计算机导航胫骨高位截骨联合关节镜的短期疗效

doi:10.3877/cma.j.issn.1674-134X.2020.05.006

目的

观察计算机导航辅助下胫骨高位截骨(HTO)联合关节镜治疗胫骨内翻畸形的临床疗效。

方法

本回顾性研究收集了2018年11月至2019年1月在上海长海医院接受治疗的20例膝内翻畸形合并内侧间室骨关节炎的患者，男性7例，女性13例。纳入标准：膝关节内侧间室骨关节炎，症状局限于膝内侧；膝关节内翻畸形，且胫骨近端内翻畸形。排除标准：膝关节外侧间室骨关节炎；外侧半月板损伤或有手术史；膝关节屈曲挛缩>10°；严重肥胖。手术方式为计算机导航辅助下开放楔形胫骨高位截骨联合关节镜手术。测量术前、目标及术后的机械胫股角(mTFA)、胫骨近端内侧角(MPTA)、关节线会聚角(JLCA)，测量术前及术后的Lysholm评分及美国特种外科医院(HSS)膝关节评分，进行配对t检验及Mann-Whitney U检验。

结果

本组20例患者，平均年龄(55±7)岁，平均随访(11±3)个月。术后mTFA、MPTA、JLCA及力线位置均较术前显著改善。术后Lysholm评分与HSS评分均高于术前[67(60，75) vs. 51(46，61)(Z＝-4.22，P<0.001)，67(59，71)vs. 55(49，59)(Z＝-3.64，P<0.001)]；术后mTFA、力线位置、矫正角度及撑开高度与术前规划目标无差异统计学意义(P>0.05)。关节镜探查发现6例患者伴有内侧半月板撕裂(其中2例患者为内侧半月板后脚根部撕裂)，5例存在内侧肥厚或纤维化的滑膜皱襞，4例股骨内侧髁明显骨赘增生，均予以相应处理。

结论

计算机导航辅助下胫骨高位截骨能获得与术前力线矫正计划一致的精确性；关节镜探查时处理关节内半月板、滑膜及骨赘增生等病理性改变，改善内侧间室的局部环境，是提高胫骨高位截骨术疗效必要的操作。

关键词: 胫骨, 截骨术, 膝关节, 关节镜

Objective

To observe the efficacyof computer-navigation-assisted high tibial osteotomy (HTO) combined with arthroscopy for genu varum.

Methods

This retrospective study collected 20 cases, including seven males and 13 females of genu varum with medial compartment osteoarthritis treated in Shanghai Changhai Hospital from November 2018 to January 2019. Inclusive criteria: medial compartment osteoarthritis of knee joint, varus deformity of knee joint and varus deformity of proximal tibia. Exclusion criteria: lateral compartment osteoarthritis of knee joint, lateral meniscus injury or operation history, knee flexion contracture > 10 °, severe obesity. The surgical method was computer-navigation-assisted open-wedge high tibial osteotomy combined with arthroscopic surgery. Mechanical tibial femoral angle (mTFA), proximal tibial medial angle (MPTA), weight-bearing line distribution, joint line convergence angle (JLCA) were measured before and after operation as well as pre-operationgoal. Lysholm score and Hospital for Special Surgery (HSS) score were measured before and after operation. Paired t test and Mann-Whitney test were performed.

Results

The average age of 20 patients was(55±7)years, and the average follow-up time was (11±3)months. MTFA, MPTA, JLCA and weight-bear-line position were significantly improved after operation. Both Lysholm score and HSS score were higher than those before surgery[67(60, 75) vs. 51(46, 61)(Z=-4.22, P<0.001), 67(59, 71)vs. 55(49, 59)(Z=-3.64, P<0.001)]. The differences in postoperative mTFA, correction angle and distraction height were not statistically significant comparing with the preoperative targets (P>0.05). Arthroscopic examination revealed six patients with medial meniscus tear, two patients with medial meniscus posterior foot root tear, three patients with intercondylar fossa osteophyte or ACL degeneration.

Conclusion

The computer-navigation-assisted high tibial osteotomy has satisfactory accuracy and arthroscopic surgery is an indispensable part of high tibial osteotomy.

Key words: Tibia, Osteotomy, Knee joint, Arthroscopes

图2 导航下术前力线与全长片对比。左图导航下肢力线位置22%，mTFA8°(内翻记为负数而外翻记为正数)；右图为术前双下肢全长片，示力线位置与导航显示一致

表1 术前与术后放射学参数比较(±s)

组别	例数	MPTA(°)	mTFA(°)	力线位置(%)	JLCA(°)
术前	20	83.5±2.5	-8.3±2.9	10.1±13.9	3.0±2.1
术后	20	92.6±2.5	2.6±1.5	59.2±5.5	1.6±1.0
t值		16.6	13.2	13.3	2.8
P值		<0.001	<0.001	<0.001	<0.05

表1 术前与术后放射学参数比较(±s)

组别	例数	MPTA(°)	mTFA(°)	力线位置(%)	JLCA(°)
术前	20	83.5±2.5	-8.3±2.9	10.1±13.9	3.0±2.1
术后	20	92.6±2.5	2.6±1.5	59.2±5.5	1.6±1.0
t值		16.6	13.2	13.3	2.8
P值		<0.001	<0.001	<0.001	<0.05

表2 术前目标与术后放射学参数比较(±s)

组别	例数	MPTA(°)	mTFA(°)	力线位置(%)	矫正角度(°)	撑开高度(mm)
目标	20	94.30±3.49	2.93±0.29	61.65±0.80	11.78±3.14	13.00±3.36
术后	20	92.55±2.53	2.58±1.51	59.19±5.45	11.10±2.29	12.10±2.21
t值		2.33	1.11	2.00	1.58	1.91
P值		<0.05	>0.05	>0.05	>0.05	>0.05

表2 术前目标与术后放射学参数比较(±s)

组别	例数	MPTA(°)	mTFA(°)	力线位置(%)	矫正角度(°)	撑开高度(mm)
目标	20	94.30±3.49	2.93±0.29	61.65±0.80	11.78±3.14	13.00±3.36
术后	20	92.55±2.53	2.58±1.51	59.19±5.45	11.10±2.29	12.10±2.21
t值		2.33	1.11	2.00	1.58	1.91
P值		<0.05	>0.05	>0.05	>0.05	>0.05

图4 关节镜显示内侧半月板后脚根部断裂

表3 HSS评分和Lysholm评分术前与术后的对比[M(P₂₅，P₇₅)]

组别	例数	HSS评分	Lysholm评分
术前	20	55(49，59)	51(46，61)
术后	20	67(59，71)	67(60，75)
Z值		-3.64	-4.22
P值		<0.001	<0.001

表3 HSS评分和Lysholm评分术前与术后的对比[M(P₂₅，P₇₅)]

组别	例数	HSS评分	Lysholm评分
术前	20	55(49，59)	51(46，61)
术后	20	67(59，71)	67(60，75)
Z值		-3.64	-4.22
P值		<0.001	<0.001

图5 术后矫正准确性散点图，示术后20例患者中有18例患者术后mTFA位于(3±2)°范围，这些患者力线位置分布在52.5%～65%

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Short term efficacy of computer-navigation-assisted high tibial osteotomy combined with arthroscope

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Short term efficacy of computer-navigation-assisted high tibial osteotomy combined with arthroscope