开放楔形胫骨高位截骨术不同程度矫正内翻畸形的比较

doi:10.3877/cma.j.issn.1674-134X.2022.03.007

目的

研究开放楔形胫骨高位截骨术(OWHTO)后过度矫正内翻畸形的并发症发生情况和临床疗效，并通过放射学指标比较髋关节、髌股关节与踝关节的代偿性变化。

方法

回顾性分析2016年1月至2020年5月期间在青岛大学附属医院行OWHTO治疗的63例患者的资料，纳入标准为诊断明确、有症状的膝骨关节炎伴内翻畸形，排除双侧手术、术前有膝关节感染及既往外伤史的患者。根据术后测量承重线比率(WBLR)，将所有患者分为正常矫正组52例(50%<WBLR<67%)和过度矫正组11例(WBLR≥67%)，测量两组患者术前及末次随访髋-膝-踝角(HKA)、胫骨近端内侧角(MPTA)、股骨远端外侧角(LDFA)、关节线会聚角(JLCA)、胫骨后倾角(PTS)评价术后下肢力线矫正疗效，测量髋外展角(HAA)、胫骨倾斜角(TPI)、距骨倾斜角(TIA)、Caton-Deschamps指数、髌骨外侧倾斜角(LPT)、髌骨外移距离(LPS)、髌股关节内侧间隙、髌骨外侧间隙评价两组患者术后临近关节的代偿性变化。随访术前及末次随访患膝的美国特种外科医院评分(HSS评分)、西安大略和麦克马斯特大学骨关节炎指数(WOMAC评分)，计量资料组间比较采用独立样本t检验。末次随访两组患者并发症发生情况，比较采用卡方检验。

结果

过度矫正组术后并发症发生4例，发生率36.4%，正常矫正组术后并发症发生4例，发生率11.5%，两组比较差异有统计学意义(χ²＝4.395，P＝0.036)。在OWHTO后，比较两组患者末次HKA和MPTA，差异有统计学意义(t＝6.586、3.709，均为P<0.001)，比较末次随访两组患者HAA，差异有统计学意义(t＝-2.309，P＝0.026)。其余影像学指标比较，差异均无统计学意义(均为P>0.05)。两组患者HSS评分、WOMAC评分末次随访比较，两组患者差异无统计学意义。

结论

过度矫正内翻畸形(术后WBLR≥67%)不影响OWHTO后早期的临床效果，但增加了术后并发症的发生率，从影像学上，引起髋关节代偿性的内收加剧。

关键词: 骨关节炎, 截骨术, 胫骨, 膝关节, 髋关节

Objective

To study the complications and clinical outcomes of overcorrection of varus deformity by open wedge high tibial osteotomy (OWHTO), and to compare the compensatory changes of hip joint, patellofemoral joint and ankle joint by radiological indexes.

Methods

The data of 63 patients who underwent OWHTO in the Affiliated Hospital of Qingdao University from January 2016 to May 2020 were retrospectively analyzed. Inclusion criteria: definite diagnosis, symptomatic knee osteoarthritis with varus deformity. Exclusion criteria: patients with bilateral surgeries, knee infection, and previous history of trauma. According to the postoperative measured weight-bearing line ratio (WBLR), all the patients were divided into the normal correction group (n=52) (50%<WBLR<67%) and the overcorrection group (n=11) (WBLR≥67%). The hip knee-ankle angle (HKA), medial tibial angle (MPTA), lateral distal femoral angle (LDFA), joint line convergence angle (JLCA) and posterior tibial slope angle (PTS) were measured to evaluate the efficacy of postoperative lower limb alignment correction. The hip abduction angle (HAA), tibial slope angle (TPI), distant inclination angle (TIA), Caton-Deschamps index, lateral patellar inclination angle (LPT), patellar lateral migration distance (LPS), medial patellofemoral joint space and lateral patellar space were measured to evaluate the compensatory changes of adjacent joints after operation. The Hospital for Special Surgery (HSS) score, Western Ontario and McMaster Universities arthritis index (WOMAC) of the affected knee were followed up. The measurement data were analyzed by t test. The incidence of complications in the two groups was followed up and compared by chi square test.

Results

The postoperative complications occurred in four cases (36.4%) in the overcorrection group; postoperative complications occurred in four cases (11.5%) in the normal correction group; the difference was statistically significant between the two groups (χ²=4.395, P=0.036). After OWHTO, the differences in HKA and MPTA between the two groups were statistically significant (t=6.586, 3.709, both P < 0.001), and the differences in HAA between the two groups had statistical significance (t=-2.309, P=0.026). There was no statistically significant difference in other imaging parameters (all P>0.05). There was no statistically significant difference in HSS score or WOMAC score between the two groups(all P>0.05).

Conclusion

Overcorrection of varus deformity (postoperative WBLR≥ 67%) does not affect clinical outcomes within two years after OWHTO, but may increase the incidence of postoperative complications and radiologically increase compensatory hip adductions.

