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中华关节外科杂志(电子版) ›› 2023, Vol. 17 ›› Issue (04) : 492 -499. doi: 10.3877/cma.j.issn.1674-134X.2023.04.006

临床论著

胫骨高位截骨术治疗膝骨关节炎的早期效果及影响因素
闫兆龙, 张镇斌, 李广兴, 赵璋, 张业勇, 殷鲁旭, 李树锋()   
  1. 250014　济南，山东第一医科大学第一附属医院（山东省千佛山医院）骨外科，山东省风湿免疫病转化医学重点实验室
    250014　济南，山东省中医药大学临床医学院
  • 收稿日期:2022-07-20 出版日期:2023-08-01
  • 通信作者: 李树锋
  • 基金资助:
    山东省自然科学基金(ZR2019MH130)

Early results and influencing factors of high tibial osteotomy in treatment of knee osteoarthritis

Zhaolong Yan, Zhenbin Zhang, Guangxing Li, Zhang Zhao, Yeyong Zhang, Luxu Yin, Shufeng Li()   

  1. Department of Orthopedic Surgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Jinan 250014, China
    School of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan 250014, China
  • Received:2022-07-20 Published:2023-08-01
  • Corresponding author: Shufeng Li
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引用本文：

闫兆龙, 张镇斌, 李广兴, 赵璋, 张业勇, 殷鲁旭, 李树锋. 胫骨高位截骨术治疗膝骨关节炎的早期效果及影响因素[J/OL]. 中华关节外科杂志(电子版), 2023, 17(04): 492-499.

Zhaolong Yan, Zhenbin Zhang, Guangxing Li, Zhang Zhao, Yeyong Zhang, Luxu Yin, Shufeng Li. Early results and influencing factors of high tibial osteotomy in treatment of knee osteoarthritis[J/OL]. Chinese Journal of Joint Surgery(Electronic Edition), 2023, 17(04): 492-499.

目的

探讨胫骨高位截骨术(HTO)术后功能恢复的影响因素。

方法

对2018年1月至2020年12月于山东第一医科大学第一附属医院行HTO的患者进行回顾性研究。纳入标准：(1)膝关节内侧OA，内翻畸形以胫骨为主；(2)年龄≤70岁，对日后活动要求较高；(3)膝关节伸直受限≤10°，屈曲>90°；(4)身体质量指数(BMI)≤40；(5)没有出现软骨下骨磨损。排除标准：(1)有手术侧下肢骨折或手术病史；(2)创伤性KOA；(3)合并有神经、肌肉或结缔组织疾病；(4)影像资料不全和失访者。根据纳入与排除标准共纳入78名患者。记录术前、术后影像学指标[胫骨近端内侧角(MPTA)，关节线相交角(JLCA)，髋－膝－踝角(HKA角)，膝关节负重线百分比(WBL%)，术后撑开距离，术后撑开角度]与膝关节功能评分[包括美国特种外科医院(HSS)膝关节评分、美国膝关节协会评分(KSS)、Lysholm评分、西安大略和麦克马斯特大学骨关节炎指数评分(WOMAC)]，并全部纳入logistic回归分析，研究HTO的手术效果及影响因素。

结果

患者术后HSS功能评分(Z＝6.830，P<0.001)、KSS评分(Z＝3.712，P<0.001)、Lysholm评分(Z＝6.057，P<0.001)、WOMAC评分(Z＝7.030，P<0.001)均较术前有明显改善。通过logistic回归筛选得出可能影响HTO术后效果的影响因素是性别、术前KSS评分、年龄。将性别、术前KSS评分、年龄纳入多元logistic回归分析，得出女性术后Lysholom评分被归类为优的概率是男性的0.19倍[比值比(OR)＝0.190，95%置信区间(CI)(0.049，0.737)，P＝0.016]；术前KSS评分每增加一分，术后Lysholm评分被归类为优的概率是原来的1.04倍。[OR＝1.039，95%CI(1.006，1.072)，P＝0.021]；年龄不是HTO手术效果的影响因素。

结论

患者术后功能评分明显改善。女性相较于男性，术后功能恢复差；术前KSS评分越高的患者，术后关节功能恢复效果越好。

关键词: 骨关节炎, 截骨术, 膝内翻, 治疗结果
Objective

To explore the influencing factors of functional recovery after high tibial osteotomy (HTO).

