全膝關節(jié)置換術的治療方案培訓課件

1、全膝關節(jié)置換術的治療方案全膝關節(jié)置換術的治療方案 什么是骨性關節(jié)炎骨關節(jié)炎是一種發(fā)生在滑膜關節(jié)、發(fā)展緩慢，以局部關節(jié)軟骨破壞，并伴有相鄰軟骨下骨板骨質增生或骨唇形成為特征，由機械性、代謝、炎癥和免疫等因素作用而造成的關節(jié)疾病。 2全膝關節(jié)置換術的治療方案 什么是骨性關節(jié)炎骨關節(jié)炎是一種發(fā)生在滑膜關節(jié)、發(fā)展緩慢，病 理 特 點病理特點為關節(jié)軟骨變性破壞、軟骨下骨硬化或囊性變、關節(jié)邊緣骨質增生、滑膜增生、關節(jié)囊攣縮、韌帶松弛或攣縮、肌肉萎縮無力等。3全膝關節(jié)置換術的治療方案病 理 特 點病理特點為關節(jié)軟骨變性破壞、軟骨下骨硬化或囊性 臨 床 表 現(xiàn)1 、關節(jié)疼痛及壓痛 初期為輕度或中度間斷性隱痛，

2、休息時好轉，活動后加重，疼痛常與天氣變化有關。晚期可出現(xiàn)持續(xù)性疼痛或夜間痛。關節(jié)局部有壓痛，在伴有關節(jié)腫脹時尤為明顯。4全膝關節(jié)置換術的治療方案 臨 床 表 現(xiàn)1 、關節(jié)疼痛及壓痛 初期2 、關節(jié)僵硬 在早晨起床時關節(jié)僵硬及發(fā)緊感，也稱之晨僵，活動后可緩解。關節(jié)僵硬在氣壓降低或空氣濕度增加時加重，持續(xù)時間一般較短，常為幾分鐘至十幾分鐘，很少超過30分鐘。5全膝關節(jié)置換術的治療方案2 、關節(jié)僵硬 在早晨起床時關節(jié)僵硬及發(fā)緊感，也稱之晨僵3 、關節(jié)腫大 手部關節(jié)腫大變形明顯，部分膝關節(jié)因骨贅形成或關節(jié)積液也會造成關節(jié)腫大。4 、骨摩擦音(感) 由于關節(jié)軟骨破壞、關節(jié)面不平，關節(jié)活動時出現(xiàn)骨摩擦音(

3、感)，多見于膝關節(jié)。6全膝關節(jié)置換術的治療方案3 、關節(jié)腫大 手部關節(jié)腫大變形明顯，部分膝關節(jié)因骨贅形5、關節(jié)無力、活動障礙 關節(jié)疼痛、活動度下降、肌肉萎縮、軟組織攣縮可引起關節(jié)無力，行走時軟腿或關節(jié)絞鎖，不能完全伸直或活動障礙。7全膝關節(jié)置換術的治療方案5、關節(jié)無力、活動障礙 關節(jié)疼痛、活動度下降、肌肉萎縮、全膝關節(jié)置換術的治療方案培訓課件9全膝關節(jié)置換術的治療方案9全膝關節(jié)置換術的治療方案10全膝關節(jié)置換術的治療方案10全膝關節(jié)置換術的治療方案Work-uptake long films of both lower limbs (standing, patellae facing forw

4、ard, feet together)trace all previous X-rays and find the previous operation records (for revision cases)consider knee aspiration and bone (Indium111) scan if sepsis is suspected (for revision cases)術 前 準 備拍攝雙側下肢全長X光片 (站立位、髕骨向前、雙足并攏)回顧所有以前拍攝過的X光片并找出以往手術記錄 (對于翻修病例)如果懷疑感染可考慮行膝關節(jié)穿刺和銦111同位素骨掃描 (對于翻修病例)

5、11全膝關節(jié)置換術的治療方案Work-up11全膝關節(jié)置換術的治療方案Pre-operative (medical) fill in the total knee replacement arthroplasty documentation form confirm the presence of all prostheses and special instruments that may be needed with OT staffmake sure that allograft is available if that is part of the surgical plan 術 前