Key words: Osteoarthritis, Osteotomy, Tibia, Knee, Hip

图1 下肢力线影像学指标测量。图A为HKA(髋-膝-踝角)；图B为WBLR(承重线比率)；图C为PTS(胫骨后倾)

图2 下肢力线影像学指标测量。图A为JLCA(关节线汇聚角)；图B为mLDFA(股骨远端外侧角)；图C为MPTA(胫骨近端内侧角)

图3 踝关节和髋关节的影像学指标测量。图A为TIA(距骨倾斜角)；图B为TPI(胫骨倾斜角)；图C为HAA(髋外展角)

图4 髌股关节稳定性影像学指标测量。图A为LPT(髌骨外侧倾斜角)；图B为LPS(髌骨外侧移位)；图C为髌股关节内侧间隙L1、外侧间隙L2；图D为Caton-Deschamps指数(a/b)

表1 两组的人口学参数及临床特征

组别	例数	年龄[岁，(±s)]	性别(例)		身体质量指数[kg/m²，(±s)]	病程[年，(±s)]	手术时间[min，(±s)]	随访时间[月，(±s)]	截角度骨[°，(±s)]	K-L分级(例)
组别	例数	年龄[岁，(±s)]	男	女	身体质量指数[kg/m²，(±s)]	病程[年，(±s)]	手术时间[min，(±s)]	随访时间[月，(±s)]	截角度骨[°，(±s)]	Ⅱ	Ⅲ	Ⅳ
过度矫正组	11	58.5±5.8	3	8	27.2±3.1	5.6±2.2	80.6±10.5	24.0±6.2	11.2±1.8	1	7	3
正常矫正组	52	58.2±5.1	9	43	26.8±2.6	5.8±2.4	80.1±12.6	23.3±5.5	8.9±2.1	5	43	4
统计值		t＝0.108	χ²＝0.117		t＝0.364	t＝-0.168	t＝0.127	t＝0.281	t＝2.782	χ²＝3.451
P值		>0.05	>0.05		>0.05	>0.05	>0.05	>0.05	0.008	>0.05

表1 两组的人口学参数及临床特征

组别	例数	年龄[岁，(±s)]	性别(例)		身体质量指数[kg/m²，(±s)]	病程[年，(±s)]	手术时间[min，(±s)]	随访时间[月，(±s)]	截角度骨[°，(±s)]	K-L分级(例)
组别	例数	年龄[岁，(±s)]	男	女	身体质量指数[kg/m²，(±s)]	病程[年，(±s)]	手术时间[min，(±s)]	随访时间[月，(±s)]	截角度骨[°，(±s)]	Ⅱ	Ⅲ	Ⅳ
过度矫正组	11	58.5±5.8	3	8	27.2±3.1	5.6±2.2	80.6±10.5	24.0±6.2	11.2±1.8	1	7	3
正常矫正组	52	58.2±5.1	9	43	26.8±2.6	5.8±2.4	80.1±12.6	23.3±5.5	8.9±2.1	5	43	4
统计值		t＝0.108	χ²＝0.117		t＝0.364	t＝-0.168	t＝0.127	t＝0.281	t＝2.782	χ²＝3.451
P值		>0.05	>0.05		>0.05	>0.05	>0.05	>0.05	0.008	>0.05

表2 正常矫正组和过度矫形术前和末次随访时下肢力线比较[°，(±s)]

组别	例数	HKA		JLCA		LDFA		MPTA		PTS
组别	例数	术前	末次随访	术前	末次随访	术前	末次随访	术前	末次随访	术前	末次随访
过度矫正组	11	-5.2±3.8	7.4±1.6	4.7±1.7	2.4±0.9	87.5±1.7	87.2±1.2	85.3±2.8	94.9±1.0	10.3±5.5	9.9±2.5
正常矫正组	52	-7.1±3.7	3.3±1.6	4.9±1.7	2.8±1.5	88.4±2.0	88.1±1.3	85.9±3.5	91.1±2.9	9.0±3.1	9.1±2.9
t值		-1.352	6.586	-0.382	-0.806	-1.079	-1.864	-0.466	3.709	0.983	0.715
P值		>0.05	<0.001^*	>0.05	>0.05	>0.05	>0.05	>0.05	0.001	>0.05	>0.05

表2 正常矫正组和过度矫形术前和末次随访时下肢力线比较[°，(±s)]

组别	例数	HKA		JLCA		LDFA		MPTA		PTS
组别	例数	术前	末次随访	术前	末次随访	术前	末次随访	术前	末次随访	术前	末次随访
过度矫正组	11	-5.2±3.8	7.4±1.6	4.7±1.7	2.4±0.9	87.5±1.7	87.2±1.2	85.3±2.8	94.9±1.0	10.3±5.5	9.9±2.5
正常矫正组	52	-7.1±3.7	3.3±1.6	4.9±1.7	2.8±1.5	88.4±2.0	88.1±1.3	85.9±3.5	91.1±2.9	9.0±3.1	9.1±2.9
t值		-1.352	6.586	-0.382	-0.806	-1.079	-1.864	-0.466	3.709	0.983	0.715
P值		>0.05	<0.001^*	>0.05	>0.05	>0.05	>0.05	>0.05	0.001	>0.05	>0.05

