡管不同研究的生存率在68%至100%之間(13)。此外，這一代人還提到了植入物下沉、疼痛和活動(dòng)范圍受限等遺留問題(13)。?Moderngenerations(thirdandfourth)AfterthefirsttwogenerationsofTAR,modernimplantswererefinedtominimizebonyresectionandrespectlocalanatomy.Moreover,surgeonshadgreaterappreciationformechanicalalignmentandbalancingtheanklewithadditionalbonyandsofttissueprocedurestoensureastableankleandfootaroundthereplacement.Modernimplantsincludebothfixed-bearing,two-componentdesignsandmobile-bearing,three-componentdesigns;althoughtheformerismorecommonintheUnitedStates,thelatterinEurope.Acknowledgingthepatternoffailureassociatedwithcementedimplantation,third-generationimplantsfeaturedcementlessdesigns,utilizingtitaniumplasma-spraycoatingsforboneingrowth(15).Popularthird-generationimplantsincludetheINBONE(WrightMedical,Memphis,TN,USA),SaltoTalaris(IntegraLifesciences,Princeton,NJ,USA),STAR(Stryker,Kalamazoo,MI,USA),andHINTEGRA(IntegraLifeSciences,Newdeal,Lyon,France)andhavebeenassociatedwithgoodsurvivorshipandhighsatisfactionscores.在前兩代TAR之后，現(xiàn)代植入物經(jīng)過改進(jìn)，以盡量減少骨切除并尊重局部解剖。此外，外科醫(yī)生對機(jī)械對齊和平衡踝關(guān)節(jié)有了更大的認(rèn)識(shí)，并通過額外的骨和軟組織手術(shù)來確保踝關(guān)節(jié)和足部在置換物周圍的穩(wěn)定?，F(xiàn)代種植體包括固定軸承，雙組件設(shè)計(jì)和移動(dòng)軸承，三組件設(shè)計(jì);盡管前者在美國更常見，后者在歐洲更常見。認(rèn)識(shí)到骨水泥植入失敗的模式，第三代種植體采用無骨水泥設(shè)計(jì)，利用鈦等離子噴涂涂層進(jìn)行骨長入(15)。流行的第三代植入物包括INBONE(WrightMedical,Memphis,TN,USA)、SaltoTalaris(Integralifessciences,Princeton,NJ,USA)、STAR(Stryker,Kalamazoo,MI,USA)和HINTEGRA(IntegraLifeSciences,Newdeal,Lyon,France)，這些植入物具有良好的生存率和高滿意度。TheINBONEtotalankleimplant,originallycreatedin2005,featuresauniquemodularstemtibialdesignandintermedullarystemalignmentguidewiththeintentiontomaximizebonyfixation(16).TheoriginalINBONEprosthesis(INBONEI)employedaflat-cut,saddletalarcomponentthatsimilarlyfeaturedarobusttalarstem;however,afterreportsoftalar-sidedfailures,thetalarcomponentwasrevisedinitsseconditeration(INBONEII)(16).Usinganexternaljigtosecurethelegandfluoroscopytoachieveproperalignment,thetibialcomponentisimplantedviaintramedullaryreamingthroughthecalcaneusandtalus.TheINBONETARcanbeusedinbothprimaryandrevisionsettings,performingasaviablealternativeincasesoffailedTARwithlooseningandboneloss.Moreover,addedstabilityfromtherobusttibialstemallowstheINBONEimplanttobeareasonableoptionforpatientswithseveredeformityorinstability(15).INBONE全踝植入物最初創(chuàng)建于2005年，具有獨(dú)特的模塊化脛骨干設(shè)計(jì)和髓間干對齊引導(dǎo)，旨在最大限度地實(shí)現(xiàn)骨固定(16)。原始的INBONE假體(INBONEI)采用平切鞍狀距骨組件，同樣具有堅(jiān)固的距骨柄;然而，在報(bào)道距側(cè)失敗后，距側(cè)組件在第二次迭代(INBONEII)中進(jìn)行了修訂(16)。使用一個(gè)外部夾具來固定腿部，并在透視下達(dá)到正確的對齊，脛骨假體通過髓內(nèi)擴(kuò)孔通過跟骨和距骨植入。INBONETAR可用于初級(jí)和翻修設(shè)置，在TAR失敗導(dǎo)致松動(dòng)和骨質(zhì)流失的情況下，作為可行的替代方案。此外，強(qiáng)健的脛骨干增加的穩(wěn)定性使得INBONE植入物成為嚴(yán)重畸形或不穩(wěn)定患者的合理選擇(15)。SurgicaloutcomesoftheINBONEITARreportsurvivorshipof89%atonly3.7yearsoffollow-up,withhighincidenceoftalarsubsidence(17).FurtherstudieshaveidentifiedtheINBONEIasanindependentriskfactorforfailure,againcitingtalarsubsidenceastheprimaryreasonforrevision(18).Therehasbeensomeevidencetosuggestthehighincidenceoftalarsubsidenceisaresultoftalarosteonecrosisinstigatedbytheintraoperativeintermedullaryreaming,thoughnodefinitivecausehasbeenelucidated(19).In2010,arevisedversionoftheimplant(INBONEII)wasintroduced,whichimplementedasulcus-shapedprofileandtwoanteriorpegstothetalarcomponent.MidtermoutcomesoftheINBONEIIreportsurvivorshipof98%anddecreasedincidenceoftalarsubsidence(20).INBONEITAR的手術(shù)結(jié)果顯示，在僅3.7年的隨訪中，患者的存活率為89%，距骨下沉的發(fā)生率很高(17)。進(jìn)一步的研究已經(jīng)確定INBONEI是一個(gè)獨(dú)立的失敗風(fēng)險(xiǎn)因素，再次將地表沉降作為修訂的主要原因(18)。有證據(jù)表明，距骨下沉的高發(fā)生率是術(shù)中髓間擴(kuò)孔引起的距骨壞死的結(jié)果，盡管沒有明確的原因被闡明(19)。2010年，引入了一種改良版的植入物(INBONEII)，它實(shí)現(xiàn)了一個(gè)溝狀輪廓和兩個(gè)前距假體。INBONEII的中期結(jié)果報(bào)告了98%的生存率，并降低了距骨下沉的發(fā)生率(20)。TheSaltoTalarisfixed-bearingTARwasfirstintroducedtotheUnitedStatesmarketin2006.However,thiswasanadaptationtoitsmobile-bearingpredecessor,theSaltoTotalAnkle,thathadbeenusedinEuropesince1997.Theimplantfeaturesacentralkeelintibiaandconical-shapedfacetinthetalarcomponent,designedtooptimizenaturalalignmentofthepatient’srotationalaxis(15).ClinicaloutcomesoftheSaltoTalarisatmidtermfollow-upciteexcellentsurvivorshipandimprovementsinpain,thoughdurabilityoftheimplantatthe10-yearmilestoneremainsundetermined(21-23).SaltoTalaris固定軸承TAR于2006年首次引入美國市場。然而，這是對其移動(dòng)軸承的前身Salto全踝的改進(jìn)，后者自1997年以來一直在歐洲使用。該植入物的特點(diǎn)是脛骨中央龍骨和距骨部分的錐形關(guān)節(jié)面，旨在優(yōu)化患者旋轉(zhuǎn)軸的自然對齊(15)。中期隨訪的臨床結(jié)果顯示，SaltoTalaris的生存期很好，疼痛得到了改善，但植入物在10年的耐久性仍不確定(21-23)。ThefirstiterationoftheSTARimplantwasinitiallyintroducedin1978,andfivedifferentversionsoftheSTARhavebeenusedforimplantationsince1981.Themostrecentiterationisthe4th-generationSTAR,whichwasapprovedintheUnitedStatesin2009(15).Theimplantfeaturesathree-component,mobile-bearingdesign,withatibialcomponentwithtwocylindricalbarsforfixationandasymmetrical,cylindricaltalarcomponent(15).Thedistalsideofthetibialcomponenthasasmooth,flatsurfacethatenablesunconstrainedmotionforthepolyethyleneinsert.TheversionoftheSTARusedintheUnitedStatespossessesatitaniumplasmaspraytostimulateboneongrowth,distinctfromitsEuropeancounterparts(15).Long-termoutcomesoftheSTARintheUnitedStateshavereportedsurvivorshipratesbetween90%to95%at10years,whichdecreasedto73%at15years(24-26).STAR植入物的第一次迭代最初于1978年推出，自1981年以來，已有五個(gè)不同版本的STAR用于植入。最新的版本是第四代STAR，于2009年在美國獲得批準(zhǔn)(15)。該植入物具有三組件，可移動(dòng)承載設(shè)計(jì)，脛骨組件具有兩個(gè)圓柱形棒用于固定，對稱圓柱形距骨組件(15)。脛骨假體的遠(yuǎn)端具有光滑、平坦的表面，使聚乙烯插入物能夠不受約束地運(yùn)動(dòng)。與歐洲同類產(chǎn)品不同，美國使用的STAR擁有鈦等離子體噴霧來刺激骨骼生長。在美國，STAR的長期預(yù)后報(bào)道10年生存率為90%-95%，15年生存率為73%(24-26)。TheHINTEGRATotalAnklesimilarlywasathree-componentmobile-bearingimplantprominentlyusedinEurope,Canada,andBrazilfollowingitsapprovalintheearly2000s.Thetibialcomponentfeaturesaflatsurfacewithananteriorshieldthathastwoholesforscrewfixationinthetibia.Thetalarcomponenthasaconicalprofileandemploysananteriorshieldwithholesforscrewfixationaswell.Severallong-termlargecohortstudiesassessingsurvivorshipoftheHINTEGRAprosthesishavebeenpublishedreportingvaryingsurvivorshiprangingbetween68%to84%at10yearspostoperatively(27,28).HINTEGRA全踝是一種類似的三組件移動(dòng)軸承植入物，在21世紀(jì)初獲得批準(zhǔn)后，在歐洲、加拿大和巴西得到了廣泛應(yīng)用。脛骨組件具有平坦的表面，其前屏蔽層具有兩個(gè)孔，用于脛骨螺釘固定。距骨組件具有圓錐形輪廓，并采用具有螺釘固定孔的前護(hù)罩。一些評(píng)估HINTEGRA假體生存率的長期大型隊(duì)列研究已經(jīng)發(fā)表，報(bào)告術(shù)后10年生存率在68%至84%之間(27,28)。TheZimmerTrabecularMetalTotalAnkle(Warsaw,IN,USA)wasanotableintroductiontothethirdgenerationofTARimplants.Contrarytootherimplants,whichuseananteriorsurgicalapproachtotheanklejoint,theTrabecularMetalTARemploysalateraltransfibularapproach,whichrequiresfibularosteotomyandanteriortalofibularligamentresectiontoaccessthejoint.Therationalebehindthistechniquewastoallowbetterreplicationofthenaturalcurvatureofthetibiaandtalusandminimizeboneresection.Additionally,itwastheorizedthatthisapproachwoulddecreaseincidenceofwoundhealingcomplications(15).MidtermoutcomesoftheTrabecularMetalTARhavereportedgoodimplantsurvivorshipandimprovedfunctionalscoresat5years(29,30).However,inonesmallcaseseriesof16lateralapproachTARpatients,therewasa25%incidenceofcomplicationsassociatedwiththefibularosteotomy(31).Thoughthisimplanthasdemonstratedgoodsurvivorshipandpatient-reportedoutcomes,theincreasedriskoffibularnonunion,aswellasthechallengesforrevisionoftheimplant,remainaconcern(30).Zimmer金屬小梁全踝(Warsaw,IN,USA)是第三代TAR植入物的重要介紹。與其他采用前路手術(shù)入路進(jìn)入踝關(guān)節(jié)的植入物不同，金屬小梁TAR采用外側(cè)經(jīng)腓骨入路，需要腓骨截骨和前距腓骨韌帶切除術(shù)才能進(jìn)入關(guān)節(jié)。這項(xiàng)技術(shù)背后的原理是允許更好地復(fù)制脛骨和距骨的自然彎曲，并盡量減少骨切除。此外，理論上認(rèn)為這種方法可以減少傷口愈合并發(fā)癥的發(fā)生率(15)。金屬小梁TAR的中期結(jié)果報(bào)告了良好的種植體存活和5年功能評(píng)分的改善(29,30)。然而，在16例外側(cè)入路TAR患者的小病例系列中，腓骨截骨術(shù)相關(guān)并發(fā)癥的發(fā)生率為25%(31)。盡管該植入物表現(xiàn)出良好的成活率和患者報(bào)告的結(jié)果，但腓骨不連的風(fēng)險(xiǎn)增加以及對植入物翻修的挑戰(zhàn)仍然令人擔(dān)憂(30)。ThefourthgenerationofTARimplantscontinuestoimproveuponthestrengthsofthethirdgenerationtooptimizeboneintegration,mechanicalalignment,andsurgicaltechnique.IntheUnitedStates,modernfourth-generationimplantsincludeINFINITY(Stryker),Cadence(IntegraLifeSciences,Princeton,NJ,USA),Vantage(Exactech,Gainesville,FL,USA),Axiom(Kinos,Wayne,PA,USA),Apex(Paragon28,Englewood,CO,USA),Quantum(In2Bones,Memphis,TN,USA).Thesedesignsfeaturelow-profiletibialandtalarcomponentswhichminimizeboneresectionwhilestillmaintainingrobustsurfacecontact(15).Giventheirrelativenoveltyoftheseimplants,thelong-termoutcomesareuncertain;however,earlyreportsdemonstrategoodsurvivorshiprangingbetween92%to98%,andsignificantimprovementsinfunctionalandpainscorespostoperativelyinthefirsttwoyears(32-34).Long-termfollow-upandstudieswillbecriticalintheevaluationofimplantsurvivorshipaftertheearlyandmid-termperiods.第四代TAR植入物在第三代的基礎(chǔ)上繼續(xù)改進(jìn)，以優(yōu)化骨整合、機(jī)械對準(zhǔn)和手術(shù)技術(shù)。在美國，現(xiàn)代第四代植入物包括INFINITY(Stryker)、Cadence(IntegraLifeSciences,Princeton,NJ,USA)、Vantage(Exactech,Gainesville,FL,USA)、Axiom(Kinos,Wayne,PA,USA)、Apex(Paragon28,Englewood,CO,USA)、Quantum(In2Bones,Memphis,TN,USA)。這些設(shè)計(jì)具有低輪廓的脛骨和距骨組件，可最大限度地減少骨切除，同時(shí)仍保持堅(jiān)固的表面接觸(15)?？紤]到這些植入物相對新穎，長期結(jié)果尚不確定;然而，早期的報(bào)告顯示，生存率在92%至98%之間，術(shù)后頭兩年功能和疼痛評(píng)分有顯著改善(32-34)。長期隨訪和研究將是評(píng)估早期和中期種植體存活的關(guān)鍵。AdditionalinnovationinthefieldofTARhasledtothedevelopmentofrevisionankleimplants.Inthepast,treatmentoptionsforTARimplantfailurewerelimitedtoarthrodesisorbelow-kneeamputation(9,11,35).Inthemodernera,theINBONEimplanthascommonlybeenusedintherevisionTARsetting(36),butthereissignificantroomforimprovementinthetreatmentoffailedTAR.Currently,theonlyavailablerevisionsystemsonthemarketaretheINVISION(Stryker)andSaltoTalarisXT(IntegraLifeSciences),whicharedesignedforsettingsoflargeboneresectionandaugmentedinstability.ReportsonrevisionTARsystemoutcomesarelargelylimitedandrequirefurtherinvestigation.ItisexpectedthatnovelrevisionsystemswillcontinuetoenterthemarketasmorecompaniesinvestinthisfuturedirectionofTAR.TAR領(lǐng)域的其他創(chuàng)新導(dǎo)致了踝關(guān)節(jié)修復(fù)植入物的發(fā)展。過去，TAR假體失敗的治療選擇僅限于關(guān)節(jié)融合術(shù)或膝下截肢(9,11,35)。在現(xiàn)代，INBONE種植體已被普遍用于翻修TAR設(shè)置(36)，但在治療失敗的TAR方面仍有很大的改進(jìn)空間。