胫骨高位截骨联合微骨折术治疗膝内侧间室骨关节炎

doi:10.3877/cma.j.issn.1674-134X.2020.01.007

目的

探讨胫骨高位截骨术联合关节镜下微骨折术治疗膝内侧间室骨关节炎的临床疗效。

方法

2014年10月至2016年10月西安交通大学第二附属医院骨一科收治的膝关节内侧间室骨关节炎患者58例，活动度均正常，保守治疗6个月无效，排除炎症性关节炎及膝外侧骨关节炎，随机分为两组，29例采用胫骨高位截骨术(HTO)联合关节镜下微骨折术(微骨折组)，29例采用HTO联合关节镜下清理术(清理组)，使用视觉模拟评分(VAS)、美国特种外科医院(HSS)膝关节功能评分、国际膝关节文献委员会(IKDC)评分对两组患者术前及术后12个月进行对比，使用负重位双下肢全长X线片测量术前、术后胫骨近端内侧角(MPTA)和股胫角(FTA)，并对术前及术后12个月进行对比，使用配对t检验和卡方检验统计学分析。

结果

所有患者均获得随访，平均随访(13.5±1.6)个月，两组患者术后12个月VAS评分、HSS评分、IKDC评分较术前均有明显改善，两组术前及术后12个月的VAS、HSS、IKDC评分差值对比，微骨折组优于清理组，差异有统计学意义(t ＝2.316、4.063、3.121P <0.05)，角度差值(MPTA、FTA)对比，(t＝1.248、1.614)，差异无统计学意义(均为P >0.05)。

结论

HTO联合关节镜下微骨折术或清理术治疗膝内侧间室骨关节炎，均能获得良好的临床疗效，但前者效果更佳，可能与存在更好的软骨修复有关，值得临床推广。

关键词: 胫骨, 截骨术, 关节镜检查, 骨关节炎

Objective

To explore the clinical effect of high tibial osteotomy(HTO) combined with arthroscopic microfracture in the treatment of medial unicompartmental knee osteoarthritis.

Methods

From October 2014 to October 2016, 58 cases with medial unicompartmental knee osteoarthritis were enrolled in the study, who were treated in the first department of orthopaedics of the second affiliated hospital of Xi'an Jiaotong University. Patients with normal range of motion and undergone conservative therapy for six months were included. Patients with inflammatory arthritis and lateral knee osteoarthritis were excluded. All the cases were randomly divided into two groups, 29 cases with HTO combined with arthroscopic microfracture (microfracture group), 29 cases with HTO combined with arthroscopic debridment (debridment group). Visual analogue scale(VAS), Hospital for Special Surgery(HSS), and International Knee Documentation Committee(IKDC)scores were used to compare the two groups before and 12 months after surgery. According to the full-length X-ray film of both lower limbs in weight-bearing position, medial proximal tibial angle(MPTA)and femur-tibia angle(FTA)were measured and used to compare the two groups before and 12 months after surgery. Paired t test and chi-square test were used for statistical analysis.

Results

All the patients were followed up for (13.5±1.6) months. The VAS, HSS and IKDC scores of the two groups at 12 months after surgery were improved comparing with the scores before surgery. The score differences of the microfracture group before and 12 months after surgery were superior to the debridment group , the difference was statistically significant (VAS t =2.316, HSS t =4.063, IKDC t =3.121, all P <0.05). The MPTA and FTA differences between the two groups before and 12 months after the surgery were not statistically significant(t =1.248, 1.614, both P >0.05).

Conclusion

HTO combined with arthroscopic microfracture or debridement can achieve good clinical efficacy in the treatment of medial unicompartmental knee osteoarthritis, and the microfracture has better clinical efficacy, which may be related to the existence of better cartilage repair, and is worthy of clinical promotion.

