Surgical treatment of chronic arthritis

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The so-called "chronic arthritis" refers to the entire joint destruction and proliferation of non bacterial arthritis group, including osteo

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The so-called "chronic arthritis" refers to the entire joint destruction and proliferation of non bacterial arthritis group, including osteoarthritis, rheumatoid arthritis, traumatic arthritis and aseptic necrosis of femoral head caused by joint injury pathogenesis, they are different, so the above definition is not very accurate. But by the late disease of articular cartilage destruction, synovial hyperplasia, joint deformity, fusion or dislocation is the end of them, will cause the patient's pain, lameness and joint activities is limited, which will make its long-term bed, loss of life, but later rely mainly on surgery, they are classified as a class okay. According to the mechanism and extent of the lesions could be treated by arthroscopic debridement, osteotomy and arthrodesis and arthroplasty, following are the pros and cons to talk about their own views and experience:

An osteotomy.

The femoral or tibial osteotomy is the main purpose of deformity correction, relieve pain, improve joint mobility and delay joint replacement time. The use of this procedure for the treatment of knee deformities and degenerative arthritis caused by incorrect body line. The tibial osteotomy (below the tibial tubercle osteotomy) as an example, it is mainly suitable for the age of 35, in the tibiofemoral joint lesions of unicompartmental knee varus patients and high tibial osteotomy (above the tibial tubercle osteotomy, HTO) mainly for patients over 35 years old. For those who are over 60 years old and the cartilage of the knee joint is severely damaged, it is difficult to solve the problem of osteotomy. In order to ensure the osteotomy effect, knee joint function and the basic requirements of the surrounding muscle intact, such as knee meniscus injury is required to do treatment of meniscus, osteotomy.

Tibial osteotomy contraindications include: over 65 years of age should be used with caution. There is obvious gap narrowing or disappearance of the joint. Knee flexion and extension of less than 90 degrees. The severe knee joint instability. The abnormal structure of severe knee joint. The patients with severe obesity. The knee muscle strength less than 4. The serious osteoporosis.

Anterior tibial osteotomy as weight-bearing knee length X-ray on anteroposterior accurately measured femoral angle, tibial angle and femoral tibial angle, to determine the degree of correction. During the operation, the fibula was cut off, the 1CM was cut under the tibial plateau, the osteotomy was performed under the periosteum, and the osteotomy guide could be used. Its complications include the common peroneal nerve injury, the intra-articular fracture, the slap artery injury, the fracture healing.

The effect of tibial osteotomy for the treatment of varus knee has been accepted and acknowledged. High tibial osteotomy on, have influence on the knee joint, but bone healing time is short, the older we love to do more in patients with high tibial osteotomy. Effect of proximal tibial osteotomy on the joint of the small, more suitable for young people.

Two. Joint debridement

Joint debridement refers to the operation of the knee joint, the repair of the damaged cartilage, the removal of meniscus and synovectomy. It is suitable for patients with mild to moderate chronic osteoarthritis, and it is difficult to do joint debridement with poor limb force line, which should be done at the same time. The analysis of the effect of joint debridement showed that the therapeutic effects were different, some reports were better, and some of them were poor. Overall, the worse the patients, the worse the effect, the shorter the duration of operation, the earlier the recurrence. Therefore, joint debridement is suitable for patients with mild to moderate chronic arthritis, and the treatment effect is relatively temporary. Currently, arthroscopic debridement is performed with less injury and faster recovery.

Three. Arthrodesis

Some severe cases of patients with chronic arthritis pain is severe, but not for economic or other reasons, the total hip or knee replacement surgery, joint fusion does not lose is a kind of type, especially for patients engaged in manual labor, the loss of fusion joint movement degree, but walking is not pain, have a certain life and labor self-reliance. Each joint fusion method is mature, there is no technical problems. The author only make supplement: ipsilateral hip and knee joint lesions were best hip joint, knee joint, the knee joint fusion fusion fusion surgery is simple, high success rate, but hip fusion has a certain failure rate, mainly due to postoperative fixation due to the poor, so after surgery the hip spica cast fixation of hip joint is the most effective and simple fusion will not advocate hip fusion at 0 degrees, 5-10 degrees of hip flexion should be, this is more beneficial to patients with functional recovery. The joint fusion after many years, if the patient has a joint replacement, patients still have the opportunity to change the joint.