目前，市場上唯一可用的修正系統(tǒng)是INVISION(Stryker)和SaltoTalarisXT(IntegraLifeSciences)，它們是為大骨切除和增強(qiáng)不穩(wěn)定性而設(shè)計(jì)的。關(guān)于修訂TAR系統(tǒng)結(jié)果的報(bào)告在很大程度上是有限的，需要進(jìn)一步調(diào)查。隨著越來越多的公司投資于TAR的未來方向，預(yù)計(jì)新的修訂系統(tǒng)將繼續(xù)進(jìn)入市場。?IndicationsTheprimaryindicationforTARisend-stageanklearthritis,whichisidentifiedthroughclinicalandradiographicassessment.AsthefrequencyofTARsperformedeachyearincrease,understandingofetiologyofarthritisandassociatedoutcomesremainsapertinentareaofresearch.Post-traumaticarthritisisthemostcommonetiologyofanklearthritis,accountingforbetween70–90%ofallincidencesofend-stageankleosteoarthritis(20,23,34,37);however,traumamayrangefromintra-articularankleortalusfracturetoextra-articularfracture,chondralinjury,orchronicligamentousinsufficiencyandinstability.Otheretiologiesofanklearthritisincludeprimaryosteoarthritis,inflammatoryarthritis,andarthritissecondarytoclubfootdeformity,avascularnecrosis(AVN),orhemochromatosis.TAR的主要適應(yīng)癥是終末期踝關(guān)節(jié)炎，可通過臨床和影像學(xué)評(píng)估確定。隨著每年進(jìn)行TARs的頻率增加，對關(guān)節(jié)炎的病因和相關(guān)結(jié)果的了解仍然是一個(gè)相關(guān)的研究領(lǐng)域。創(chuàng)傷后關(guān)節(jié)炎是踝關(guān)節(jié)最常見的病因，占所有終末期踝關(guān)節(jié)骨關(guān)節(jié)炎發(fā)病率的70-90%(20,23,34,37);然而，創(chuàng)傷的范圍可能從關(guān)節(jié)內(nèi)踝關(guān)節(jié)或距骨骨折到關(guān)節(jié)外骨折、軟骨損傷或慢性韌帶功能不全和不穩(wěn)定。踝關(guān)節(jié)關(guān)節(jié)炎的其他病因包括原發(fā)性骨關(guān)節(jié)炎、炎性關(guān)節(jié)炎和繼發(fā)于內(nèi)翻足畸形、缺血性壞死(AVN)或血色素沉著癥的關(guān)節(jié)炎。Historically,theidealTARcandidatewasanolderpatientwithlowfunctionaldemands,minimaldeformityattheankleorfoot,andminimaladjacentjointarthrosis.Thesecharacteristicshavebeenassociatedwithgreaterpainresolution,diminishedcomplicationrisks,andlowerrisksoffailure.However,improvementsinsurgeonexperience,technique,andimplantdesignshavecontributedexcellentoutcomesinpatientdemographicsbeyond“ideal”criteria.從歷史上看，理想的TAR候選者是年齡較大、功能需求低、踝關(guān)節(jié)或足部畸形最小、鄰關(guān)節(jié)關(guān)節(jié)病最小的患者。這些特征與更大的疼痛緩解、更低的并發(fā)癥風(fēng)險(xiǎn)和更低的失敗風(fēng)險(xiǎn)有關(guān)。然而，外科醫(yī)生經(jīng)驗(yàn)、技術(shù)和植入物設(shè)計(jì)的改進(jìn)使患者人口統(tǒng)計(jì)學(xué)的結(jié)果優(yōu)于“理想”標(biāo)準(zhǔn)。AgeandphysicaldemandareconsideredtohavesignificantinfluenceuponTARoutcomes.Inparticular,youngerandmorephysicallyactivepatientshavebeenthoughttohaveanincreasedriskoffailureinTAR,asaresultoftheincreasedimplantlifespanandactivitydemand.However,somereportsexplicitlyinvestigatingoutcomesofTARbyagegroupshavefoundnosignificantdifferencesinrisk(38,39),whileothersciteageasanindependentpredictoroffailure(35,40).Despiteconflictingevidence,youngerpatientsstillreportexcellentfunctionalandclinicaloutcomesthatwarrantseligibilityforTAR(39,41,42).Inparticular,thepreservationofmotionfromTARisespeciallybeneficialforyoungerpatients,asitcanhelptodiminishfutureonsetandseverityofadjacentjointarthritisinthemidfootandhindfoot.Ingeneral,patientageandactivitylevelshouldbeconsideredinpre-surgicalconsultation,andsurgeonsshouldtakethesefactorsintoaccounttoguidedecision-makingandtomanagepatients’expectationsofoutcome.年齡和體力需求被認(rèn)為對第三次評(píng)估報(bào)告的結(jié)果有重大影響。特別是，由于植入物壽命和活動(dòng)需求的增加，年輕和更活躍的患者被認(rèn)為有更高的TAR失敗風(fēng)險(xiǎn)。然而，一些明確按年齡組調(diào)查TAR結(jié)果的報(bào)告發(fā)現(xiàn)風(fēng)險(xiǎn)沒有顯著差異(38,39)，而另一些報(bào)告則認(rèn)為年齡是失敗的獨(dú)立預(yù)測因子(35,40)。盡管有相互矛盾的證據(jù)，年輕患者仍然報(bào)告了良好的功能和臨床結(jié)果，保證了TAR的資格(39,41,42)。特別是，TAR對年輕患者尤其有益，因?yàn)樗梢詭椭鷾p少未來中足和后足相鄰關(guān)節(jié)關(guān)節(jié)炎的發(fā)病和嚴(yán)重程度。一般來說，術(shù)前會(huì)診應(yīng)考慮患者的年齡和活動(dòng)水平，外科醫(yī)生應(yīng)考慮這些因素來指導(dǎo)決策和管理患者對結(jié)果的期望。PreoperativecoronalplanedeformityhasbeencitedasarelativecontraindicationforTARhistorically.However,morerecentstudiesdemonstratethatseverepreoperativedeformitydoesnotresultinincreasedfailure,aslongasthedeformityisabletobecorrectedintraoperatively(43).CurrentanalysisofTARoutcomesinthesettingofvarus,valgus,andneutralpreoperativealignmenthasreportedsimilarpainandfunctionalscoresandsimilarratesofcomplications,reoperation,andsurvivorshipacrossthethreegroups(44).Thoughpreoperativecoronaldeformityexceeding20°oncewasconsideredanabsolutecontraindicationforTAR,advancementsinsurgicaltechniqueandimplantdesignhavehelpedachievesatisfactoryoutcomesforcasesofseverecoronalplanedeformity(20°to35°ofvarusorvalgus)(45).Importantly,ensuringgoodoutcomesincasesoffootandankledeformityisdependentupontheuseofconcomitantprocedurestobalancetheankle.術(shù)前冠狀面畸形歷來被認(rèn)為是TAR的相對禁忌癥。然而，最近的研究表明，只要畸形能夠在術(shù)中矯正，術(shù)前嚴(yán)重畸形并不會(huì)導(dǎo)致手術(shù)失敗的增加(43)。目前對內(nèi)翻、外翻和中性術(shù)前對準(zhǔn)的TAR結(jié)果分析顯示，三組患者的疼痛和功能評(píng)分相似，并發(fā)癥、再手術(shù)率和生存率相似(44)。雖然術(shù)前冠狀面畸形超過20°一度被認(rèn)為是TAR的絕對禁忌癥，但手術(shù)技術(shù)和植入物設(shè)計(jì)的進(jìn)步已經(jīng)幫助嚴(yán)重冠狀面畸形(20°至35°內(nèi)翻或外翻)的病例獲得了令人滿意的結(jié)果(45)。重要的是，在足部和踝關(guān)節(jié)畸形的情況下，確保良好的結(jié)果取決于使用伴隨手術(shù)來平衡踝關(guān)節(jié)。ObesityhasalsobeencitedasarelativecontraindicationforTARinthepast,butthesepatientssimilarlyhaveachievedsignificantimprovementsinoutcomesinmorerecentliterature(46,47).Incurrentliterature,theevidenceassessingriskofcomplicationsandfailuresinobesepatientsisconflicting.Whileonereportcitedanincreasedfailureriskinobesepatients(48),otherstudieshavefoundminimaldifferencesinincidencesofcomplications,infection,orfailure(46,47,49).Inspiteofconflictingevidence,thereisaconsensusthatobesepatientscanachievesignificantimprovementsinpainandfunctionaloutcomesfollowingTAR,thoughtheymayhavelowerfunctionalscorescomparedtotheirnon-obesecounterparts.肥胖在過去也被認(rèn)為是TAR的相對禁忌癥，但在最近的文獻(xiàn)中，這些患者同樣取得了顯著的改善(46,47)。在目前的文獻(xiàn)中，評(píng)估肥胖患者并發(fā)癥和失敗風(fēng)險(xiǎn)的證據(jù)是相互矛盾的。雖然一份報(bào)告指出肥胖患者衰竭風(fēng)險(xiǎn)增加(48)，但其他研究發(fā)現(xiàn)并發(fā)癥、感染或衰竭的發(fā)生率差異很小(46,47,49)。盡管有相互矛盾的證據(jù)，但有一個(gè)共識(shí)，即肥胖患者在TAR后可以顯著改善疼痛和功能結(jié)果，盡管與非肥胖患者相比，他們的功能評(píng)分可能較低。DiabetespersistsasarelativecontraindicationtoTAR,especiallyinthesettingofuncontrolleddiabetes(A1C>7.0%)(50).Thoughdiabeticpatientscanstillachieveimprovementsinpainandfunctionaloutcomes,thereissignificantevidencedemonstratinganincreasedriskofcomplicationsanddelayedwoundhealingfordiabeticTARpatients(50-52).糖尿病仍然是TAR的相對禁忌癥，特別是在糖尿病未控制的情況下(A1C>7.0%)(50)。雖然糖尿病患者在疼痛和功能預(yù)后方面仍然可以得到改善，但有重要證據(jù)表明糖尿病TAR患者出現(xiàn)并發(fā)癥和傷口愈合延遲的風(fēng)險(xiǎn)增加(50-52)。AbsolutecontraindicationsforTARincludeactiveinfection,excessivelossofbonestock,neuropathicorCharcotarthropathy,inadequatesofttissueenvelopearoundtheankle,confirmedmetalallergy,andvasculardeficiencyofthelimb.Inaddition,surgeonsshouldusediscretioninpatientselectionforTARbeyondtheseabsolutecharacteristicsanddeveloptheiroperativeplanbasedontheirpatient’scharacteristics,relativerisks,andfunctionaldemands.Surgeonsmayusemagneticresonanceimaging(MRI),computedtomography(CT),orweightbearingCT(WBCT)tobettercharacterizebonequality,deformity,presenceofperiarticularcysts,andassociatedsofttissuepathologytofinalizetheirsurgicalplan(53).TAR的絕對禁忌癥包括活動(dòng)性感染、骨質(zhì)過度流失、神經(jīng)性或沙氏關(guān)節(jié)病、踝關(guān)節(jié)周圍軟組織包膜不足、確診的金屬過敏和肢體血管缺乏。此外，除了這些絕對特征外，外科醫(yī)生在選擇TAR患者時(shí)應(yīng)酌情決定，并根據(jù)患者的特征、相對風(fēng)險(xiǎn)和功能需求制定手術(shù)計(jì)劃。外科醫(yī)生可以使用磁共振成像(MRI)、計(jì)算機(jī)斷層掃描(CT)或負(fù)重CT(WBCT)來更好地表征骨質(zhì)量、畸形、關(guān)節(jié)周圍囊腫的存在以及相關(guān)的軟組織病理，從而確定他們的手術(shù)計(jì)劃(53)。?TechniquesAnanteriorapproachisthemostusedapproachformajorityofTARimplants;thereisoneimplantthatemploysalateralapproachforitsdesign,andaposteriorapproachforTARhasbeendescribedinliterature(54).Amidlineincisioncenteredovertheanklejointandtheintervalbetweenthetibialisanteriorandextensorhallucislongusisutilized.Thesuperficialperonealnerveisidentifiedandretractedthroughoutthecase.Theextensorretinaculumisincisedwithcareforrepairattheendofthecase.Theanteriortibialneurovascularbundleisencounteredandretractedlaterally.Thecapsuleisthenincisedandelevatedoffthejoint.Adequateexposureoftheanklejointshouldallowforcompletevisualizationofthemedialandlateralguttersoftheankle.前路入路是大多數(shù)TAR植入物最常用的入路;有一種植入物采用外側(cè)入路設(shè)計(jì)，文獻(xiàn)中描述了TAR的后路入路(54)。在踝關(guān)節(jié)和脛骨前肌和拇長伸肌之間的間隙處作中線切口。腓淺神經(jīng)在整個(gè)病例中被識(shí)別和縮回。在病例結(jié)束時(shí)小心地切開伸肌支持帶進(jìn)行修復(fù)。脛前神經(jīng)血管束與脛前神經(jīng)血管束接觸并向外側(cè)縮回。然后將關(guān)節(jié)囊切開并抬高。充分暴露踝關(guān)節(jié)可以使踝關(guān)節(jié)內(nèi)側(cè)和外側(cè)溝完全可見。Theoperativesequencesarespecifictoeachimplant,butgenerallyincludethefollowingsteps:(I)placementofanextramedullaryalignmentguidetofacilitatecuts;(II)provisionalpinningofacuttingblocktotheankle;(III)bonycutsofthetibialandtalus;(IV)trialcomponentplacement;and(V)placementoffinalcomponents(Figure1).Intraoperativefluoroscopyiscriticalthroughtheprocess.Inadditiontoplacementofcomponents,theotherdrivingoperativegoalofTARistoappropriatelyaligntheanklejointandthefootunderneaththeankle.Adequatealignmentisachievedthroughacombinationofintraarticulardeformitycorrectionandexternalprocedures,whichallassistinbalancingoftheankleandfoot(Table2).每個(gè)植入物的操作順序是特定的，但通常包括以下步驟:(I)放置髓外對準(zhǔn)導(dǎo)向器以方便切割;(II)將切割塊臨時(shí)釘在腳踝上;(III)脛骨和距骨的骨切口;(四)試件放置;(五)最終部件的放置(圖1)。術(shù)中透視在整個(gè)過程中至關(guān)重要。除了放置組件外，TAR的另一個(gè)驅(qū)動(dòng)操作目標(biāo)是適當(dāng)對齊踝關(guān)節(jié)和踝關(guān)節(jié)下方的足部。通過關(guān)節(jié)內(nèi)畸形矯正和外部手術(shù)的結(jié)合可以達(dá)到適當(dāng)?shù)膶R，這些都有助于平衡踝關(guān)節(jié)和足部(表2)。??Figure1Visualizationofthetotalanklereplacementprocedureintraoperatively.(A)Anexternalalignmentguideisplacedtofacilitatebonycuts.(B)Bonycutsaremadeinthetibiaandtalususingthealignmentguide.(C)Thetrialtibialandtalarcomponentsareplacedtodetermineaccuratesizing.(D)Thefinalimplantisplaced.??Table2ConcomitantproceduresduringTAAfordeformitycorrectionProceduresforvarusdeformity?ProceduresforvalgusdeformityDeltoidligamentrelease???Deltoid/springligamentreconstructionLateralligamentrepair??????LateralligamentrepairAchilleslengthening?AchilleslengtheningGastrocnemiusrecession???GastrocnemiusrecessionLateralizingcalcanealosteotomy???????Medializingcalcanealosteotomy1stmetatarsaldorsiflexionosteotomyFibularlengtheningosteotomyMedialrelease??Medialcolumnstabilization????Talonavicularjointcapsulerelease??????????Cottonosteotomy????Posteriortibialtendonrelease?????????1sttarsometatarsalfusion????NaviculocuneiformfusionPeroneuslongustobrevistransfer??????PeroneuslongustobrevistransferPosteriortibialtendontoperoneusbrevis???HindfootfusionforrigiddeformityHindfootfusionforrigiddeformity????TalonavicularfusionNaviculocuneiformfusion??Finalradiographsaretakentoensureadequateimplantcontacttoboneandmechanicalalignment.Thewoundisclosedinlayers,withmeticulousattentiontoextensorretinacularrepairtoreducetheriskofbowstringingfromthetibialisanteriortendon,whichcanthreatentheanteriorskin.