X型腿

全膝关节置换治疗膝关节外翻畸形大于90度(2019)Totalkneearthroplastyforavalgusdeformityangleof>90degrees:Acasereport GuoJ,CaoG,ZhangY,SongW,QinS,MaT,WangY,YangW.Totalkneearthroplastyforavalgusdeformityangleof>90degrees:Acasereport[J].Medicine(Baltimore),2019,98(23):e15745.转载文章的原链接1：https://pubmed.ncbi.nlm.nih.gov/31169673/转载文章的原链接2：https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6571272/ AbstractRationale:Valguskneesarerelativelyrareintheclinic.Treatmentsforvalgusdeviations>90°representasurgicalchallengetoachieveabalancebetweenthesofttissueandboneandpreventnervedamage.膝外翻在临床上比较少见。外翻偏差>90°的治疗是实现软组织和骨骼之间平衡并防止神经损伤的外科挑战。 Patientconcerns:A63-year-oldwomanwithvalgusdeviations>90°inbothkneescomplainedthatshehadbeenunabletowalkfor50years.一名63岁女性，双膝外翻>90°，自诉已不能行走50年。 Diagnoses:Congenitalmalformationvalgusdeformity.先天性外翻畸形 Interventions:Bilateraltotalkneearthroplasty(TKA)wasperformedusingarotatinghingekneeinstrumentfromEndo-Modelforaxialcorrectionandstabilizationofthejoint.双侧全膝关节置换术(TKA)采用Endo-Model的旋转铰链膝关节器械进行轴向矫正和关节稳定。 Outcomes:Thepatientfullyrecovered3monthsaftersurgery.Atthefollow-up6yearsaftertheoperation,thefunctionofthekneejointclearlyimproved.Thekneesocietyscore(KSS)increasedfrom35to90.术后3个月患者完全康复。术后随访6年，膝关节功能明显改善。膝关节协会评分(KSS)由35分上升至90分。 Lessons:Constrainedimplantsarecommonlyusedtostabilizethejointandcorrecttheboneaxisinpatientswithsevereligamentalinstability,grossdeformity,boneloss,andextremedeviationofthestraightlegaxis.Intraoperativeexplorationofthecommonperonealnerveandthepostoperativeflexedpositionofthekneejointscouldhelppreventnerveinjuries.对于严重韧带不稳、严重畸形、骨质缺失和直腿轴极度偏离的患者，限制性假体通常用于稳定关节和矫正骨轴。术中探查腓总神经及术后膝关节屈曲位置有助于预防神经损伤。 Keywords:totalkneearthroplasty,valgusdeformity,hingeknee 1.IntroductionTotalkneearthroplasty(TKA)isusedtotreatkneevalgusdeformity,andapproximately10%ofallpatientswhorequireTKApresentwithvalgusdeformity.[1,2]AccordingtotheKeblishclassification,thefemorotibialangle(FTA)canbemeasuredonthex-rayimageofthevalgusdeformity;amildangleis<15°,amoderatedegreeis15°to30°,andaseveredeformityisanangle>30°.[3]Becauseofthedifferenttensionsofsofttissueandbonedefects,differentprosthesescanbeselected.Formilddeformitiesandsomemoderateandseverekneevalgusdeformities,wecanfirstreleasethelateralcollateralligamentthroughtenolysisofthesofttissuethenreleasetheposterolateralarticularcapsule,theiliotibialbandandthelateralheadofthegastrocnemius,bicepstendon,andpoplitealtendontissue.Thus,soft-tissuebalancecanbeobtained.Formoderateandsomeseverevalguskneedeformities,posteriorcruciate-retainingtotalkneeprostheses,constrainedcondylarkneeprostheses,orvarus-valgusconstrainedimplantscanbeusedtoobtainagoodresult.[4]Someofthemoreseverevalguskneedeformitieswithbonedefectsneedtobefixedwithanextensionrodandtheplacementofaspacerblocktoachievebalanceandstability.However,forsomepatientswithseveredeformitiesofthevalgusknee,surfaceprostheseswithsofttissuereleaseareunabletoachievebalanceandstability.Thesecasesoftenrequiretheuseofahingekneeprosthesistosolvetheproblem.Hingekneeprostheseswithgoodcoronalstabilitycanstablyreplacesoft-tissuebalance,butcomplicationsofloosenesscanoccur,whicharemainlyduetosagittalalignmentbecausethesagittalplaneoutputsahighamountofpower;thispulleventuallyleadstoprosthesisloosening.[5–7]Nonetheless,thelooseningrateoftheEndo-Modelhingeprosthesisreportedinthepreviouslypublishedliteratureislow.[8–11][3]KeblishPA.Thelateralapproachtothevalgusknee.Surgicaltechniqueandanalysisof53caseswithovertwo-yearfollow-upevaluation.ClinOrthopRelatRes1991;271:52–62.全膝关节置换术(TKA)用于治疗膝关节外翻畸形，大约10%需要全膝关节置换术的患者存在外翻畸形[1,2]。根据Keblish分类，可以在外翻畸形的X线图像上测量股胫角(FTA);轻度畸形为<15°，中度畸形为15°至30°，重度畸形为>30°[3]。