双平面胫骨高位截骨治疗伴下肢力线不良的膝关节后外复合体损伤

Dual-plane high tibial osteotomy to treat posterolateral corner injuries combined with varus deformity of knee joint

目的探讨双平面胫骨高位截骨在伴下肢力线不良的膝关节后外复合体损伤修复中的作用。方法2008年10月至2014年3月采用双平面胫骨高位截骨治疗的伴下肢力线不良的膝关节后外复合体损伤并随访2年以上的患者12例，男10例，女2例；年龄20~44岁，平均29．8岁；单膝11例，双膝1例。所有患者均有后十字韧带损伤，伴有膝关节过伸5膝，不伴膝关节过伸8膝。双平面胫骨高位截骨，在冠状面调整下肢力线通过胫骨平台62％的位置，在矢状面矫正膝关节过伸至膝关节完全伸直。术前和术后2年摄下肢负重位全长x线片，测量下肢机械轴通过胫骨平台的相对位置、股胫角和胫骨平台后倾角；摄膝关节应力位x线片，评估膝关节后向稳定性（胫骨后移距离）和内翻稳定性（外侧间隙张开程度）；通过Opti—knee步态分析测量负重期膝关节内翻角，评估截骨对内翻步态矫正的效果。结果下肢机械轴通过胫骨平台的相对位置由术前19．6％±19．1％改善至42．6％±17．9％，股胫角由术前172．8。±4．20改善至178．10±4．2。，胫骨平台后倾角由术前10．2。±5．3。改善至18．4。±6．3。，手术前后差异均有统计学意义（P〈0．05）。9例患者行膝关节应力位x线检查，胫骨后移距离由术前（11．4±5．3）mm改善至（8．1±6．9）mm，外侧间隙张开程度由术前（16．3±6．5）mm改善至（14．2±4．9）mm，差异均有统计学意义（P〈0．05）。7例患者行步态分析，负重期膝关节内翻角由术前3．0°±2．6°改善至一2．7°±2．5°，差异有统计学意义（P＜0．05）。8例患者主观认为不再需要二期韧带重建。结论双平面胫骨高位截骨治疗伴下肢力线不良的膝关节后外复合体损伤能够显著改善下肢力线和膝关节稳定性，多数患者主观认为不再需要二期韧带重建。

Objective To investigate the clinical outcome of dual-plane high tibia1 osteotomy to treat posterolateral corner injuries combined with varus and/or hyperextension deformity. Methods From October 2008 to March 2014, there were 12 patients （13 knees） undergoing high tibial osteotomy. All the patients were double or triple varus knee combined with posterior cruciate ligament and posterolateral corner （PLC） injuries. During the surgery, the weight bearing line of lower extremity was set to 62% position of the tibial plateau on the coronal plane. The tibial slope was increased to diminish the hyperextension on the sagittal plane. Full-length weight bearing X-ray was used to evaluate the position of weight bearing line, femoral-tibial angle and tibial slope preand post-operatively. The stress radiograph was used to evaluate the posterior and posterolateral stability. The Opti_knee gait analysis system was used to evaluate the varus of angle during weight bearing stage. Results The weight bearing line was corrected from 19.6%±19.1% preoperatively to 42.6%_±17.9% postoperatively （t=-4.178, P=0.002）. The femoral-tibial angle was 172.8°±4.2° preoperatively and improved to 178.1°±4.2° postoperatively （t=-4.520, P=0.001）. The tibial slope was increased from 10.2°±5.3° preoperatively to 18.4°±6.3° postoperatively （t=-5.735, P=0.000）. The tibial posterior translation was decreased from 11.4±5.3 mm preoperatively to 8.1±6.9 mm postoperatively （t=2.415, P=0.042） in 9 patients. The separation of lateral compartment was decreased from 16.3±6.5 mm preoperatively to 14.2±4.9 mm postoperatively （t=3.194, P= 0.019）. Gait analysis was performed in 7 patients and showed that the varus was improved from 3.00±2.6° preoperatively to - 2.70±2.5° postoperatively during weight bearing stage （t=-8.500, P=0.014）. Eight patients had sufficient improvement in knee function so that a subsequent posterolateral corner reconstruction was not necessary. Conclusion The dual-plane medial open wedge high tibial osteotomy can improve the alignment of lower extremity and the stability of knee joint, and 67% patients do not need a staged PLC and posterior cruciate ligament reconstruction.