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%

[1]	Ruangsomboon P, Chareancholvanich K, Harnroongroj T, et al. Survivorship of medial opening wedge high tibial osteotomy in the elderly: two to ten years of follow up[J]. Int Orthop, 2017, 41(10): 2045-2052.
[2]	Lee OS, Ahn S, Lee YS. Effect and safety of early weight-bearing on the outcome after open-wedge high tibial osteotomy: a systematic review and meta-analysis[J]. Arch Orthop Trauma Surg, 2017, 137(7): 903-911.
[3]	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.
[4]	Jacobi M, Villa V, Reischl N, et al. Factors influencing posterior tibial slope and tibial rotation in opening wedge high tibial osteotomy[J]. Knee Surg Sports Traumatol Arthrosc, 2015, 23(9): 2762-2768.
[5]	Schallberger A, Jacobi M, Wahl P, et al. High tibial valgus osteotomy in unicompartmental medial osteoarthritis of the knee: a retrospective follow-up study over 13-21 years[J]. Knee Surg Sports Traumatol Arthrosc, 2011, 19(1): 122-127.
[6]	Lobenhoffer P, Agneskirchner JD. Improvements in surgical technique of valgus high tibial osteotomy[J]. Knee Surg Sports Traumatol Arthrosc, 2003, 11(3): 132-138.
[7]	Bode G, Von Heyden J, Pestka J, et al. Prospective 5-year survival rate data following open-wedge valgus high tibial osteotomy[J]. Knee Surg Sports Traumatol Arthrosc, 2015, 23(7): 1949-1955.
[8]	Yan J, Musahl V, Kay J, et al. Outcome reporting following navigated high tibial osteotomy of the knee: a systematic review[J]. Knee Surg Sports Traumatol Arthrosc, 2016, 24(11): 3529-3555.
[9]	Akamatsu Y, Kobayashi H, Kusayama Y, et al. Comparative study of opening-wedge high tibial osteotomy with and without a combined computed tomography-based and image-free navigation system[J]. Arthroscopy, 2016, 32(10): 2072-2081.
[10]	Chang J, Scallon G, Beckert M, et al. Comparing the accuracy of high tibial osteotomies between computer navigation and conventional methods[J]. Comput Assist Surg (Abingdon), 2017, 22(1): 1-8.
[11]	Nha KW, Shin YS, Kwon HM, et al. Navigated versus conventional technique in high tibial osteotomy: a meta-analysis focusing on weight bearing effect[J]. Knee Surg Relat Res, 2019, 31(2): 81-102.
[12]	Schröter S, Ihle C, Elson DW, et al. Surgical accuracy in high tibial osteotomy: coronal equivalence of computer navigation and gap measurement[J]. Knee Surg Sports Traumatol Arthrosc, 2016, 24(11): 3410-3417.
[13]	Kim SJ, Koh YG, Chun YM, et al. Medial opening wedge high-tibial osteotomy using a kinematic navigation system versus a conventional method: a 1-year retrospective, comparative study[J]. Knee Surg Sports Traumatol Arthrosc, 2009, 17(2): 128-134.
[14]	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.
[15]	Reising K, Strohm PC, Hauschild O, et al. Computer-assisted navigation for the intraoperative assessment of lower limb alignment in high tibial osteotomy can avoid outliers compared with the conventional technique[J]. Knee Surg Sports Traumatol Arthrosc, 2013, 21(1): 181-188.
[16]	Bae DK, Ko YW, Kim SJ, et al. Computer-assisted navigation decreases the change in the tibial posterior slope angle after closed-wedge high tibial osteotomy[J]. Knee Surg Sports Traumatol Arthrosc, 2016, 24(11): 3433-3440.
[17]	Na YG, Eom SH, Kim SJ, et al. The use of navigation in medial opening wedge high tibial osteotomy can improve tibial slope maintenance and reduce radiation exposure[J]. Int Orthop, 2016, 40(3): 499-507.
[18]	Smith JO, Wilson AJ, Thomas NP. Osteotomy around the knee: evolution, principles and results[J]. Knee Surg Sports Traumatol Arthrosc, 2013, 21(1): 3-22.
[19]	Kuriyama S, Watanabe M, Nakamura S, et al. Classical target coronal alignment in high tibial osteotomy demonstrates validity in terms of knee kinematics and kinetics in a computer model[J]. Knee Surg Sports Traumatol Arthrosc, 2020, 28(5): 1568-1578.
[20]	Dugdale TW, Noyes FR, Styer D. Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length[J]. Clin Orthop Relat Res, 1992, (274)：248-264.
[21]	Kim CW, Lee CR, Seo SS, et al. Clinical efficacy of an arthroscopic surgery in open wedge high tibial osteotomy[J]. J Knee Surg, 2017, 30(4): 352-358.
[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]	Murayama K, Nakayama H, Murakami T, et al. The effect of concomitant arthroscopic lateral retinacular release on postoperative patellar position and orientation in open wedge high tibial osteotomy[J]. Knee Surg Relat Res, 2018, 30(3): 241-246.
[24]	Freitag J, Norsworthy C, Wickham J, et al. High tibial osteotomy in combination with arthroscopic abrasion arthroplasty and autologous adipose-derived mesenchymal stem cell therapy in the treatment of advanced knee osteoarthritis[J/OL]. BMJ Case Rep, 2019, 12(2): e228003. doi: 10.1136/bcr-2018-228003.

