TAR total ankle replacement TAA total ankle arthroplasty 全踝关节置换术（全踝关节置换术（PLUS 适应症禁忌症及手术步骤）适应症禁忌症及手术步骤） 原创原创 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. Marys 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 Prosthesistibial 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 technique1.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 gutter and proximal tibial surface approximately 4.0 cm above the level of the joint.distally exposure must provide visualization of the talar body and neck; 10.tibial preparation 11.preparation of the talus. 12.component sizing. 13.final component implantaton 14.closure:a final radiographic exam is performed to ensure proper size and placement of the components.motion of the ankle joint is evaluated again to assure adequate dorsiflexion.the wound is closed over a hemovac drain using nonabsorbable ethibond suture to close the ankle joint capsule and the extensor retinaculum.absorbable sutures are used to close the subcutaneous layers and the skin is closed with 4-0 nylon sutures; 15. the surgical site is infiltrated with plain, long acting local anesthesia; 16.after a sterile surgical dressing is placed, a well padded below the kness fiberglass splint is placed to maintain the ankle joint at 90 degrees. 17. the tourniquet is released and vascular status evaluated, the tourniquet time should not exceed two hours.术后处理： 石膏固定 4 周 第五周：双拐部分负重，活动踝关节 第六周：单拐部分负重 第七周：不用拐杖负重