两种截骨模式胫骨延长矫正下肢短缩畸形比较

Comparison of two osteotomies in tibial lengthening to correct lower extremity shortening deformity

摘要:

［目的］ 比较两种截骨模式胫骨延长矫正脊髓灰质炎后遗症下肢短缩的临床效果。［方法］ 回顾性分析 2008 年 3 月 —2017 年 7 月采用肱骨髓内钉联合外固定架小腿延长术 50 例患者的临床资料。根据医患沟通结果，25 例采用胫骨干骺端横形截骨（横形组），25 例采用胫骨干骺端-倒 V 形截骨（V 形组）。比较两组治疗期、随访及影像结果。［结果］所有患者均顺利完成延长手术。V 形组在下地行走时间 [(129.5±5.7)d vs (146.2±4.2)d, P<0.05]、带架时间 [(67.2±1.3)d vs (69.9±2.3)d, P<0.05]、骨愈合指数 [(51.2±6.4)d/cm vs (53.9±4.4)d/cm, P<0.05]、力线偏移率 [0(0.0%) vs 4 (16.0%), P<0.05]、膝关节屈曲挛缩率 [1(4.0%) vs 6 (24.0%), P<0.05] 均显著优于横形组；两组手术时间、切口总长度、术中失血量、切口愈合等级、住院时间、胫骨延长的长度、延长率、牵张指数、成骨不佳、钉道感染、足下垂发生率的差异均无统计学意义（P>0.05）。患者随访时间平均（4.1±0.9）年，V 形组恢复完全负重活动显著早于横形组 [(191.1±8.2)d vs (211.5±4.6)d, P<0.05]。随着时间推移，两组 VAS 评分显著降低（P<0.05）， HSS 评分显著增加（P<0.05），而膝、踝关节屈伸 ROM 均无明显变化（P>0.05）。相应时间点，两组间上述指标的差异均无统计学意义（P>0.05）。影像方面，V 形组延长区骨愈合评级拆架前 1 个月 [0/I/II/III/IV, (0/1/18/6/0) vs (0/2/20/3/0), P<0.05]，拆架时间 [(0/0/19/6/0) vs (0/0/22/3/0), P<0.05]，拆架 3 个月 [(0/0/5/12/8) vs ( 0/0/7/14/4), P<0.05] 均显著优于横形组。相应时间点两组间 FTA 角、踝 K-L 分级差异均无统计学意义（P>0.05）。［结论］两种截骨方法均能获得令人满意的延长效果，但胫骨干骺端-倒 V 型截骨对膝关节的影响更小，更能减少膝关节屈曲挛缩、轴线偏移的发生，有利于骨愈合。

Abstract:

[Objective] To compare the clinical outcomes of two osteotomies in tibia lengthening for correction of lower limb shorteningsecondary to poliomyelitis. [Methods] A retrospective study was performed on 50 patients who underwent leg lengthening with humerus in-tramedullary nail combined with external frame from March 2008 to July 2017. Based on doctor-patient communication, 25 patients had thetibial metaphyseal osteotomized transversely (transverse group), while the other 25 patients had tibial metaphyseal osteotomy performed inthe inverted “V” shape (V-shaped group). The documents regarding to treatment period, follow-up and images were compared betweenthe two groups. [Results] All patients had corresponding surgical procedures performed successfully. The V-shaped group proved signifi-cantly superior to the transverse group in terms of ambulation time [(129.5±5.7)days vs (146.2±4.2)days, P＜0.05], frame bearing time [(67.2±1.3)days vs (69.9±2.3)days, P＜0.05], bone healing index [(51.2±6.4)d/cm vs (53.9±4.4)d/cm, P＜0.05], alignment deviation ratio [0 (0.0%) vs4 (16.0%), P＜0.05], knee flexion contracture rate [1(4.0%) vs 6(24.0%), P＜0.05]. There were no significant differences in operation time, to-tal incision length, intraoperative blood loss, incision healing grade, hospital stay, length of tibia lengthened, elongation rate, stretch index,incidence of osteogenesis poor, nail tract infection and foot drop between the two groups (P＞0.05). All the patients in both groups were fol-lowed up for a mean of (4.1±0.9) years, and the V-shaped group returned to full weight-bearing activity significantly earlier than the trans-verse group [(191.1±8.2)days vs (211.5±4.6)days, P＜0.05]. The VAS score significantly decreased (P＜0.05), while HSS score significantly in-creased (P＜0.05), and knee and ankle range of motion (ROM) remained unchanged over time in both groups (P＞0.05), which were not statisti-cally significant between the two groups at any time point accordingly (P＞0.05). Radiographically, the V-shaped group proved significantlysuperior to the transverse group in term of bone healing in lengthened area [0/I/II/III/IV, (0/1/18/6/0) vs (0/2/20/3/0), P＜0.05] 1 month before frame removal, [(0/0/19/6/0) vs (0/0/22/3/0), P＜0.05] at the time of frame removal, [(0/0/5/12/8) vs (0/0/7/14/4), P＜0.05] 3 months after frame removal. There were no significant differences in femorotibial angle and Kellgren-Lawrence grade of ankle between the two groups at any corresponding time points (P＞0.05). [Conclusion] Both osteotomy techniques do achieve satisfactory lengthening outcomes. In contrast, the inverted V osteotomy has less impacts on the knee, and less chance of knee flexion contracture and axis deviation, which is conducive to bone healing.