全膝关节置换术中股骨后髁个体化截骨方法与临床应用

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摘要目的介绍一种术前精确测量股骨后髁角(posterior condylar angle，PCA)的方法并行临床应用，比较使用传统参考股骨后髁线(posterior femoral condylar line，PCL)外旋3°截骨和个体化测量PCA截骨行人工全膝关节置换术(total knee arthroplasty，TKA)治疗晚期膝骨关节炎的短期临床疗效。方法取6具正常国人膝关节标本为研究对象，男2例，女4例；年龄55～76岁，平均(67.2±6.1)岁；左4例，右2例。分别行CT扫描分析和解剖标记，将股骨外上髁最凸点、内上髁最凹点、外后髁最低点与内后髁最低点所在的4副图像同轴心重叠为1副图像，测量PCA值，并行临床应用；对行初次TKA治疗的61例膝骨关节炎患者随机分为两组，比较两组术后6个月的临床效果。3°PCL截骨组30例，其中男6例，女24例；年龄57～79岁，平均(68.2±5.2)岁；个体化测量PCA值组31例，其中男9例，女22例；年龄56～78岁，平均(67.9±5.5)岁。比较两组术后6个月时美国膝关节协会评分(knee society score，KSS)、疼痛视觉模拟评分(visual analogue scale，VAS)、膝关节活动度(range of motion，ROM)等。结果 6例膝关节标本经CT超薄层扫描后，股骨远端后髁角的4个“真性”解剖标志点清晰可辨，图像重叠技术分别在影像学测量与解剖学测量中结果相同。术后6个月时KSS评分：个体化截骨组(81.9±8.8)分优于3°PCL截骨组的(77.5±6.9)分，两组比较差异有统计学意义(P＜0.05)；而组间功能评分比较，差异无统计学意义(P＞0.05)。VAS：个体化截骨组(2.1±0.7)分低于3°PCL截骨组的(2.6±0.9)分，两组间比较差异有统计学意义(P＜0.05)。ROM：个体化测量组术后屈曲活动度(106.8±15.6)°优于3°PCL截骨组的(102.1±16.2)°，但组间比较差异无统计学意义(P＞0.05)；个体化测量组术后伸直滞缺角度(1.4±2.4)°明显小于3°PCL截骨组的(3.0±3.3)°，两组比较差异有统计学意义(P＜0.05)。结论图像重叠技术可精确测量PCA角度，可提高全膝关节置换术旋转截骨精度。术前规划的个体化股骨后髁旋转截骨组在术后膝关节功能恢复方面明显优于传统参考PCL外旋3°截骨组，图像重叠个体化测量PCA方法值得推广。

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关键词 ：全膝关节置换术, 旋转截骨, 股骨外科上髁轴, 后髁线, 后髁角

Abstract：Objective To introduce a method to accurately measure the posterior condylar angle (PCA) before operation and clinical application，and compare the traditional reference posterior femoral condylar line (PCL) with external rotation 3° osteotomy and individualized measurement PCA osteotomy for the short-term clinical efficacy of total knee arthroplasty (TKA) in the treatment of advanced knee osteoarthritis.Methods Six normal Chinese knee joint specimens were taken as the research objects，including 2 males and 4 females；aged 55~76 years，with an average age of (67.2±6.1)years；4 cases on the left and 2 cases on the right.CT scan analysis and anatomical marking were performed respectively，and the four images of the most convex point of the femoral lateral epicondyle，the most concave point of the medial epicondyle，the lowest point of the lateral posterior condyle and the lowest point of the medial posterior condyle were superimposed into one image.The PCA value was measured and clinically applied；61 patients with knee osteoarthritis who underwent the initial TKA treatment were randomly divided into two groups，and the clinical effects of the two groups were compared at 6 months after surgery.There were 30 cases in the 3° PCL osteotomy group，including 6 males and 24 females；aged 57~79 years old，with an average age of(68.2±5.2)years；31 cases in the individualized PCA value group，including 9 males and 22 females；The age ranged from 56 to 78 years，with an average of(67.9±5.5)years old.The American Knee Society score (KSS)，visual analogue scale (VAS) of pain，and range of motion (ROM) of knee joints were compared between the two groups at 6 months after operation.Results After ultra-thin CT scan of 6 knee joint specimens，the 4“true” anatomical landmarks of the posterior condyle angle of the distal femur were clearly distinguishable，and the results of image overlap technology were the same in imaging and anatomical measurement.KSS score at 6 months after operation：the score of the individualized osteotomy group (81.9±8.8) was better than that of the 3° PCL osteotomy group (77.5±6.9).The difference between the two groups was statistically significant (P＜0.05)；There was no statistically significant difference in functional scores between groups (P＞0.05).VAS：The score of the individualized osteotomy group (2.1±0.7) was lower than that of the 3°PCL osteotomy group (2.6±0.9).The difference between the two groups was statistically significant (P＜0.05).ROM：The postoperative flexion mobility of the individualized measurement group (106.8±15.6)° is better than that of the 3°PCL osteotomy group (102.1±16.2)°，but the difference between the groups is not statistically significant (P＞0.05)；individualized The postoperative extensional lag angle (1.4±2.4)° in the measurement group was significantly smaller than (3.0±3.3)° in the 3°PCL osteotomy group，and the difference between the two groups was statistically significant (P＜0.05).Conclusion Image overlay technology can accurately measure the PCA angle and improve the accuracy of rotational osteotomy in total knee arthroplasty.The preoperatively planned individualized posterior condylar femoral rotation osteotomy group is significantly better than the traditional reference PCL external rotation 3° osteotomy group in terms of postoperative knee function recovery.The image overlap individualized measurement PCA method is worthy of promotion.

Key words： total knee arthroplasty rotational osteotomy surgical transepicondylar axis posterior femoral condylar line posterior condylar angle

通讯作者: 郜玉忠

作者简介: 晏涛(1984－ )，男，主治医师，湖北中医药大学附属襄阳市中医医院下肢骨科病区，441000。

引用本文:

晏涛 1，张云飞 1，李鹏 1，余志勇 1，王慧声 2，郜玉忠 3*. 全膝关节置换术中股骨后髁个体化截骨方法与临床应用[J]. 实用骨科杂志, 2021, 27(1): 14-20.
Yan Tao，Zhang Yunfei，Li Peng，et al. Individualized Osteotomy of the Posterior Femoral Condyle in Total Knee Arthroplasty and its Clinical Application. sygkzz, 2021, 27(1): 14-20.

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http://www.sygkzz.com/CN/ 或 http://www.sygkzz.com/CN/Y2021/V27/I1/14

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