内翻型单间室膝关节骨关节炎胫骨髁外翻截骨术的临床疗效

Tibial condylar valgus osteotomy in the treatment of varus unicompartmental knee osteoarthritis

目的探讨胫骨髁外翻截骨术(tibial condylar valgus osteotomy,TCVO)治疗内翻型单间室膝关节骨关节炎的临床疗效及手术指征。方法回顾性分析2016年6月至2018年6月接受TCVO手术的内翻型单间室膝关节骨关节炎患者32例(45膝),男12例(18膝)、女20例(27膝);年龄(65.8±8.3)岁(范围52~79岁)。患侧膝关节均存在明显的外侧间隙增宽,关节线会聚角为7.19°±2.69°。于术前与术后2年站立位双下肢全长X线片、膝关节正侧位X线片上测量机械轴百分比、股骨胫骨角、髋膝踝角、股骨远端外侧角、股骨近端内侧角,评估下肢解剖轴及机械轴对线变化;测量胫骨平台内侧凹陷角与胫后角,评估胫骨平台形态变化;测量关节线会聚角与关节间隙宽度,评估膝关节对合状态的恢复。依据术前、术后1年及术后2年的疼痛视觉模拟评分(visual analogue scale,VAS)、西安大略与麦克马斯特大学(Western Ontario and McMaster Universities,WOMAC)骨关节炎指数评估临床疗效。结果32例均获得随访,随访时间(33.4±7.4)个月(范围25~40个月)。术后2年,下肢机械轴百分比由术前3.78%±14.34%提高至66.16%±9.90%、股骨胫骨角由185.41°±4.45°矫正至170.81°±2.87°、髋膝踝角由169.69°±1.70°提高至181.16°±2.39°、胫骨近端内侧角由83.03°±3.20°提高至90.84°±3.67°(P<0.05);而股骨远端外侧角为89.22°±1.52°,与术前88.97°±1.57°的差异无统计学意义(t=0.638,P=0.526);胫骨平台内侧凹陷角由术前-7.81°±3.27°改善至5.78°±2.19°(t=19.218,P<0.001);胫后角为81.63°±3.28°,与术前82.25°±2.21°的差异无统计学意义(t=0.881,P=0.382);关节线会聚角由术前7.19°±2.69°降低至0.22°±2.09°,内、外侧关节间隙宽度分别由(2.45±0.23)mm、(5.86±0.25)mm矫正至(3.73±0.27)mm、(4.68±0.34)mm(P<0.05)。VAS及WOMAC评分分别由术前(6.46±2.21)分、(52.66±16.69)分下降至术后1年(2.94±1.72)分、(19.31±14.87)分,术后2年(1.36±1.45)分、(13.66±15.44)分(P<0.05)。结论TCVO治疗膝关节外侧间隙增宽、关节线会聚角增大的内翻型单间室膝关节骨关节炎可以取得良好的早期疗效,有效矫正膝关节内翻畸形并外移下肢机械力线,缓解术后早期膝关节疼痛及改善日常活动能力。

Objective To investigate the clinical effects and indications of tibial condylar valgus osteotomy(TCVO)in treating varus unicompartmental knee osteoarthritis.Methods A retrospective analysis was conducted in 32 patients(45 knees)who suffered from varus unicompartmental knee osteoarthritis and underwent TCVO from June 2016 to June 2018.These patients were aged 65.8±8.3(range from 52 to 79)years,including 12 males(18 knees)and 20 females(27 knees).All enrolled individuals presented obvious expansion of the lateral joint space with joint line convergence angle(JLCA)of 7.19°±2.69°.Based on the full-length standing X-ray imaging of the lower limbs at before and 2 years after surgery,the percentage of mechanical axis(%MA),femorotibial angle(FTA),hip-knee-ankle angle(HKA),lateral distal femoral angle(LDFA)and medial proximal tibial angle(MPTA)were measured and analyzed to evaluate the improvements of lower extremity alignments.The medial tibial plateau depression(MTPD),posterior proximal tibial angle(PPTA),JLCA and joint space width(JSW)were measured and analyzed to evaluate the congruency of the knee joint and shape of the tibial plateau based on positive and lateral radiographs of knee joint.In addition,visual analogue scale(VAS)and Western Ontario and McMaster Universities(WOMAC)score were evaluated to assess the clinical effects of TCVO pre-operatively and at 1 year or 2 years after surgery.Results All patients were followed up for 33.4±7.4(range from 25 to 40)months.Comparing to the preoperative radiological data,%MA at 2 years after surgery increased from 3.78%±14.34%to 66.16%±9.90%,FTA from 185.41°±4.45°to 170.81°±2.87°,HKA from 169.69°±1.70°to 181.16°±2.39°,MPTA from 83.03°±3.20°to 90.84°±3.67°all with statistical significance(P<0.05).There was no significant difference for PPTA between before(89.22°±1.52°)and 2 years(88.97°±1.57°)after surgery(t=0.638,P=0.526).MTPD improved from-7.81°±3.27°to 5.78°±2.19°(t=19.218,P<0.001).However,there was no significant difference for PPTA between before(81.63°±3.28°)and 2 years(82.25°±2.21°)after surgery(t=0.881,P=0.382).JLCA reduced from 7.19°±2.69°to 0.22°±2.09°.The medial and lateral JSW were corrected from 2.45±0.23 mm and 5.86±0.25 mm to 3.73±0.27 mm and 4.68±0.34 mm(P<0.05),respectively.Additionally,VAS and WOMAC scores improved from 6.46±2.21 and 52.66±16.69 preoperatively to 2.94±1.72 and 19.31±14.87 at 1 year after surgery,and to 1.39±1.45 and 13.66±15.44 at 2 years after surgery,respectively(P<0.05).Conclusion Satisfactory early therapeutic outcomes could be achieved by TCVO in varus unicompartmental knee osteoarthritis with subluxated lateral joint and increased JLCA.TCVO can correct intra-articular varus deformity,adjust mechanical axis and relieve knee joint pain and dysfunction.