拉花松解技术在关节外内翻畸形全膝置换术的应用

doi:10.3877/cma.j.issn.1674-134X.2022.05.015

目的

探索在关节外膝内翻畸形全膝关节置换术(TKA)中应用拉花松解技术(pie-crusting)可矫正的内翻程度并评估疗效。

方法

本研究回顾2018年11月至2020年6月在赤峰市医院收治的内翻膝TKA中应用pie-crusting技术40例，测量股骨远端机械外侧角(mLDFA)、胫骨近端机械内侧角(MPTA)、关节线相交角(JLCA)、机械轴偏向(MAD)、关节内外整体内翻角[180°减去髋－膝－踝角(HKA)]，评估内翻来源、内翻程度、下肢力线。比较手术前后美国特种外科医院(HSS)膝关节评分、疼痛视觉模拟量表(VAS)评分、膝关节活动度(ROM)，采用配对样本t检验和Wilcoxon符号秩和检验评估疗效。

结果

本组TKA中应用pie－crusting技术40例均伴有膝关节内翻畸形，术前mLDFA(92.7±3.1)°；MPTA(74.7±2.6)°；关节内外整体内翻角(23.1±3.5)°。比较手术前后HSS评分(t＝－93.4)、VAS评分(Z＝－5.57)、ROM(t＝－37.1)、MAD(t＝64.8)差异均有统计学意义(均为P<0.05)。

结论

内翻膝TKA中应用pie-crusting技术，关节内外整体内翻角<29°可应用该技术恢复关节平衡和下肢力线，关节外畸形在关节内矫正，疗效确切且安全。

关键词: 膝内翻, 下肢畸形，先天性, 内侧副韧带，膝, 关节成形术，置换，膝

Objective

To investigate the correctable degree and source of varus deformity utilizing the pie-crusting technique in total knee arthroplasty (TKA) of knees with varus deformity, and evaluate its efficacy.

Methods

A total of 40 patients with varus knee deformity treated by pie-crusting technique during TKA at the Chifeng Municipal Hospital from November 2018 to June 2020 were retrospectively analysed. The mechanical lateral distal femoral angle(mLDFA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), mechanical axis deviation (MAD) and 180° minus hip-knee-ankle (HKA) angle were measured before operation. The degree and source of deformity, and the restoration of the lower limb force line were assessed. Paired-samples t test and Wilcoxon signed-rank test were conducted to compare changes in the Hospital for Special Surgery (HSS) score, visual analogue scale (VAS) and knee joint range of motion (ROM) before and after surgery.

Results

All the patients subjected to pie-crusting technique treatments in TKA were accompanied by extra-articular varus deformity. The pre-operative mLDFA, MPTA and knee varus angle were (92.7±3.1)°, (74.7±2.6)°and (23.1±3.5)° respectively. The HSS score(t=-93.4), VAS score(Z=5.57), knee ROM(t=-37.1) and MAD(t=64.8) were improved when compared with preoperative ones (all P<0.05).

Conclusion

When the global knee varus angle is less than 29 °, pie-crusting technique can be used in TKA to regain the joint balance and the lower limb mechanical alignment line efficiently and safely; the extra-articular deformities may be corrected intra-articularly.

Key words: Genu varum, Lower extremity deformities, congenital, Medial collateral ligament, knee, Arthroplasty, replacement, knee

表1 术前和术后末次随访各评价指标比较(n＝40)

时间	HSS评分(±s)	VAS评分[M(P₂₅，P₇₅]	ROM[°，(±s)]	MAD[mm，±s)]
术前	58.8±1.6	7.0(6.0，8.0)	83.0±7.9	71.1±7.5
术后	89.3±2.2	0(0，1.0)	110.2±6.9	1.4±1.1
统计值	t＝－93.4	Z＝－5.57	t＝－37.1	t＝64.8
P值	<0.05	<0.05	<0.05	<0.05

表1 术前和术后末次随访各评价指标比较(n＝40)

时间	HSS评分(±s)	VAS评分[M(P₂₅，P₇₅]	ROM[°，(±s)]	MAD[mm，±s)]
术前	58.8±1.6	7.0(6.0，8.0)	83.0±7.9	71.1±7.5
术后	89.3±2.2	0(0，1.0)	110.2±6.9	1.4±1.1
统计值	t＝－93.4	Z＝－5.57	t＝－37.1	t＝64.8
P值	<0.05	<0.05	<0.05	<0.05

图1 伴有膝关节外内翻畸形应用pie-crusting(拉花松解技术)的TKA(全膝关节置换术)典型病例情况。前后下肢力线全长片。图A为pie-crusting工具；图B、C分别为右膝伸直位和屈曲位关节间隙均不平衡，处在内紧外松状态；图D为撑开器撑开后用5 ml注射器针头pie-crusting内侧副韧带；图E为放置间隙测块做适度持续外翻应力，释放内侧关节间隙；图F为内外侧关节间隙恢复平衡；图G~H为术前下肢负重位全长正位X线片，图G示右膝骨关节炎伴有膝关节外内翻畸形，图H示术前异常下肢力线，异常MAD，右膝内翻畸形重；图I为术后下肢负重位全长正位X线片，示下肢力线恢复，MAD恢复正常

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Application of pie-crusting technique to varus knee during total knee arthroplasty

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Application of pie-crusting technique to varus knee during total knee arthroplasty