胫骨高位截骨术治疗膝内侧间室骨关节炎的疗效分析

doi:10.3877/cma.j.issn.1674-134X.2021.01.006

目的

探讨内侧开放式胫骨高位截骨术治疗膝关节内侧骨关节炎的临床疗效。

方法

选取2016年1月至2019年2月于暨南大学附属第一医院骨关节科诊断为膝内侧骨关节炎并行内侧开放式胫骨高位截骨术的患者56例(64膝)。纳入标准：膝关节内侧间室骨关节炎；合并胫骨侧内翻畸形。排除标准：炎症性、感染性关节炎；多间室的关节退变；膝关节活动度<90°；屈曲畸形>10°。采用HSS评分、VAS评分，评价手术前后膝关节功能和疼痛的改善情况，通过测量胫股角(FTA)、胫骨近端内侧角(MPTA)、胫骨内翻角(KVA)、下肢负重线比率(WBL)，评价术后膝内翻的矫正效果。各时间点评分及测量值采用重复测量方差分析，各时间点间比较采用WSC检验，两两比较采用LSD检验。

结果

术后切口均获Ⅰ期愈合。5例出现截骨旋转轴无移位骨折，推迟负重后愈合；10例出现明显的小腿肿胀、皮下瘀斑，对症处理后缓解。所有患者均获随访，平均随访(15±3)个月。随访中未见内固定失败、骨延迟愈合或不愈合。术后3、6、12个月随访时，患者HSS评分较术前均明显增高(F＝312.7，P<0.05)；VAS评分与术前相较均降低(F＝185.6，P<0.05)。影像学检查指标中，术后FTA(t＝3.2)、MPTA(t＝6.3)、KVA(t＝5.8)及WBL(t＝2.7)均获得改善，与术前比较，内翻畸形获得矫正(均P<0.05)。

结论

内侧开放式胫骨高位截骨术通过矫正下肢力线，缓解关节疼痛、改善关节功能，对于合并胫骨内翻的膝骨关节炎有较好疗效。

关键词: 截骨术, 骨关节炎, 胫骨, 膝关节, 治疗效果

Objective

To investigate the clinical effect of open wedge high tibial osteotomy(OWHTO)in the treatment of medial compartment osteoarthritis (MCOA) of the knee.

Methods

A total of 56 patients (64 knees) with MCOA diagnosed in the Department of orthopedics, the First Affiliated Hospital of Jinan University were included in this study. All the cases underwent OWHTO, from January, 2016 to Febrary, 2019. Inclusion criteria: medial compartment osteoarthritis of knee joint; complicated with tibial varus deformity. Exclusion criteria: inflammatory and infectious arthritis, joint degeneration in multiple compartments, range of motion of knee joint<90°, flexion deformity>10°.The knee function and pain were evaluated by the visual analogue score (VAS) and Hospital for Special Surgery (HSS) score before and after surgery. The correction effect of postoperative knee varus was evaluated by femorotibial angle (FTA), medial proximal tibial angle (MPTA), knee varus angle (KVA), and weight-bearing line ratio of lower limbs (WBL). The scores and measured values were analyzed by repeated measurement analysis of variance, WSC test was used for comparison between each follow-up visit, and LSD test was used for pairwise comparison.

Results

All the incisions healed by first intention after operation. The lateral hinge undisplaced fracture occurred in five cases, which were healed by delayed weight bearing. Swelling and ecchymoses in leg occurred in 10 cases, which disappeared after symptomatic treatment. All the patients were followed up for an average of (15±3) months. During the follow-up, there was no failure of internal fixation, delayed union or nonunion of bone. At the follow-up of three, six and 12 months, the HSS scores of the patients were significantly higher than those before the operation(F=312.7, P<0.05). The VAS scores of the cases were significantly lower than those before the operation(F=185.6, P<0.05). Among the imaging indexes, FTA(t=3.2), MPTA(t=6.3), KVA(t=5.8)and WBL(t=2.7) were improved after operation. Compared with those before operation, varus deformity was corrected (all P<0.05).

Conclusion

OWHTO has a good effect in the treatment of medial compartment osteoarthritis of knee joint with varus deformity by correcting the mechanical alignment of lower extremities, alleviating pain and improving knee joint function.

