骨水泥螺钉技术修复大骨节病胫骨平台缺损的疗效

doi:10.3877/cma.j.issn.1674-134X.2026.04.007

目的

探讨骨水泥螺钉技术在大骨节病（KBD）膝关节置换术（TKA）中修复胫骨平台后内侧非包容性骨缺损的临床疗效。

方法

纳入2018年11月至2023年12月符合KBD诊断标准（WS/T 10026-2024）、保守治疗无效、伴胫骨平台后内侧非包容性骨缺损及内翻畸形，且无手术禁忌的TKA患者。排除膝部手术/骨折史、外翻或其他膝外畸形、影响功能的神经疾病及活动性感染者。按骨缺损深度分组：深度≤10 mm为浅缺损组，深度＞10 mm为深缺损组。均采用螺钉骨水泥技术重建骨缺损。记录术前及末次随访的美国膝关节协会评分（KSS）、WOMAC评分、关节活动度（ROM）、X线片及胫股角（TFA），统计假体及螺钉使用情况。组内术前术后计量资料比较用配对t检验，组间疗效采用等效性检验，透亮线发生率用卡方检验。

结果

共48例患者（50膝），其中2例双膝，浅、深缺损组各25例。缺损深度分别为（6.4±2.9）mm和（15.1±3.2）mm；两组性别、年龄、身体质量指数差异无统计学意义（均为P＞0.05）。随访时间浅缺损组（49±11）个月，深缺损组（54±18）个月。两组术后KSS临床（t=-37.516、-19.859）和功能评分（t=-110.667、-40.208）、WOMAC评分（t=19.105、11.941）及ROM（t=-33.963、-15.531）均较术前显著改善（均为P＜0.001）。末次随访假体位置固定良好，无松动、移位；骨水泥-骨界面＜2 mm透亮线共23例（浅8例、深15例），随访无进行性增宽，无假体下沉或骨溶解。两组术前TFA［（166.1±5.5）° vs（166.9±5.6）°］差异无统计学意义（P＞0.05），术后均获得矫正（t=-8.229、-7.132，均为P＜0.001）；术后TFA两组间差异无统计学意义（P＞0.05）。等效性检验显示两组术后临床疗效及下肢力线矫正效果具有等效性。

结论

骨水泥螺钉技术可有效修复KBD患者TKA术中胫骨平台后内侧非包容性骨缺损，恢复膝关节生物力学性能，短期随访固定可靠，且费用较低，适宜在KBD贫困人群中推广应用。

关键词: 关节成形术，置换，膝, 骨水泥, 骨螺钉, 大骨节病

Objective

To investigate the clinical efficacy of the screwcement technique for reconstructing noncontained posteromedial tibial plateau bone defects during total knee arthroplasty (TKA) in patients with Kashin-Beck disease (KBD).

Methods

This study included patients who underwent TKA between November 2018 and December 2023 and met the following criteria: diagnosis of KBD according to the Chinese diagnostic standard (WS/T 10026—2024), failure of conservative treatment, presence of non contained posteromedial tibial plateau defects with varus deformity, and no contraindications to surgery. Exclusion criteria: knee surgery or fracture histories, valgus or other extra-articular knee deformities, neurological disorders affecting function, and active infection. Patients were stratified by defect depth: those with defects ≤10 mm were assigned to the shallow defect group, and those with defects >10 mm to the deep defect group. All the patients underwent bone defect reconstruction using the screw cement technique. Preoperative and final follow-up data were recorded, including the Knee Society score (KSS), Western Ontario and McMaster Universities osteoarthritis index (WOMAC) score, range of motion (ROM), radiographic findings, and tibiofemoral angle (TFA). Prosthesis implantation and the number of screws used were also documented. Paired t tests were used for within group comparisons between preoperative and postoperative continuous variables, equivalence testing was applied for intergroup efficacy comparisons, and chi square test was used to compare the incidence of radiolucent lines.

