初次全膝关节置换术中胫骨内侧平台骨缺损的处理

Management of bone deficiency of the medial tibial plateau during primary total knee arthroplasty

目的：探讨严重膝内翻畸形初次全膝关节置换术中颗粒性与结构性植骨处理内侧平台骨缺损的近期效果。方法回顾性分析2005年5月—2012年2月蚌埠医学院第一附属医院骨科初次全膝关节置换术治疗13例13侧膝内翻（〉25°）畸形伴内侧平台严重缺损（AORI Ⅱ型9例、Ⅲ型4例）患者的临床资料,在彻底松解获得内外侧间隙平衡的前提下,外侧截骨厚度为9~11 mm,截骨后遗留骨缺损6~19 mm,利用外侧平台截下骨板为结构性植骨、股骨和平台剩余骨修剪松质骨粒,移植处理内侧平台缺损,常规或延长胫骨柄假体置换。结果术中内侧平台缺损处理良好,有效地承载平台假体,术后假体位置良好,力线偏离〈2°,骨缺损消失。平均随访63个月,随访时未见骨吸收和假体松动现象。美国膝关节协会评分（KSS）由术前平均42．3分恢复至末次随访时平均92．1分。结论在严重膝内翻畸形内侧平台骨缺损的初次全膝关节置换术中,在内外侧韧带获得平衡的前提下,利用截骨获得的结构性和颗粒性植骨材料打压植骨处理内侧平台缺损,避免过多截骨而保留平台骨量,能获得良好的近期效果。

Objective To investigate the short-term clinical result of structural and particulate bone graft for bone defects of the medial tibial plateau during primary total knee arthroplasty. Methods The clinical data of 13 patients（13 knees） of genu varum （ 〉 25°） with serious medial tibial plateau bone defects （9 cases AORI Ⅱ, 4 casesⅢ） were treated in primary total knee arthroplasty at the First Affiliated Hospital of Bengbu Medical College from May 2005 to February 2012. During operation, the depth of the lateral tibial plateau resection was from 9 mm to 11 mm and the average depth of bone defects was 9. 1 mm, ranging from 6 mm to 19 mm. In order to manage the bone deficiency, the bone removed from the proximal tibia was attached as structural bone grafting and the remaining cavitary deficits were filled with particulate cancellous graft removed from the distal femur or proximal tibia. Most knee arthroplasties were cemented at the interfaces between the stemmed tibial base plate and the bone, and sometimes the tibial base plate with stem extension were used in a fully cemented technique. Results The bone defects of the medial tibial plateau were reconstructed well, which markedly provided the initial stability of the prostheses. The prostheses were fixed well and the deviation of limb alignment was usually under 2°. The average follow-up time was 63 months. Bone absorption and loosening of the prostheses were not found in all cases at the latest follow-up. The American Knee Society score（KSS） improved from preoperative 42. 3 to postoperative 92. 1. Conclusions For genu varum patients, serious medial tibial plateau bone defects can be reconstructed by using structural bone graft and particulate bone graft removed from the distal femur or proximal tibia, which can reserve knee bone in primary total knee arthroplasty.