Key words: Tibia, Osteotomy, Arthroscopy, Osteoarthritis

表1 两组患者术前一般资料的比较

组别	例数	性别(男/女)	年龄[岁，(±s)]	BMI [kg/m², (±s)]	侧别(例，左/右)	病程(年，±s)	K-L分级[例，(Ⅱ/Ⅲ)]
微骨折组	29	11/18	53.4±5.2	22.1±1.6	12/17	4.8±1.6	12/17
清理组	29	10/19	52.8±4.6	21.9±2.1	13/16	4.5±2.1	14/15
统计值		χ²＝0.542	t＝1.475	t＝1.516	χ²＝0.385	t＝0.713	χ²＝0.465
P值		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表1 两组患者术前一般资料的比较

组别	例数	性别(男/女)	年龄[岁，(±s)]	BMI [kg/m², (±s)]	侧别(例，左/右)	病程(年，±s)	K-L分级[例，(Ⅱ/Ⅲ)]
微骨折组	29	11/18	53.4±5.2	22.1±1.6	12/17	4.8±1.6	12/17
清理组	29	10/19	52.8±4.6	21.9±2.1	13/16	4.5±2.1	14/15
统计值		χ²＝0.542	t＝1.475	t＝1.516	χ²＝0.385	t＝0.713	χ²＝0.465
P值		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表2 微骨折组术前及术后12个月相关指标的比较[n＝29，(±s)]

时间点	VAS	HSS	IKDC	MPTA	FTA
术前	5.4±1.2	53.6±4.8	46.4±3.2	82.6±2.1	182.4±3.6
术后12个月	1.1±0.3	86.7±4.5	80.1±2.2	90.3±1.3	169.7±4.1
t值	t ＝5.364	t ＝20.185	t ＝21.244	t ＝8.117	t ＝13.544
P值	<0.05	<0.05	<0.05	<0.05	<0.05

表2 微骨折组术前及术后12个月相关指标的比较[n＝29，(±s)]

时间点	VAS	HSS	IKDC	MPTA	FTA
术前	5.4±1.2	53.6±4.8	46.4±3.2	82.6±2.1	182.4±3.6
术后12个月	1.1±0.3	86.7±4.5	80.1±2.2	90.3±1.3	169.7±4.1
t值	t ＝5.364	t ＝20.185	t ＝21.244	t ＝8.117	t ＝13.544
P值	<0.05	<0.05	<0.05	<0.05	<0.05

表3 清理组术前及术后12个月相关指标的比较[n＝29，(±s)]

时间点	VAS	HSS	IKDC	MPTA	FTA
术前	5.2±1.3	54.3±4.7	45.5±3.5	82.8±2.4	183.1±4.2
术后12个月	1.5±0.4	84.1±3.8	78.1±3.0	90.6±1.8	170.6±3.9
t值	t ＝4.623	t ＝18.876	t ＝19.465	t ＝8.897	t ＝13.217
P值	<0.05	<0.05	<0.05	<0.05	<0.05

表3 清理组术前及术后12个月相关指标的比较[n＝29，(±s)]

时间点	VAS	HSS	IKDC	MPTA	FTA
术前	5.2±1.3	54.3±4.7	45.5±3.5	82.8±2.4	183.1±4.2
术后12个月	1.5±0.4	84.1±3.8	78.1±3.0	90.6±1.8	170.6±3.9
t值	t ＝4.623	t ＝18.876	t ＝19.465	t ＝8.897	t ＝13.217
P值	<0.05	<0.05	<0.05	<0.05	<0.05

表4 两组患者术前及术后12个月相关指标差值的比较(±s)

组别	例数	VAS差值	HSS评分差值	IKDC评分差值	MPTA差值	FTA差值
微骨折组	29	4.3±0.2	33.2±3.6	33.7±1.8	7.6±0.8	12.8±0.9
清理组	29	3.7±0.3	29.8±3.5	32.5±1.6	7.8±0.7	12.6±1.1
t值		2.316	4.063	3.121	1.248	1.614
P值		<0.05	<0.05	<0.05	>0.05	>0.05