Results

A total of 48 patients (50 knees) were enrolled, including two patients with bilateral involvement. The shallow defect and deep defect groups each comprised 25 knees. The mean defect depths were (6.4±2.9) mm and (15.1±3.2) mm, respectively. There were no statistically significant differences in gender, age, or body mass index between the two groups (all P>0.05). The follow up duration was (49±11) months for the shallow defect group and (54±18) months for the deep defect group. Both groups showed significant improvements in KSS clinical (t=-37.516, -19.859) and functional scores (t=-110.667, -40.208) , WOMAC scores (t=19.105, 11.941) and ROM (t=-33.963, -15.531) after surgery (all P<0.001). At the final follow up, all prostheses were well fixed without loosening or migration. Radiolucent lines <two millimeters at the bone cement interface were observed in 23 cases (eight in the shallow defect group and 15 in the deep defect group), with no progressive widening during follow up and no cases of subsidence or osteolysis. TFA [(166.1±5.5)° vs (166.9±5.6)°] showed no statistically significant difference between groups before surgery (P>0.05). Compared with the data before surgery, TFA values were significantly improved in both groups after surgery (t=-8.229, -7.132, both P<0.001), with no statistically significant difference between two groups (P>0.05). Equivalence testing demonstrated that the postoperative clinical outcomes and correction of lower limb alignment were equivalent between the two groups.

Conclusions

The screw cement technique is a viable option for reconstructing non contained posteromedial tibial plateau defects in KBD patients undergoing TKA. It effectively restores knee biomechanical performance, provides reliable fixation in the short term, and is cost effective, making it particularly suitable for widespread application in the impoverished KBD affected population.

Key words: Arthroplasty, replacement, knee, Bone cements, Bonescrews, Kashin-Beck disease

图1 患者术前大体像，示膝关节畸形严重。图A为站立正位；图B为术前站立侧位；图C为术前左侧屈曲位；图D为术前右侧屈曲位

Figure 1 General appearance of the patient before surgery, showing severe knee deformity. A is image of standing at anteroposterior view; B is image of standing at lateral view; C is image of left knee in flexion; D is image of right knee in flexion

图2 术前下肢X线片。图A为下肢全长显示双下肢呈内翻畸形；图B为右膝正侧位，示胫骨骨缺损16 mm；图C为左膝正侧位，示胫骨骨缺损14 mm

Figure 2 Radiographs of lower limbs before surgery. A is full-length anteroposterior view of the lower extremities, showing varus deformity of both lower limbs; B is anteroposterior and lateral view of the right knee, showing a tibial bone defect of 16 mm; C is anteroposterior and lateral view of the left knee, showing a bone defect of 14 mm

图3 右膝术中照片。图A为术中显露可见股骨内髁磨损严重，胫骨内侧平台缺损；图B～C为显示胫骨内侧平台骨缺损情况；图D为平台骨质缺损处使用螺钉栽桩；图E为栽桩后螺钉稍低于骨平面；图F为假体安装完成

Figure 3 Intraoperative photographs of the right knee. A is intraoperative exposure image, showing severe wear of the medial femoral condyle and a medial tibial plateau defect; B and C are intraoperative views demonstrating the bone defect of the medial tibial plateau; D shows that screws were placed as reinforcement at the site of the tibial bone defect; E shows that the screws are slightly below the articular surface after placement; F is the final view after prosthetic component implantation

图4 右膝术后X线。图A为下肢全长片显示下肢力线恢复良好；图B为右膝正侧位片，示骨水泥界面存在透亮线（白色箭头）

Figure 4 Postoperative radiographs of the right knee. A is full-length radiograph of the lower extremities at anteroposterior view, showing satisfactory restoration of lower limb alignment; B is radiograph of the right knee at anteroposterior and lateral view, showing radiolucent lines at the bone–cement interface (white arrows)

表1 患者一般资料

Table 1 General patient data

组别 Groups	例数Number of cases	性别（男/女） Gender （male/ female）	年龄［岁，（ $x ¯$ ±s）］ Age（year）	侧别（左/右） Side（left/ right）	BMI ［kg/m²，（ $x ¯$ ±s）］
浅缺损组 Shallow defect group	25	8/17	62.8±5.7	14/11	22.0±2.6
深缺损组 Deep defect group	25	13/12	65.3±6.7	13/12	22.6±2.3
统计值 Statistical values		χ²=-1.418	t=-1.456	χ²=-0.281	t=-0.817
P值		＞0.05	＞0.05	＞0.05	＞0.05