Key words: Osteotomy, Osteoarthritis, Tibia, Knee joint, Treatment outcome

表1 HTO手术前后患者VAS和HSS评分比较[n＝64，(±s)]

时间	VAS评分	HSS评分
时间	VAS评分	疼痛	功能	活动度	肌力	屈曲畸形	稳定性	总分
术前	6.8±1.3^a	12.7±1.3^a	11.8±3.8^a	13.3±2.9^a	7.8±3.5^a	5.6±0.3^a	5.2±0.5^a	60.3±5.7^a
术后3月	3.5±2.4^b	20.1±2.9^b	16.3±3.1^b	15.5±4.3^b	8.6±1.3^b	8.6±0.5^b	7.8±0.7^b	81.7±4.9^b
术后6月	2.6±1.7^b	23.3±1.3^b	18.1±2.1^b	16.2±2.4^b	8.9±1.5^b	8.8±0.3^b	8.2±0.8^b	85.2±5.8^b
术后12月	1.8±1.1^b	23.9±1.2^b	18.4±1.5^b	16.6±1.1^b	8.8±1.1^b	8.9±0.9^b	8.1±0.3^b	85.4±3.2^b
F值	185.6	199.6	187.1	324.1	234.9	198.4	122.7	312.7
P值	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

表1 HTO手术前后患者VAS和HSS评分比较[n＝64，(±s)]

时间	VAS评分	HSS评分
时间	VAS评分	疼痛	功能	活动度	肌力	屈曲畸形	稳定性	总分
术前	6.8±1.3^a	12.7±1.3^a	11.8±3.8^a	13.3±2.9^a	7.8±3.5^a	5.6±0.3^a	5.2±0.5^a	60.3±5.7^a
术后3月	3.5±2.4^b	20.1±2.9^b	16.3±3.1^b	15.5±4.3^b	8.6±1.3^b	8.6±0.5^b	7.8±0.7^b	81.7±4.9^b
术后6月	2.6±1.7^b	23.3±1.3^b	18.1±2.1^b	16.2±2.4^b	8.9±1.5^b	8.8±0.3^b	8.2±0.8^b	85.2±5.8^b
术后12月	1.8±1.1^b	23.9±1.2^b	18.4±1.5^b	16.6±1.1^b	8.8±1.1^b	8.9±0.9^b	8.1±0.3^b	85.4±3.2^b
F值	185.6	199.6	187.1	324.1	234.9	198.4	122.7	312.7
P值	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

表2 HTO手术前后患者影像学检查指标比较[n＝64，(±s)]

时间	FTA(°)	MPTA(°)	KVA(°)	WBL(%)
术前	188.2±4.6^a	80.2±3.1^a	11.3±2.1^a	23.8±4.1^a
术后3月	170.9±4.5^b	95.5±2.1^b	1.9±2.6^b	62.3±5.7^b
术后6月	171.2±3.3^b	95.2±1.9^b	2.2±1.5^b	62.1±4.3^b
术后12月	171.4±2.1^b	94.5±1.1^b	2.5±1.4^b	61.9±4.2^b
F值	216.2	186.4	345.1	291.5
P值	<0.001	<0.001	<0.001	<0.001

表2 HTO手术前后患者影像学检查指标比较[n＝64，(±s)]

时间	FTA(°)	MPTA(°)	KVA(°)	WBL(%)
术前	188.2±4.6^a	80.2±3.1^a	11.3±2.1^a	23.8±4.1^a
术后3月	170.9±4.5^b	95.5±2.1^b	1.9±2.6^b	62.3±5.7^b
术后6月	171.2±3.3^b	95.2±1.9^b	2.2±1.5^b	62.1±4.3^b
术后12月	171.4±2.1^b	94.5±1.1^b	2.5±1.4^b	61.9±4.2^b
F值	216.2	186.4	345.1	291.5
P值	<0.001	<0.001	<0.001	<0.001

图1 右膝内侧间室关节炎合并胫骨内翻畸形行OWHTO(开放式胫骨高位截骨术)治疗前后X线正位片。图A为术前，示胫骨内翻畸形；图B为术后3个月，示胫骨内翻已矫正，手术截骨面由外向内开始愈合，骨痂生成；图C为术后12个月，示截骨面已完全愈合；图D为术后12个月拆除内固定术后，示原手术截骨面已愈合，胫骨内翻已矫正

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Effect analysis of high tibial osteotomy for treatment of knee medial compartment osteoarthritis

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Effect analysis of high tibial osteotomy for treatment of knee medial compartment osteoarthritis