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中华关节外科杂志(电子版) ›› 2022, Vol. 16 ›› Issue (06) : 705 -714. doi: 10.3877/cma.j.issn.1674-134X.2022.06.009

临床论著

胫骨高位截骨联合关节镜治疗老年膝骨关节炎的短期疗效
张海东1, 滕涛1,†(), 陈阳1, 刘俊英1, 郑宏伟1, 英吉林1, 武志刚1, 何保玉1   
  1. 1. 100062　北京市普仁医院骨科
  • 收稿日期:2020-08-13 出版日期:2022-12-01
  • 通信作者: 滕涛

Short-term efficacy of high tibial osteotomy combined with arthroscopy in treatment of senile degenerative osteoarthritis

Haidong Zhang1, Tao Teng1,†(), Yang Chen1, Junying Liu1, Hongwei Zheng1, Jilin Ying1, Zhigang Wu1, Baoyu He1   

  1. 1. Department of Orthopedic, Beijingshi Puren Hospital, Beijing 100062, China
  • Received:2020-08-13 Published:2022-12-01
  • Corresponding author: Tao Teng
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引用本文：

张海东, 滕涛, 陈阳, 刘俊英, 郑宏伟, 英吉林, 武志刚, 何保玉. 胫骨高位截骨联合关节镜治疗老年膝骨关节炎的短期疗效[J]. 中华关节外科杂志(电子版), 2022, 16(06): 705-714.

Haidong Zhang, Tao Teng, Yang Chen, Junying Liu, Hongwei Zheng, Jilin Ying, Zhigang Wu, Baoyu He. Short-term efficacy of high tibial osteotomy combined with arthroscopy in treatment of senile degenerative osteoarthritis[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2022, 16(06): 705-714.

目的

探讨胫骨高位截骨术(HTO)联合关节镜对比单纯关节镜治疗老年退变性膝骨关节炎(KOA)的短期临床疗效(运动及疼痛的改善)。

方法

对北京市普仁医院从2017年7月至2019年5月内的老年X线Kellgren-Lawrence(K-L)Ⅲ期的KOA患者共41例(42个膝关节)进行回顾分析。选取符合膝骨关节炎诊断标准，且术前磁共振影像证实为内侧KOA，韧带功能完好，膝关节活动度≥100°的60岁以上可连续随访的健康老年患者，除外不符合KOA诊断标准、非骨关节炎、膝关节不稳、术前膝关节活动度<100°或屈曲挛缩>25°、不能耐受麻醉或手术者、严重的髌股关节炎、骨质疏松或外侧间室骨关节炎或外侧半月板切除的60岁以下、失访或非健康患者。根据患者治疗意愿选择治疗方法不同将其分为两组，HTO联合关节镜治疗(联合治疗组)和单纯关节镜治疗组，记录患者基线特征，比较两组术前及术后12个月的膝关节损伤和关节炎评分(KOOS)、活动度和代谢当量。比较联合治疗组术前、术后2周、12个月的胫骨近端内侧角(MPTA)和股胫角(FTA)，并记录矫正角度的丢失。使用配对和独立样本t检验、秩和检验和卡方检验进行统计学分析，比较两组患者的术后疼痛缓解时间(生存期)，进行Kaplan-Meier曲线分析。

结果

两组(关节镜组和HTO联合治疗组)患者术后KOOS(疼痛、症状、日常生活能力、运动娱乐、生活质量)评分较术前均有改善(Z＝－4.036，t＝－12.116，t＝－9.392，Z＝－3.897，t＝－3.623，Z＝－4.041，t＝－36.102，t＝－12.116，Z＝－4.133，t＝－56.950，均为P<0.001)，HTO组术后活动度及代谢当量(METs)较术前明显改善(t＝－13.436，Z＝－4.116，均为P<0.001)，但关节镜组改善不明显，HTO组术后KOOS评分、活动度、代谢当量较关节镜组改善明显(Z＝－5.793，t＝－27.755，t＝－24.366，Z＝－5.629，t＝－43.958，t＝－11.730，Z＝－6.099，均为P<0.001)，术后2周和12个月FTA及MPTA均较术前改善，术后HTO组可以中、短期(时间>12个月)无痛或微痛生存，明显优于关节镜组，两组生存期差异有统计学意义(χ2＝42.290，P<0.001)。

结论

HTO联合关节镜治疗老年K-L Ⅲ期KOA患者短期临床疗效(运动及疼痛改善)良好；患者疼痛缓解及运动恢复的主要原因是矫正了畸形的力线。

关键词: 胫骨, 截骨术, 关节镜, 老年人, 骨关节炎，膝
Objective

To investigate the short-term clinical efficacy of high tibial osteotomy (HTO) combined with arthroscopy versus arthroscopy alone in the treatment of senile degenerative knee osteoarthritis (KOA) (improvement of sport and pain).