表3 两组组术前及末次随访时髋踝关节影像学指标比较[°，(±s)]

组别	例数	HAA		TPI		TIA
组别	例数	术前	末次随访	术前	末次随访	术前	末次随访
过度矫正组	11	1.0±2.7	-3.0±1.6	6.2±3.9	0.7±5.4	8.3±4.3	1.9±5.7
正常矫正组	52	1.7±2.5	-1.0±2.3	5.3±5.7	2.5±4.3	5.7±6.1	2.8±4.6
t值		-0.707	-2.309	0.437	-0.969	1.126	-0.456
P值		>0.05	0.026	>0.05	>0.05	>0.05	>0.05

表3 两组组术前及末次随访时髋踝关节影像学指标比较[°，(±s)]

组别	例数	HAA		TPI		TIA
组别	例数	术前	末次随访	术前	末次随访	术前	末次随访
过度矫正组	11	1.0±2.7	-3.0±1.6	6.2±3.9	0.7±5.4	8.3±4.3	1.9±5.7
正常矫正组	52	1.7±2.5	-1.0±2.3	5.3±5.7	2.5±4.3	5.7±6.1	2.8±4.6
t值		-0.707	-2.309	0.437	-0.969	1.126	-0.456
P值		>0.05	0.026	>0.05	>0.05	>0.05	>0.05

表4 两组术前和末次随访髌股关节的影像学指标比较(±s)

组别	例数	LPT(°)		LPS		Caton-Deschamps指数		髌股关节内侧间隙(mm)		髌股关节外侧间隙(mm)
组别	例数	术前	末次随访	术前	末次随访	术前	末次随访	术前	末次随访	术前	末次随访
过度矫正组	11	11.00±3.78	10.95±3.20	0.10±0.04	0.11±0.04	0.96±0.11	0.89±0.08	6.27±3.32	6.42±3.40	2.52±2.00	2.55±1.99
正常矫正组	52	10.61±2.43	10.72±2.22	0.09±0.04	0.10±0.04	0.93±0.11	0.82±0.11	4.99±2.35	5.16±2.45	2.73±2.19	2.76±1.99
t值		0.369	0.246	0.611	0.778	-0.151	1.919	1.291	1.227	-0.445	-0.271
P值		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表4 两组术前和末次随访髌股关节的影像学指标比较(±s)

组别	例数	LPT(°)		LPS		Caton-Deschamps指数		髌股关节内侧间隙(mm)		髌股关节外侧间隙(mm)
组别	例数	术前	末次随访	术前	末次随访	术前	末次随访	术前	末次随访	术前	末次随访
过度矫正组	11	11.00±3.78	10.95±3.20	0.10±0.04	0.11±0.04	0.96±0.11	0.89±0.08	6.27±3.32	6.42±3.40	2.52±2.00	2.55±1.99
正常矫正组	52	10.61±2.43	10.72±2.22	0.09±0.04	0.10±0.04	0.93±0.11	0.82±0.11	4.99±2.35	5.16±2.45	2.73±2.19	2.76±1.99
t值		0.369	0.246	0.611	0.778	-0.151	1.919	1.291	1.227	-0.445	-0.271
P值		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表5 两组末次随访膝关节功能评分比较(±s)

组别	例数	HSS评分		t值	P值	WOMAC		t值	P值
组别	例数	术前	末次随访	t值	P值	术前	末次随访	t值	P值
过度矫正组	11	62.1±6.9	87.6±3.6	-9.525	<0.001	38.3±3.3	9.5±1.6	22.250	<0.001
正常矫正组	52	60.9±1.1	89.8±3.6	-23.265	<0.001	38.1±5.0	8.9±3.3	31.164	<0.001
t值		0.155	-1.509			0.103	0.679
P值		>0.05	>0.05			>0.05	>0.05

表5 两组末次随访膝关节功能评分比较(±s)

组别	例数	HSS评分		t值	P值	WOMAC		t值	P值
组别	例数	术前	末次随访	t值	P值	术前	末次随访	t值	P值
过度矫正组	11	62.1±6.9	87.6±3.6	-9.525	<0.001	38.3±3.3	9.5±1.6	22.250	<0.001
正常矫正组	52	60.9±1.1	89.8±3.6	-23.265	<0.001	38.1±5.0	8.9±3.3	31.164	<0.001
t值		0.155	-1.509			0.103	0.679
P值		>0.05	>0.05			>0.05	>0.05

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Comparison on normal correction versus overcorrection of varus deformity following open wedge high tibial osteotomy

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Comparison on normal correction versus overcorrection of varus deformity following open wedge high tibial osteotomy