最后拍X光片以確保植入物與骨有足夠的接觸并機(jī)械對齊。創(chuàng)面分層閉合，并對伸肌支持帶進(jìn)行細(xì)致的修復(fù)，以減少脛骨前腱弓弦的風(fēng)險(xiǎn)，因?yàn)楣視?huì)威脅到前面的皮膚。ThoughtheanteriorapproachtotheankleismostrelevantformanyimplantsinTARliterature,thereisoneimplant(TrabecularMetalTotalAnkleSystem)thatemploysatransfibularapproach.Inthiscase,anincisionismadeoverlyingthelateralmalleolus,andtheanteriortalofibularligamentisidentifiedandsectioned.Afterthefibulaandanteriortibiaareexposed,anobliquefibularosteotomyisperformedapproximately1cmproximaltothetibiotalarjointline.Followingthefibularosteotomy,theankleisplacedintoanexternalframeandcuttingguidesareplaced.AfterTARimplantation,thefibulaisanatomicallyreducedandfixedusingascreworplate,andtheanteriortalofibularligamentisrepaired.盡管在TAR文獻(xiàn)中，許多植入物都采用踝關(guān)節(jié)前路入路，但有一種植入物(小梁金屬全踝關(guān)節(jié)系統(tǒng))采用經(jīng)腓骨入路。在這種情況下，在外踝上做一個(gè)切口，識(shí)別并切開距腓骨前韌帶。暴露腓骨和脛骨前骨后，在脛距關(guān)節(jié)線近端約1cm處行斜腓骨截骨術(shù)。在腓骨截骨術(shù)后，將踝關(guān)節(jié)置入外支架并放置切割導(dǎo)具。TAR植入后，解剖復(fù)位腓骨，用螺釘或鋼板固定，修復(fù)距腓骨前韌帶。PostoperativerecoveryprotocolforpatientsfollowingTARcanvarybyinstitution,especiallyinregardtothepatient’sweightbearingtimeline.GenerallyfollowingTAR,thepatientisimmobilizedinashort-legplastersplintandisnon-weightbearingforthefirstfourtosixweeks.Followingdischarge,patientsareputonacourseofpainmedicationconsistingofacetaminophen,non-steroidalanti-inflammatorydrugs(NSAIDs),andalimiteddoseoforalopioids;medicationtopreventvenousthromboembolismmaybeadministeredperthehospitalistsormedicaldoctors’discretion.Atthetwo-weekpostoperativevisit,thesplintandsuturesareremoved,andthepatientistransitionedtoacontrolledanklemotion(CAM)boot.Atthefour-tosix-weekpostoperativevisit,postoperativeradiographsareobtained,andthepatientbeginsfollowingaprogressiveweightbearingprotocol.Atthe8-to10-weekpostoperativevisit,two-monthradiographsareobtained,andifthepatientisfully-weightbearing,theycannowswitchoutoftheCAMboottoasupportivesneaker.Follow-upvisitsandradiographswillcontinueatfourmonths,sevenmonths,andoneyearpostoperatively,thenareperformedannuallyduringsubsequentfollow-upvisits.TAR術(shù)后患者的術(shù)后恢復(fù)方案因機(jī)構(gòu)而異，特別是考慮到患者的負(fù)重時(shí)間。一般在TAR后，患者用短腿石膏夾板固定，頭4-6周不負(fù)重。出院后，患者接受一個(gè)療程的止痛藥治療，包括對乙酰氨基酚、非甾體抗炎藥(NSAIDs)和有限劑量的口服阿片類藥物;預(yù)防靜脈血栓栓塞的藥物可由醫(yī)院醫(yī)生或醫(yī)生自行決定。在術(shù)后兩周的隨訪中，拆除夾板和縫合線，并將患者過渡到受控踝關(guān)節(jié)運(yùn)動(dòng)(CAM)靴。術(shù)后4-6周隨訪時(shí)，獲得術(shù)后X線片，患者開始接受漸進(jìn)式負(fù)重治療。在術(shù)后8-10周的隨訪中，獲得兩個(gè)月的X光片，如果患者完全可以負(fù)重，他們現(xiàn)在可以換掉CAM靴，換上支持性運(yùn)動(dòng)鞋。術(shù)后4個(gè)月、7個(gè)月和1年繼續(xù)進(jìn)行隨訪和X光檢查，隨后每年進(jìn)行一次隨訪。?OutcomesInthemodernera,TARisassociatedwithexcellentoutcomesintermsofpainreliefandfunction.ThepasttwodecadesofTARresearchhasdemonstratedsignificantimprovementsinclinicalandfunctionaloutcomes,suchasincreasedimplantsurvivorship,decreasedcomplicationandreoperationrates,andimprovementsinfunctionalscoresandperceivedpainrelief.Asaresultoftheseconsiderableadvancements,TARhasbecomeincreasinglypopularasatreatmentoptionforend-stagearthritisandhasraiseddebateaboutitsmeritsoverthecurrentgold-standardtreatmentoption,anklearthrodesis.在現(xiàn)代，TAR與疼痛緩解和功能方面的良好結(jié)果相關(guān)。過去二十年的TAR研究已經(jīng)證明了臨床和功能結(jié)果的顯著改善，例如增加了植入物存活率，減少了并發(fā)癥和再手術(shù)率，改善了功能評(píng)分和感知疼痛緩解。由于這些相當(dāng)大的進(jìn)步，TAR作為終末期關(guān)節(jié)炎的治療選擇越來越受歡迎，并引發(fā)了關(guān)于其與目前的金標(biāo)準(zhǔn)治療選擇——踝關(guān)節(jié)融合術(shù)的優(yōu)點(diǎn)的爭論。?OutcomesversusarthrodesisComparedtoarthrodesis,TARhasbeendemonstratedtohavesimilarsurvivorship,betterpainreduction,anddecreasedreoperationrates(55).SeveralstudieshavebeenpublishedcomparingoutcomesofindividualTARimplants(HINTEGRA,SaltoTalaris,STAR,andINBONE)toanklearthrodesis,whichcorroboratefindingsofsurvivorshipandclinicalimprovements(55-58).EvolutionofTARinthepastdecadehasfurtherdemonstrateditsadvantagesoverarthrodesis;third-generationTARimplantshavesignificantlylowerratesofasepticlooseningcomparedtoratesofnonunioninarthrodesis(59).Furthermore,TARpatientsreportgreaterimprovementsinsatisfactionscoresandbetterfulfillmentofpreoperativeexpectationsversusarthrodesis(60).FunctionaloutcomesfollowingTARdemonstratesuperiorresultstoarthrodesisinregardstogait,rangeofmotion,andfunctionalability.MultiplestudiesassessingcomparativegaitanalysisbetweenTARandarthrodesishavedemonstratedmoresymmetricalgaittiming,recoveredbilateralgait,andrestoredgroundreactionforcetransmissioninTARthatbetterreplicatedthatofahealthycontrol(61-63).Further,TARpatientshavegreatertotalarcofmovementcomparedtoarthrodesis,andsubsequentlylesscompensatorymovementinadjacentjoints,allowingforgreaterpreservationofadjacentjointsfromdegenerativechanges(64).Improvedperformanceascendinganddescendingstairs,andbetternegotiationofunevensurfaceshaveadditionallybeencorrelatedwithTAR(65,66).Asmodern,fourth-generationTARimplantreach5-yearand10-yearmilestones,furtherstudiesarenecessarytoreportuponoutcomesandtocomparewithanklearthrodesis.ThoughTARoutcomesarepromising,thereareinherenttrade-offsbetweenthetwoprocedures,andpatientselectionremainsanimportantconsiderationpriortosurgicalintervention.?ClinicalandfunctionaloutcomesPatientswhoundergoTARexperiencesignificantimprovementsinpainandphysicalfunction.Assessmentsofpatient-reportedoutcomehaveconsistentlyconfirmedsignificantimprovementsinpainreductionandqualityoflifefollowingTAR(43,67,68).Inaddition,patientsatisfactionfollowingTARishigh,withratesrangingbetween80–97%,buttypicallyexceeding90%(69).FunctionaloutcomesforTARpatientshavebeenassessedthroughvariousmetrics,includingpatient-reportedoutcomescores,clinicalassessmentofrangeofmotion,gaitanalysis,andparticipationinsportspriorandfollowingTAR.Postoperatively,rangeofmotionincreasesonaverageby5–10°,foratotalarcofmotionrangingbetween34–40°(64,70).Patient-reportedoutcomesoffunctionalabilitiesconsistentlydemonstratesignificantimprovementspostoperatively(69);further,patientswithworsepreoperativefunctionhaveshowngreaterimprovementsinoutcomescorescomparedtothosewithhigherpreoperativefunctionscores(71).Moreover,patientshavedemonstrateda20%increasedparticipationinsportsactivitiesfollowingTAR,thoughusuallytheseactivitieswere“l(fā)ow-impact”,suchasswimming,golf,andcycling(72,73).Thoughhigh-impactsportsarenotadvisedtopreservethelongevityofTARimplants,patientscanstillexpecttoachievemarkedimprovementintheirdailyfunctionandabilitiesinlow-impactsports.?ImplantsurvivorshipCurrentsurvivorshipforTARimplantsrangesfrom70%to98%at3–6yearsand80%to95%at8–12yearspostoperatively(Table3)(69).Comprehensivemeta-analysesreportinguponoutcomesforTARaresparse;themostrecentofwhichcalculatedanadjustedsurvivorshipof90%at5-yearacross1,105TARs(13).Theseanalyses,however,arelimitedtosecondandthirdgenerationimplants,anddonotreporttheoutcomesofmanymodernimplantscurrentlyusedbysurgeons.Fourth-generationimplantssuchastheVantage,INFINITY,andCadencearewidelyusedbycurrentTARsurgeons,buttheirmid-tolong-termreportsonoutcomesarelimitedbytheirrelativenovelty.Earlyreportsonoutcomesforthesenovelimplantsarepromising,withsurvivorshiprangingbetween93.7%to100%at2years(20,32,33,84).However,itisimportanttonotethatmostTARproceduresarecarriedoutinhigh-volumehospitalsinmetropolitanareasintheUnitedStates,andtendtobeperformedbysurgeonswithhighvolumesofTARexpertise(85,86).Inspiteofthis,lowvolumehospitalsforTARhavealsobeenshowntoachieveimprovedoutcomesandgoodsurvivorship(87).??Table3Summaryofrecentand/orpopulartotalanklereplacementsandtheiroutcomesImplant????Study???????No.ofimplantsFollow-up(years),median(IQR)???Survivorship????ReoperationrateAgility?????Knecht,2004(74)????132?9.0(7.0to16)????????89.00%????NotrecordedRaikin,2017(22)?????115??9.1(4.0to14)??78.20%????????NotrecordedCadence???Fram,2022(75)???????58????Minimum2????????94.80%????20.70%Kim,2023(30)48????2.8(2.0to4.2)?93.80%????6.30%HINTEGRA????Yang,2019(76)???????210?6.4(2.0to13.4)????????91.70%????9.00%Yoon,2022(77)???????151?11.3(10to17)?93.50%????????22.50%INBONEI???????Adams,2014(17)????1943.7(2.2to5.5)????????89.00%????25%Harston,2017(78)???149?5.9(4.0to9.4)?90.60%????????13.40%INBONEII??????Lewis,2015(79)??????56??2.1(1.3to2.9)????????97.40%????15.90%Gagne,2022(20)?????51????6.4(5.0to9.0)?98.00%????????7.80%INFINITY???????Saito,2018(33)???????64??2.0(1.5to3.3)????????95.30%????17.10%Cody,2019(80)???????159?1.6(1.0to3.1)?90.00%????????NotrecordedSaltoTalaris?????Stewart,2017(23)???1066.8(5.0to9.6)????????95.80%????19.00%Day,2020(22)85????7.1(5.0to12)??97.60%????21.20%STAR??????Wood,2003(81)??????143?7.3(5.0to13.0)????????80.30%????NotrecordedClough,2019(82)????87????15.8(11.1to24.5)???76.16%????????NotrecordedZimmer????Barg,2018(83)????????55????2.2(1.9to2.6)????????93.00%????18.20%Maccario,2022(29)86????5.4(5.0to7.5)?97.70%????????NotrecordedIQR,interquartilerange.??RevisionsandriskfactorsInthecaseofTARfailure,revisionoptionsincluderevisionTAR,tibiotalararthrodesis,andinmoreseverecases,tibiotalocalcaneal(TTC)fusionorbelowkneeamputation(BKA).ThemostcommonindicationsforrevisioninTARareduetoinfection,asepticloosening,andsubsidence.Revisionisclassicallydefinedasimplantfailuresnecessitatingareturntotheoperatingroomforexchangeorremovalofthetibialand/ortalarimplant(17,88),whereasreoperationsarecharacterizedasallotherreturnstotheORthatpreservethemetalliccomponents.OutcomesforrevisionTARsdemonstraterelativelygoodsurvivorshiprangingbetween80%to97%,withimprovingsurvivalratesinrecentyearsfollowingtheintroductionofrobust,stemmedimplantsthataccountforlossofbonestock(36,89,90).RevisionTARhasbeenfoundtopreserveanklerangeofmotionandprotecttheadjacentjointsfromcompensatoryload,offeringgreaterfunctioncomparedtorevisiontoanklearthrodesis(91,92).Moreover,patient-reportedoutcomescoresfollowingrevisionTARshowedgreaterimprovementscomparedtoanklearthrodesis,yetfailedtoreachthethresholdofimprovementobservedwithprimaryTAR(89,93).TibiotalararthrodesisfollowingfailedprimaryTARhasalsohadsatisfactoryoutcomesandsurvivorship.Inonemeta-analysisof193patientswithfailedTARsconvertedtoanklearthrodesis,84%hadsuccessfulfusion;thoughtheseratesrangedfrom50%to100%whensubcategorizedbymodeoffusion(94-96).BothrevisionTARandanklearthrodesisareviabletreatmentoptionsfollowingfailedTAR,thoughdifferencesinfunction,pain,andsurvivorshipdoexistbetweenthetwoprocedures.DeterminingthepatientfactorsthatmaycontributetoimplantfailureisanimportantareaofresearchinTAR.RecentassessmentsofpatientdemographicsandTARoutcomeshaveidentifiedprioranklefusionandipsilateralhindfootfusionasriskfactorsforfailure,likelyduetotheincreasedstressesplacedonthefootandimplant(18,97,98).Othertheorizedriskfactorscontributingtofailureincludeactivitylevel,bodymassindex(BMI),preoperativediagnosisofinflammatoryarthritis,andsevereankledeformity,butreportsontheirassociationsarevaried(18).Younger,moreactivepatientshavebeenthoughttobeatgreaterriskforfailureduetogreaterestimatedstressandlongerimplantlifetime,butlargecohortanalysisofTARoutcomesinyoungerpatientsdidnotidentifyanyincreasedrisk(18,38).Similarly,highBMIhasalsobeenidentifiedasapotentialriskfactorforfailure,butthisassociationwasnotidentifiedinrecentoutcomeassessments(18,47).PreoperativediagnosisofinflammatoryarthritishashadconcernsforimpactonTARsurvivorshipduetoitscorrelationwithpoorbonestock,increasedinflammatoryresponse,andconfoundinginfluenceofimmunomodulatorymedication(99,100).However,currentanalyseshavereportedsimilaroutcomesintermsofsurvivorship,complications,andreoperationsbetweenpatientswithandwithoutinflammatoryarthritis(18,100).Finally,patientswithseverevarusorvalgusdeformityhavedemonstratedcomparableresultsinrecentstudies,solongasthedeformityiscorrectedintraoperatively(18,44,45).Furtherstudieswithlongerfollow-uparenecessarytocorroboratewiththecurrentliteratureaboutriskfactorsinTAR.Survivorship,painscores,andclinicaloutcomeshavecontinuedtoimproveinnewergenerationsofimplants,whilecomplicationsandreoperationrateshavedecreased.However,despitethetrendsinimprovementsforTAR,outcomesstudiesformodernimplantsareinherentlylimitedbythelow-qualityofevidenceandinsufficiencyoflong-termstudies.?ComplicationsComplicationsassociatedwithTARincludedelayedwoundhealing,infection,periprostheticfracture,impingement,andperiprostheticlucencyandcysts.Treatmentofthesecomplicationscaninvolvenonoperativeintervention,reoperation,revision,orconversiontoanklefusion/amputationbasedoncaseseverity.CategorizationofTARcomplicationsbasedontheirassociatedclinicaloutcomeswasfirstproposedbyGlazebrooketal.,andestablishedthreecategories:high-grade,medium-grade,andlow-grade(101).Thiscategorizationcanhelpguidesurgeondecisionmakingandinterventionplansattheonsetofcomplications.Wound-healingcomplicationsareaprominentconcernintheearlypostoperativeperiodandcanjeopardizetheintegrityoftheimplant.Wound-healingcomplicationsmaybeminorandhavecompleteresolutionofsymptomsfollowingtreatmentwithlocalwoundcareororalantibiotics.Moreseverewoundissuesmayrequireareturntotheoperatingroomformoreaggressiveintervention,suchasirrigationanddebridement,vacuum-assistedclosure,orflapcoverage.Longeroperativetimeandlongertourniquettimehavebeenassociatedwithhigherratesofwoundcomplications,aswellaspatientswithadiagnosisofprimaryosteoarthritis,historyofdiabetes,andhistoryofsmoking(102-104).Periprostheticjointinfection(PJI)followingTARhasareportedincidenceof0%to6.7%incurrentliterature(13,105,106).PJIcanbedividedintotwocategories:acutePJIandchronicPJI.AcutePJIischaracterizedasinfectionseitheroccurringintheearlypostoperativeperiodoroccurringwithsuddenonsetinapatientpreviouslydoingwell,withsymptomdurationbelow4weeks(106,107).Acuteinfectionsaretypicallytreatedwithdebridement,antibiotics,andimplantretention(DAIR)withpolyethyleneexchange.Thelong-termoutcomesfollowingDAIRhavebeensuboptimal,withrecentreportscitingafailurerateof54%andhighratesofreinfection(107).However,ithasbeendeterminedthatearliersurgicalinterventionfollowingtheonsetofsymptomsisdirectlycorrelatedsuccessrateoftreatmentwithDAIR(107).Chronicinfectionsrequireatwo-stagerevision,consistingfirstofcompleteremovalofallimplantsandinsertionofanantibioticcementspacer,withacourseofintravenousantibioticsforatleastsixweeks.Dependingonthepatient’scondition,statusofinfection,andavailablebonestock,thesecondstageoftherevisionmayinvolvereimplantationofarevisionTARimplant,conversiontoarthrodesis,permanentretentionofthecementspacer,orbelow-kneeamputation.Currently,reportsdetailingoutcomesfollowing2-stagerevisionforchronicPJIarelimited.Inonesingle-centerseriesofanklePJIin34patients,the10patientstreatedwith2-stagerevisionhadareinfectionrateof0%(105).Similarly,ameta-analysisof105casesofanklePJIacross6studiesreporteda0%reinfectionrateinthe22patientstreatedwith2-stagerevision(108).LargercohortstudiesarenecessarytodrawdefinitiveconclusionsonoutcomesfollowinganklePJI,butcurrentliteratureindicates2-stagerevisionasaneffectiveinterventionforeradicatinginfectionfollowingTARPJI.Intraoperatively,themostcommoncomplicationduringTARisperi-prostheticfracture,typicallymedialorlateralmalleolarfracture(109).Medialmalleolarfracturesaremostfrequent,withanincidencerateof6%,whilelateralmalleolarfractureshavearateof1%(109);however,theoccurrenceofintraoperativefractureshasbeenshowntodecreasewithincreasedsurgeonexperience(110,111).Intraoperativefracturesshouldbetreatedwithopenreductioninternalfixation,thoughpatientscanachieveoptimaloutcomeswithoutfixationiffractureisnondisplaced(112).IncasesofmedialmalleolarthinningduringbonyresectionatthetimeofindexTAR,prophylacticfixationisrecommended.Postoperatively,theincidenceoffracturesisbetween2%to4%,primarilyaroundthemedialmalleolus,followedbythetibialdiaphysis,talus,andfibula(113,114).Operativemanagementisrecommendedforallinstancesofpostoperativeperiprostheticfracture,asnonoperativetreatmenthasbeendemonstratedasapredictoroftreatmentfailureinTAR(114).Periprostheticfractureswithimplantstabilitycanbesuccessfullytreatedwithopenreductionandinternalfixation;fracturewithanunstableimplantshouldbeindicatedforrevisionTARorconversiontoarthrodesis(113,114).SymptomaticbonyimpingementisthemostcommonindicationforreoperationfollowingTAR,andonsetofimpingementislargelycorrelatedtoinadequategutterdebridementatthetimeoftheindexprocedure(22,115).Therateofreoperationforsymptomaticimpingementcurrentlycitedinliteraturerangesfrom7%to18%(18,115,116).Inasingle-centerstudyforincidenceofsymptomaticimpingementin489TARs,itwasdeterminedthatincidencedroppedfrom18%to2%ifthepatientsunderwentgutterdebridementatthetimeoftheindexTAR(116).Otherfactorsassociatedwithimpingementincludeimplantmalpositionorsubsidence,persistentmalalignment,overstuffingoftheanklejoint,heterotopicossification,andshiftingofthepolyethyleneinsert(116).Gutterimpingementistypicallytreatedwithopenorarthroscopicgutterdebridement,however,symptomaticimpingementduetoimplantmalposition,subsidence,orpersistentmalalignmentmayrequirefurthersurgicalintervention,includingpolyethyleneexchange,revisionofthemetalliccomponents,ordeformitycorrection.AsepticlooseningandsubsidencecontinuetobethemostcommoncausesofimplantfailureinTAR(93,101,117),thoughtheincidenceoflooseningand/orsubsidencevariesintheliterature.Implantlooseningandsubsidencecanbeattributedtoseveralfactors:progressiveosteolysis,poorbonequality,poorinitialfixation,implantmalposition,andincreasedcontactpressure(118-120).Additionally,biomechanicalmodelsofimplantfixationdemonstratedthatimplantdesignmayaffectimplant-bonemicromotionandsubsequentosseousintegration(121),thoughfurtherstudiesarewarrantedtoinvestigatethisassociationacrossimplanttypes.Symptomaticasepticlooseningand/orsubsidencetypicallyistreatedwithrevisionofthetibialand/ortalarcomponentifsufficientbonestockisavailable.Otherwise,ifrevisionisnotfeasible—duetoinsufficientbonestock,severecomponentsubsidence,orinsufficientsofttissueenvelope—arthrodesisisaviablealternative.Radiographicabnormalities,suchaslucenciesandperi-prostheticcysts,arecommonfindingsinpostoperativeradiographs.Thedevelopmentofradiographiclucenciesandosteolyticcystshasbeenassociatedwithseveralpotentialfactors,includingimplantmicromotion,implantpositioning,synovialfluidpressure,andimmunologicresponseinstigatedbypolyethyleneinsertwearorbybonynecrosis(122-125).Thoughtheassociationofmanyofthesefactorswithosteolysishasbeenwelldescribedinhipandkneeliterature(123,125,126).furtherclinicalstudiesarenecessarytolinktoTARs.Althoughperi-implantlucencycanbeobservedinaround30%ofanklesfollowingTAR,lucencydoesnotalwaysrequiresurgicalintervention(127,128).Radiolucenciesinpostoperativeradiographsshouldbemonitoredforprogressionandcorrelatedtoclinicalassessmenttodetermineifsurgicalinterventioniswarranted(124,125).Peri-prostheticcystsarelesscommonthanradiolucencies,butprevalentnonetheless.Peri-prostheticcystsaretypicallyevaluatedwiththoroughclinicalexaminationandradiographicimagingtoassesssymptoms,cystsizeandlocation,progression,andimminentthreattoimplantintegrity;patientswithassociatedpainshouldalsobeworkedupforinfection(129,130).Incidencesofcystswithsignificantprogressionorsymptomsofpaincanbetreatedwithcurettageandbonegrafting,orwithrevisionTARorarthrodesisincasesofseverebonelossorimplantsubsidence(129).Theinterventionofsymptomaticperi-prostheticcystswithcurettageandgraftinghasdemonstratedasuccessrateof90%(131).Theoptimaltreatmentforperi-prostheticcystsandradiolucencies,however,hasyettobedetermined;interventionoptionsarestronglydependentuponpatientsymptoms,cystorradiolucencysizeandlocation,andintegrityofimplantandsurroundingbonestock.?FutureWiththemountingpopularityofTARoverthepastdecade,thereisconsiderableinteresttocontinuetoinnovate,refine,andimprove.TheevolutionofTARoverits50yearsofexistencehasprovidedtremendousinsightforimplantdesign,surgicaltechniqueandplanning,andoverallimprovementsofoutcomes.ThoughthemostrecentfourthgenerationofTARimplantshavesucceededinoptimizingclinical,radiographic,andfunctionaloutcomes,therestillexistsareasoffurtherdevelopmentinTAR.