表1 患者一般资料

Table 1 General patient data

组别 Groups	例数Number of cases	性别（男/女） Gender （male/ female）	年龄［岁，（ $x ¯$ ±s）］ Age（year）	侧别（左/右） Side（left/ right）	BMI ［kg/m²，（ $x ¯$ ±s）］
浅缺损组 Shallow defect group	25	8/17	62.8±5.7	14/11	22.0±2.6
深缺损组 Deep defect group	25	13/12	65.3±6.7	13/12	22.6±2.3
统计值 Statistical values		χ²=-1.418	t=-1.456	χ²=-0.281	t=-0.817
P值		＞0.05	＞0.05	＞0.05	＞0.05

表2 两组术前、术后KSS和KSS功能评分（

x ¯

±s）

Table 2 KSS score and KSS function score before and after surgery in two groups

时点 Time	例数 Number of cases	浅缺损组KSS评分 KSS of shallow defect group	浅缺损组KSS功能评分 KSS function score of shallow defect group	时点 Time	例数 Number of cases	深缺损组KSS评分 KSS of deep defect group	深缺损组KSS功能评分 KSS function score of deep defect group
术前 Before surgery	25	32.2±6.8	32.0±7.4	术前 Before surgery	25	19.0±2.3	11.8±4.7
术后 After surgery	25	86.2±2.0	79.8±5.0	术后 After surgery	25	85.4±2.6	79.6±4.7
MD（95%CI）		-54.04（-57.01，-51.07）	-47.80（-52.77，-42.83）	MD（95%CI）		-66.400（-67.64，-65.16）	-67.80（-71.28，-64.32）
t值		-37.516	-19.859	t值		-110.667	-40.208
P值		＜0.001	＜0.001	P值		＜0.001	＜0.001

表2 两组术前、术后KSS和KSS功能评分（

x ¯

±s）

Table 2 KSS score and KSS function score before and after surgery in two groups

时点 Time	例数 Number of cases	浅缺损组KSS评分 KSS of shallow defect group	浅缺损组KSS功能评分 KSS function score of shallow defect group	时点 Time	例数 Number of cases	深缺损组KSS评分 KSS of deep defect group	深缺损组KSS功能评分 KSS function score of deep defect group
术前 Before surgery	25	32.2±6.8	32.0±7.4	术前 Before surgery	25	19.0±2.3	11.8±4.7
术后 After surgery	25	86.2±2.0	79.8±5.0	术后 After surgery	25	85.4±2.6	79.6±4.7
MD（95%CI）		-54.04（-57.01，-51.07）	-47.80（-52.77，-42.83）	MD（95%CI）		-66.400（-67.64，-65.16）	-67.80（-71.28，-64.32）
t值		-37.516	-19.859	t值		-110.667	-40.208
P值		＜0.001	＜0.001	P值		＜0.001	＜0.001

表3 两组术前、术后WOMAC评分（

x ¯

±s）

Table 3 WOMAC score before and after surgery in two groups

组别 Groups	例数 Number of cases	术前 Before surgery	术后 After surgery	MD（95%CI）	t值	P值
浅缺损组 Shallow defect group	25	62±9	22±14	39.76（35.47，44.06）	19.105	＜0.001
深缺损组 Deep defect group	25	71±10	23±15	48.28（39.93，56.63）	11.941	＜0.001

表3 两组术前、术后WOMAC评分（

x ¯

±s）

Table 3 WOMAC score before and after surgery in two groups

组别 Groups	例数 Number of cases	术前 Before surgery	术后 After surgery	MD（95%CI）	t值	P值
浅缺损组 Shallow defect group	25	62±9	22±14	39.76（35.47，44.06）	19.105	＜0.001
深缺损组 Deep defect group	25	71±10	23±15	48.28（39.93，56.63）	11.941	＜0.001

图5 末次随访大体像显示下肢力线恢复良好，膝关节屈伸活动度满意。图A示仰卧屈膝位膝关节屈曲活动度恢复满意；图B示站立位力线恢复良好；图C示负重屈曲位膝关节屈曲活动度恢复良好