表4 两组患者术前及术后12个月相关指标差值的比较(±s)

组别	例数	VAS差值	HSS评分差值	IKDC评分差值	MPTA差值	FTA差值
微骨折组	29	4.3±0.2	33.2±3.6	33.7±1.8	7.6±0.8	12.8±0.9
清理组	29	3.7±0.3	29.8±3.5	32.5±1.6	7.8±0.7	12.6±1.1
t值		2.316	4.063	3.121	1.248	1.614
P值		<0.05	<0.05	<0.05	>0.05	>0.05

图1 典型病例术前术中及术后影像资料。图A为术前右膝关节正侧位X线片；图B为术前双下肢负重位全长X线片，红线示右膝关节内翻畸形；图C为术后双下肢负重位全长X线片，红线示右下肢力线恢复正常；图D为术后半年右膝关节正侧位X线片；图E为关节镜下股骨内侧髁行微骨折术

[1]	Michael JW, Schlüter-Brust KU, Eysel P. The Epidemiology, etiology, diagnosis, and rreatment of osteoarthritis of the knee[J]. Dtsch Arztebl Int, 2010, 107 (9): 152-162.
[2]	Yoshimura N. Cartilage/chondrocyte research and osteoarthritis. Epidemiology of osteoarthritis in Japan[J]. Clin Calcium, 2018, 28(6): 761-766.
[3]	张世峰，金群华．胫骨高位截骨术治疗膝内侧单间室骨关节炎的研究进展[J/CD]．中华老年骨科与康复电子杂志，2018，4(5)：312-316.
[4]	Beaufils P, Becker R, Kopf S, et al. Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus[J]. Knee Surg Sports Traumatol Arthrosc, 2017, 25(2): 335-346.
[5]	Lustig S, Lording T, Frank F, et al. Progression of medial osteoarthritis and long term results of lateral unicompartmental arthroplasty: 10 to 18 year follow-up of 54 consecutive implants[J]. Knee, 2014, 21(1): S26-S32.
[6]	Rodríguez-Merchán EC, Gómez-Cardero P. Unicompartmental knee arthroplasty: current indications, technical issues and results[J]. EFORT Open Rev, 2018, 3(6): 363-373.
[7]	Vasso M, Antoniadis A, Helmy N. Update on unicompartmental knee arthroplasty: current indications and failure modes[J]. EFORT Open Rev, 2018, 3(8): 442-448.
[8]	于沂阳，常恒瑞，张英泽．保膝治疗的研究进展[J/CD]．中华关节外科杂志(电子版)，2017，11(1)：73-77.
[9]	Khan M, Evaniew N, Bedi A, et al. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis[J]. CMAJ, 2014, 186(14): 1057-1064.
[10]	Jarraya M, Roemer FW, Englund M, et al. Meniscus morphology: does tear type matter? A narrative review with focus on relevance for osteoarthritis research[J]. Semin Arthritis Rheum, 2017, 46(5): 552-561.
[11]	Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear[J]. N Engl J Med, 2013, 369(26): 2515-2524.
[12]	Roos EM, Hare KB, Nielsen SM, et al. Better outcome from arthroscopic partial meniscectomy than skin incisions only? A sham-controlled randomised trial in patients aged 35－55 years with knee pain and an MRI-verified meniscal tear[J/OL]. BMJ Open, 2018, 8(2): e019461.doi: 10.1136/bmjopen-2017-019461.
[13]	辛龙，张春，徐卫星，等．膝关节软骨损伤的外科治疗进展[J]．中国骨伤，2018，31(3)：281-285.
[14]	Kim MS, Koh IJ, Choi YJ, et al. Collagen augmentation improves the quality of cartilage repair after microfracture in patients undergoing high tibial osteotomy: a randomized controlled trial[J]. Am J Sports Med, 2017, 45(8): 1845-1855.
[15]	Albright JC, Daoud AK. Microfracture and microfracture plus[J]. Clin Sports Med, 2017, 36(3): 501-507.