[1]	欧阳剑锋, 李炳权, 叶永恒, 胡少宇, 向阳. 关节镜联合富血小板血浆治疗粘连性肩周炎的疗效[J]. 中华关节外科杂志(电子版), 2023, 17(06): 765-772.
[2]	刘瀚忠, 黄生辉, 万俊明, 李家春, 舒涛. 髌上入路和髌旁外侧入路髓内钉治疗胫骨骨折疗效比较[J]. 中华关节外科杂志(电子版), 2023, 17(06): 795-801.
[3]	罗旺林, 杨传军, 许国星, 俞建国, 孙伟东, 颜文娟, 冯志. 开放性楔形胫骨高位截骨术不同植入材料的Meta分析[J]. 中华关节外科杂志(电子版), 2023, 17(06): 818-826.
[4]	樊绪国, 赵永刚, 杨砚伟. 腓骨在膝骨关节炎作用的研究观点[J]. 中华关节外科杂志(电子版), 2023, 17(06): 855-859.
[5]	夏传龙, 迟健, 丛强, 连杰, 崔峻, 陈彦玲. 富血小板血浆联合关节镜治疗半月板损伤的临床疗效[J]. 中华关节外科杂志(电子版), 2023, 17(06): 877-881.
[6]	李善武, 叶永杰, 王兵, 王子呓, 银毅, 孙官军, 张大刚. 胫骨高位截骨与单髁置换的早期疗效比较[J]. 中华关节外科杂志(电子版), 2023, 17(06): 882-888.
[7]	肖志满, 龚煜, 谢景凌, 刘斌伟. 上下肢关节镜手术后患者下肢深静脉血栓发生的对比研究[J]. 中华关节外科杂志(电子版), 2023, 17(05): 601-606.
[8]	杨国栋, 张辉, 郭珈, 曲迪, 张静, 戚超. 外侧半月板后角撕裂是否修复的术后疗效对比[J]. 中华关节外科杂志(电子版), 2023, 17(05): 619-624.
[9]	夏效泳, 王立超, 朱治国, 丛云海, 史宗新. 深度塌陷性胫骨平台骨折的形态特点和治疗策略[J]. 中华关节外科杂志(电子版), 2023, 17(05): 625-632.
[10]	张中斌, 付琨朋, 朱凯, 张玉, 李华. 胫骨高位截骨术与富血小板血浆治疗膝骨关节炎的疗效[J]. 中华关节外科杂志(电子版), 2023, 17(05): 633-641.
[11]	马鹏程, 刘伟, 张思平. 股骨髋臼撞击综合征关节镜手术中闭合关节囊的疗效影响[J]. 中华关节外科杂志(电子版), 2023, 17(05): 653-662.
[12]	吴香敏, 吴鹏. 超声引导下收肌管阻滞联合腘动脉与膝关节后囊间隙阻滞在老年患者全膝关节置换术中的应用效果[J]. 中华损伤与修复杂志(电子版), 2023, 18(06): 516-522.
[13]	中华医学会骨科分会关节学组. 中国髋、膝关节置换日间手术围手术期管理专家共识[J]. 中华老年骨科与康复电子杂志, 2023, 09(06): 321-332.
[14]	邱红生, 林树体, 梁朝莹, 劳世高, 何荷. 模拟现实步态训练对膝关节前交叉韧带损伤的功能恢复及对跌倒恐惧的影响[J]. 中华老年骨科与康复电子杂志, 2023, 09(06): 343-350.
[15]	付庆鹏, 邓晓强, 高伟, 姜福民, 范永峰, 吴海贺, 齐岩松, 包呼日查, 徐永胜. 新型股骨测量定位器在全膝关节置换术中的临床应用[J]. 中华临床医师杂志(电子版), 2023, 17(9): 980-987.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

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

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

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