膝外翻的手术治疗和功能重建策略

Surgical treatment and reconstruction strategy of knee valgus deformity

背景:膝外翻畸形有骨与软组织的特征性改变,目前有多种治疗方式,如股骨远端内翻截骨、髁上杵臼截骨、全膝关节置换等均能矫正外翻畸形,恢复下肢正常机械轴。其优缺点及适应证均不同,应根据不同患者的具体情况选择对应治疗手段。目的:综述近年国内外多种手术方法治疗膝外翻畸形的研究进展。方法:第一作者应用计算机检索2000年1月至2018年12月PubMed数据库、中国期刊全文数据库相关文章,英文检索词"knee joint,valgus deformity,distal femoral varus osteotomy,supracondylar dome osteotomy,totalkneearthroplasty,surgery,treatment";中文检索词"膝关节,外翻畸形,股骨远端内翻截骨术,髁上杵臼截骨术,全膝关节置换术,手术,治疗"。共检索到247篇相关文献,47篇文献符合纳入标准。结果与结论:①膝外翻畸形常合并有骨与软组织的特征性改变,目前有多种治疗方式,如股骨远端内翻截骨、髁上杵臼截骨、全膝关节置换换均能矫正外翻畸形,恢复下肢正常机械轴。其优缺点及适应证均不同,不同患者应根据畸形的严重程度、病史长短、年龄情况等选择对应治疗手段;②股骨远端内翻截骨术适用于青年,能有效防止或延缓骨关节炎的发生发展,其中截骨术内固定物的选择多种多样,如Ilizarov外固定架、Puddu接骨板、Tomofix接骨板、髓内钉固定等,均有其优缺点;③但对于已经形成的关节内病变的膝外翻患者,单纯股骨远端内翻截骨治疗效果往往不理想,髁上杵臼截骨联合关节镜则能有效解决这一问题;④对于晚期膝关节炎患者,全膝关节置换往往是最理想的选择,应根据患者膝关节外翻畸形的严重程度及病理改变来决定全膝置换的手术入路。对于髌骨轨迹不正常、外侧结构挛缩严重患者,则使用髌旁外侧入路;反之采用内侧入路。假体选择亦至关重要,直接影响术后疗效和使用寿命等。内外侧软组织失衡可通过松解平衡后恢复关节力线,但是具体软组织松解策略仍有争议,应结合患者关节及软组织综合考虑。

BACKGROUND: Knee valgus deformity is often accompanied by bone and soft tissue changes. There are many treatments, such as distal femoral varus osteotomy, supracondylar acetabular osteotomy, total knee arthroplasty, which can correct valgus deformity and restore the normal mechanical axis of lower limbs. Its advantages, disadvantages and indications are different, and corresponding treatment methods should be selected according to the specific conditions of different patients. OBJECTIVE: To review the research progress of various surgical methods for treating genu valgus deformity at home and abroad in recent years. METHODS: A computer-based search was conducted in PubMed and CNKI databases from January 2000 to December 2018 with the keywords of “knee joint, valgus deformity, distal femoral varus osteotomy, supracondylar dome osteotomy, total knee arthroplasty, surgery, treatment” in English and Chinese, respectively. A total of 247 relevant literatures were retrieved, and 47 articles were eligible for the inclusion criteria. RESULTS AND CONCLUSION:(1) Valgus deformity is often associated with some characteristic changes in bone and soft tissue. There are a variety of treatments, for example, distal femoral varus osteotomy, supraorbital iliac crest osteotomy, total knee arthroplasty. They can correct valgus deformity and restore the normal mechanical axis of the lower extremities. Their advantages and disadvantages and indications are different, so different patients should choose appropriate treatment according to the severity of deformity, length of disease history, age and so on.(2) Distal femoral varus osteotomy is suitable for young people and can effectively prevent or delay the occurrence and development of osteoarthritis. There are many kinds of internal fixators for osteotomy, such as Ilizarov external fixator, Puddu plate, Tomofix plate and intramedullary nail, which have their advantages and disadvantages.(3) However, for patients with knee valgus who have already developed intra-articular diseases, the effect of simple distal femoral varus osteotomy is often unsatisfactory. Supracondylar acetabular osteotomy combined with arthroscopy can effectively solve this problem.(4) Total knee arthroplasty is often the best choice for patients with advanced knee arthritis. According to the severity and pathological changes of valgus deformity of the knee joint, the operative approach of total knee replacement is decided. For patients with abnormal patellar track and severe lateral structural contracture, the lateral approach is used and the medial approach is used instead. The choice of prosthesis is also very important, which directly affects the curative effect and life span after operation. The internal and external soft tissue imbalance restores the articular force line by releasing the balance, but the specific soft tissue release strategy is still controversial. The joint and soft tissue of the patient should be considered comprehensively.