Methods

A retrospective study was conducted on patients who underwent HTO in the First Affiliated Hospital of Shandong First Medical University from January 2018 to December 2020.The inclusion criteria: (1)medial OA of the knee joint, varus deformity mainly in the tibia; (2)age ≤70 years old, with high requirements for future activities; (3)limited extension of the knee joint ≤10°, flexion>90°; (4)body mass index(BMI)≤40; (5)no subchondral bone wear. Exclusion criteria: (1)patients with lower limb fractures or surgery history; (2)traumatic KOA; (3)combined with nerve, muscle or connective tissue diseases; (4)incomplete imaging data and lost to follow-up. A total of 78 patients were included according to the inclusion and exclusion criteria. The preoperative and postoperative imaging indicators obtained through observation and follow-up [medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), hip-knee-ankle angle (HKA), knee weight bearing line ratio (WBL%), postoperative opening distance (opening gap), postoperative opening angle] and knee joint function scores[the American Hospital for Special Surgery (HSS) knee score, the American Knee Society score (KSS), Lysholm score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)] were included in logistic regression analysis to study the effect of HTO surgery and its influencing factors.

Results

The postoperative functional score of HSS (Z=6.830, P<0.001), KSS (Z=3.712, P<0.001), Lysholm score(Z=6.057, P<0.001), and WOMAC (Z=7.030, P<0.001) were significantly improved compared with preoperative data. According to logistic regression analysis, it was found that the influencing factors that might affect the postoperative effect of HTO were gender, preoperative KSS score, and age. Gender, preoperative KSS score, and age were included in the multiple logistic regression analysis, and it was concluded that the probability of postoperative Lysholom score being classified as excellent for females was 0.19 times that of males[odds ratio (OR)=0.190, 95% confidence interval (CI) (0.049, 0.737), P=0.016]. For each increasing point in the preoperative KSS score, the probability of being classified as excellent in the postoperative Lysholm score was 1.04 times that of the base line. [OR=1.039, 95%CI (1.006, 1.072), P=0.021]. Age was not an influencing factor for the effect of HTO surgery.

Conclusions

The functional scores of the patients may improve significantly after the operation.Compared with male patients, female patients have inferior postoperative functional recovery; patients with higher preoperative KSS scores have better postoperative joint function recovery.

