Deorio James K, Easley Mark E
Duke Orthopaedics, Department of Orthopaedics, Duke University Medical Center, Durham, North Carolina, USA.
Instr Course Lect. 2008;57:383-413.
Recent investigations support the belief that ankle replacement represents an attractive surgical alternative to arthrodesis for patients with advanced ankle arthritis. Although longer follow-up is necessary for total ankle arthroplasty (TAA) to displace arthrodesis as the surgical "gold standard," intermediate-term results are encouraging. Indications for TAA include primarily posttraumatic and inflammatory arthritis. Contraindications to TAA include unresectable osteonecrotic bone, peripheral vascular disease, neuropathy, active and/or recent ankle infection, nonreconstructible ankle ligaments, loss of lower leg muscular control, and severe osteopenia or osteoporosis. Young, active, high-demand patients with ankle arthritis may be better candidates for arthrodesis than for TAA. Rigorous patient selection is essential in the success of TAA, more than in other joint arthroplasty procedures. Total ankle prosthetic designs (Agility, Scandinavian Total Ankle Replacement, Hintegra, Salto, and Buechel-Pappas) with a minimum of published intermediate follow-up results, and several other innovative and biomechanically supported designs (the Mobility Total Ankle System, BOX, INBONE, and Salto-Talaris) are reviewed to demonstrate the recent evolution of TAA. Some TAA designs feature a nonconstrained polyethylene meniscus (mobile bearing) that articulates between the porous-coated tibial and talar components. The concern for edge loading (when the polyethylene component comes in contact with a metal edge) has been addressed in more recent designs by reducing the superior polyethylene surface area, expanding the tibial component surface, and even offering a convex tibial component. More practical, effective, and safer instrumentation for implantation has also been developed and has been essential to the success of TAA. However, complications with TAA (such as inadequate wound healing and malleolar fractures) are more frequent when compared with total hip and knee arthroplasty, irrespective of the surgeon's training method. As an individual surgeon gains more experience, the chances of a favorable outcome are increased.
近期研究支持这样一种观点，即对于晚期踝关节关节炎患者而言，踝关节置换术是一种比关节融合术更具吸引力的手术选择。尽管全踝关节置换术（TAA）要取代关节融合术成为手术“金标准”还需要更长时间的随访，但中期结果令人鼓舞。TAA的适应证主要包括创伤后和炎性关节炎。TAA的禁忌证包括不可切除的骨坏死骨、外周血管疾病、神经病变、活动性和/或近期的踝关节感染、无法重建的踝关节韧带、小腿肌肉控制丧失以及严重的骨质减少或骨质疏松。年轻、活跃、需求高的踝关节关节炎患者可能更适合关节融合术而非TAA。严格的患者选择对于TAA的成功至关重要，比其他关节置换手术更为关键。本文综述了至少有中期随访结果发表的全踝关节假体设计（敏捷型、斯堪的纳维亚全踝关节置换、欣泰格拉、萨尔托和比歇尔 - 帕帕斯），以及其他几种创新的、有生物力学支持的设计（活动型全踝关节系统、BOX、INBONE和萨尔托 - 距骨型），以展示TAA的最新进展。一些TAA设计采用了无约束聚乙烯半月板（活动轴承），其在多孔涂层的胫骨和距骨部件之间形成关节。在最近的设计中，通过减小聚乙烯上表面面积、扩大胫骨部件表面面积甚至提供凸面胫骨部件，解决了边缘负荷问题（即聚乙烯部件与金属边缘接触时）。还开发了更实用、有效和安全的植入器械，这对TAA的成功至关重要。然而，与全髋关节和膝关节置换术相比，TAA的并发症（如伤口愈合不良和内踝骨折）更为常见，无论外科医生的培训方式如何。随着个体外科医生经验的增加，取得良好结果的机会也会增加。
