内侧开放楔形胫骨高位截骨术中并发外侧铰链断裂早期疗效分析

Early effectiveness analysis of lateral hinge fracture during medial opening-wedge high tibial osteotomy

目的比较内侧开放楔形胫骨高位截骨术(medial opening-wedge high tibial osteotomy,MOWHTO)中发生铰链断裂者与无铰链断裂者的临床疗效及影像学资料,以评估铰链断裂对MOWHTO早期疗效的影响。方法2015年9月—2018年7月,采用MOWHTO治疗84例(97膝)膝关节内侧单间室骨关节炎患者,其中男10例(10膝),女74例(87膝);年龄45~65岁,平均57.7岁。依据术中透视影像和术后即刻X线片判定是否并发有外侧铰链断裂,依照Takeuchi分型对铰链断裂分型。手术前后通过X线片测量比较铰链未断裂组(A组)和铰链断裂组(B组)的髋-膝-踝角(hip-knee-ankle angle,HKA)、股胫角(femur tibia angle,FTA)、胫骨近端内侧角(medial proximal tibial angle,MPTA)。采用美国特种外科医院(HSS)膝关节评分及美国膝关节协会评分(KSS)评价膝关节功能。结果术后切口均Ⅰ期愈合。患者均获随访,随访时间15~48个月,平均24.8个月。97膝中78膝(80.41%)未发生铰链断裂(A组),19膝(19.59%)发生外侧铰链断裂(B组),其中Ⅰ型13膝(13.40%)、Ⅲ型6膝(6.19%),未见Ⅱ型铰链断裂。Ⅰ型断裂未予以进一步处理;Ⅲ型术中将外侧平台骨折解剖复位后,自外侧平台下方辅助2枚螺钉固定。随访复查X线片及CT提示,术后3个月患者截骨处均达骨性愈合,无延迟愈合及不愈合。随访期间无内固定接骨板及螺钉松动、断裂发生。A、B组(Ⅰ、Ⅲ型)患者术后各时间点HKA、FTA、MPTA均较术前显著改善(P<0.05);手术前后各时间点组间比较差异均无统计学意义(P>0.05)。术后患者膝关节疼痛明显减轻或缓解,关节功能得到改善。末次随访时,A、B组KSS评分及HSS评分均较术前显著改善(P<0.05);但组间比较差异均无统计学意义(P>0.05)。结论MOWHTO术中可能会并发外侧铰链断裂,只要根据铰链断裂分型选择恰当的治疗和康复方案,术后可以取得与铰链未断裂者相似的临床疗效。

Objective To compare the clinical and radiologic effectiveness in patients with versus without lateral hinge fracture during medial opening-wedge high tibial osteotomy(MOWHTO)to evaluate the effect of lateral hinge fracture on short-term effectiveness.Methods The clinical data of 84 patients(97 knees)with medial compartment osteoarthritis who treated with MOWHTO between September 2015 and July 2018 was retrospectively analyzed.There were 10 males(10 knees)and 74 females(87 knees).The age ranged from 45 to 65 years with an average of 57.7 years.Lateral hinge fracture was recognized by the intraoperative fluoroscopy or immediate postoperative X-ray film.Fractures were classified into typesⅠ,Ⅱ,andⅢaccording to the Takeuchi classification.The healing of osteotomy was observed by radiographs during follow-up;the femur tibia angle(FTA),medialproximal tibial angle(MPTA),and hip-knee-ankle angle(HKA)were also calculated.The knee joint function was evaluated by Hospital for Special Surgery(HSS)score and knee society score(KSS).Results The incision healed by first intention.All patients were followed up 15-48 months with an average of 24.8 months.No hinge fracture occurred in 78 knees(80.41%,group A),and lateral hinge fractures were observed in 19 knees(19.59%,group B)and were divided into the typeⅠ(13 knees,13.40%)and typeⅢ(6 knees,6.19%)groups.TypeⅠfractures were not additionally treated,typeⅢfractures were anatomic reduced fixed with additional lag screws.X-ray film and CT examination showed that all patients had bone healing at 3 months after operation without delayed healing or nonunion.During follow-up,there was no loosening or fracture of internal fixation plates and screws.HKA,FTA,and MPTA of patients in group A and group B(typeⅠandⅢ)were significantly improved at each time point after operation compared with preoperative values(P<0.05);there was no significant difference between groups at each time point before and after operation(P>0.05).After operation,the pain of knee joint was alleviated and the function of joint was improved.At last follow-up,KSS score and HSS score of groups A and B were significantly improved compared with those before operation(P<0.05),but there was no significant difference between the two groups(P>0.05).Conclusion The lateral hinge fracture may occur during MOWHTO.As long as the treatment and rehabilitation were guided according to the fracture classification of the hinge,the effectiveness can be similar to those without the hinge fracture.