Four. Artificial joint replacement

Artificial joint or total joint replacement for the extensive destruction of the joints, the obvious deformity of joint lesions can reduce joint pain, improve the joint function of patients. Hip and knee replacement for the senile degenerative osteoarthritis, rheumatoid arthritis, ankylosing spondylitis and avascular necrosis of the femoral head and the femoral neck fracture (especially suspected acetabular lesions) with congenital hip dislocation or acetabular dysplasia and hip bone tumor and septic arthritis of the hip or hip joint. No recurrence of tuberculosis. But the situation is not suitable or carefully chosen, such as: the cardiac function of serious disorders (beyond the control of heart failure, myocardial infarction occurred within six months, within 3 months of frequent episodes of angina) in hypertension complicated by cerebral vascular lesions (intraoperative or postoperative sudden cerebrovascular accident or hemiplegia is combined with rehabilitation therapy) the liver and kidney function is damaged badly. The diabetic body (lung, urinary infection or suspected infection) potential (ESR fast, C-RP) are the hip skin condition is not good (or furuncle bedsore), anemia, electrolyte disorder (corrected after surgery) and progressive neurological disease (caused by syringomyelia) the Charcot joints to the frail elderly high-risk patients (age is not absolute basis, to see whether the physiological age of surgery).

The need for surgery and possible preoperative estimate of surgery is worth: surgery to solve many problems, to help patients, such as patients around the stiff joint soft tissue contracture, postoperative effect is poor, whether the surgery is questionable whether patients tolerated surgery operative time and sequence is correct: hip the knee joint stiff (strong) straight ahead, the long-term use of hormone hip replacement patients, preoperative and postoperative use of hormones, prevent the occurrence of China whether Froude syndrome in the revision surgery need bone graft bone cement or fracture of the prosthesis removed the difficulty of knee joint stiff (strong) straight through physical therapy the knee function improved and osteoporosis in the elderly, with bone cement prosthesis, to prevent patients with ankylosing spondylitis and fracture surgery, is difficult to puncture and should be used in general anesthesia. Have the hip flexion deformity of hip joint contracture, needing to loose organization, and adjust the acetabular abduction angle, angle.

Preoperative medication and preparation, including the use of antibiotics in a day ahead of the night before surgery the use of sedative drugs and skin preparation: preoperative washing operation, skin preparation, the dressing with blood: blood, enough the prosthesis right size: X light sheet and die the measurement of vacuum suction and anti swing shoes.

Surgical incision can be as follows: the anterolateral incision: Smith-Peterson incision (injury, bleeding); lateral incision (I recommend: Hardinge, Wstson-Jones (incision) incision recommended incision tumor segment composite prosthesis), Ollier ("U") incision; posterolateral incision: Gibson, Mcfarlind incision; rear: Moore Osborne modified Moore incision, incision, incision and so on. Take my suggested Hardinge approach as an example to introduce some surgical procedures and basic methods. Patients in the lateral decubitus position: in the affected side, the patient needs to be fixed, the front clip with pubic symphysis, back against the sacrum, prevent the skin after shaking: (2% iodine and 70% alcohol) with the single exposure: the ipsilateral greater trochanter as the center, on the 7cm, cut the skin, subcutaneous, electric coagulation, skin incision incision along the direction of the tensor fascia lata, automatic retraction hook, large forceps separate joint capsule muscle fiber deep white front part of the gluteus medius, electric knife longitudinal middle gluteal muscle and vastus lateralis muscle incision in the trochanteric reattachment point, the two will be retracted medially and external rotation with limb, showing the lesser trochanter. Femoral head puller pull out of femoral head, exploration of acetabulum, there is no obvious bone defect of the osteotomy, joint head and removal is located in the small trochanter 1cm oblique trochanteric osteotomy osteotomy when do, pay attention to keep the middle gluteal muscle reattachment point. The cleaning of the acetabulum, electric knife excision of the transverse acetabular ligament and the articular surface of the soft tissue of the ear by adjusting the tension electric knife resection of the joint capsule, especially joint capsule after the hip muscle balance to adjust, when necessary, can release the iliopsoas muscle and the tensor fascia lata and gluteus maximus the muscle of acetabulum: capsule resection and marginal osteophyte, curette and acetabular cartilage surface of acetabulum file clear, heart not worn thin and loose mortar. Non - bone - type acetabulum to pay attention to the installation of the pressure distribution, screws can only play a temporary role.