隨著TAR在過去十年中越來越受歡迎，人們對繼續(xù)創(chuàng)新、改進(jìn)和改進(jìn)產(chǎn)生了相當(dāng)大的興趣。TAR在其50多年的發(fā)展歷程中，為植入物設(shè)計(jì)、手術(shù)技術(shù)和計(jì)劃以及整體預(yù)后的改善提供了巨大的見解。盡管最近的第四代TAR植入物已經(jīng)成功地優(yōu)化了臨床、放射學(xué)和功能結(jié)果，但TAR仍有進(jìn)一步發(fā)展的領(lǐng)域。WhiledemandforTARhasincreasedacrosstheUnitedStates,thenumberofsurgeonswhoregularlyperformTARproceduresisfairlylimited(85,86).TARisassociatedwithasteeplearningcurvethatinfluencesoutcomes,aswellassurgicaltimeandriskofintraoperativefracture(132).Thisbarrierhasledtothedevelopmentofpatient-specificinstrumentation(PSI)toassistinminimizingthelearningcurveandimprovingoutcomesforna?veTARsurgeons.ResultsofPSIusageinTARhavedemonstratedreducedoperativetime,accuratepresurgicalplans,andaccuratejointalignment(133-135).Recently,twoadditionalimplantshaveintroducedtheirownPSIsystems,suggestingthatPSImaybecomeanestablishedtoolforanklereplacementsurgeons.However,therearestillsomelimitationsthatprevailinthecurrentPSItechnology,includinginaccuraciesintibialsizingandlimitationsinpresurgicalplanningforcaseswithseveredeformity.AlthoughthepaucityofcurrentliteratureassessingPSIinTARmakesitdifficulttodrawfiniteconclusions,initialevidencedemonstratespromisingresultsforPSIasareliableandaccuratetoolforTAR.雖然美國各地對TAR的需求有所增加，但定期進(jìn)行TAR手術(shù)的外科醫(yī)生數(shù)量相當(dāng)有限(85,86)。TAR與陡峭的學(xué)習(xí)曲線相關(guān)，影響預(yù)后、手術(shù)時(shí)間和術(shù)中骨折風(fēng)險(xiǎn)(132)。這一障礙導(dǎo)致了患者特異性器械(PSI)的發(fā)展，以幫助na?veTAR外科醫(yī)生最大限度地減少學(xué)習(xí)曲線并改善結(jié)果。在TAR中使用PSI的結(jié)果顯示減少了手術(shù)時(shí)間，準(zhǔn)確的術(shù)前計(jì)劃和準(zhǔn)確的關(guān)節(jié)對齊(133-135)。最近，又有兩個(gè)植入物引入了自己的PSI系統(tǒng)，這表明PSI可能成為踝關(guān)節(jié)置換手術(shù)的一種成熟工具。然而，目前的PSI技術(shù)仍然存在一些局限性，包括脛骨尺寸的不準(zhǔn)確性和嚴(yán)重畸形病例的術(shù)前計(jì)劃的局限性。雖然目前評(píng)估TAR中PSI的文獻(xiàn)很少，因此很難得出有限的結(jié)論，但初步證據(jù)表明PSI作為TAR可靠和準(zhǔn)確的工具有希望的結(jié)果。SuccessfuloutcomesachievedinTARhaspromptedinterestinexpandedanatomy-replicatingimplants,suchaswiththetotaltalusreplacement(TTR).TTRwasdesignedasanalternativetreatmentoptionforpatientswithseveretalarAVN,talardomecollapse,orsignificantlossoftalarbonestock,whenusedinadjunctwithtotalanklearthroplasty(TAA)(136).Althoughthefirstreportofasynthetictalarprosthesiswasperformedin1997,foraseriesof16patientswithAVN,significantattentiontowardsTTRonlyrecentlydevelopedinthepasttenyearsinparalleltothegrowingprevalenceofthree-dimensional(3D)printing(137).CurrentliteraturereportingTTRoutcomesisscarce,typicallylimitedtocasereportsandanecdotalfindings,whichmakesitdifficulttodeterminethefeasibilityorrelativesuccessoftheprocedure.Inameta-analysisofoutcomesin196TTRankles,resultsreportedarelativelylowincidenceofrevisions(10ankles),improvementindorsiflexion,andimprovedpatient-reportedoutcomesatfour-yearfollow-up(138).However,thereareseveralchallengesthatimpactthefeasibilityofTTR,includingthedevelopmentofadjacentjointarthritis,prosthesisinstability,andPJI(136,139).Moreover,followingTTRfailure,salvageoptionsarelimitedandtechnicallydemanding.Duetotheshort-termfollow-upandsmallsamplesizesfeaturedinTTRliterature,definitiveconclusionsonsurvivorship,outcomes,andcomplicationsinthelongtermareimpossible.Currently,TTRshowspromiseasatreatmentoptionforpatientswithseveretalarpathology,butfurtherstudieswithadequatefollow-uparenecessarytovalidatecurrentfindings.TAR取得的成功結(jié)果引起了人們對擴(kuò)展解剖復(fù)制植入物的興趣，例如全距骨置換術(shù)(TTR)。TTR被設(shè)計(jì)為嚴(yán)重距骨AVN、距骨圓頂塌陷或距骨缺損患者的替代治療選擇，當(dāng)與全踝關(guān)節(jié)置換術(shù)(TAA)聯(lián)合使用時(shí)(136)。雖然合成距骨假體的第一個(gè)報(bào)道是在1997年，針對一系列16例AVN患者，但在過去的十年里，隨著三維(3D)打印的日益普及，對TTR的關(guān)注最近才開始出現(xiàn)(137)。目前報(bào)道TTR結(jié)果的文獻(xiàn)很少，通常僅限于病例報(bào)告和軼事發(fā)現(xiàn)，這使得很難確定該手術(shù)的可行性或相對成功。在一項(xiàng)對196個(gè)TTR踝關(guān)節(jié)結(jié)果的薈萃分析中，結(jié)果報(bào)告了相對較低的修復(fù)發(fā)生率(10個(gè)踝關(guān)節(jié))，背屈改善，以及四年隨訪中患者報(bào)告的改善結(jié)果(138)。然而，存在一些影響TTR可行性的挑戰(zhàn)，包括鄰近關(guān)節(jié)關(guān)節(jié)炎的發(fā)展、假體不穩(wěn)定和PJI(136139)。此外，在TTR失敗后，救助選擇有限且技術(shù)要求高。由于TTR文獻(xiàn)的隨訪時(shí)間較短，樣本量小，因此無法對長期的生存率、結(jié)局和并發(fā)癥得出明確的結(jié)論。目前，TTR有望作為嚴(yán)重距骨病變患者的治療選擇，但需要進(jìn)一步的研究和充分的隨訪來驗(yàn)證當(dāng)前的發(fā)現(xiàn)。?ConclusionsTARhasundergonemarkedinnovationinthepast50years,andhascontinuedtogrowinpopularityinthepastdecade.ThethirdandfourthgenerationsofTARimplantscurrentlycirculatingthemarkethaveimplementedimprovementsinbonefixation,mechanicalalignment,andsofttissuebalancethathavecontributedtoincreasesinsurvivorship,functionaloutcomes,andpainresolution.ThecontinualrefinementofprosthesisdesignandsurgicaltechniquehaveallowedindicationsforTARtoexpand,andcomplicationsassociatedwiththeproceduretodecrease.CurrentoutcomesforTARdemonstrateitsmeritasaviablealternativetreatmentoptiontoanklearthrodesisinthesettingofend-stageankleosteoarthritis.FutureinnovationinthefieldofTARlookstoexpandupontheimplementationofPSIandrevisionTARsystemstofurtherimproveoutcomesandguidesurgicalapproach.TAR在過去50年中經(jīng)歷了顯著的創(chuàng)新，并在過去十年中繼續(xù)普及。目前市場上流通的第三代和第四代TAR植入物在骨固定、機(jī)械對準(zhǔn)和軟組織平衡方面進(jìn)行了改進(jìn)，有助于提高生存率、功能預(yù)后和疼痛緩解。假體設(shè)計(jì)和手術(shù)技術(shù)的不斷改進(jìn)使得TAR的適應(yīng)癥得以擴(kuò)大，與手術(shù)相關(guān)的并發(fā)癥得以減少。目前的結(jié)果表明，在終末期踝關(guān)節(jié)骨關(guān)節(jié)炎的治療中，TAR作為踝關(guān)節(jié)融合術(shù)的一種可行的替代治療方案。TAR領(lǐng)域的未來創(chuàng)新將在PSI實(shí)施和TAR系統(tǒng)修訂的基礎(chǔ)上進(jìn)行擴(kuò)展，以進(jìn)一步改善結(jié)果并指導(dǎo)手術(shù)方法。

全膝關(guān)節(jié)置換治療膝關(guān)節(jié)外翻畸形大于90度(2019)Totalkneearthroplastyforavalgusdeformityangleof>90degrees:Acasereport?GuoJ,CaoG,ZhangY,SongW,QinS,MaT,WangY,YangW.Totalkneearthroplastyforavalgusdeformityangleof>90degrees:Acasereport[J].Medicine(Baltimore),2019,98(23):e15745.轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/31169673/轉(zhuǎn)載文章的原鏈接2：https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6571272/?AbstractRationale:Valguskneesarerelativelyrareintheclinic.Treatmentsforvalgusdeviations>90°representasurgicalchallengetoachieveabalancebetweenthesofttissueandboneandpreventnervedamage.膝外翻在臨床上比較少見。外翻偏差>90°的治療是實(shí)現(xiàn)軟組織和骨骼之間平衡并防止神經(jīng)損傷的外科挑戰(zhàn)。?Patientconcerns:A63-year-oldwomanwithvalgusdeviations>90°inbothkneescomplainedthatshehadbeenunabletowalkfor50years.一名63歲女性，雙膝外翻>90°，自訴已不能行走50年。?Diagnoses:Congenitalmalformationvalgusdeformity.先天性外翻畸形?Interventions:Bilateraltotalkneearthroplasty(TKA)wasperformedusingarotatinghingekneeinstrumentfromEndo-Modelforaxialcorrectionandstabilizationofthejoint.雙側(cè)全膝關(guān)節(jié)置換術(shù)(TKA)采用Endo-Model的旋轉(zhuǎn)鉸鏈膝關(guān)節(jié)器械進(jìn)行軸向矯正和關(guān)節(jié)穩(wěn)定。?Outcomes:Thepatientfullyrecovered3monthsaftersurgery.Atthefollow-up6yearsaftertheoperation,thefunctionofthekneejointclearlyimproved.Thekneesocietyscore(KSS)increasedfrom35to90.術(shù)后3個(gè)月患者完全康復(fù)。術(shù)后隨訪6年，膝關(guān)節(jié)功能明顯改善。膝關(guān)節(jié)協(xié)會(huì)評(píng)分(KSS)由35分上升至90分。?Lessons:Constrainedimplantsarecommonlyusedtostabilizethejointandcorrecttheboneaxisinpatientswithsevereligamentalinstability,grossdeformity,boneloss,andextremedeviationofthestraightlegaxis.Intraoperativeexplorationofthecommonperonealnerveandthepostoperativeflexedpositionofthekneejointscouldhelppreventnerveinjuries.對于嚴(yán)重韌帶不穩(wěn)、嚴(yán)重畸形、骨質(zhì)缺失和直腿軸極度偏離的患者，限制性假體通常用于穩(wěn)定關(guān)節(jié)和矯正骨軸。術(shù)中探查腓總神經(jīng)及術(shù)后膝關(guān)節(jié)屈曲位置有助于預(yù)防神經(jīng)損傷。?Keywords:totalkneearthroplasty,valgusdeformity,hingeknee?1.IntroductionTotalkneearthroplasty(TKA)isusedtotreatkneevalgusdeformity,andapproximately10%ofallpatientswhorequireTKApresentwithvalgusdeformity.[1,2]AccordingtotheKeblishclassification,thefemorotibialangle(FTA)canbemeasuredonthex-rayimageofthevalgusdeformity;amildangleis<15°,amoderatedegreeis15°to30°,andaseveredeformityisanangle>30°.[3]Becauseofthedifferenttensionsofsofttissueandbonedefects,differentprosthesescanbeselected.Formilddeformitiesandsomemoderateandseverekneevalgusdeformities,wecanfirstreleasethelateralcollateralligamentthroughtenolysisofthesofttissuethenreleasetheposterolateralarticularcapsule,theiliotibialbandandthelateralheadofthegastrocnemius,bicepstendon,andpoplitealtendontissue.Thus,soft-tissuebalancecanbeobtained.Formoderateandsomeseverevalguskneedeformities,posteriorcruciate-retainingtotalkneeprostheses,constrainedcondylarkneeprostheses,orvarus-valgusconstrainedimplantscanbeusedtoobtainagoodresult.[4]Someofthemoreseverevalguskneedeformitieswithbonedefectsneedtobefixedwithanextensionrodandtheplacementofaspacerblocktoachievebalanceandstability.However,forsomepatientswithseveredeformitiesofthevalgusknee,surfaceprostheseswithsofttissuereleaseareunabletoachievebalanceandstability.Thesecasesoftenrequiretheuseofahingekneeprosthesistosolvetheproblem.Hingekneeprostheseswithgoodcoronalstabilitycanstablyreplacesoft-tissuebalance,butcomplicationsofloosenesscanoccur,whicharemainlyduetosagittalalignmentbecausethesagittalplaneoutputsahighamountofpower;thispulleventuallyleadstoprosthesisloosening.[5–7]Nonetheless,thelooseningrateoftheEndo-Modelhingeprosthesisreportedinthepreviouslypublishedliteratureislow.[8–11][3]KeblishPA.Thelateralapproachtothevalgusknee.Surgicaltechniqueandanalysisof53caseswithovertwo-yearfollow-upevaluation.ClinOrthopRelatRes1991;271:52–62.全膝關(guān)節(jié)置換術(shù)(TKA)用于治療膝關(guān)節(jié)外翻畸形，大約10%需要全膝關(guān)節(jié)置換術(shù)的患者存在外翻畸形[1,2]。根據(jù)Keblish分類，可以在外翻畸形的X線圖像上測量股脛角(FTA);輕度畸形為<15°，中度畸形為15°至30°，重度畸形為>30°[3]。由于軟組織張力和骨缺損的不同，可以選擇不同的修復(fù)體。對于輕度畸形和部分中重度膝外翻畸形，可先通過軟組織松解術(shù)松解外側(cè)副韌帶，然后松解后外側(cè)關(guān)節(jié)囊、髂脛束和腓腸肌外側(cè)頭、二頭肌肌腱、腘肌腱組織。因此，可以獲得軟組織平衡。對于中度及部分重度外翻膝關(guān)節(jié)畸形，可采用后交叉韌帶保留假體的全膝關(guān)節(jié)假體、限制性髁膝關(guān)節(jié)假體或內(nèi)外翻限制性假體，均可獲得較好的效果[4]。一些更嚴(yán)重的外翻膝關(guān)節(jié)畸形伴骨缺損需要用延伸棒和放置間隔塊來固定，以達(dá)到平衡和穩(wěn)定。然而，對于一些外翻膝關(guān)節(jié)嚴(yán)重畸形的患者，具有軟組織松解的表面假體無法達(dá)到平衡和穩(wěn)定。這些病例通常需要使用鉸鏈膝關(guān)節(jié)假體來解決問題。具有良好冠狀面穩(wěn)定性的鉸鏈?zhǔn)较リP(guān)節(jié)假體可以穩(wěn)定地替代軟組織平衡，但由于矢狀面輸出功率大，因此可能出現(xiàn)松動(dòng)并發(fā)癥，這主要是由于矢狀面對準(zhǔn)所致;這種拉力最終會(huì)導(dǎo)致假體松動(dòng)[5-7]。然而，先前發(fā)表的文獻(xiàn)報(bào)道的endomodel鉸鏈假體的松動(dòng)率很低[8-11]。