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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2022, Vol. 16 ›› Issue (03) : 352 -361. doi: 10.3877/cma.j.issn.1674-134X.2022.03.015

综述

胫骨高位截骨术在老年退变性膝骨关节炎的应用
张海东1, 滕涛,1   
  1. 1. 100062　北京市普仁医院骨科
  • 收稿日期:2020-02-05 出版日期:2022-06-01
  • 通信作者: 滕涛

Application of high tibial osteotomy in aged degenerative knee osteoarthritis

Haidong Zhang1, Tao Teng,1   

  1. 1. Department of Orthopedics, Beijingshi PuRen Hospital, Beijing 100062, China
  • Received:2020-02-05 Published:2022-06-01
  • Corresponding author: Tao Teng
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引用本文：

张海东, 滕涛. 胫骨高位截骨术在老年退变性膝骨关节炎的应用[J/OL]. 中华关节外科杂志(电子版), 2022, 16(03): 352-361.

Haidong Zhang, Tao Teng. Application of high tibial osteotomy in aged degenerative knee osteoarthritis[J/OL]. Chinese Journal of Joint Surgery(Electronic Edition), 2022, 16(03): 352-361.

随着老龄化进展，老年退变性膝骨关节炎越来越多，近年来，随着"保膝"理念的发展，胫骨高位截骨治疗老年退变性膝骨关节炎得到国内、外专家的认可，并得到了快速发展。胫骨高位截骨术是通过转变负重点，纠正下肢力线，使膝关节负重载荷从退变的内侧间室转向相对正常的外侧间室，从而延缓膝关节炎的进展，并促进内侧间室软骨修复，改善膝关节疼痛等症状，逐渐恢复关节活动及功能。早期的胫骨高位截骨术用于相对年轻的患者，但随着老龄化的进展及研究的深入，胫骨高位截骨用于老年退变性膝骨关节炎治疗的研究越来越多，本文对目前胫骨高位截骨术治疗老年退变性膝骨关节炎进行综述。

关键词: 胫骨, 截骨术, 老年人, 骨关节炎，膝

With the development of aging, degenerative knee osteoarthritis in the elderly is becoming more and more common. In recent years, with the development of the concept of " knee preservation surgery" , high tibial osteotomy for treating degenerative knee osteoarthritis in the elderly has been well-accepted by domestic and foreign experts and has achieved rapid development. High Tibial osteotomy is to transfer the weight-bearing point and weight-bearing loads to the relatively unaffected lateral compartment in varus knees, realign the lower limb line, so as to delay the need for knee replacement by slowing or stopping destruction of the medial joint compartment, and promote the repair of medial compartment cartilage, improve knee joint pain and other symptoms, then gradually restore joint activity and function. Early high tibial osteotomy was used in relatively young elderly patients, but with the development of aging and the research, more and more studies on treatment of elderly degenerative knee osteoarthritis with high tibial osteotomy. This article reviewed how to use high tibial osteotomy to treat of elderly degenerative knee osteoarthritis.

