人工全膝关节置换术治疗终末期膝关节病变合并膝外翻畸形的手术技巧及临床疗效评价

目的探讨对终末期膝关节病变合并膝外翻畸形患者行经髌旁内侧入路人工全膝关节置换(total kneearthroplasty,TKA)时膝外翻畸形矫正方法及临床疗效。方法 1998年11月-2010年10月,收治64例72膝合并膝外翻畸形的终末期膝关节病变患者。男18例,女46例;年龄23～82岁,平均62.5岁。骨关节炎44例49膝,类风湿性关节炎17例20膝,血友病性关节炎2例2膝,创伤性关节炎1例1膝。双膝8例,单膝56例。膝关节屈伸活动度为(82.2±28.7)°,X线片测量股胫角为(18.0±5.8)°。膝关节学会评分系统(KSS)临床评分为(31.2±10.1)分,功能评分(37.3±9.0)分。根据Krackow膝外翻分型标准:Ⅰ型65膝,Ⅱ型7膝。手术经髌旁内侧入路,采用常规方法行股骨及胫骨截骨,Ranawat技术进行软组织松解。6例7膝采用保留后交叉韧带型假体,54例60膝采用后稳定型假体,4例5膝采用髁限制型假体。结果术后患者切口均Ⅰ期愈合。1例血友病性关节炎合并严重膝外翻畸形(股胫角41°)、屈曲挛缩20°的患者术后出现腓总神经麻痹,经保守治疗1年后神经功能恢复。1例术后2年发生深部感染,行二期翻修术后治愈。患者术后均获随访,随访时间1～13年,平均4.9年。末次随访时X线片示股胫角为(7.0±2.5)°,与术前比较差异有统计学意义(t=15.502,P=0.000)。KSS临床评分为(83.0±6.6)分,功能评分(85.1±10.5)分,膝关节屈伸活动度为(106.1±17.0)°,与术前比较差异均有统计学意义(P0.05)。5例遗留12～15°膝外翻畸形,但患膝关节功能良好。结论通过恰当的术中截骨和软组织平衡,采用经髌旁内侧入路TKA治疗合并膝外翻畸形的终末期膝关节病变可有效改善膝外翻畸形和恢复关节功能,临床疗效满意。

Surgical technique and clinical results of total knee arthroplasty in treating endstage gonarthrosis combined with valgus knee deformity

Objective To investigate the surgical technique and the clinical results of total knee arthroplasty(TKA) in treating end-stage gonarthrosis combined with valgus knee deformity. Methods Between November 1998 and October 2010,64 patients(72 knees) with end-stage gonarthrosis combined with valgus knee deformity underwent TKA by a medial parapatellar approach.Of the 64 patients,18 were male and 46 were female with an average age of 62.5 years(range,23-82 years),including 44 cases(49 knees) of osteoarthritis,17 cases(20 knees) of rheumatoid arthritis,2 cases(2 knees) of haemophilic arthritis,and 1 case(1 knee) of post-traumatic arthritis.Bilateral knees were involved in 8 cases,and single knee in 56 cases.The flexion and extension range of motion(ROM) of the knee joint was(82.2 ± 28.7)°;the femur-tibia angle(FTA) was(18.0 ± 5.8)°;according to Knee Society Score(KSS) criterion,the preoperative clinical score was 31.2 ± 10.1 and functional score was 37.3 ± 9.0.According to Krackow’s classification,there were 65 knees of type I and 7 knees of type II.By medial parapatellar approach,conventional osteotomy and Ranawat soft tissue release were performed in all cases.Prosthesis of preserved posterior cruciate ligament were used in 7 cases(7 knees),posterior stabilize prosthesis in 54 cases(60 knees),constrained prosthesis in 4 cases(5 knees). Results Incisions healed by first intention in all cases.Peroneal nerve palsy occurred in 1 patient with haemophilic arthritis,severe valgus deformity(FTA was 41°),and flexion contracture(20°),which was cured after 1 year of conservative treatment.Revison surgery was performed in 1 case of deep infection at 2 years after surgery.All the patients were followed up 4.9 years on average(range,1-13 years).At last follow-up,the FTA was(7.0 ± 2.5)°,showing significant difference when compared with preoperative value(t=15.502,P=0.000).The KSS clinical score was 83.0 ± 6.6 and functional score was 85.1 ± 10.5,the flexion and extension ROM of the knee joint was(106.1 ± 17.0)°,all showing significant differences when compared with preoperative values(P < 0.05).Five patients had 12-15° valgus knee deformity,but the function of the affect knees were good. Conclusion TKA is an effective way for the patients with end-stage gonarthrosis combined with valgus knee deformity by medial parapatellar approach combined with conventional osteotomy and Ranawat soft tissue release.The correction of deformity and improvement of joint function can be achieved significantly.The clinical result is satisfactory.