Figure 5 Clinical photographs at the latest follow-up, showing satisfactory restoration of lower limb alignment and knee range of motion. A shows knee flexion range of motion in the supine position; B shows good limb alignment in the standing position; C shows good knee flexion recovery in the weight-bearing flexed position

表4 两组术前术后TFA［°，（

x ¯

±s）］

Table 4 TFA before and after surgery in two groups

组别 Groups	例数 Number of cases	术前 Before surgery	术后 After surgery	MD（95%CI）	t值	P值
浅缺损组 Shallow defect group	25	166.1±5.5	176.1±1.4	-10.00（-12.51，-7.49）	-8.229	＜0.001
深缺损组 Deep defect group	25	166.9±5.6	175.6±1.9	-8.72（-11.24，-6.20）	-7.132	＜0.001

表4 两组术前术后TFA［°，（

x ¯

±s）］

Table 4 TFA before and after surgery in two groups

组别 Groups	例数 Number of cases	术前 Before surgery	术后 After surgery	MD（95%CI）	t值	P值
浅缺损组 Shallow defect group	25	166.1±5.5	176.1±1.4	-10.00（-12.51，-7.49）	-8.229	＜0.001
深缺损组 Deep defect group	25	166.9±5.6	175.6±1.9	-8.72（-11.24，-6.20）	-7.132	＜0.001

图6 末次随访X线片资料。A为双下肢全长片，可见术后TFA（股胫角）恢复良好；B为右膝术后20个月正侧位X线片，示胫骨平台骨缺损处骨水泥界面有透亮线存在，透亮线（白色箭头）与术后比较无变化；C为左膝术后16个月正侧位X线片，示左膝骨水泥螺钉重建胫骨缺损，骨水泥界面无透亮线

Figure 6 Radiographic data at the latest follow-up. A is full-length of both lower extremities at anteroposterior view, showing satisfactory restoration of postoperative TFA (femorotibial angle); B is anteroposterior and lateral view of the right knee 20 months after surgery, revealing a radiolucent line at the bone-cement interface in the region of tibial plateau bone defect reconstructed with bone cement, and the radiolucent line (white arrow) showed no progression compared with the immediate postoperative radiograph; C is anteroposterior and lateral view of the left knee 16 months after surgery, demonstrating reconstruction of the tibial bone defect using bone cement combined with screws, with no radiolucent line at the bone-cement interface

表5 术后临床评分及下肢力线等效性检验（

x ¯

±s）

Table 5 Equivalence test of postoperative clinical scores and lower limb alignment

组别 Groups	例数 Number of cases	KSS评分	KSS功能评分	WOMAC评分	TFA（°）
浅缺损组 Shallow defect group	25	86.2±2.0	79.8±5.0	22.4±13.9	176.1±1.4
深缺损组 Deep defect group	25	85.4±2.6	79.6±4.7	23.1±14.9	175.6±1.9
预设等效性界值Δ Preset equivalence threshold Δ		±5	±5	±10	±3
F值		1.643	0.090	0.186	3.086
t值		1.260	0.176	-0.167	0.904
90%CI		（-0.278，1.958）	（-2.043，2.523）	（-7.521，6.161）	（-0.346，1.226）

表5 术后临床评分及下肢力线等效性检验（

x ¯

±s）

Table 5 Equivalence test of postoperative clinical scores and lower limb alignment

组别 Groups	例数 Number of cases	KSS评分	KSS功能评分	WOMAC评分	TFA（°）
浅缺损组 Shallow defect group	25	86.2±2.0	79.8±5.0	22.4±13.9	176.1±1.4
深缺损组 Deep defect group	25	85.4±2.6	79.6±4.7	23.1±14.9	175.6±1.9
预设等效性界值Δ Preset equivalence threshold Δ		±5	±5	±10	±3
F值		1.643	0.090	0.186	3.086
t值		1.260	0.176	-0.167	0.904
90%CI		（-0.278，1.958）	（-2.043，2.523）	（-7.521，6.161）	（-0.346，1.226）

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Efficacy of screw cement technique for tibial plateau defect reconstruction in Kashin-Beck disease

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Efficacy of screw cement technique for tibial plateau defect reconstruction in Kashin-Beck disease