摘要目的 研究胫骨结节下斜式双平面胫骨高位截骨术(distal tibial tuberosity in open wedge high tibial osteotomy,DTT-OWHTO)对髌股关节影像学和功能评分的影响。方法 自2015年1月至2019年12月于沧州市中心医院行胫骨结节下斜式双平面截骨手术治疗内翻膝骨关节炎合并髌股关节炎的患者共36例,男15例,女21例;年龄43~64岁,平均(52.96±4.59)岁。比较手术前后髌股关节Iwano分级、胫骨近端内侧角、髌骨高度、外侧髌骨角、胫骨后倾角和Lysholm评分、Kujala评分、西安大略和麦克马斯特大学(the Western Ontario and McMaster Universities,WOMAC)骨关节炎指数评分的变化。结果 所有患者随访15~33个月,平均随访(23.69±4.22)个月,手术前后髌股关节Iwano分级比较差异有统计学意义(P<0.05);胫骨近端内侧角由术前(81.84±3.96)°提高到术后(90.57±2.53)°,充分矫正膝内翻;手术前后髌骨高度、外侧髌骨角和胫骨后倾角比较差异无统计学意义。Lysholm评分由术前(58.50±5.87)分提高到术后(86.39±2.14)分(P<0.05);Kujala评分由术前(56.69±9.43)分提高到术后(72.69±5.79)分(P<0.05);WOMAC评分由术前(65.19±6.48)分降低为术后(43.81±8.48)分(P<0.05)。结论 胫骨结节下斜式双平面截骨可以避免髌骨低位,改善髌股关节功能。对于合并有髌股关节炎的内翻膝患者,该术式可作为其保膝治疗的有效方法。
Abstract:Objective To assess the radiographic and functional scores of patellofemoral joint following a distal tibial tuberosity open-wedge high tibial osteotomy (DTTOWHTO).Methods A total of 36 patients with varus knee osteoarthritis with patellofemoral arthritis were treated by DTT-OWHTO in our hospital,including 15 males and 21 females.The age range was (43~64) years,with an average age of (52.96±4.59)years.Changes in Iwano’s classification,medial angle of the proximal tibia (MPTA),patellar height,lateral patellofemoral angle (LPFA),tibial posterior slope (TPS),the Lysholm score,Kujala score and the Western Ontario and McMaster Universities(WOMAC) were assessed.Results All patients were followed up for (23.69±4.22)months (range:15~33 months).The Iwano’s classification of patellofemoral joint was statistically significant before and after surgery (P<0.05).The MPTA shifted from a mean (81.84±3.96)° before operation to a mean (90.57±2.53)° after operation (P<0.05).No changes in patellar height,LPFA and TPS were observed.The Lysholm score and Kujala score increased significantly from (58.50±5.87) and (56.69±9.43) before operation to (86.39±2.14) and (72.69±5.79) after operation,respectively (P<0.05).The WOMAC score decreased significantly from (65.19±6.48)preoperatively to (43.81±8.48)postoperatively (P<0.05).Conclusion DTT-OWHTO maintains the preoperative patellar height,which could help prevent progression of cartilage degeneration in the patellofemoral joint after surgery,and the radiographic as well as the clinical results support the use of this technique to treat varus knee osteoarthritis with patellofemoral arthritis.
[1]Huang SC,Chen YF,Liu XD,et al.The efficacy and safety of opening-wedge high tibial osteotomy in treating unicompartmental knee osteoarthritis:Protocol for a systematic review and meta-analysis[J].Medicine(Baltimore),2019,98(12):e14927.
[2]Amzallag J,Pujol N,Maqdes A,et al.Patellar height modification after high tibial osteotomy by either medial opening-wedge or lateral closing-wedge osteotomies[J].Knee Surg Sports Traumatol Arthrosc,2013,21(1):255-259.
[3]Yong SL,Sang BL,Oh WS,et al.Changes in patellofemoral alignment do not cause clinical impact after open-wedge high tibial osteotomy[J].Knee Surg Sports Traumatol Arthrosc,2016,24(1):129-133.
[4]Kataoka K,Watanabe S,Nagai K,et al.Patellofemoral osteoarthritis progresses after medial open wedge high tibial osteotomy:A systematic review[J].Arthroscopy,2021,37(10):3177-3186.
[5]Kloos F,Becher C,Fleischer B,et al.High tibial osteotomy increases patellofemoral pressure if adverted proximal,while open-wedge HTO with distal biplanar osteotomy discharges the patellofemoral joint:Different open-wedge high tibial osteotomies compared to an extra-articular unloading device[J].Knee Surg Sports Traumatol Arthrosc,2019,27(7):2334-2344.
[6]Kim KI,Kim DK,Song SJ,et al.Medial open-wedge high tibial osteotomy may adversely affect the patellofemoral joint[J].Arthroscopy,2017,33(4):811-816.
[7]Horikawa T,Kubota K,Hara S,et al.Distal tuberosity osteotomy in open-wedge high tibial osteotomy does not exacerbate patellofemoral osteoarthritis on arthroscopic evaluation[J].Knee Surg Sports Traumatol Arthrosc,2020,28(6):1750-1756.
[8]Javidan P,Adamson GJ,Miller JR,et al.The effect of medial opening wedge proximal tibial osteotomy on patellofemoral contact[J].Am J Sports Med,2013,41(1):80-86.
[9]Elson DW,Petheram TG,Dawson MJ.High reliability in digital planning of medial opening wedge high tibial osteotomy,using Miniaci′s method[J].Knee Surg Sports Traumatol Arthrosc,2015,23(7):2041-2048.
[10]钟珊,柳剑,黄野.双平面开放楔形胫骨高位截骨术的术后康复研究[J].实用骨科杂志,2021,27(10):881-885.
[11]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.
[12]Kawai R,Kawashima I,Maeda A,et al.The factors affecting the timing of bone union after closing-wedge high tibial osteotomy[J].J Clin Orthop Trauma,2020,11(Suppl 4):S526-S529.
[13]Ding T,Tan Y,Tian X,et al.Patellar height after high tibial osteotomy of the distal tibial tuberosity:A retrospective study of age stratification[J].Comput Math Methods Med,2022(27):7193902.
[14]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.
[15]Otakara E,Nakagawa S,Arai Y,et al.Large deformity correction in medial open-wedge high tibial osteotomy may cause degeneration of patellofemoral cartilage:A retrospective study[J].Medicine,2019,98(5):e14299.
[16]汪瑞东,白金广,李冬梅,等.胫骨高位截骨术治疗膝内侧骨关节炎的体会[J].中国骨与关节损伤杂志,2021,36(10):1080-1082.
[17]Lu J,Tang S,Wang Y,et al.Clinical outcomes of closing and opening-wedge high tibial osteotomy for treatment of anteromedial unicompartmental knee osteoarthritis[J].J Knee Surg,2019,32(8):758-763.
[18]Wu L,Lin J,Jin Z,et al.Comparison of clinical and radiological outcomes between opening-wedge and closing-wedge high tibial osteotomy:A comprehensive meta-analysis[J].Plos One,2017,12(2):e0171700.
[19]Ozel O,Yucel B,Mutlu S,et al.Changes in posterior tibial slope angle in patients undergoing open-wedge high tibial osteotomy for varus gonarthrosis[J].Knee Surg Sports Traumatol Arthrosc,2017,25(1):314-318.
[20]Brinkman JM,Lobenhoffer P,Agneskirchner JD,et al.Osteotomies around the knee:patient selection,stability of fixation and bone healing in high tibial osteotomies[J].J Bone Joint Surg(Br),2008,90(12):1548-1557.