6、準 備 ( 醫(yī) 生 ) 填寫全膝關節(jié)置換術記錄表與手術室同事確認所需的假體和特殊器械均已到位手術方案中若需植骨則事先確認有合適的異體骨可供選用12全膝關節(jié)置換術的治療方案Pre-operative (medical) 12全膝關節(jié)Pre-operative (therapists)baseline assessment by physiotherapist & occupational therapistassess range & quadriceps power, measure circumferences at knee joint, 10 cm. above it and 10 cm

7、. below itteach post-op. exercises e.g. active knee mobilization, static quadriceps, straight-leg-raising, bridging術 前 準 備 ( 治 療 師 )由物理治療師和職業(yè)治療師進行基本狀況評估膝關節(jié)活動范圍及股四頭肌肌力評估在距離膝關節(jié)上下各10厘米處測量大腿及小腿的周徑指導術后的操練例如膝關節(jié)的主動活動股四頭肌靜力收縮直腿高舉以及伸腰彎弓動作的練習13全膝關節(jié)置換術的治療方案Pre-operative (therapists)13全膝Operative supine positio

8、n, apply foot positioner before draping (so that the knee can be locked in full flexion)thigh tourniquet is applied but is only inflated after draping (tourniquet only used for cementation after 2001)no bulking drape around foot and anklesurgical approach (Insall) with periosteum elevated from media

9、l third of the patella is adopted patella is replaced routinely in rheumatoid arthritis, but not osteoarthritisintramedullary guide for femoral cuts and extramedullary guide for tibial cutscut surfaces are cleansed with pulsatile lavage system before cementation (no need for cementless fixation)all

10、three components are inserted with one pack of Endurance cement mixed in partial vacuum; if exposure is sub-optimal, cement the patellar button and tibial tray first, and then insert the femoral component with another pack of cement (cement gun after 2001)tourniquet is deflated after all components

11、are inserted and before wound closure for hemostasisbulking dressing is applied afterwardsfor bilateral involvement with similar severity, both knees will be replaced under the same anaesthesia, one after the other - “one-stage, sequential” bilateral replacement14全膝關節(jié)置換術的治療方案Operative 14全膝關節(jié)置換術的治療方案

12、手 術 操 作仰臥位在鋪巾前放置足固定擋板以使術中膝關節(jié)在完全屈曲位時能被固定使用大腿空氣止血帶并僅在消毒鋪巾后才向止血帶充氣 (2001年后僅在注入骨水泥時才充氣)避免在足踝部鋪過多的消毒巾采用Insall手術入路從髕骨內側三分之一處剝離骨膜將髕骨向外翻開以暴露整個膝關節(jié)節(jié)類風濕性關節(jié)炎進行常規(guī)置換髕骨, 骨性關節(jié)炎則不需要用髓內定位指導股骨遠程切骨髓外定位指導脛骨近端切骨切骨表面在骨水泥處理前用脈沖灌洗系統(tǒng)沖洗 (非骨水泥固定則不需要)用一包在半真空條件下混和攪拌的Endurance骨水泥來固定所有三部份假體如果手術野暴露不佳則先用一包骨水泥固定髕骨和脛骨假體然后用另一包骨水泥固定股骨假體

13、 (2001 年后采用骨水泥槍)止血帶在所有假體置入后、手術切口關閉前放松以利徹底止血切口關閉后用大量敷料包扎如果雙側膝關節(jié)病變程度相似可在同一次麻醉下將雙側膝關節(jié)先后置換。15全膝關節(jié)置換術的治療方案手 術 操 作15全膝關節(jié)置換術的治療方案POST-OPERATIVE CARE:術 后 處 理 Medical We do not use continuous passive motion (CPM) treatment anymorethe aim is to have 90 degrees of knee flexion in the first week full weight bea

14、ring is allowed for cemented prosthesis mobilization under anaesthesia (MUA) at 2 weeks may be considered if the range is unsatisfactory (rarely performed)check long film of the lower limbs again at 4 - 6 weeks after the operation when the patient is walking well醫(yī) 療 不給病人使用“持續(xù)被動運動”(CPM)希望術后一周時患膝能達到屈曲

