全膝关节置换术中胫骨近端骨缺损的处理

Bone graft for tibial bone defects during primary total knee arthroplasty

目的探讨初次人工全膝关节置换术中胫骨近端骨缺损的植骨方法和疗效。方法2001年10月至2006年3月，在23例（42膝）初次人工全膝关节置换术中采用自体或异体骨移植修复胫骨近端骨缺损，男5例（9膝），女18例（33膝）。骨关节炎19例（35膝），类风湿性关节炎2例（4膝），大骨节病1例（2膝），关节结核1例（1膝）。非包容型骨缺损22例40膝，包容型骨缺损1例2膝。参照Engh ＆ Parks分类法，T1级5膝，T2级33膝，B级4膝。自体髂骨2例3膝，1例2膝为类风湿性关节炎，包容型，为T2级，骨移植起填充作用；另1例1膝为左膝骨关节炎，非包容型，为T3级。异体冷冻骨1例1膝为膝关节结核，同时股骨外髁和胫骨内侧平台骨缺损，为T3级，行大块骨移植，螺钉固定。自体股骨内髁加异体冻于骨移植修复胫骨内侧平台骨缺损1例1膝，为T3级。其余19例37膝均为自体股骨内髁或胫骨外侧平台修整后移植，修复胫骨内侧平台骨缺损，其中螺钉固定14膝。结果术后随访38．2（3-56）个月。所有患者术前均有内或外翻畸形和屈曲挛缩畸形，术后畸形得到矫正，疼痛消失；3个月后均可弃拐行走，生活可以自理。膝关节HSS评分由术前15.3（10-26）分提高到术后86（79-95）分。膝关节活动范围由术前74．4°（0°--90°）提高到术后109．4°80°-135°）。1例于术后3年死于心肺功能衰竭。术后X线复查1年以上者20例（39膝），胫股角为5°-7°，平均6．4°。结论骨移植尤其是自体骨移植在初次人工全膝关节置换术中可以恢复胫骨近端的完整性，为胫骨假体提供初始稳定性，具有简便、实用、经济实惠等优点；可以保留足够的骨量，为以后的翻修提供良好的基础。

Objective The method and clinical of bone graft for bone defects of proximal tibia are evaluated during primary total knee arthroplasty （TKA）, Methods From October 2001 to March 2006, 23 cases （42 knees） were treated by autograft or allograft to repair bone defects of proximal tibias during the operative procedure of primary TKAs. There were 5 males with 9 knees and 18 females with 33 knees. The average age of the patients was 66.2 years old ranging from 51 to 80 years. The components were used 38 PFC and 4 G Ⅱ -PS. The diagnoses of the patients were osteoarthritis in 19 cases （35 knees）, rheumatoid arthritis in 2 cases （4 knees）,Kashin-Bek syndrome in 1 case （2 knees） and tuberculosis of knee joint in 1 case （1 knee）. 22 cases （40 knees） of 23 cases belong to uncontained type and 1 case （2 knees） belongs to contained type. The categories of bone graft consisted of autograft of iliac crest used in 2 cases （3 knees）, allograft used in 1 case （1 knee）, autograft of femur medial condyle with allograft used in 1 case （1 knee） and autograft of femur medial condyle or lateral tibia plateau used in the rest 19 cases （37 knees）, which it was fixed with screws in 14 knees. Results The patients were followed up 3 to 56 months with the average of 38.2 months. All of the patients who had varus or valgus and contraction deformities before operation were rectified and could walk without crutch and self-care 3 months after operation. The HSS knee score increased from preoperative 15.3 （10-26）to postoperative 86 （79-95）. The range of movement improved from preoperative 74.4° （0°-90°） to postoperative 109.4°（80°-135°）. One patient died of cardio-respiratory malfunction 3 years after operation. Conclusion The bone graft of primary TKA, especially the autograft, can reconstruct the integrity of proximal tibia and provide a initial stability for the prosthesis, but also provide for favorable foundation of revision total knee through adding and reserving knee bone.