胫骨高位截骨术:闭合与开放楔形截骨对比

A comparative study between closed and open wedge osteotomy in high tibial osteotomy

目的比较胫骨高位截骨术中闭合楔形截骨法（闭合楔）与开放楔形截骨法（开放楔）的临床结果及影像学特点。方法选取2013年7月至2014年6月北京积水潭医院矫形骨科收治的因膝内翻畸形施行的29例（44膝）胫骨高位截骨术患者。其中16例（24膝）采用闭合楔形截骨术,13例（20膝）采用开放楔形截骨术,均采用Tomofix系列钢板进行固定,随访时间分别为平均18.3个月（18-24个月）和16.6个月（18-25个月）。于末次评价两组患者Lysholm评分的变化、关节活动度变化及并发症发生情况。影像学方面,对比两组患者力线矫正的准确性、矫正角度及,术前、术后髌骨高度的变化及胫骨平台后倾角的变化。结果闭合楔组患者Lysholm评分从术前的（96.8±6.3）分增加至术后的（98.2±3.3）分（P=0.828）;开放楔组患者从术前的（95.4±8.3）分增加至术后的（98.1±3.4）分（P=0.656）。闭合楔组关节活动度术前为（137.7°±14.2°）,术后为（133.5°±15.0°）（P=0.146）;开放楔组术前为（138.5°±15.6°）,术后为（134.3°±17.3°）（P=0.207）。闭合楔组有1例（1膝,4.2%）出现腓神经损伤症状,半年后恢复;另有1例（1膝,4.2%）出现截骨延迟愈合,术后6个月复查时截骨愈合。闭合楔组与开放楔组畸形矫正满意率分别为87.5%和90%（P=1.000）。闭合楔组矫正胫骨内翻的角度为（10.3°±4.3°）;开放楔组为（9.4°±5.3°）（P=0.289）。在髌骨高度方面,术后闭合楔组Caton Deschamps指数（CDI）从（1.09±0.17）增大至（1.11±0.18）（P=0.761）;开放楔组从（1.16±0.25）减小至（0.99±0.23）（P=0.034）。闭合楔组胫骨后倾角从（13.4°±5.1°）减小至（9.4°±5.3°）（P=0.010）;开放楔组从（12.0°±4.1°）增大至14.9°±5.1°（P=0.050）。结论闭合楔与开放楔两种截骨技术都能获得满意的临床结果。开放楔可能减小髌骨高度,故对于术前即存在髌骨低位的患者,应避免采用开放楔,或者采用开放楔时冠状面截骨斜向前下方,将胫骨结节保留在近端截骨块,以避免进一步加重髌骨低位,影响关节活动。由于闭合楔可能减小胫骨平台后倾而开放楔可能增加后倾,故应按照实际需要个体化地选择截骨方式。

Objective To compare the clinical effect between the closed and open wedge osteotomy in high tibial osteotomy and imaging characteristics. Methods From July 2013 to June 2014,Beijing Jishuitan Hospital Orthopedic Department,orthopedics for knee varus deformity of the implementation of the 29 cases（ 44 knees） of high tibial osteotomy in patients with selection. In 16 cases（ 24knees） using closed wedge osteotomy,13 patients（20 knees） using open wedge osteotomy,Tomofix series plates were fixed,follow-up time was respectively with an average of 18. 3 months（ range from 18 to 24 months） and 16. 6 months（ range from 18 to 25 months）.The changes of Lysholm score,the activity of the joint and the complication of the two groups were evaluated at the end of the last evaluation. In imaging aspects,the accuracy and correction of the two groups of patients were compared,the changes of the height of the patella and the changes of the posterior inclination of the tibial platform were compared before and after the operation. Results Closed wedge group with Lysholm score was from preoperative（ 96. 8 ± 6. 3） points increased to postoperative（ 98. 2 ± 3. 3） points（ P =0. 828）;the score in open wedge group was from preoperative（95. 4 ± 8. 3） points increased to postoperative（ 98. 1 ± 3. 4） points（P = 0. 656）. The active degrees of the joint range of motion of closed wedge group were from preoperative（137. 7° ± 14. 2°） to postoperative（133. 5° ± 15°）（ P = 0. 146）;the open wedge group was from preoperative（138. 5° ± 15. 6°） to postoperative（134. 3° ±17. 3°）（ P = 0. 207）. There was 1 case（1 knee,4. 2%） in the closed wedge group. The symptoms of the injury of the tibial nerve were recovered after half a year,and 1 patient（ 1 knee,4. 2%） had delayed healing. The healing of the osteotomy was recovered 6months after the operation. The satisfactory rates of the closed wedge group and the open wedge group were 87. 5% and 90%（ P =1. 000）. The angle of the correction of the tibial inversion in the closed wedge group was（10. 3° ± 4. 3°）;the open wedge group was（9. 4° ± 5. 3°）（P = 0. 289）. In the patellar height,postoperative Caton Deschamps index（ CDI） of closed wedge group was from（1. 09 ± 0. 17） increased to（1. 11 ± 0. 18）（P = 0. 761）;open wedge group was from（1. 16 ± 0. 25） decreased to（0. 99 ± ＋ 0. 23）（P = 0. 034）. The tibial posterior inclination of the closed wedge group was from 13. 4° ± 5. 1° decreased to（9. 4° ± 5. 3°）（ P =0. 010）;the open wedge group was from（12° ± 4. 1°） increased to（14. 9° ± 5. 1°）（ P = 0. 050）. Conclusion Satisfactory clinical results can be obtained by two kinds of osteotomy techniques of closed wedge and open wedge. Open wedge may reduce patellar height,therefore,to preoperative patients in low patella,should avoid the use of open wedge,or with open wedge osteotomy on the coronal plane inclined forward and downward tilt. Keep the tibial tubercle in proximal cut bone block,in order to avoid further patellar low,influence of joint activities. As a result of the closed wedge may reduce the inclination of the tibial plateau and open wedge may increase the posterior tilt,which should be in accordance with the actual needs of individual choice of osteotomy.