Bone cement acetabular acetabular: punch on acetabular roof boreholes with different directions 3 ~ 5, 6 ~ 8mm depth, punch punch widening dresser. Choose the proper mortar, generally higher than maximum reamer small diameter 2 ~ 4mm, try to touch the black acetabulum fixed on the handle, used to check the size and direction of determination of artificial acetabulum, artificial acetabulum should be 45 degrees of abduction, backward 10 degrees. Cold high pressure flushing acetabulum: dry gauze compression hemostasis, keep dry, bone cement. Cement gun bone cement injection with acetabular cement extruder and wet silicon plate pressing cement, and make the acetabular fossa and cancellous bone surface bonding hole. The extruder will according to the requirements of the direction of artificial acetabulum and further promote bone cement with acetabulum, to maintain the original position, until the cement glued firmly, remove the edge of excess cement.

The placement of the bone cement stem prosthesis. Select the appropriate prosthesis, the center of the corresponding number on the end of the handle. Scrub with a brush to remove the bone marrow cavity: blood clot, cold high pressure washing medullary cavity, suction and liquid oozing of blood. Bone cement: bone cement prepared with cement gun from the medullary cavity low from deep to shallow (while push back) will cement filled with intramedullary femoral neck, silica gel sealed eggs, with cement gun pressurized cement, pressurized after insertion of femoral prosthesis selected, until the neck section to reach water mud glue hardening neck after removal of excess cement. Choose the right head fixed on the neck. Manual reset, check the tension and stability, inappropriate when the head off to switch to another suitable femoral head.

Placement of cementless stem prosthesis. According to the preoperative marking the osteotomy plane resection of femoral neck, retain the moment shares 1 ~ 1.5cm, using a chisel, scraping or chisel curettage osteotomy of the Emei cancellous bone. Close to the direction of rotor cavity file parallel to the medullary cavity (if necessary, removal of part of the greater trochanter) gradually expanded to the depths (can make the handle way straight). The maximum number of small file to file the medullary cavity, this file size is the size of the prosthesis selection. Put the plug in the distal medullary cavity to expand the amount is about ready handle the length of the stem, with expanded medullary cavity is measured at the end of the stem below 1 ~ 2cm diameter shaft, appropriate to expand the medullary cavity, use a large expansion of the distal plug 1mm, fixed to the insert rod, the plug will be below a predetermined prosthesis the depth of 1 ~ 2cm, loosen the screws, taking the inserted rod. The maximum number of files selected according to the in situ medullary cavity was inserted into the medullary cavity, and try to touch the placed in the bone file, mark "0" at the starting point into the long head, arrived at the lowest position, this is the standard neck. Pull the test mode to "1" and insert it in the end, add the standard neck with a neck length of 4 4mm. Spin again to "2" are inserted for long neck, neck length increased 4mm. Spin again to "3" insert long necked plus 4, neck length increased again 4mm. Reset the joints, check leg length, tension, and joint stability. Using this method to select the appropriate length of the femoral head.

Check if there is any foreign body in the wound, wash the wound, put the drainage tube, and then cut off the incision.

Should pay attention to the strict aseptic technique in operation level and anatomic relationship to be clear in total hip arthroplasty, protect nearby neurovascular operation to avoid light, dry neck splitting, acetabular perforating accidents such as bone cement and pay attention to the effect on blood pressure and the position of the prosthesis to the appropriate placement of acetabular abduction 45 degrees tilt 15 degrees of anteversion angle of the handle of the handle and the medullary cavity is parallel to the reduction of tension to the right: low tension, joint instability easy dislocation, tension force, can be complicated by postoperative thigh pain.

During postprocessing include: postoperative always wear anti swing shoes after surgery 2 days out of wound drainage, suction drainage unobstructed, depending on how much, generally 2 days drainage, penetration of the dressing should be changed to prevent the contamination of wounds after 2 day (only according to X-ray a) the 3 day after operation in the CPM help do hip flexion, maintain limb abduction in neutral position, the posterior approach to avoid foot pronation, anterior approach to avoid foot pronation, prevent a week after the operation began the practice of sitting the dislocation 12 days after suture removal, postoperative month hold double ambulation in bed.

 

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