Kneevalgusdeformitiescanbecongenitalormayoccursecondarytoconditionssuchasosteoarthrosis,rheumaticdiseases,andposttraumaticarthritis,ortoanovercorrectionfollowingavalgusosteotomy.[4]Valgusdeviations<20°,whichaccountforapproximately95%ofallvalgusknees,arerelativelyeasytocorrectwithsurgery.[2]However,thecorrectionofvalgusdeviations>20°isachallengingundertakingforjointsurgeons.[2,12]Herein,wereportacaseofseverevalgusdeformitywithavalgusdeviation>90°ina63-year-oldwomanwhowassuccessfullytreatedwithTKA.Tothebestofourknowledge,thisisthefirstdocumentedcaseofsuccessfultreatmentofa>90°valgusdeformitywithTKA.Thepatientandherfamilyhaveconsentedtothepublicationofthisarticle.膝外翻畸形可能是先天性的，也可能是由骨關(guān)節(jié)病、風(fēng)濕性疾病和創(chuàng)傷后關(guān)節(jié)炎等繼發(fā)疾病引起的，或者是外翻截骨術(shù)后矯治過度引起的[4]。外翻偏差<20°約占所有外翻膝關(guān)節(jié)的95%，相對容易通過手術(shù)矯正[2]。然而，對于關(guān)節(jié)外科醫(yī)生來說，矯正>20°的外翻是一項(xiàng)具有挑戰(zhàn)性的工作[2,12]。在此，我們報(bào)告一例63歲女性外翻畸形，外翻偏度>90°，經(jīng)TKA成功治療。據(jù)我們所知，這是第一例用TKA成功治療>90°外翻畸形的病例?；颊呒捌浼覍僖淹獍l(fā)表這篇文章。?2.CasereportA63-year-oldwomanpresentedatourhospitalwithcongenitalmalformationvalgusdeformity>90°(Fig.1A,B).Anx-rayofthekneeshowedamalformedfemoralcondyleandtibialplateauwithseverebonedefects(Fig.2).AccordingtotheKeblishclassification,thiscasewasclassifiedasaseveredeformity.[3]Thepatienthasnotbeenabletowalknormallysincetheageof12.Themusclestrengthofthequadricepswaslow.Aphysicalexaminationshowedthatallligamentsaroundthekneewereslack.Throughtheaboveexamination,thepatient'skneesocietyscore(KSS)scorewasassessedtobe35.[13]Thekneeextensionreached90°,andtheflexionreached80°.??Figure1(A,B)Preoperativephotographofthepatientshowingseverekneevalgusdeformity.??Figure2Preoperativex-rayradiograph(nonweight-bearing)showingmalformationsandbonydefectsinthefemoralcondyleandthetibialplateau.??Beforetheoperation,wecreatedathreedimensionalmodelofbothknees,simulatedthepatellatrajectoryandcarefullyexaminedthepatient'ssofttissuetightness.Duetothepresenceofseverebonedefectionandthesevererelaxationofthemedialandlateralsofttissuedevices,theEndo-Modelrotatinghingekneeprosthesiswaschosenforthepatient,andabilateralTKAwasperformed.Thekneejointswereexposedviaamedialparapatellarapproachtoachieveagoodviewbecausewedidneedtoworryaboutsoft-tissuebalance.Thefemoralcondyleswereseverelydeformedwithasmalllateralfemoralcondyleandarelativelylargemedialfemoralcondyle.Tibialextorsion,lateraldislocationofthepatella,andseveredegenerationofarticularsurfacesofthefemur,tibia,andpatellawerealsoobserved.Bonehyperplasiaandsyndesmophyteformationaroundthejointwereobservedalongwiththewornmedialandlateralmenisci.Theanteriorandposteriorcruciateligamentswerealmostinvisible.Afterresectionofthehyperplasticosteophyteandsynovialmembrane,theiliotibialbandwasfirstreleased,thenthelateralretinaculumwasreleased.Subsequently,thelateralligamentwasdirectlyincised.Becausetheligamentsaroundthekneewereslack,theEndo-Modelrotatinghingekneeprosthesiswasused.Basedonthepreoperativex-ray,thefemoralcanalinthemedialfemoralcondylewasselectedastheentrypointfortheintramedullaryguide.Aftertheinternalrotation,externalrotation,alignment,andtautnessofthekneejointweretestedtomeetthephysiologicalrequirements,theGermanyLinkkneeprosthesis(leftknee:tibiasize55?mm/160?mm,femursize55?mm/160?mm,polysize16mm;therightkneeprosthesiswasthesamesizeastheleft)wasinstalled.Fullreleaseofthepatellarlateralretinaculumandstrengtheningofthepatellarmedialretinaculumwereperformedtocorrectthelateralpatellardislocation.Aftersurgery,thekneeswereingoodalignment.Theankleactivitywasnormal.Onedayaftersurgery,thepatientwasunabletodorsiflextheanklejoints.Thenervusperoneuscommuniswassuspectedtohavebeendamagedbytraction.Thepatientreceivedanoralmethylaminedispersibletabletandperformedjointfunctionalexercises.Oneweekaftersurgery,themovementsofthekneejointrangedfrom5°to90°.Thex-rayimageshowedanappropriateprosthesisposition(Fig.3).??Figure3Postoperativex-rayradiographshowingtheimplantedprosthesis.??Theonlypostoperativecomplicationwasaninjurytotheperonealnerve,whichledtolossofdorsiflexionatbothanklejoints.However,thepatientwasabletowalkwiththeuseofwalkingaids.Thepatientwasregularlyfollowedup,andtheanklemotiondeficitwasfoundtobecompletelyrecovered3monthsaftersurgery.Atthefollow-up6yearsaftertheoperation,thekneeextensionreached180°,kneeflexionreached125°,andtheactivejointfunctionclearlyimproved(Fig.4).TheKSShadimprovedto80atthe2-yearfollow-up,87atthe4-yearfollow-up,and90at6-yearfollow-up.??Figure4Postoperativephotographafter18monthsshowingcompleterecoveryofdorsiflexion.??3.DiscussionAprimaryTKAforavalguskneedeformityof>20°representsachallengefororthopedicsurgeons.[12]Herein,wepresentourexperiencewitha63-year-oldwomanwithaseverevalguskneedeformityangle>90°,whichwasclassifiedasaseveredeformity.Duringsurgery,wereleasedthelateralcollateralligamentsofttissuesandexcisedthemedialandlateralmeniscusandtheremainingcruciateligament.Arotatinghingekneeinstrumentwasusedtocorrecttheboneaxisandstabilizethejoint.TheuseofhingedimplantsinprimaryTKAshouldberestrictedtopatientswithseverebonydeformitiesorligamentousinstability,especiallyinelderlypatients.[14]ConstrainedimplantsarefrequentlyusedforprimaryTKAinpatientswithmoderateandseveregenuvalgum(>10°).[15]ConstrainedTKAiscommonlyperformedtostabilizethejointandcorrecttheboneaxisinpatientswithsevereligamentalinstability,grossdeformity,boneloss,andextremedeviationofthestraightlegaxis.Inthepresentcase,arotatinghingekneeprosthesiswasselected.外翻膝畸形>20°的原發(fā)性全膝關(guān)節(jié)置換術(shù)對骨科醫(yī)生來說是一個(gè)挑戰(zhàn)[12]。在此，我們報(bào)告了一位63歲女性的經(jīng)驗(yàn)，她的膝關(guān)節(jié)嚴(yán)重外翻畸形角度>90°，被歸類為嚴(yán)重畸形。在手術(shù)中，我們松解了外側(cè)副韌帶軟組織，切除了內(nèi)側(cè)和外側(cè)半月板以及剩余的交叉韌帶。使用旋轉(zhuǎn)鉸鏈膝關(guān)節(jié)器械矯正骨軸并穩(wěn)定關(guān)節(jié)。在原發(fā)性全膝關(guān)節(jié)置換術(shù)中使用鉸鏈?zhǔn)街踩胛飸?yīng)僅限于嚴(yán)重骨畸形或韌帶不穩(wěn)定的患者，尤其是老年患者[14]。限制性假體常用于中度和重度膝外翻（>10°）患者的初次TKA[15]。對于嚴(yán)重韌帶不穩(wěn)、嚴(yán)重畸形、骨質(zhì)流失和直腿軸極度偏離的患者，通常采用限制性TKA來穩(wěn)定關(guān)節(jié)和矯正骨軸。在本病例中，選擇了旋轉(zhuǎn)鉸鏈膝關(guān)節(jié)假體。AmedialorlateralparapatellarapproachcanbeusedtoperformTKAforvalguskneedeformities.Thelateralpatellarincisioniscommonlyusedinmild-to-moderatevalguskneedeformitiestosimplyreleasethelateralstructure.Giventhepositionofthepatellainthepresentcase,thelateralparapatellarapproachwasnotsuitabletogainadequateexposureofthekneejoint;thus,themedialparapatellarapproachwasused.InjurytotheperonealnerveisacommoncomplicationofTKA.TheperonealnerveinjuryiscommonwhenTKAisperformedtocorrectvalguskneedeformities,withanincidenceof2%to3%.[16–19]Weshouldpaymoreattentiontothetensioninthenerve,whichcouldbealleviatedbycuttingoffthefibularhead,ifnecessaryinosteotomy.Postoperatively,thekneeswereplacedin10°offlexionfor3to4daystopreventstretchingoftheperonealnerve,andactiveandpassiverange-of-motionexercises(rangefrom10°to70°)wereallowed.[20]Inthepresentcase,basedonthepreoperativeevaluationofthesurgicalprocedure,webelievedthattheperonealnervewouldnotbetransected,andthuswedidnotexposetheperonealnerveduringtheoperation.However,postoperatively,thepatientwasunabletodorsiflextheankle.Tractioninjurytothecommonperonealnervemayresultinthelossofanklefunction.Atractioninjurytothecommonperonealnervewaslikelycausedbystraighteningtheknees.Thiscomplicationcouldhavebeenavoidedbypositioningofthekneesinaflexedpositionaftersurgeryandthengraduallystraighteningthekneesbackout.Fortunately,thepatientfullyrecovered3monthsaftersurgery.內(nèi)側(cè)或外側(cè)髕旁入路可用于外翻膝關(guān)節(jié)畸形的全膝關(guān)節(jié)置換術(shù)。髕骨外側(cè)切口通常用于輕度至中度膝外翻畸形，以簡單地松解外側(cè)結(jié)構(gòu)?？紤]到本病例中髕骨的位置，外側(cè)髕旁入路不適合獲得足夠的膝關(guān)節(jié)暴露;因此，我們采用內(nèi)側(cè)髕旁入路。腓神經(jīng)損傷是TKA的常見并發(fā)癥。在TKA矯正外翻膝關(guān)節(jié)畸形時(shí)，腓神經(jīng)損傷是常見的，發(fā)生率為2%~3%[16-19]。應(yīng)注意神經(jīng)緊張，必要時(shí)截骨可切除腓骨頭緩解神經(jīng)緊張。術(shù)后，膝關(guān)節(jié)屈曲10°3-4天，以防止腓神經(jīng)拉伸，并允許主動(dòng)和被動(dòng)活動(dòng)范圍（10°至70°范圍）鍛煉[20]。在本病例中，基于術(shù)前對手術(shù)方法的評(píng)估，我們認(rèn)為腓神經(jīng)不會(huì)被橫斷，因此我們在手術(shù)中沒有暴露腓神經(jīng)。然而，術(shù)后患者無法踝關(guān)節(jié)背屈。牽引損傷腓總神經(jīng)可導(dǎo)致踝關(guān)節(jié)功能喪失。牽拉傷腓骨總神經(jīng)可能是伸直膝蓋引起的。這種并發(fā)癥可以通過手術(shù)后將膝關(guān)節(jié)置于彎曲位置，然后逐漸將膝關(guān)節(jié)拉直來避免。幸運(yùn)的是，患者在手術(shù)后3個(gè)月完全康復(fù)。Patellardislocationorsubluxationisacommonfindinginvalgusknees.Patellardislocationassociatedwithcongenitaldisordersappearstobeclassifiableintothefollowing3types:conditionsduetosofttissuelaxityandincreasedjointlaxity;conditionsduetopatellarhypoplasiaandskeletaldysplasiaofthefemurandtibia;andconditionsduetosofttissuefibrosisandcontracture.[21]Anabnormalpatellartrajectoryinthemild-to-moderatevalguskneecanbecorrectedafterkneearthroplasty.[22]Inseverevalgusconditions,thelateralpatellarretinaculum,popliteustendon,andthelateralportionofthegastrocnemiusmayrequiredetachmenttorestoretheanatomicalaxisofthelimb.Ananteromedialtibialtubercletransfermaybeperformedtocorrectpatellardislocation.Inthepresentcase,wecorrectedthesevereabnormalpatellartrajectoryandtibialinternalrotationbyreleasingthepatellarlateralsurface,vastuslateralis,andtheintramusculargapoftherectusfemoris.AZ-shapedreleaseofthebicepsfemoriswasalsoperformed.Sincethepatellartrajectorywasstillnotcompletelycorrected,wesubsequentlyreleasedthelateralcollateralligamentbycreatingmultipleneedlepunctures,incisingthevastuslateralis,andextendingitbymalposed-suturetocompletelycorrectthepatellatrajectory.髕骨脫位或半脫位是外翻膝的常見表現(xiàn)。與先天性疾病相關(guān)的髕骨脫位似乎可分為以下3種類型:由于軟組織松弛和關(guān)節(jié)松弛增加引起的情況;髕骨發(fā)育不全，股骨和脛骨骨骼發(fā)育不良;以及軟組織纖維化和攣縮引起的疾病[21]。輕度至中度外翻膝關(guān)節(jié)的異常髕骨軌跡可以在膝關(guān)節(jié)置換術(shù)后得到糾正[22]。在嚴(yán)重外翻的情況下，髕骨外側(cè)支持帶、腘肌肌腱和腓腸肌外側(cè)部分可能需要脫離以恢復(fù)肢體的解剖軸。脛骨前內(nèi)側(cè)結(jié)節(jié)轉(zhuǎn)移可用于矯正髕骨脫位。在本病例中，我們通過松解髕骨外側(cè)面、股外側(cè)肌和股直肌肌內(nèi)間隙來糾正嚴(yán)重的異常髕骨軌跡和脛骨內(nèi)旋。同時(shí)進(jìn)行股二頭肌Z形松解術(shù)。由于髕骨軌跡仍未完全矯正，我們隨后通過多次穿刺從而松解外側(cè)副韌帶，切開股外側(cè)肌，并通過錯(cuò)位縫合延長，以完全矯正髕骨軌跡。Insummary,inthisrarecase,wesuccessfullyperformedTKAusingarotatinghingekneeinstrumentforthetreatmentofavalgusdeformityangle>90°associatedwithseverebonydefectsinthefemurandtibia.Thepatellardislocationwascorrectedwithouttheuseofanteromedialtibialtubercletransfer.Postoperatively,thepatientexperiencedbilaterallossofankledorsiflexionduetoatractioninjurytothecommonperonealnerve,which,however,wascompletelyrecoveredin3months.Intraoperativeexplorationofthecommonperonealnerveandpostoperativeflexedpositioningofthekneejointscouldhelppreventnerveinjuries.However,sincethehingeprosthesiswashighlyrestricted,thelifetimeoftheprosthesisisacauseofconcern.Westillneedtoconductlong-termfollow-upsofthepatient.總之，在這個(gè)罕見的病例中，我們成功地使用旋轉(zhuǎn)鉸鏈膝關(guān)節(jié)器械進(jìn)行了TKA，治療了角度>90°的外翻畸形，并伴有股骨和脛骨的嚴(yán)重骨缺損。髕骨脫位不采用脛骨前內(nèi)側(cè)結(jié)節(jié)轉(zhuǎn)移。術(shù)后，由于腓總神經(jīng)牽拉損傷，患者雙側(cè)踝關(guān)節(jié)背屈喪失，但在3個(gè)月內(nèi)完全恢復(fù)。術(shù)中探查腓總神經(jīng)和術(shù)后膝關(guān)節(jié)屈曲定位有助于預(yù)防神經(jīng)損傷。然而，由于鉸鏈假體受到高度限制，假體的使用壽命是一個(gè)值得關(guān)注的問題。我們還需要對患者進(jìn)行長期隨訪。