Key words: Osteoarthritis, Osteotomy, Genu varum, Treatment outcome
图1 左下肢全长正位X线片的各影像学角度测量。图A示股骨头中心与踝关节中心连线为WBL(力线)，a为胫骨内侧皮质沿胫骨近端关节走行方向性与力线之间的距离，b为胫骨内外侧皮质间的距离，a与b比值为WBL%；图B示胫骨机械轴与股骨机械轴间的夹角为HKA(髋－膝－踝角)；图C同一关节相对的关节走行方向线之间所形成的角度为JLCA(关节线相交角)，画出胫骨近端关节走行方向线，从踝关节中心点到胫骨膝关节线上的膝关节中心点作一直线，两线之间夹角为MPTA(胫骨近端内侧角)
Figure 1 Measurement of each imaging angle. A shows that the line connecting the center of the femoral head and the center of the ankle joint is WBL (weight bearing line), a is the distance between the directionality of the medial tibial cortex along the proximal tibial joint and the force line, and b is the distance between the medial and lateral tibial cortex, the ratio of a to b is WBL%; B shows that the angle between the mechanical axis of the tibia and the mechanical axis of the femur is HKA (hip-knee-ankle angle); C shows that the angle formed by the joint running direction lines of femoral and tibial articular facets is JLCA (joint line convergence angle). The angle between the direction line of the proximal tibial joint facet and a straight line from the center point of the ankle joint to the center point of the knee joint along the tibia, is MPTA (medial proximal tibial angle)
图2 术后撑开距离及撑开角度示意图。图A为正位图；图B为45°投照位图；图C为侧位图注：L为合页点；M、M’分别为上下切面内侧皮质点；MM’之间的距离为撑开距离；LM与LM’之间的夹角为撑开角度
Figure 2 Schematic diagram of postoperative opening distance and opening angle. A is front view; B is 45° projection view; C is side viewNote: L is the hinge point; M and M' are the inner cortex points of the upper and lower cut planes respectively; the distance between MM' is the opening distance; the angle between LM and LM' is the opening angle
表1 患者术前术后的影像学测量数据(n＝86)
Table 1 X-ray findings of patients before and after surgery
时间点Time point MPTA[°，M(P25，P75)] JLCA[°，M(P25，P75)] HKA[°，M(P25，P75)] WBL%(±s)
术前Before operation 84.0(82.0，86) 3.0(2.0，4.0) 173.5(170.3，180.0) 19.0±14.7
术后值After operation 91.0(90.0，94.0) 2.0(1.2，3.0) 178.0(177.0，180.0) 49.3±12.3
统计值 Z＝－6.634 Z＝－1.695 Z＝－5.852 t＝17.943
P值 <0.001 >0.05 <0.001 <0.001
图3 50岁女性患者术前与术后X片比较注：术前膝关节WBL%(负重线百分比)为45%，术后WBL%为58%，手术后影像学参数得到显著改善
Figure 3 Comparison of preoperative and postoperative X-ray films of a 50-year-old womanNote: Preoperative knee joint WBL% (weight-bearing line percentage) was 45%, postoperative WBL% was 58%, and postoperative imaging parameters were significantly improved
表2 术前、术后膝关节的临床结果对比[n＝86，分，M(P25，P75)]
Table 2 Comparison of clinical results of knee joint before and after operation
时间点Time point HSS评分 KSS评分 Lysholm评分 WOMAC评分
术前Before operation 54(45，61) 60(50，80) 58(46，66) 44(39，48)
术后值After operation 81(71，85) 80(60，90) 84(67，98) 11(4，22)
Z值 6.830 3.712 6.057 7.030
P值 <0.001 <0.001 <0.001 <0.001
表3 术后Lysholm评分的单因素分析
Table 3 Univariate analysis of Lysholm score after surgery
变量Variables χ2值 Wald值 OR值 95%CI P值
性别Gender －1.386 6.290 0.250 (0.085，0.739) 0.012
年龄Age －0.104 4.022 0.901 (0.814，0.998) 0.045
BMI 0.030 0.141 1.031 (0.881，1.206) 0.707
病程(个月) Course of disease (months) 0.011 1.076 1.011 (0.991，1.031) 0.300
有无植骨With or without bone graft 0.405 0.116 1.500 (0.146，15.461) 0.733
术前HSS Preoperative HSS 0.038 2.770 1.039 (0.993，1.087) 0.096
术前Lysholm Preoperative Lysholm 0.016 0.823 1.016 (0.982，1.051) 0.364
术前WOMAC Preoperative WOMAC －0.027 1.071 0.973 (0.925，1.024) 0.301
术前KSS Preoperative KSS 0.041 7.170 1.042 (1.011，1.073) 0.007
术前MPTA Preoperative MPTA 0.030 0.081 1.031 (0.836，1.271) 0.776
术后MPTA Postoperative MPTA 0.077 0.674 1.080 (0.899，1.298) 0.412
术前JLCA Preoperative JLCA －0.125 0.535 0.883 (0.632，1.233) 0.465
术后JLCA Postoperative JLCA 0.022 0.020 1.022 (0.753，1.388) 0.889
术前HKA Preoperative HKA 0.026 0.289 1.026 (0.933，1.129) 0.591
术后HKA Postoperative HKA －0.022 0.035 0.978 (0.777，1.231) 0.851
术前膝关节负重线百分比Preoperative WBL% 2.510 0.973 12.300 (0.084，1 801.636) 0.324
术后膝关节负重线百分比Postoperative WBL% －0.461 0.040 0.631 (0.007，56.853) 0.841
术后撑开距离Postoperative opening gap 0.042 0.683 1.043 (0.943，1.154) 0.408
术后撑开角度Postoperative opening angle －0.002 0.004 0.998 (0.921，1.081) 0.952
表4 性别、术前KSS评分和年龄的多元logistic回归分析结果
Table 4 Multivariate logistic regression analysis results of gender, preoperative KSS score and age
变量Variables χ2值 Wald值 OR值 95%CI P值
性别Gender －1.662 5.765 0.190 (0.049，0.737) 0.016
年龄Age －0.130 3.755 0.878 (0.771，1.001) 0.053
术前KSS评分Preoperative KSSscore 0.038 5.336 1.039 (1.006，1.072) 0.021
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