滑移截骨在关节外畸形全膝关节置换中的应用

目的:针对伴有复杂股骨关节外畸形导致的严重膝骨性关节炎、内翻膝患者在进行全膝关节置换手术时施行滑移截骨技术达到内外侧软组织平衡,观察其临床疗效。方法:自2014年6月至2018年1月共收治22例伴有复杂股骨关节外畸形的重度膝骨性关节炎患者,施行全膝关节置换手术。男5例,女17例;年龄48~76(61.3±13.8)岁。均为内翻畸形,由股骨关节外畸形所导致。术前测量髋膝踝角(hip-knee-ankle,HKA)角(158.8±9.7)°,膝关节学会评分系统(Knee Society score,KSS)临床评分(32.6±6.1)分,功能评分(35.8±9.6)分,美国特种外科医院(Hospital for Special Surgical,HSS)评分(39.7±4.6)分。术前膝关节活动度(80.6±10.7)°。在关节置换时均采用机械对线法,先平衡屈曲间隙,冠状面的不平衡均采用内侧股骨髁行冠状面垂直上下滑移截骨,伸直间隙内外侧的差距决定截骨块滑移的距离,直至间隙平衡。以数枚螺钉固定截骨块后按常规安装假体。结果:所有患者伤口Ⅰ期愈合,无伤口并发症发生。22例均获随访,时间18~36(28.2±10.1)个月。拍X线片见截骨块骨折线消失时间2~5(3.5±1.5)个月,无骨不愈合发生;末次随访测量HKA角(178.8±0.7)°,较术前提高;HSS评分(91.3±6.0)分,KSS临床评分(93.7±3.5)分,KSS功能评分(81.2±6.5)分,膝关节活动度(121.7±11.6)°,均较术前改善。结论:针对伴有复杂股骨关节外畸形的严重膝骨性关节炎患者施行滑移截骨,内翻畸形严重者向下滑移股骨内髁,手术相对简单、损伤小,易于达到屈伸间隙内外侧软组织平衡,短期临床疗效满意。

Application of sliding osteotomy in total knee arthroplasty for patients with extra-articular femoral deformity

Objective: In order to observe the clinical effects of sliding osteotomy for patients with severe knee osteoarthritis and varus knee due to complex femoral extra-articular deformity to achieve the medial and lateral soft tissue balancing during total knee arthroplasty.Methods: From June 2014 to January 2018,a total of 22 patients with severe knee osteoarthritis and complex extra-articular malformation of femurs were treated with total knee arthroplasty. There were 5 males and 17 females in this group,aged 48 to 76 years old,with an average age of (61.3±13.8) years old. All the patients had varus deformities caused by extra-articular deformities of femur. Hip-knee-ankle(HKA) angle was(158.8±9.7) ° before operation,and the average Knee Society Score(KSS) clinical score was 32.6±6.1;KSS function score was 35.8 ±9.6;the average Hospital for Special Surgical(HSS) score was 39.7±4.6;the average range of motion before operation was (80.6±10.7) °. The mechanical alignment method was used in joint replacement. The flexion space was balanced first. The coronal plane vertical sliding osteotomy was performed on the medial femoral condyle for the imbalance of coronal plane. The sliding distance of the osteotomy block was determined by straightening the gap between the inner and outer sides of the space until the space was balanced. After the separated segments were fixed with several screws,the prosthesis was installed as usual.Results: The wounds of all patients healed in the first stage,and no wound complications occurred. All the 22 patients were followed up,and the duration ranged from 18 months to 3 years with an average of (28.2±10.1) months. X-ray showed that the fracture line disappeared for 2 to 5(3.5±1.5) months without nonunion. HKA angle measured at the latest follow-up was (178.8±0.7) °,which was significantly different from that before operation. The HSS score was 91.3 ±6.0;KSS clinical score 93.7±3.5;KSS functional score 81.2±6.5;and the average range of motion of knee joint was(121.7±11.6) °,which was statistically significant compared with that before operation.Conclusion: For severe knee osteoarthritis patients with complex femoral extra-articular deformity,sliding osteotomy is performed. For severe varus deformity,downward sliding the medial femoral condyle is performed. The operation is relatively simple and the damage is small. It is easy to achieve the balance of internal and external soft tissue in flexion extension space. The short-term clinical effect is satisfactory.