全膝關(guān)節(jié)置換治療膝關(guān)節(jié)夏科氏關(guān)節(jié)病的中長期療效（2024）Mid-toLong-TermResultsofTotalKneeArthroplastyforCharcotArthropathyoftheKnee?OnoiY,MatsumotoT,NakanoN,TsubosakaM,KamenagaT,KurodaY,IshidaK,HayashiS,KurodaR.Mid-toLong-TermResultsofTotalKneeArthroplastyforCharcotArthropathyof?theKnee[J].IndianJOrthop,2024,58(3):308-315.?轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/38425826/?轉(zhuǎn)載文章的原鏈接2：https://link.springer.com/article/10.1007/s43465-023-01094-z?AbstractBackground:Totalkneearthroplasty(TKA)forCharcotarthropathyofthekneeisconsideredcontroversialbecauseofitshighercomplicationratecomparedwiththatofTKAforosteoarthritis.Inthisstudy,weinvestigatedtheclinicaloutcomes,survivalrates,andcomplicationsofprimaryTKAforCharcotarthropathy.全膝關(guān)節(jié)置換術(shù)(TKA)治療膝關(guān)節(jié)Charcot關(guān)節(jié)病被認(rèn)為是有爭議的，因?yàn)榕c骨關(guān)節(jié)炎的TKA相比，其并發(fā)癥發(fā)生率更高。在這項(xiàng)研究中，我們調(diào)查了初次TKA治療Charcot關(guān)節(jié)病的臨床結(jié)果、生存率和并發(fā)癥。?Methods:Weconductedaretrospectiveanalysisofninepatients(12knees)withCharcotarthropathywhounderwentTKA.Themeanageofthepatientswas63.9±9.4years(range,52-83years).Themostfrequentcausativediseasewasdiabetesmellitus(threepatients).Patients'clinicaloutcomes,includingthe2011KneeSocietyScoreandtherangeofmotion,werecomparedbetweenpreoperativeandthemostrecentpostoperativedata.The5-and10-yearsurvivalratesforasepticrevision,revisionduetoinfection,andcomplicationswereexamined.Themeanfollow-upperiodwas7.3±3.9years(range,3-14years).我們對9例Charcot關(guān)節(jié)病患者(12個(gè)膝關(guān)節(jié))進(jìn)行了全膝關(guān)節(jié)置換術(shù)的回顧性分析?；颊咂骄挲g為63.9±9.4歲(52~83歲)。最常見的病因是糖尿病(3例)?；颊叩呐R床結(jié)果，包括2011年膝關(guān)節(jié)社會(huì)評(píng)分和活動(dòng)范圍，在術(shù)前和術(shù)后的最新數(shù)據(jù)之間進(jìn)行比較。檢查無菌翻修、感染翻修和并發(fā)癥翻修的5年和10年生存率。平均隨訪時(shí)間7.3±3.9年(范圍3~14年)。?Results:The2011KneeSocietyScoreandthekneeflexionanglesignificantlyimprovedafterTKAsurgery(P<0.05).The5-yearsurvivalratesforasepticrevision,revisionduetoinfection,andcomplicationswere100%,91.7%,and83.3%,respectively;the10-yearsurvivalratesfortheseparameterswerethesame.Onepatientunderwentrevisionforinsertreplacementduetoperiprostheticinfection,andtheotherpatienthadvarus/valgusinstabilityduetosofttissueloosening.TKA術(shù)后膝關(guān)節(jié)社會(huì)評(píng)分和膝關(guān)節(jié)屈曲角度均顯著提高(P<0.05)。無菌翻修、感染翻修和并發(fā)癥翻修的5年生存率分別為100%、91.7%和83.3%;這些參數(shù)的10年生存率是相同的。一名患者因假體周圍感染接受假體置換翻修，另一名患者因軟組織松動(dòng)出現(xiàn)內(nèi)翻/外翻不穩(wěn)定。?Conclusions:Themid-tolong-termresultsofTKAforCharcotarthropathyweregenerallyfavorable.OurfindingsindicatethatTKAmaybeaviabletreatmentoptionforCharcotarthropathy.TKA治療Charcot關(guān)節(jié)病的中長期結(jié)果通常是有利的。我們的研究結(jié)果表明TKA可能是治療Charcot關(guān)節(jié)病的可行選擇。?Keywords:Charcotarthropathy;Constrainedcondylarprosthesis;Neuropathicarthropathy;Rotatinghingeprosthesis;Survivalrates;Totalkneearthroplasty.?IntroductionCharcotarthropathyisadegenerativeneuropathicarthropathythatleadstoseverejointdestructionandinstability,causedbyrepetitiveasymptomaticmicrotraumaduetodecreasedorabsentjointnociception[1].Theglobalincreaseintheincidenceofdiabetesmellitus(DM),themaincausativediseaseofCharcotarthropathy,isexpectedtoleadtoahigherprevalenceofCharcotarthropathy[2,3].BecauseofthenatureofCharcotarthropathy,patientsrarelycomplainofpainduringtheearlydeformitystagesandtypicallyseektreatmentonlyafterseveredeformity,instability,andgaitdisturbancehaveoccurred[4].ThismakesCharcotarthropathyoneofthemostdifficultconditionsfororthopaedicsurgeonstotreat.Charcot關(guān)節(jié)病是一種退行性神經(jīng)性關(guān)節(jié)病，可導(dǎo)致嚴(yán)重的關(guān)節(jié)破壞和不穩(wěn)定，由關(guān)節(jié)痛覺減少或缺失引起的重復(fù)性無癥狀微創(chuàng)傷引起[1]。糖尿病(DM)是Charcot關(guān)節(jié)病的主要致病疾病，隨著全球糖尿病發(fā)病率的增加，預(yù)計(jì)將導(dǎo)致Charcot關(guān)節(jié)病的患病率升高[2,3]。由于Charcot關(guān)節(jié)病的性質(zhì)，患者在早期畸形階段很少主訴疼痛，通常只有在發(fā)生嚴(yán)重畸形、不穩(wěn)定和步態(tài)障礙后才尋求治療[4]。這使得Charcot關(guān)節(jié)病成為骨科醫(yī)生最難治療的疾病之一。Althoughtotalkneearthroplasty(TKA)forCharcotarthropathywaspreviouslynotrecommendedbecauseofitshighrateofcomplications,suchasperiprostheticinfection,fracture,anddislocation[5,6],severalrecentstudieshaveshowngoodshort-termclinicaloutcomeswithTKA[2,7].However,thereislimitedliteratureonthemid-tolong-termresultsofTKAforCharcotarthropathy[8,9],andimportantquestionsregardingsurvivalrates,potentialcomplications,andclinicaloutcomesofTKAremainunresolved.ThislackofinformationmaypreventpropermanagementofCharcotarthropathy.Therefore,weaimedtoreportthemid-tolong-termresultsofprimaryTKAforpatientswithCharcotarthropathy.盡管全膝關(guān)節(jié)置換術(shù)(TKA)治療Charcot關(guān)節(jié)病之前不被推薦，因?yàn)槠洳l(fā)癥發(fā)生率高，如假體周圍感染、骨折和脫位[5,6]，但最近的幾項(xiàng)研究表明，TKA的短期臨床效果良好[2,7]。然而，關(guān)于TKA治療Charcot關(guān)節(jié)病的中長期結(jié)果的文獻(xiàn)有限[8,9]，TKA的生存率、潛在并發(fā)癥和臨床結(jié)果等重要問題仍未解決。這種信息的缺乏可能會(huì)妨礙對Charcot關(guān)節(jié)病的適當(dāng)治療。因此，我們的目的是報(bào)道原發(fā)性全膝關(guān)節(jié)置換術(shù)治療Charcot關(guān)節(jié)病患者的中長期結(jié)果。MaterialsandMethodsPatientsThestudywasapprovedbytheInstitutionalReviewBoardofourinstitution(PermissionNo;1510),andwritteninformedconsentwasobtainedfromthepatients.Weconductedaretrospectiveanalysisof11consecutivepatientswithCharcotarthropathyofthekneewhounderwentprimaryTKAatourinstitutionbetweenAugust2008andMarch2020.TwopatientswereexcludedfromthestudybecausetheydiedwithinoneyearforreasonsunrelatedtoTKA.Theremainingninepatients(12knees),consistingoffourmenandfivewomenwithameanageof63.9?±?9.4years(range,52–83years)atthetimeofTKA,wereenrolledinthestudy.NoneofthepatientshadundergonearthroscopicdebridementorotherkneesurgeriespriortotheTKAs.PriortoTKA,threepatientshadipsilateralanklejointfracturesandunderwentopenreductionandinternalfixation.TheCharcotarthropathy-causativeneuropathywasdiagnosedbyneurologistsusingnerveconductionstudies,electromyography,andclinicalevaluations.Orthopaedicsurgeonsverifiedthediagnosesbyphysicalexaminationandradiographicstudies,revealingfeaturescharacteristicofCharcotarthropathy,includingseveredeformity,instability,andrestrictedrangeofmotion.Theninepatientsincludedinthestudyhadavarietyofcausativediseases.Ofthese,DMwasthemostcommon(threepatients),withameanHbA1cof5.9?±?0.2%(range,5.6–6.1%).Twopatientshadneurosyphilis,onehadCharcot-Marie-Toothdisease,onehadGuillain–Barresyndrome,onehadcervicalossificationoftheposteriorlongitudinalligament,andonehadmeningealaneurysm(Table1).Noneofthepatientswerelosttofollow-up,andthemeanfollow-upperiodwas7.3?±?3.9years(range,3–14years).??Table1Patients’characteristics??OperativeProceduresAllsurgerieswereperformedbyseniorsurgeonswith>?15yearsofexperienceinTKAprocedures.Allpatientsreceivedgeneralanesthesiaandfemoral/sciaticnerveblockwith0.75%ropivacaine(40mL).Afterinflatingtheairtourniquetto250mmHg,thekneeswereexposedbymedialparapatellararthrotomy;osteotomywasperformedusingthemeasuredresectiontechnique.ALegacyconstrainedcondylarkneeprosthesis(LCCK;ZimmerBiomet,Warsaw,IN,USA)wasinsertedintenkneesandarotatinghingekneeprosthesis(RHK;ZimmerBiomet)wasinsertedintwokneespresentinghyperextension.Stemswereusedinboththefemurandtibiaforsevenknees;infourknees,thestemswereusedinthetibiaonly;inoneknee,nostemswereused,followingaprotocoltousestemsinfragilebones.Augmentationwasappliedtoreplacetibialbonedefectsof>5mmineightknees.Allthefemoralandtibialprostheseswerefixedwithcementafterpulsedlavage,drying,andpressurizationofthecement.Patellarresurfacingwasconductedinsevenkneeswithpatellardeformity.Afteralltheprostheseswereimplanted,lateralretinacularreleasewasneededinfourcasesofkneesbasedontheassessmentofpatellartracking.Duringsurgery,nocaseshadsofttissueinjuriessuchasmedialorlateralcollateralligamentsorpatellartendons(Table1).?PostoperativeTherapyTheoperatedkneedidnotwearanybracefromthedayofsurgery.Fromthedayaftersurgery,allpatientswereallowedfullweight-bearingandbeganactivekneemotionexercises,alongwithquadriceps-strengtheningexercisesandstandingatthebedsideorwalkingwithcrutchesorawalkerunderthesupervisionofaphysicaltherapist.Onthe14thpostoperativeday,thewoundstitcheswereremoved.Nopatienthadanyinfectionorwounddehiscenceatthispoint.Twotofourweeksaftersurgery,patientsweredischargedfromthehospital,andphysicaltherapyattheoutpatientclinicwasconductedonceaweekforthreemonthsaftersurgery.Inadditiontotheinpatientrehabilitationprogram,outpatientrehabilitationfocusedonactivitiesofdailylivingexercisessuchasbathing,hillwalking,andstairclimbing,tailoredtoeachpatient'scondition.Forpostoperativeanalgesia,NSAIDswereadministeredupto1monthpostoperativelyandacetaminophenfrom1to3monthspostoperatively.AfterdiagnosisofosteoporosisbydualenergyX-rayabsorptiometry,patientsreceivedoraladministrationof35mgalendronateonceaweekand0.75μgeldecalcitoldaily.?ClinicalandRadiographicEvaluationsClinicalandradiographicevaluationswereperformedforeachpatientpreoperatively,andat3-,6-,and12-monthspostoperatively,andannuallythereafter.The2011KneeSocietyScore(KSS)[10]wasrecordedandassessed.Therangeofmotion(ROM)wasmeasuredthreetimeseachusingagoniometerinthesupinepositionbyseveralseniorphysiotherapistswith>?5yearsofclinicalexperience.Duringradiographicevaluation,thefemorotibialangle(FTA)wasmeasuredinfull-lengthviewsofthelowerextremities,inthestandingposition.ThestageofCharcotarthropathywasclassifiedaccordingtotheKoshinoclassification[11].Prosthesislooseningwasassessedbycomponentsubsidence>2mmorbyacompleteradiolucentlinearoundthecomponent[12].Allradiographicevaluationswereindependentlyanalyzedbytwoinvestigators,whohad>?10yearsofclinicalexperienceandwerenotinvolvedintheoperations.11.Koshino,T.