[16]	全海祥，康一凡，沈国华，等．关节镜下微骨折术和关节清理术修复膝关节软骨缺失临床疗效对比研究[J]．中国骨与关节损伤杂志，2016，31(10)：1088-1089.
[17]	Hernigou P, Medevielle D, Debeyre J, et al. Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study[J]. J Bone Joint Surg Am, 1987, 69(3): 332-354.
[18]	王兴山，黄野．开放楔形胫骨高位截骨术的研究进展[J/CD]．中华关节外科杂志(电子版)，2016，10(5)：525-529.
[19]	Niemeyer P, Stöhr A, Köhne M, et al. Medial opening wedge high tibial osteotomy[J]. Oper Orthop Traumatol, 2017, 29(4): 294-305.
[20]	Hantes ME, Natsaridis P, Koutalos AA, et al. Satisfactory functional and radiological outcomes can be expected in young patients under 45 years old after open wedge high tibial osteotomy in a long-term follow-up[J]. Knee Surg Sports Traumatol Arthrosc, 2018, 26(11): 3199-3205.
[21]	Bastard C, Mirouse G, Potage D, et al. Return to sports and quality of life after high tibial osteotomy in patients under 60 years of age[J]. Orthop Traumatol Surg Res, 2017, 103(8): 1189-1191.
[22]	Lee OS, Ahn S, Ahn JH, et al. Effectiveness of concurrent procedures during high tibial osteotomy for medial compartment osteoarthritis: a systematic review and meta-analysis[J]. Arch Orthop Trauma Surg, 2018, 138(2): 227-236.
[23]	黄野．胫骨高位截骨术治疗膝关节骨关节炎的现状[J/CD]．中华关节外科杂志(电子版)，2016，10(5)：470-473.
[24]	Day M, Wolf BR. Medial opening-wedge high tibial osteotomy for medial compartment arthrosis/overload[J]. Clin Sports Med, 2019, 38(3): 331-349.
[25]	Yoo MJ, Shin YE. Open wedge high tibial osteotomy and combined arthroscopic surgery in severe medial osteoarthritis and varus malalignment: minimum 5-year results[J]. Knee Surg Relat Res, 2016, 28(4): 270-276.
[26]	Schuster P, Schulz M, Mayer P, et al. Open-wedge high tibial osteotomy and combined abrasion/microfracture in severe medial osteoarthritis and varus malalignment: 5-year results and arthroscopic findings after 2 years[J]. Arthroscopy, 2015, 31(7): 1279-1288.
[27]	Kahlenberg CA, Nwachukwu BU, Hamid KS, et al. Analysis of outcomes for high tibial osteotomies performed with cartilage restoration techniques[J]. Arthroscopy, 2017, 33(2): 486-492.
[28]	向先祥，周焱涛．关节镜下微骨折联合胫骨高位截骨治疗膝内侧关节炎疗效观察[J]．实用骨科杂志，2018，24(1)：71-74.
[29]	Schuster P, Geβlein M, Schlumberger M, et al. Ten-year results of medial open-wedge high tibial osteotomy and chondral resurfacing in severe medial osteoarthritis and varus malalignment[J]. Am J Sports Med, 2018, 46(6): 1362-1370.
[30]	王现海，刘佳超，罗颖，等．关节镜加胫骨高位截骨钢板内固定治疗内翻性膝关节骨关节炎[J/CD]．中华关节外科杂志(电子版)，2016，10(5)：557-561.

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Clinical study of high tibial osteotomy combined with microfracture in treatment of medial unicompartmental knee osteoarthritis

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Clinical study of high tibial osteotomy combined with microfracture in treatment of medial unicompartmental knee osteoarthritis