后交叉韧带保留型膝关节置换治疗外翻膝的技术及结果

doi:10.3877/cma.j.issn.1674-134X.2021.05.004

目的

探索后交叉韧带保留型(CR)膝关节置换(TKA)治疗膝关节外翻畸形的手术技术并评估短期结果。

方法

回顾性分析自2017年4月至2020年10月在上海长海医院接受CR TKA的外翻膝患者，排除非同一主刀医生或有重要参数缺失的患者，最终纳入28例，均采用保留骨岛的手术技术。测量髋-膝-踝角(HKA)和股骨胫骨解剖轴夹角(AVA)等角度，对外翻膝分型，记录手术前后活动度、西安大略和麦克马斯特大学(WOMAC)功能评分以及术中后交叉韧带(PCL)保留情况，对CR TKA手术结果进行评估，对符合正态分布的术前术后比较采用配对样本t检验；对不符合正态分布的采用配对秩和检验。

结果

平均随访(14±12)个月，无翻修病例。按Keblish分型，轻度外翻13例(46.4%)，中度外翻15例(53.6%)。术后HKA均在±3°以内，恢复中立位对线。术后WOMAC评分(45±12)，较术前降低，差异有统计学意义(t＝11.788，P<0.001)；术后膝关节最大屈曲角度133°(116°，140°)，较术前增加，差异有统计学意义(Z＝-4.383，P<0.001)；在不同外翻程度、性别、年龄、身体质量指数(BMI)、假体等亚组中，术前术后差异也均具有统计学意义(均为P<0.05)。术中PCL胫骨止点撕脱骨折1例，PCL松解2例，其术后功能评分及活动度均良好。

结论

从短期结果来看，CR TKA治疗膝关节外翻畸形具有充分的可行性，可恢复中立位对线，能获得良好的术后活动度及功能评分。但重度外翻膝以及远期结果仍有待进一步证实。术中对PCL的保留是关键，采用保留骨岛等方法可明显提高PCL保留率。

关键词: 关节成形术，置换，膝, 膝关节，人工, 外科手术, 治疗结果

Objective

To explore the surgical procedures of posterior cruciate-retaining (CR) total knee arthroplasty (TKA) for the treatment of knee valgus deformity and evaluate the short-term outcomes.

Methods

A retrospective study was carried out to analyze all the cases of CR TKA for valgus knee in Shanghai Changhai Hospital from April 2017 to October 2020, excluding patients who were not the same surgeon or patients with missing important parameters. Finally 28 cases were included. The valgus knees were classified by the hip-knee-ankle(HKA)and anatomic valgus angulation (AVA)angles. The range of motion, Western Ontario and McMaster Universities osteoarthritis index (WOMAC)function score and intraoperative posterior cruciate ligament(PCL)retention were recorded pre- and post-operation. The outcomes of CR TKA were evaluated. Paired sample t test was used to compare those with normal distribution before and after operation, and paired rank sum test was used to those who did not conform to normal distribution.

Results

The mean follow-up time was (14±12)months. There was no revision case. According to Keblish classification, mild valgus was found in 13 cases (46.4%) and moderate valgus in 15 cases (53.6%). All the alignments were neutrally restored within HKA±3 ° after operation. The postoperative WOMAC score was (45±12), which was significantly lower than that before operation (t=11.788, P<0.001), and the maximum flexion angle of knee joint after operation was 133(116, 140)°, which was significantly larger than that before and after operation (Z=-4.383, P<0.001). There were also significant differences between the pre- and post-operation data in different valgus, sex, age, body mass index(BMI) and prosthesis subgroups(all P<0.05). There was one case of tibial avulsion fracture and two cases of PCL release during the operation, but the outcomes were good.

Conclusions

From the short-term outcomes, CR TKA is feasible in the treatment of valgus deformity of the knee, which can restore neutral alignment and obtain good postoperative range of motion and function score. However, the severe valgus knee and the long-term outcomes should be further confirmed. The retention of PCL during operation is the key, and the retention rate of PCL can be significantly improved by using methods such as bone island preservation.

