摘要目的 探究开放楔形胫骨高位截骨术(open-wedge high tibial osteotomy，OWHTO)中不同矫正角度对胫骨后倾角(posterior tibial slope，PTS)及髌骨高度(patellar height，PH)的影响，为维持术后PTS及PH稳定及获得良好的临床疗效。方法 选取2015年12月1日至2017年12月1日在广州中医药大学第一附属医院行OWHTO的35例患者(38膝)，其中男13例，女22例；年龄19～77岁，平均(61.5±9.8)岁。对所有患者术前和术后末次随访行膝关节膝关节协会评分(keen society score，KSS)、视觉模拟评分(visual analogue scale，VAS)及美国特种外科医院膝关节评分(hospital for special surgery knee score，HSS)，评估患者膝关节疼痛及功能改善情况。记录患者OWHTO中矫正角度，按术中常规矫正角度平均分为三组：A组7°～9°，B组10°～12°、C组13°～15°，测量患者术前及术后PTS及PH［Insall-Salvati指数(IS)、Blackbume-Peel指数(BP)］指数值，计算手术前后PTS、IS和BP指数的差值(术前值－术后值)，采用单因素方差分析探究不同矫正角度组间的PTS、IS及BP的差值是否具有统计学意义。结果 随访时间5.2~25.5个月，平均随访(10.0±5.4)个月。A组12例(13膝)，B组11例(13膝)，C组12例(12膝)。所有患者术前KSS评分平均为(60.4±7.3)分，末次随访提高至(83.2±6.9)分；术前VAS平均为(5.2±1.1)分，术后降至(1.2±1.0)分；HSS评分由术前(59.4±7.2)分提高至(87.7±5.7)分；术前及术后比较，差异均有统计学意义(P＜0.05)。根据HSS评分结果，术后膝关节优良率达81.5％。术后IS指数平均值由术前(0.98±0.11)降至(0.81±0.13)；术后BP指数平均值由术前(0.76±0.13)降至(0.65±0.1)；术后PTS平均角度由术前(7.82±0.93)°增大至(10.76±0.93)°；术前及术后比较，差异均有统计学意义(P＜0.05)。三组患者术后IS、BP指数差值进行方差分析(F=85.922，F=73.518，P＜0.05)，C组分别与A组和B组比较，差异具有统计学意义(P＜0.05)。术后PTS差值进行方差分析(F=70.883，P＜0.05)，三组组间差异均有统计学意义(P＜0.05)。结论 OWHTO是治疗膝骨关节炎(knee osteoarthritis，KOA)的有效方法，可有效缓解膝关节疼痛并改善关节功能。OWHTO术后PTS和PH均可能会发生相应的变化，术后PTS变化与术中矫正角度的大小呈正相关；PH变化与矫正角度的大小总体呈负相关趋势，尤其当矫正角度过大(＞12°)时，PH降低更为明显。
Abstract：Objective To evaluate the effect of correction angle on posterior tibia slope(posterior tibia slope，PTS)and patella height(patella height，PH) in order to maintain stability of PTS and PH and get good clinical outcomes.Methods A total of 35 patients(38 knees) treated with OWHTO (open wedge high tibial osteotomy，OWHTO)in our hospital from 12th 2015 to 12th 2017 were included.There were 13 males and 22 females.The average age was (61.5±9.8)years(19～77 years).We collected all patients’KSS(keen society score，KSS)、VAS(visual analogue scale，VAS)and HSS(hospital for special surgery knee score，HSS)scores before and after surgery in order to evaluate pain relieve and function improvement.According to the amount of correction angles，we divided all patients into 3 groups：group A(7°～9°)，group B(10°～12°) and group C(13°～15°).We measured the value of PTS and PH [Insall-Salvati(IS)、Blackbume-Peel(BP)] and calculated the difference values of PTS，IS and BP after surgery.We used one-way analysis of variance to explore whether the amount of correction and the difference values of PTS，IS and BP had statistical significant between 3 groups.Results The average follow-up time was (10.0±5.4)m (5.2～25.5 m).There were 13 knees(12 patients)，13 knees(11 patients) and 12 knees(12 patients) in Group A，B and C，respectively.After surgery，the average KSS score increased from (60.4±7.3) points to (83.2±6.9) points at final follow-up.The average VAS score decreased from (5.2±1.1) points to (1.2±1.0) points and the HSS score increased from (59.4±7.2)points to (87.7±5.7) points.They all had significant differences(P＜0.05).According to the result of HSS score，the excllent-good rate reached 81.5%.The average value of IS and BP reduced from (0.98±0.11)，(0.76±0.13)to (0.81±0.13)，(0.65±0.1)after surgery，respectively. While，the PTS increased from (7.82±0.93)°to (10.76±0.93)°.They all had statistical differences(P＜0.05).We used one-way analysis of variance to explore the difference in IS and BP difference value(F=85.922，F=73.518，P＜0.05).Group C had statistical difference with group A and group B(P＜0.05).In terms of PTS(F=70.883，P＜0.05)，there were statistical differences between all groups(P＜0.05).Conclusion OWHTO is an effective method for the treatment of knee osteoarthritis(KOA).It can relieve knee pain and improve joint function effectively.The values of PTS and PH altered in OWHTO.The alteration of PTS are positively correlated with the amount of correction angle，while the PH are negatively correlated with the angle.Especially when correction angle is large(>12°)，the value of PH may decrease obviously.
［1］邱贵兴.骨关节炎诊治指南(2007年版)［J］.中华关节外科杂志(电子版)，2007，2(4)：281-285.
［2］王记选，王续鹏，王怡康，等.胫骨高位截骨术治疗膝内翻合并内侧单间隙退变骨关节炎［J］.中国卫生标准管理，2017，8(27)：54-56.
