胫骨高位外翻截骨、胫骨结节内旋治疗膝内翻型髌股关节紊乱症

High tibial osteotomy combined with tibial tuberosity limited rotation in the treatment of disorder of pateliofemoral joint with knee varus

目的探讨胫骨高位外翻截骨、胫骨结节有限旋转治疗膝内翻型髌股关节紊乱症的可行性及中期疗效。方法回顾性分析2008年1月至2009年12月，采用胫骨高位外翻截骨、胫骨结节有限旋转治疗42例膝内翻型髌股关节紊乱症患者资料，男7例，女35例；年龄34~55岁，平均44岁；单膝36例（右膝25例，左膝11例），双膝6例。针对术前髌骨轨迹及胫骨结节一股骨滑车间距（tibialtuberosity．trochleargroovedistance，TT-TG）将膝内翻型髌股关节紊乱症分为三型，依据不同分型在胫骨高位外翻截骨的基础上通过胫骨结节旋转调整胫骨结节位置，改善髌骨轨迹及下肢力线。其中Ⅰ型紊乱10例，Ⅱ型紊乱12例，采用胫骨高位外翻截骨治疗；Ⅲ型紊乱20例，采用胫骨高位外翻截骨＋胫骨结节内旋治疗。测量手术前后下肢力线、外侧股胫角、胫骨近端内侧角及Q角、IT-TG；依据术前、术后髌骨倾斜角、髌股适合角及外侧髌骨角评估髌骨轨迹改善情况。根据术前影像学测量结果及足前进角决定旋转角度，避免步态异常。结果42例患者均获得随访，随访时间60-88个月，平均（72．20±12．60）个月，无一例发生神经损伤、感染及骨不愈合。术后12个月膝关节屈伸活动度基本恢复正常，能完全下蹲。髌骨倾斜角由术前12．45°±3．76°改善至术后5年6．98°±1．78°；髌股适合角由术前12°510±4．71°改善至术后5年-4．70°±2．57°；外侧髌骨角由术前1．50。±4．90。改善至术后5年7．80°±3．10°。外侧股胫角由术前182．45±2．20。改善至术后5年174．60°±3．50°，胫骨近端内侧角由术前78．75°±3．50°改善至术后5年93．25°±1．950°术前膝关节Lysholm评分、IKDC主观评分、Kujala评分、视觉模拟评分分别为（53．10±5．60）分、（47．50±6．40）分、（62．40±8．70）分、（7．50±2．45）分，术后5年分别为（92．70±5．50）分、（91．30±6．90）分、（87．30±4．10）分、（1．50±0．90）分，以上指标比较差异均有统计学意义。经中期随访，膝关节髌骨轨迹及下肢力线纠正良好，膝前疼痛及内侧疼痛缓解。结论对膝内翻型髌股关节紊乱症，采用胫骨高位外翻截骨、胫骨结节有限旋转，可有效改善髌骨轨迹及下肢力线进而缓解疼痛，中期随访疗效满意。

Objective To investigate the mid-term outcome of high tibia osteotomy （HTO） combined with tibial tuberosi- ty limited rotation in the treatment of disorder of patellofemoral joint with knee varus. Methods HTO was performed in all 42 pa- tients. The lower limb alignment, lateral femoral tibial angle, medial proximal tibia1 angle, Q angle and TF-TG were measured be- fore and after operation. All the patients with disorder of patellofemoral joint were divided into three types based on preoperative patellar trajectory and TT-TG. According to different types we chose the limided rotation of distal tibia through adjustment of tibial tubercle location to improve patellar track. Type I in 10 cases and type II in 12 cases only accepted HTO, type III in 20 cases ac- cepted HTO and tibial tubercle rotation. The rotation angle was determined according to preoperative imaging resuhs and foot for- ward angle. Before and after operation patellar tilt angle, patellofemoral angle and lateral patellar angle were measured. Results 42 patients were followed up for more than 5 years, an average of 72.20± 12.60 months （60-88 months）. No nerve damage, infec- tion and bone nonunion occurred. The patellar tilt angle was improved from 12.45°±3.76° to 6.98°±1.78° 5 years after operation. The patellofemoral angle was improved from 12.51°4.71° to -4.700±2.57° 5 years after operation, and the lateral patellar angle was improved from 1.50°±4.90° to 7.8°±3.10°. Preoperative lateral femoral tibial angle was improved from 182.45°±2.20° to post- operative 174.60°±3.50°, medial proximal tibial angle was improved from preoperative 78.75°±3.50° to postoperative 93.25°± 1.95°. The Lysholm score was improved from preoperative 53.10±5.60 to 92.70±5.50. The preoperative IKDC subjective score was improved from 47.50±6.40 to 91.30±6.90. The Kujala score was 62.40±8.70 before operation and 87.30±4.10 5 years after opera- tion. Visual analogue score （VAS） was 7.50±2.45 before operation and 1.50±0.90 5 years after operation. The short and mid-termfollow-up, knee patellar trajectory and lower limb alignment was good, postoperative symptoms was satisfactory and acceptable. Conclusion HTO combined with limited rotation of the tibial tubercle could improve patellar trajectory and lower limb align- ment to relieve pain, and has satisfactory mid-term outcome in the disorder of patellofemoral joint with knee varus patients.