15、90 度的活動范圍 對使用骨水泥假體的病人允許完全負重 如果對膝關節(jié)活動度不滿意可考慮術后兩周時在麻醉下做手法活動松解(MUA) 但通常很少采用如果病人行走良好在術后四至六周時再拍攝一次下肢全長X光片16全膝關節(jié)置換術的治療方案POST-OPERATIVE CARE:術 后 處 理 Nursing watch out for excessive bleeding - additional compression bandage, off vacuum suction and informdressing protocol: lotion - aqueous chlorhexidine 0.1%

16、 / normal salinebulking dressing (alternate layers of velban and crepe bandage for 3 times, total 6 layers) after surgery, debulking (to single layer of velban & crepe bandage) D1keep dressing intact until drain(s) is/are removed on D2 - D4; wound inspection when drain offthen transparent dressing +

17、 gauze or adhesive dressing under elastic stockingwound inspection and swab for culture on D7 (change dressing) and then D14off clips D14 and light dressing under elastic stockingavoid pillow at knee level, place it under the heelpatient education - exercises and precautions護 理密切觀察有無加壓繃帶或真空引流不暢引起的過量

18、出血并及時報告敷料護理方案: 洗液用0.1% 洗必太溶液或生理鹽水術后用大量敷料包扎 (交替用棉質和彈性繃帶各三次總共六層) 術后第一天去除并改為單層棉質和彈性繃帶包扎) 保持敷料的完整性直至術后第二至第四天將引流去除時同時觀察手術切口情況然后用紗布加透明敷料或黏性敷料覆蓋外加彈性襪套于第七天更換敷料時檢查切口并做拭子培養(yǎng)第十四天時重復一次于第十四天拆除手術切口的縫合釘輕薄敷料覆蓋外加彈性襪套避免在膝關節(jié)水平放置枕頭應放于足跟下對患者宣教并告知各注意事項17全膝關節(jié)置換術的治療方案Nursing 17全膝關節(jié)置換術的治療方案 Rehabilitation - First 2 weeks D1/

19、2 - on bulky dressing; static quadriceps, static gluteal, ankle & toes, bridging exercises (3 times/day, 10 repetitions each time) D2/3 (after drains off) - D6 - elastic stocking; add active knee mobilization, straight-leg-raising and bed mobility exercises D5 - 7 onwards - begin full-weight-bearing

20、 walking exercise D7 onwards - add progressive strengthening exercise for quadriceps and hamstrings; ice treatment if indicatedD8 onwards - ambulation on level ground and stairs, progress to unaided walking if condition allowed for cemented replacement; hamstring stretching range of motion is docume

21、nted daily, knee circumferences and quadriceps power are measured on D14aim - achieve 90 degrees knee flexion without flexion contracture, and able to walk steadily with a frame on D1418全膝關節(jié)置換術的治療方案 Rehabilitation - First 2 術 后 康 復 - 兩 周 內 第一至第二天在大量敷料覆蓋下做股四頭肌靜力收縮練習臀肌靜力收縮練習踝關節(jié)和足趾練習伸腰彎弓動作練習 (每天三次每次十回合

22、)第二或第三天 (去除引流后) 至第六天穿著彈性襪套增加膝關節(jié)的主動活動直腿高舉練習及床上活動練習第五至第七天起開始完全負重行走練習第七天起進一步加強股四頭肌和腘繩肌的力量練習必要時用冰療第八天起平地行走和上下樓梯練習對于用骨水泥固定假體的病人如果情況允許可逐步過渡至不扶拐行走腘繩肌牽拉練習每天記錄膝關節(jié)活動范圍術后第14天測量膝周徑和股四頭肌肌力目標膝關節(jié)屈曲達90度沒有屈曲攣縮在第十四天時能夠借助框架式助步器平穩(wěn)地行走19全膝關節(jié)置換術的治療方案術 后 康 復 - 兩 周 內 19全膝關節(jié)置換術的治療方Rehabilitation - After 2 weeksstrengthen the

23、 muscles and train the gait - walking speed and endurance, stairs and slope management, hill walk programif indicated - passive stretching, hydrotherapy, home visitADL training aims at maximal independence; prescription of assistive device if necessaryfunctional training and reconditioning - in preparation of resuming previous life role with or without assistive deviceaim - muscle