［3］Hinterwimmer S，Beitzel K，Paul J，et al.Control of posterior tibial slope and patellar height in open-wedge valgus high tibial osteotomy［J］.Am J Sports Med，2011，39(4)：851-856.
［4］Portner O.High tibial valgus osteotomy：closing，opening or combined? Patellar height as a determining factor［J］.Clin Orthop Relat Res，2014，472(11)：3432-3440.
［5］Kim KI，Seo MC，Song SJ，et al.Change of Chondral Lesions and Predictive Factors After Medial Open-Wedge High Tibial Osteotomy With a Locked Plate System［J］.Am J Sports Med，2017，45(7)：1615-1621.
［6］Schuster P，Geβlein M，Schlumberger M，et al.Ten-year results of medial open-wedge high tibial osteotomy and chondral resurfacing in severe medial osteoarthritis and varus malalignment［J］.Am J Sports Med，2018，46(6)：1362-1370.
［7］Yasuda K，Majima T，Tsuchida T，et al.A ten-to 15-year follow-up observation of high tibial osteotomy in medial compartment osteoarthrosis［J］.Clin Orthop Relat Res，1992(282)：186-195.
［8］Rinonapoli E，Mancini GB，Corvaglia A，et al.Tibial osteotomy for varus gonarthrosis.A 10-to 21-year followup study［J］.Clin Orthop Relat Res，1998 (353)：185-193.
［9］Baur W，Hönle W，Schuh A.Proximal tibial osteotomy for osteoarthritis of the knee with varus deformity［J］.Oper Orthop Traumatol，2005，17(3)：326-344.
［10］Akizuki S，Shibakawa A，Takizawa T，et al.The long-term outcome of high tibial osteotomy：a ten-to 20-year follow-up［J］.J Bone Joint Surg(Br)，2008，90(5)：592-596.
［11］Jo HS，Park JS，Byun JH，et al.The effects of different hinge positions on posterior tibial slope in medial open-wedge high tibial osteotomy［J］.Knee Surg Sports Traumatol Arthrosc，2018，26(6)：1851-1858.
［12］Loia MC，Vanni S，Rosso F，et al.High tibial osteotomy in varus knees：indications and limits［J］.Joints，2016，4(2)：98-110.
［13］Chiu KY，Zhang SD，Zhang GH.Posterior slope of tibial plateau in Chinese［J］.J Arthroplasty，2000，15(2)：224-227.
［14］Shaw JA，Dungy DS，Arsht SS.Recurrent varus angulation after high tibial osteotomy：an anatomic analysis［J］.Clin Orthop Relat Res，2004 (420)：205-212.
［15］Whiteside LA，Amador DD.The effect of posterior tibial slope on knee stability after Ortholoc total knee arthroplasty［J］.J Arthroplasty，1988，3 (Suppl)：S51-57.
［16］黄文华，姜楠，钟世镇，等.胫骨平台后倾角的测量及临床意义［J］.中国骨与关节损伤杂志，2007，9(10)：825-828.
［17］Amis AA.Biomechanics of high tibial osteotomy［J］.Knee Surg Sports Traumatol Arthrosc，2013，21(1)：197-205.
［18］Giffin JR，Vogrin TM，Zantop T，et al.Effects of increasing tibial slope on the biomechanics of the knee［J］.Am J Sports Med，2004，32(2)：376-382.
［19］Kesmezacar H，Erginer R，Ogut T，et al.Evaluation of patellar height and measurement methods after valgus high tibial osteotomy［J］.Knee Surg Sports Traumatol Arthrosc，2005，13(7)：539-544.
［20］El-Azab H，Glabgly P，Paul J，et al.Patellar height and posterior tibial slope after open-and closed-wedge high tibial osteotomy：a radiological study on 100 patients［J］.Am J Sports Med，2010，38(2)：323-329.
［21］Bin SI，Kim HJ，Ahn HS，et al.Changes in patellar height after opening wedge and closing wedge high tibial osteotomy：a Meta-analysis［J］.Arthroscopy，2016，32(11)：2393-2400.
［22］Moghtadaei M，Otoukesh B，Bodduhi B，et al.Evaluation of patellar position before and after medial opening wedge high tibial osteotomy：Radiographic and computed tomography findings［J］.Med Arch，2016，70(4)：293-295.
［23］Dowd GS，Somayaji HS，Uthukuri M.High tibial osteotomy for medial compartment osteoarthritis［J］.Knee，2006，13(2)：87-92.
［24］Scuderi GR，Windsor RE，Insall JN.Observations on patellar height after proximal tibial osteotomy［J］.J Bone Joint Surg(Am)，1989，71(2)：245-248.
［25］Gaasbeek RD，Sonneveld H，van Heerwaarden RJ，et al.Distal tuberosity osteotomy in open wedge high tibial osteotomy can prevent patella infera：a new technique［J］.Knee，2004，11(6)：457-461.
［26］Matar WY，Boscariol R，Dervin GF.Open wedge high tibial osteotomy：a roentgenographic comparison of a horizontal and an oblique osteotomy on patellar height and sagittal tibial slope［J］.Am J Sports Med，2009，37(4)：735-742.
［27］Stoffel K，Willers C，Korshid O，et al.Patellofemoral contact pressure following high tibial osteotomy：a cadaveric study［J］.Knee Surg Sports Traumatol Arthrosc，2007，15(9)：1094-1100.
［28］Windsor RE，Insall JN，Vince KG.Technical considerations of total knee arthroplasty after proximal tibial osteotomy［J］.J Bone Joint Surg(Am)，1988，70(4)：547-555.
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