改良单平面胫骨高位截骨术治疗膝关节骨关节炎的早期临床研究

Early efficacy of distal tibial tuberosity-high tibial osteotomy in treatment of knee osteoarthritis

背景:对于内侧单间室膝关节骨关节炎,胫骨高位截骨术(HTO)是有效的治疗方法。目前HTO主要分为双平面截骨和单平面截骨,其中改良单平面胫骨高位截骨术(DTT-HTO)的临床研究尚少。目的:分析DTT-HTO的有效性和安全性,并对其影像学、功能及并发症情况进行早期临床研究。方法:回顾性分析2016年10月至2017年12月行DTT-HTO的52例(52膝)内翻膝关节骨关节炎患者的临床资料,记录术中撑开高度、术后纠正角度,随访取板时间、丢失角度、截骨面愈合及并发症发生情况。分别于术前、术后7 d、术后6个月、术后1年及之后每年进行随访,拍摄双下肢全长X线片评估髋膝踝角(HKA)、下肢负重力线百分比(WBL%)、胫骨近端内侧角(MPTA),股骨远端外侧机械角(mLDFA);膝关节侧位X线片评估胫骨后倾角(PTS)、ISI指数;采用HSS评分、WOMAC指数、膝关节ROM和VAS评分评估患者膝关节功能和疼痛缓解情况。结果:术中平均撑开高度为(11.4±3.4)mm,平均纠正角度为10.4°±5.1°。52例(52膝)全部获得24~38个月随访,平均(30.4±4.2)个月,术后7 d至末次随访的HKA、MPTA、WBL%与术前比较差异均有统计学意义(P<0.05),而术后各时间点两两比较差异无统计学意义(P>0.05);术后7 d至末次随访的mLDFA、PTS、ISI指数与术前比较差异无统计学意义(P>0.05),术后各时间点两两比较差异无统计学意义(P>0.05);术后6个月至末次随访的HSS评分、WOMAC评分、VAS评分及膝关节ROM与术前比较差异有统计学意义(P<0.05),而术后各时间点的两两比较无统计学差异(P>0.05)。术后6个月、1年、2年及末次随访的平均丢失角度分别为0.3°,0.7°,0.9°,1.1°。术后外侧合页骨折1例,切口皮下积液1例,糖尿病患者血糖控制不佳出现内植物感染1例。术后6个月随访时所有患者的截骨间隙均正常愈合,无一例出现不愈合或延迟愈合。结论:DTT-HTO能够较为精确地矫正内翻膝关节骨关节炎的胫骨畸形,术后接骨板稳定性较好,功能恢复良好,并发症较少,短期获得比较满意的临床随访结果,中远期疗效有待进一步随访研究。

Background:High tibial osteotomy(HTO)is an effective treatment for medial compartment knee osteoarthritis.At present,HTO is mainly divided into biplane osteotomy and uniplanar osteotomy,and the clinical research of distal tibial tubercle-high tibial osteotomy(DTT-HTO)is still rare.Objective:To investigate the safety and efficacy of DTT-HTO and to early study on its imaging,function and complications.Methods:From October 2016 to December 2017,data of 52 patients(52 knees)with varus knee osteoarthritis underwent DTT-HTO were retrospectively analyzed.Size of opening gap,postoperative correction angle,plate removing time,loss of corrective angle,the osteotomy site healing and complications were recorded.The hip-knee-ankle angle(HKA),weight bearing line ratio(WBL%),medial proximal tibial angle(MPTA)and mechanical lateral distal femur angle(mLDFA)were evaluated by anteroposterior whole-leg standing radiograph;the posterior tibial slope(PTS)and insall salvati index(ISI)were measured by lateral view of knee joint pre-operatively and 7 days,6 months,one year after the operation,as well as every year follow-up ever after.The knee function and pain relief before and after surgery were evaluated by HSS score,WOMAC score,knee range of motion(ROM)and visual analogue scale(VAS).Results:All patients were followed up for 24-38 months with the mean of(30.4±4.2)months.Size of opening gap was(11.4±3.4)mm,and the correction angle was 10.4°±5.1°.There was significant difference in HKA,MPTA,WBL%during period from 7 days after operation to final follow-up compared with the pre-operation(P<0.05),and no significant difference was found among the time points after the operation(P>0.05).There was no significant difference in mLDFA,PTS,ISI during period from 7 days after operation to final follow-up compared with the pre-operation(P>0.05)and among the time points after the operation(P>0.05).There were significant differences in HSS score,WOMAC score and knee ROM during period from six months after the operation to final follow-up compared with the pre-operation(P<0.05),and no significant difference was found among the time points after the operation(P>0.05).The loss of corrective angle was 0.3°,0.7°,0.9°,1.1°at six months,one year,two years and final follow-up after the surgery.After the operation,there was one patient occurring lateral hinge fracture,one patient occurring incision subcutaneous hydrops and one diabetic patient with poor blood glucose control occurring internal fixation infection.The osteotomy gap in all patients healed normally 6 months after the surgery.Conclusions:DTT-HTO can correct the tibia deformity caused by varus knee osteoarthritis accurately with good stability of the plate,good function recovery and fewer complications.The short-term results are satisfactory and the medium-long-term outcomes require further study.