Methods

A total of 41 elderly patients (42 knees) with Kellgren-Lawrence (K-L) stage Ⅲ KOA in Beijing Puren Hospital from July 2017 to May 2019 were retrospectively analyzed. The inclusion criteria: patients met the diagnostic criteria of knee osteoarthritis and were confirmed as medial KOA by preoperative MRI with intact ligament function; healthy elderly patients over 60 years; the range of motion of knee above 100 °; the patients could be followed up continuously. The exclusion criteria: the patients who did not meet the diagnostic criteria for KOA; age under 60 years; severe patellofemoral arthritis or osteoporosis or lateral compartment osteoarthritis; lateral meniscectomy; not degenerative osteoarthritic; unstable knees; preoperative range of motion of knee under 100° or flexion contracture >25°; the patients could not tolerate anesthesia or surgery; the patients lost follow-up, or were not healthy. The enrolled patients were divided into two groups according to their willingness for treatment methods: the HTO combined with arthroscopy group(the combined treatment group) and the arthroscopy group. The baseline characteristics of the patients were recorded. Knee injury & osteoarthritis score (KOOS), range of motion (ROM) and metabolic equivalents (METs) were compared between the two groups before the operation and 12 months after the operation. The proximal medial tibial angle (MPTA) and femorotibial angle (FTA) of the combined treatment group were compared before the operation, two weeks and 12 months after the operation, and the loss of correction angle was recorded. Paired and independent sample t test, rank sum test and chi square test were used for statistical analysis. Kaplan-Meier curve analysis was performed.

Results

The postoperative KOOS (pain, symptoms, activities of daily living, sports and recreation, quality of life) scores of patients in the two groups were improved compared with those before operation (Z=-4.036, t=-12.116, t=-9.392, Z=-3.897, t=-3.623, Z=-4.041, t=-36.102, t=-12.116, Z=-4.133, t=-56.950, all P<0.001). The mobility and METs of the HTO group were significantly improved compared with those before operation (t=-13.436, Z=-4.116, both P<0.001), but there was no improvement in the arthroscopy group. The postoperative KOOS score, range of motion, and metabolic equivalent in the HTO group were significantly improved compared with those in the arthroscopy group (Z=-5.793, t=-27.755, t=-24.366, Z=-5.629, t=-43.958, t=-11.730, Z=-6.099, all P<0.001). Compared with the preoperative group, the FTA and MPTA of the HTO group had significantly improved at two weeks and 12 months after surgery. The postoperative combination group were able to survive without pain or with mild pain for a short-and medium-term time (time>12 months), which was better than the arthroscopy group, and the survival time difference between the two groups was statistically significant (χ2=42.290, P<0.001).

Conclusion

HTO combined with arthroscopy has good short-term clinical efficacy (sport and pain relief) in the treatment of elderly patients with K-L Ⅲ KOA; the correction of deformed force lines could lead to pain relief and sport improvement.