Key words: Arthroplasty, replacement, knee, Knee prosthesis, Surgical procedures, Treatment outcome

图1 术中对PCL的保护。图A为患者术前负重位双下肢全长X片，并分别标示出股骨和胫骨的解剖轴，a点为股骨开髓点，即股骨解剖轴与股骨髁的交点；图B为膝关节脱位后对PCL的保护；图C为对PCL胫骨止点的骨岛进行初步成形；图D所示胫骨平台截骨后PCL保存完好；图E所示安装假体后PCL保存依然完好；图F为患者术后负重位双下肢全长X片，标示红线为下肢机械轴，可见基本恢复中立位对线

图2 术前术后WOMAC(西安大略和麦克马斯特大学)功能评分

图3 术前术后最大屈曲角度

表1 各亚组手术前后WOMAC评分差异(±s)

分类	亚组	例数	术前	术后	t值	P值
Keblish分型	轻度	13	85±14	49±12	8.010	<0.001
	中度	15	89±16	42±11	9.260	<0.001
性别	男	9	92±11	45±11	8.636	<0.001
	女	19	85±16	46±12	8.699	<0.001
年龄	<70岁	11	83±11	45±10	7.515	<0.001
	≥70岁	17	90±17	45±13	9.176	<0.001
BMI	<24 kg/m²	12	89±15	50±9	7.098	<0.001
	≥24 kg/m²	16	85±15	42±13	9.236	<0.001
假体	ATTUNE	8	84±17	42±11	5.482	0.001
	LEGION	20	88±14	47±12	10.326	<0.001

表1 各亚组手术前后WOMAC评分差异(±s)

分类	亚组	例数	术前	术后	t值	P值
Keblish分型	轻度	13	85±14	49±12	8.010	<0.001
	中度	15	89±16	42±11	9.260	<0.001
性别	男	9	92±11	45±11	8.636	<0.001
	女	19	85±16	46±12	8.699	<0.001
年龄	<70岁	11	83±11	45±10	7.515	<0.001
	≥70岁	17	90±17	45±13	9.176	<0.001
BMI	<24 kg/m²	12	89±15	50±9	7.098	<0.001
	≥24 kg/m²	16	85±15	42±13	9.236	<0.001
假体	ATTUNE	8	84±17	42±11	5.482	0.001
	LEGION	20	88±14	47±12	10.326	<0.001

表2 各亚组中手术前后最大屈曲角度的差异(°)

分类	亚组	例数	术前	术后	统计值	P值
Keblish分型	轻度(±s)	13	105±14	128±9	t＝-5.035	<0.001
	中度[M(P₂₅，P₇₅)]	15	110(95，115)	135(115，140)	Z＝-3.305	0.001
性别	男性(±s)	9	106±13	126±12	t＝-4.243	0.003
	女性(±s)	19	106±13	130±9	t＝-7.071	<0.001
年龄	<70岁(±s)	11	112±14	129±10	t＝-3.450	0.006
	≥70岁[M(P₂₅，P₇₅)]	17	105(95，110)	135(117，140)	Z＝-3.634	<0.001
BMI	<24 kg/m²(±s)	12	100±11	125±11	t＝-5.623	<0.001
	≥24 kg/m² [M(P₂₅，P₇₅)]	16	110(101，120)	135(121，140)	Z＝-3.308	0.001
假体	ATTUNE [M(P₂₅，P₇₅)]	8	115(110，124)	137(127，140)	Z＝-2.388	0.017
	LEGION(±s)	20	103±13	127±10	t＝-6.951	<0.001

表2 各亚组中手术前后最大屈曲角度的差异(°)

分类	亚组	例数	术前	术后	统计值	P值
Keblish分型	轻度(±s)	13	105±14	128±9	t＝-5.035	<0.001
	中度[M(P₂₅，P₇₅)]	15	110(95，115)	135(115，140)	Z＝-3.305	0.001
性别	男性(±s)	9	106±13	126±12	t＝-4.243	0.003
	女性(±s)	19	106±13	130±9	t＝-7.071	<0.001
年龄	<70岁(±s)	11	112±14	129±10	t＝-3.450	0.006
	≥70岁[M(P₂₅，P₇₅)]	17	105(95，110)	135(117，140)	Z＝-3.634	<0.001
BMI	<24 kg/m²(±s)	12	100±11	125±11	t＝-5.623	<0.001
	≥24 kg/m² [M(P₂₅，P₇₅)]	16	110(101，120)	135(121，140)	Z＝-3.308	0.001
假体	ATTUNE [M(P₂₅，P₇₅)]	8	115(110，124)	137(127，140)	Z＝-2.388	0.017
	LEGION(±s)	20	103±13	127±10	t＝-6.951	<0.001

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Surgical procedures and outcomes of cruciate-retaining total knee arthroplasty in treatment of valgus deformity of knee

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Surgical procedures and outcomes of cruciate-retaining total knee arthroplasty in treatment of valgus deformity of knee