Key words: Tibia, Osteotomy, Aged, Knee osteoarthritis
表1 HTO患者的选择因素
病史 影像学 体格检查 其他因素
实际生理年龄 解剖力线 畸形
程度
方向		 患者的期望值
患者所需的生活水平 机械力线 先前的切口 手术医生的能力
疼痛位置 关节炎的严重程度
畸形的程度		 身体状况
活动范围		 动态步态因素
软组织张力
身体上部的活动
特点髌股关节 髌股关节半脱位 总活动度
屈曲挛缩		 潜在并发症
风湿性疾病情况 其他间室的情况 韧带缺失 术后恢复
制动时间
既往半月板切除史 关节软骨丢失的情况 髌股关节机械力学 术后患者恢复的依从性
感染病史 焦磷酸钙沉积
骨质缺损
关节处的变形
膝关节后倾		 内收肌力量 易于进行全膝关节置换
表2 HTO患者选择的禁忌因素
绝对禁忌 相对禁忌
弥漫性、非特异性膝关节痛 年龄大于60岁
原发性髌股关节痛 膝关节活动弧度小于90°
外侧间室的半月板切除 肥胖(>1.3倍的理想体重)
外侧间室的关节炎 胫股关节半脱位
潜在的关节感染性疾病 严重关节炎
不切实际的患者期望值 中、重度韧带不稳定
图1 膝关节前后位示TBVA (胫骨内翻角)注：TBVA (红色角度标线)是胫骨机械轴(黑色线)与胫骨近端骺线轴(胫骨髁间棘的中点和残存骺线中点的连线)(红色线)的交角
表3 KOA的Ahlback分级
Ⅰ级 关节间隙变窄(50%关节软骨磨损)
Ⅱ级 关节线消失
Ⅲ级 轻度骨磨损
Ⅳ级 中度骨磨损(磨损0.5~1cm)
Ⅴ级 严重骨磨损及存在关节半脱位
表4 外侧闭合楔形HTO的优缺点和并发症
优点 缺点 并发症
立即负重 狭窄的截骨窗 腓神经损伤
较低的畸形愈合/不愈合率 即刻修正 腓骨截骨术
楔形骨块去除后骨丢失 骨不连
更多暴露前间室 内侧胫骨皮质骨折断裂
较低的后倾和低位髌骨 可能伴随腓骨截骨术 筋膜室综合征
腓神经暴露与损伤风险  
表5 内侧开放楔形HTO的优缺点和并发症
优点 缺点 并发症
避免暴露小腿外侧面 增加胫骨后倾 胫骨平台外侧骨折
    内侧副韧带损伤
易于纠正和允许微调 更高的不愈合率 内固定物刺激
    矫形角度丢失
直接暴露   骨不愈合
图2 用下肢全长X线计算胫骨高位截骨术矫正角度的方法注：从股骨头中心和距骨中心的连线在胫骨平台62%的坐标中相交，形成期望的校正角，这个角度需要考虑2~3 mm的关节间隙
表6 HTO术前影像学评估内容
影像学 评估内容
下肢全长，三关节的负重位像 关节的对线情况
屈曲45°的前后位片 胫股关节后方间室的狭窄
侧位片 髌骨高度和髌股关节
髌骨轴位片 髌股关节
膝关节MRI 软骨损伤的情况
表7 HTO经常选择的截骨点以及矫正角度
分组 术前基础病理 术后的外翻位置
组1 内侧间室负重多，无OA征象
内侧间室软骨修复，无OA征象
内侧半月板移植，无OA征象
韧带功能不全合并内翻/过伸性内翻，无OA征象		 50%~55 %
组2 内侧间室OA 1级和2级±韧带功能不全
内侧间室软骨修复，轻度OA症状
内侧半月板移植伴轻度OA症状		 55%~60%
组3 内侧室OA 3、4级±韧带功能不全 60%~65 %
图3 胫骨宽度与撑开高度的关系示意图注：给出相同的矫正角度(e)，随着胫骨宽度的增加，所需撑开的高度也会增加，当胫骨宽度超过56 mm时，1 mm等于1°的做法会导致矫正不足，故应根据三角函数去实际计算需要撑开的角度
图4 根据三角函数计算撑开的高度b注：a为胫骨宽度，e为计算所得的需要撑开的角度
图5 小腿前后位X线图，示一条带有纵向刻度的腿注：EHLM-踇长伸肌；该图显示了与腓深神经的运动支存在的相关术中损伤高风险区和低风险区
表8 HTO相关的并发症
主要并发症 次要并发症
神经损伤 伤口表面愈合不良及延迟愈合
血管损伤 针道感染
筋膜间室综合征 皮肤麻木
深部感染 神经瘤形成
螺钉穿透关节 关节纤维化
移位的胫骨平台外侧骨折 膝关节不稳
内固定失败，带来严重的痛苦或矫正丢失 不良的关节后倾
骨不愈合 低位髌骨
骨折畸形愈合 骨折延迟愈合
矫正角度丢失 疼痛缓解不足
矫正不足 内固定处疼痛
矫正过度 发作性软骨钙化症
任何原因的术后2年内进行关节置换 胫骨平台骨坏死
需要取出内固定的症状 未移位的外侧合页处断裂(<2 mm)
II型复杂区域性疼痛综合征(complex regional pain syndrome，CRPS) 移位的外侧合页处骨折(≥2 mm)
  截骨部周围血肿
  胫骨平台外侧无移位性骨折
  术后膝关节僵硬
  I型复杂区域性疼痛综合征(CPRS)
  蜂窝织炎
  胫骨平台后倾增加(大于10°)
  肌腱炎
  轻度的内固定问题但无矫正丢失
  血栓栓塞性疾病：深静脉血栓及肺栓塞
表9 近10余年HTO主要研究的术后10年生存率
作者 年份 病例数 年龄跨度(平均年龄)(岁) 10年生存率(%)
Van Raaij[51] 2008 100 24~67 (49.0 ± 11.0) 75
Babis[52] 2008 51 19~71(53.0) 76
Akizuki[53] 2008 132 45~76 (62.9) 97.6
Gstottner [54] 2008 111 19~74(56.0) 79.9
Benzakour [47] 2010 192 40~72(55.0) 73a
Waciakowski [55] 2011 92 42~78(59.8 ± 8.7) 80.4
Efe[56] 2011 199 25~72 (54.0 ± 8.0) 84
Saragaglia [57] 2011 124 32~74(53.2 ±10.7) 74
Schalleberger[48] 2011 71 15~68(40.0) 92
Hui[58] 2011 394 24~70(50.0) 79
Howells[59] 2014 100 26~66(50.0) 79
Saito[60] 2014 77 63~73(69.0) 96.2b
Polat[61] 2017 187 22~68(44.9 ± 10.6) 71.2
Ruangsomboon [50] 2017 50 (66.0 ± 5.0) 95.5c
Darées[38] 2018 48 48~72(58.5) 88
van Wulfften Palthe[62] 2018 223 24~80(50.0) 75
Kuwashima[9] 2019 234 40~82(61.4 ± 7.8) 94.4±1.2
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