Key words: Tibia, Osteotomy, Arthroscopy, Aged, Osteoarthritis, knee
表1 两组患者基本信息特征比较
特征 联合治疗组 关节镜组 统计值 P值
例数 20 21
年龄[岁，(±s)] 69.1±6.7 71.2±4.1 t ＝－1.227 >0.05
性别(男/女) 5/15 6/15 χ2＝0.067 >0.05
病变部位(左/右) 6/15 5/16 χ2＝0.123 >0.05
BMI [kg/m2，(±s)] 26.5±2.9 26.4±2.9 t ＝0.151 >0.05
术前关节活动度[°，(±s)] 105.2±5.1 104.1±4.1 t ＝0.834 >0.05
术前KOOS评分
疼痛M(P25，P75) 55.5(52.8，58.3) 55.5(50.0，55.5) Z＝－1.182 >0.05
症状(±s) 54.4±6.0 55.1±4.5 t ＝－0.418 >0.05
日常生活能力(±s) 48.7±3.4 49.2±2.5 t ＝－0.455 >0.05
运动娱乐M(P25，P75) 20.0(15.0，25.0) 20.0(15.0，25.0) Z＝－1.061 >0.05
生活质量(±s) 39.9±5.0 38.7±6.1 t ＝0.682 >0.05
WORMS分级[例(5级/6级)] 7/14 7/14 χ2＝0 >0.05
发病前METs (±s) 3.6±0 3.6± 0 t ＝0 >0.05
发病后METs M(P25，P75) 2.5(2.5，2.5) 2.5(2.5，2.5) Z＝－0.422 >0.05
术前FTA [°，(±s)] 180.3±2.9 181.2±2.9 t ＝－0.687 >0.05
术前MFTA [°，(±s)] 84.3±2.0 84.7±1.9 t ＝－1.074 >0.05
图1 关节镜组和联合治疗组术后疼痛缓解时间的生存曲线
表2 两组患者术前及术后KOOS评分、ROM及代谢当量对比
关节镜组 例数(例/膝) KOOS评分 ROM[°，(±s)] METs M(P25，P75)
疼痛M(P25，P75) 症状(±s) 日常生活能力(±s) 运动娱乐M(P25，P75) 生活质量(±s)
术前 21/21 55.5(50.0，55.5) 55.1±4.5 49.2±2.5 20.0(15.0，25.0) 38.7±6.1 104.1±4.1 2.5(2.5，2.5)
术后 21/21 61.1(61.1，61.1) 65.0±4.9 62.1±5.4 30.0(20.0，30.0) 41.7±4.1 102.9±3.4 2.5(2.5，2.5)
统计值 Z＝－4.036 t＝－12.116 t＝－9.392 Z＝－3.897 t＝－3.623 t＝－56.950 Z＝－2.070
P值 <0.001 <0.001 <0.001 <0.001 <0.001 <0.05 <0.05
联合治疗组 例数(例/膝) KOOS评分 ROM[°，(±s)] METs M(P25，P75)
疼痛M(P25，P75) 症状(±s) 日常生活能力(±s) 运动娱乐M(P25，P75) 生活质量(±s)
术前 20/21 55.5(52.8，58.3) 54.4±5.8 48.7±3.4 20.0(15.0，25.0) 39.9±5.0 105.2±5.1 2.5(2.5，2.5)
术后 20/21 97.2(94.4，97.2) 95.7±1.4 91.6±1.5 55.0(55.0，60.0) 86.6±2.2 116.9±4.3 3.6(3.6，4.0)
统计值 Z＝－4.041 t＝－36.102 t＝－12.116 Z＝－4.133 t＝－56.950 t＝－13.436 Z＝－4.116
P值 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
统计值* Z＝－5.793 t＝－27.755 t＝－24.366 Z＝－5.629 t＝－43.958 t＝－11.730 Z＝－6.099
P值* <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
表3 HTO联合治疗组患者术后2周、1年的矫正角度及其统计值[n＝21，°，(±s)]
MPTA FTA
术前 84.3±2.0 180.3±2.9
术后2周 93.8±1.4 167.4±1.9
术后1年 92.5±1.4 169.6±2.6
F值 570.039 240.519
P值 <0.001 <0.001
图2 典型病例术前及术中、术后影像资料。图A为术前负重位左膝关节正侧位为K-L Ⅲ级；图B为术前双下肢负重位全长片示下肢力线内移；图C为术前MRI所见，前内侧软骨信号完全消失，局部伴有骨髓水肿；图D为术中关节镜所见，内侧软骨基本消失，外侧软骨形态及厚度尚可；图E为术后2周左膝关节X线示内侧关节间隙较前增宽，局部植骨填充良好，内固定牢靠；图F为术后1年双下肢负重位全长片，下肢力线外移，内固定良好，骨折植骨处愈合
图3 K-L Ⅲ期患者内翻膝力线变化。图A为内侧软骨磨损、间隙狭窄、外侧韧带松弛后力线内移示意图；图B为右下肢负重位全长X线片分期进展，示内侧软骨磨损加重，间室压力增加，力线逐渐内移
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