(1991).Stageclassifications,typesofjointdestruction,andbonescintigraphyinCharcotjointdisease.BulletinoftheHospitalforJointDiseasesOrthopaedicInstitute,51(2),205–217.12.Ewald,F.C.(1989).TheKneeSocietytotalkneearthroplastyroentgenographicevaluationandscoringsystem.ClinicalOrthopaedicsandRelatedResearch,248,9–12.?StatisticalAnalysisAllvalueswerenormallydistributedandwereexpressedasmean?±?standarddeviation(SD).AllstatisticalanalyseswereperformedusingthestatisticalsoftwareEZR(SaitamaMedicalCenter,JichiMedicalUniversity,Saitama,Japan)[13].Pairedttestswereusedtocomparethe2011KSSandROMbetweenpreoperativeandthemostrecentdata.Forpatientswhodiedorexperiencedrevisionsurgery,thevaluesatthepre-eventvisitwereconsideredthemostrecentdata.TheKaplan–Meiermethodwasusedtocreatesurvivalcurvesforrevisionandcomplications[14].StatisticalsignificancewassetatP?<?0.05.?ResultsClinicalOutcomesTheaveragepre-andpostoperative2011KSSandtheirsubscales,ROMs,andmobilityarepresentedinTable2.The2011KKS,allitssubscales,andkneeflexionanglesweresignificantlyimprovedfollowingsurgery(P?<?0.05)(Table2).Preoperatively,noneofthepatientscouldwalkindependentlyandonlythreepatientscouldwalkwithasinglecane;however,postoperatively,threepatientswereabletowalkindependentlyandfivepatientscouldwalkwithasinglecane(Table2).???Table2Clinicaloutcomespre-andpost-operatively??RadiographicResultsAccordingtotheKoshinoclassification,twokneeshadstageII,and10kneeshadstageIIICharcotarthropathy(Table1).Preoperatively,theFTAofeightvaruskneeswas199.8?±?11.1°(range,186–223°)andtheFTAoffourvalguskneeswas155.1?±?5.4°(range,148–163°);postoperatively,theFTAimprovedto176.6?±?3.7°(range,170–183°).Nocasesshowedcomponentsubsidence>?2mmorprogressiveradiolucentlinesaroundthefemoral,tibial,orpatellarcomponents(Figs.1,2).??Fig.1Radiographsofa61-year-oldmalewithKoshinoclassificationstageIIICharcotarthropathy(No.2inTable1)preoperatively(A,B),immediatelypostoperatively(C,D),andmostrecently,14yearspostoperatively(E,F)??Fig.2Radiographsofa74-year-oldfemalewithKoshinoclassificationstageIIICharcotarthropathy(No.4.1inTable1)preoperatively(A,B),immediatelypostoperatively(C,D),andmostrecently,5yearspostoperatively(E,F)??ImplantSurvival,Revisions,andComplicationsThesurvivalratesforasepticrevision,revisionduetoinfection,andcomplicationsarepresentedinFig.3.The5-yearsurvivalrateswere100%(12/12)forasepticrevision,91.7%(11/12)forrevisionduetoinfection,and83.3%(10/12)forcomplications.The10-yearsurvivalrateswerethesame.Only2outof12patientshadcomplicationsduringfollow-upperiod.??Fig.3Kaplan–Meiercurvesofsurvivalratesforasepticrevision,revisionduetoinfection,andcomplications??Onepatientexperiencedaperiprostheticinfection4yearspostoperatively.Undergeneralanesthesia,thepolyethyleneinsertwasremoved,andthekneejointwasthoroughlydebridementandwashedwith9Lofsalinesolution.Thefemoralandtibialcomponentsshowednosepticlooseningandwerenotreplaced.Anewpolyethylenewasinsertedandthewoundwasclosed.Thedrainplacedinthekneejointwasremovedthedayaftersurgery.ThepathogenicbacteriawasE.coli,andthepatientwastreatedwithceftriaxoneintravenouslyfor6weekspostoperatively,followedbycefditorenpivoxilorallyfor6weeks.Noadditionalrevisionsurgerywasrequiredinthiscase.Theotherpatienthadcoronalplaneinstabilityduetosofttissueloosening1yearpostoperatively.Laterallooseningwassignificant,andalateralthrustwasobserved.Nolateralcollateralligamentinjurywasobservedduringsurgery,however,thesofttissuefragilitywasapparent,probablyduetoincreasedpostoperativeactivityandstress.Thepatientneededtowearahingedkneebracewhenwalking.Noneofthepatientsdevelopedpatellardislocation,periprostheticfracture,deepveinthrombosis,orpatellarcranksyndrome.?DiscussionThemostimportantfindingofthisstudyisthatTKAwasgenerallyasafetreatmentoptionforCharcotarthropathyoftheknee.Clinicaloutcomesincluding2011KSSandROMweresignificantlyimprovedatthelastfollow-up,similartopreviousreports[7,8],andthemid-tolong-termsurvivalrateforasepticrevisioninthisstudywas100%.However,severalpostoperativecomplicationswereobserved.本研究最重要的發(fā)現(xiàn)是TKA通常是膝關(guān)節(jié)Charcot關(guān)節(jié)病的安全治療選擇。最后一次隨訪時(shí)，包括2011年KSS和ROM在內(nèi)的臨床結(jié)果均有顯著改善，與既往報(bào)道相似[7,8]，本研究無菌翻修的中長期生存率為100%。然而，觀察到一些術(shù)后并發(fā)癥。SurvivalratesforasepticrevisionofTKAforCharcotarthropathyhavebeenreportedtobeexcellent,with100%atfiveyearsand88%attenyears[8],andourdatasupportthatresult.However,thepreviousreportshowedahighincidence(16%)ofperiprostheticinfections,whichoccurredatanaverageof3yearspostoperatively(range,1–6years)[8].Inourstudy,theincidenceofperiprostheticinfectionwasslightlylower,affecting1in12knees(8%).Charcotarthropathypatientsareoftenfrailduetotheirunderlyingdisease,andthefrailtyincreasestheincidenceofinfectionafterTKA[15].DM,themostcommondiseasecausativeofCharcotarthropathy,isalsorelatedtoahighincidenceofperiprostheticinfection[16].Inthisstudy,onecaseexperiencedpostoperativevarus/valgusinstability,whichwassimilarlyreportedinpreviousreportsandrequiredrevisionsurgeryinsomecases[6,9].However,thepatientdidnotneedrevisionsurgerybecauseofnosymptomsrelatedtotheinstabilitywithabrace.JointinstabilityisoneofthemostimportantcomplicationsinCharcotarthropathybecauseligamentouslaxityoftenoccursduetoadvancedjointdeformity.RemaininghyperextensionofthekneeafterTKAincreasestheriskofneurovascularinjuryandresidualkneepain.Insuchcases,itisimportanttochooseRHKtorestricttheextensormechanismandavoidrevisionsurgery[17,18],andthishingedprosthesiswasappliedfor2casesintheseriesofthestudy.據(jù)報(bào)道，無菌改良TKA治療Charcot關(guān)節(jié)病的生存率非常好，5年生存率為100%，10年生存率為88%[8]，我們的數(shù)據(jù)支持這一結(jié)果。然而，先前的報(bào)道顯示假體周圍感染的發(fā)生率很高(16%)，平均發(fā)生在術(shù)后3年(范圍1-6年)[8]。在我們的研究中，假體周圍感染的發(fā)生率略低，影響12個(gè)膝關(guān)節(jié)中的1個(gè)(8%)。Charcot關(guān)節(jié)病患者往往因其基礎(chǔ)疾病而身體虛弱，這種虛弱增加了TKA后感染的發(fā)生率[15]。DM是Charcot關(guān)節(jié)病最常見的病因，也與假體周圍感染的高發(fā)有關(guān)[16]。在本研究中，1例患者出現(xiàn)了術(shù)后內(nèi)翻/外翻不穩(wěn)，這在之前的報(bào)道中也有類似的報(bào)道，在一些病例中需要進(jìn)行翻修手術(shù)[6,9]。然而，由于沒有與支具不穩(wěn)定相關(guān)的癥狀，患者不需要翻修手術(shù)。關(guān)節(jié)不穩(wěn)定是Charcot關(guān)節(jié)病最重要的并發(fā)癥之一，因?yàn)橥砥陉P(guān)節(jié)畸形常導(dǎo)致韌帶松弛。全膝關(guān)節(jié)置換術(shù)后膝關(guān)節(jié)持續(xù)過伸會(huì)增加神經(jīng)血管損傷和膝關(guān)節(jié)疼痛的風(fēng)險(xiǎn)。在這種情況下，選擇RHK來限制伸肌機(jī)制，避免翻修手術(shù)是很重要的[17,18]，本系列研究中有2例使用了這種鉸鏈?zhǔn)郊袤w。InTKAforCharcotarthropathy,variousprostheseshavebeenused,includingcruciate-retaining(CR),posterior-stabilized(PS),LCCK,andRHK.Thechoiceofimplantsisstillamatterofdebate[19,20].Unrestrainedcomponents(e.g.,CR,PS)areofteninappropriateforCharcotarthropathy,becausetheycanleadtopostoperativejointinstabilityduetoseveredeformityandsoft-tissueimbalance[4,19].RHKshouldbeselectedcarefully,becauseexcessiverestraintcanincreasetheriskofasepticlooseningandperiprostheticfractures[18,20].Therefore,somesurgeonsconsiderthatLCCK,whichprovidesgoodstabilitywithminimalrestriction,istheoptimalprosthesisforCharcotarthropathy[7,8].Inourstudy,LCCKwasthepreferredprothesis,withRHKusedonlyinpatientspresentingwithkneehyperextension.Moreover,whenusingconstrainedcomponents,theuseoflongstemsisimportanttodistributetheincreasedstressonthebone[21,22].Inapreviousreport,16%ofCharcotarthropathypatientstreatedwithoutstemsdevelopedasepticlooseningwithin5years[4].Conversely,anotherstudyreportednocasesofasepticlooseningafterfiveyearsandonly6%after10yearsinpatientstreatedwithstems[8].Ofthepatientsincludedinourstudy,stemswereusedin92%ofcases,withnoneofthepatientsshowingasepticlooseningduringthefollow-upperiod.在Charcot關(guān)節(jié)病的TKA中，使用了各種假體，包括交叉關(guān)節(jié)保留(CR)、后穩(wěn)定(PS)、LCCK和RHK。植入物的選擇仍然是一個(gè)有爭議的問題[19,20]。無約束假體(如CR、PS)通常不適合用于Charcot關(guān)節(jié)病，因?yàn)樗鼈兛赡軐?dǎo)致嚴(yán)重畸形和軟組織失衡導(dǎo)致術(shù)后關(guān)節(jié)不穩(wěn)定[4,19]。應(yīng)謹(jǐn)慎選擇RHK，因?yàn)檫^度約束會(huì)增加無菌性松動(dòng)和假體周圍骨折的風(fēng)險(xiǎn)[18,20]。因此，一些外科醫(yī)生認(rèn)為LCCK具有良好的穩(wěn)定性和最小的限制，是治療Charcot關(guān)節(jié)病的最佳假體[7,8]。在我們的研究中，LCCK是首選的假體，RHK僅用于出現(xiàn)膝關(guān)節(jié)過伸的患者。此外，當(dāng)使用受限組件時(shí)，使用長柄對于分配骨上增加的應(yīng)力很重要[21,22]。在先前的報(bào)道中，16%的Charcot關(guān)節(jié)病患者在5年內(nèi)發(fā)生無菌性松動(dòng)[4]。相反，另一項(xiàng)研究報(bào)告5年后沒有無菌性松動(dòng)病例，10年后只有6%的患者接受了莖干治療[8]。在我們的研究中，92%的患者使用了支架，在隨訪期間沒有患者出現(xiàn)無菌性松動(dòng)。ManagementoflargebonedefectsinCharcotarthropathyisamajorconcern.Treatmentstrategiesforbonedefectsincludeautografts,allografts,metalaugmentation,andtantalumimplants[6,23].However,thebonestructureofCharcotarthropathyisveryweak,andevenifautologousorallogeneicboneisgraftedintothedefect,aboneunionisdifficulttoachieve[9,24].Therefore,inourcases,metalaugmentationwasusedtofillthebonedefect.Immediatelyaftersurgery,fullweightbearingwasallowed;however,nocasesresultedinlooseningorperiprostheticfractures.Charcot關(guān)節(jié)病大骨缺損的處理是一個(gè)主要問題。骨缺損的治療策略包括自體移植物、同種異體移植物、金屬隆胸和鉭植入物[6,23]。然而，Charcot關(guān)節(jié)病的骨結(jié)構(gòu)非常薄弱，即使將自體或異體骨移植到缺損處，也難以實(shí)現(xiàn)骨愈合[9,24]。因此，在我們的病例中，我們使用金屬隆胸來填充骨缺損。手術(shù)后立即允許完全負(fù)重;然而，沒有病例導(dǎo)致松動(dòng)或假體周圍骨折。Thisstudyhadsomelimitations.First,itwasaretrospectivecaseserieswithalimitednumberofpatients.Thislimitedtheabilitytoperformsubgroupanalysisbasedoncausativedisease,Charcotstage,orimplanttype.Toperformsubgroupanalysis,alargernumberofpatientsisneeded.Second,alongerfollow-upperiodisdesirabletoaccuratelyevaluatetheefficacyoftheTKAprocedureinCharcotarthropathy.這項(xiàng)研究有一些局限性。首先，這是一個(gè)回顧性病例系列，患者數(shù)量有限。這限制了基于病因、Charcot分期或植入物類型進(jìn)行亞組分析的能力。為了進(jìn)行亞組分析，需要更多的患者。其次，為了準(zhǔn)確評(píng)估TKA手術(shù)治療Charcot關(guān)節(jié)病的療效，需要更長的隨訪期。Inconclusion,ourmid-tolong-termresultsofTKAforCharcotarthropathyweregenerallyfavorable.Patientsinthisstudyachieveddefiniteimprovementinkneepain,function,andmobility,andthe5-and10-yearsurvivalratesforasepticrevisionwereexcellent.Therefore,TKAmaybeaviabletreatmentoptionforCharcotarthropathywhilethecomplicationssuchasperiprostheticinfectionandinstabilityshouldbekeptinmind.總之，TKA治療Charcot關(guān)節(jié)病的中長期結(jié)果總體上是有利的。在這項(xiàng)研究中，患者在膝關(guān)節(jié)疼痛、功能和活動(dòng)方面得到了明確的改善，無菌翻修術(shù)的5年和10年生存率非常好。因此，TKA可能是Charcot關(guān)節(jié)病的一種可行的治療選擇，但應(yīng)注意假體周圍感染和不穩(wěn)定等并發(fā)癥。