由于软组织张力和骨缺损的不同，可以选择不同的修复体。对于轻度畸形和部分中重度膝外翻畸形，可先通过软组织松解术松解外侧副韧带，然后松解后外侧关节囊、髂胫束和腓肠肌外侧头、二头肌肌腱、腘肌腱组织。因此，可以获得软组织平衡。对于中度及部分重度外翻膝关节畸形，可采用后交叉韧带保留假体的全膝关节假体、限制性髁膝关节假体或内外翻限制性假体，均可获得较好的效果[4]。一些更严重的外翻膝关节畸形伴骨缺损需要用延伸棒和放置间隔块来固定，以达到平衡和稳定。然而，对于一些外翻膝关节严重畸形的患者，具有软组织松解的表面假体无法达到平衡和稳定。这些病例通常需要使用铰链膝关节假体来解决问题。具有良好冠状面稳定性的铰链式膝关节假体可以稳定地替代软组织平衡，但由于矢状面输出功率大，因此可能出现松动并发症，这主要是由于矢状面对准所致;这种拉力最终会导致假体松动[5-7]。然而，先前发表的文献报道的endomodel铰链假体的松动率很低[8-11]。Kneevalgusdeformitiescanbecongenitalormayoccursecondarytoconditionssuchasosteoarthrosis,rheumaticdiseases,andposttraumaticarthritis,ortoanovercorrectionfollowingavalgusosteotomy.[4]Valgusdeviations<20°,whichaccountforapproximately95%ofallvalgusknees,arerelativelyeasytocorrectwithsurgery.[2]However,thecorrectionofvalgusdeviations>20°isachallengingundertakingforjointsurgeons.[2,12]Herein,wereportacaseofseverevalgusdeformitywithavalgusdeviation>90°ina63-year-oldwomanwhowassuccessfullytreatedwithTKA.Tothebestofourknowledge,thisisthefirstdocumentedcaseofsuccessfultreatmentofa>90°valgusdeformitywithTKA.Thepatientandherfamilyhaveconsentedtothepublicationofthisarticle.膝外翻畸形可能是先天性的，也可能是由骨关节病、风湿性疾病和创伤后关节炎等继发疾病引起的，或者是外翻截骨术后矫治过度引起的[4]。外翻偏差<20°约占所有外翻膝关节的95%，相对容易通过手术矫正[2]。然而，对于关节外科医生来说，矫正>20°的外翻是一项具有挑战性的工作[2,12]。在此，我们报告一例63岁女性外翻畸形，外翻偏度>90°，经TKA成功治疗。据我们所知，这是第一例用TKA成功治疗>90°外翻畸形的病例。患者及其家属已同意发表这篇文章。 2.CasereportA63-year-oldwomanpresentedatourhospitalwithcongenitalmalformationvalgusdeformity>90°(Fig.1A,B).Anx-rayofthekneeshowedamalformedfemoralcondyleandtibialplateauwithseverebonedefects(Fig.2).AccordingtotheKeblishclassification,thiscasewasclassifiedasaseveredeformity.[3]Thepatienthasnotbeenabletowalknormallysincetheageof12.Themusclestrengthofthequadricepswaslow.Aphysicalexaminationshowedthatallligamentsaroundthekneewereslack.Throughtheaboveexamination,thepatient'skneesocietyscore(KSS)scorewasassessedtobe35.[13]Thekneeextensionreached90°,andtheflexionreached80°.  Figure1(A,B)Preoperativephotographofthepatientshowingseverekneevalgusdeformity.  Figure2Preoperativex-rayradiograph(nonweight-bearing)showingmalformationsandbonydefectsinthefemoralcondyleandthetibialplateau.  Beforetheoperation,wecreatedathreedimensionalmodelofbothknees,simulatedthepatellatrajectoryandcarefullyexaminedthepatient'ssofttissuetightness.Duetothepresenceofseverebonedefectionandthesevererelaxationofthemedialandlateralsofttissuedevices,theEndo-Modelrotatinghingekneeprosthesiswaschosenforthepatient,andabilateralTKAwasperformed.Thekneejointswereexposedviaamedialparapatellarapproachtoachieveagoodviewbecausewedidneedtoworryaboutsoft-tissuebalance.Thefemoralcondyleswereseverelydeformedwithasmalllateralfemoralcondyleandarelativelylargemedialfemoralcondyle.Tibialextorsion,lateraldislocationofthepatella,andseveredegenerationofarticularsurfacesofthefemur,tibia,andpatellawerealsoobserved.Bonehyperplasiaandsyndesmophyteformationaroundthejointwereobservedalongwiththewornmedialandlateralmenisci.Theanteriorandposteriorcruciateligamentswerealmostinvisible.Afterresectionofthehyperplasticosteophyteandsynovialmembrane,theiliotibialbandwasfirstreleased,thenthelateralretinaculumwasreleased.Subsequently,thelateralligamentwasdirectlyincised.Becausetheligamentsaroundthekneewereslack,theEndo-Modelrotatinghingekneeprosthesiswasused.Basedonthepreoperativex-ray,thefemoralcanalinthemedialfemoralcondylewasselectedastheentrypointfortheintramedullaryguide.Aftertheinternalrotation,externalrotation,alignment,andtautnessofthekneejointweretestedtomeetthephysiologicalrequirements,theGermanyLinkkneeprosthesis(leftknee:tibiasize55 mm/160 mm,femursize55 mm/160 mm,polysize16mm;therightkneeprosthesiswasthesamesizeastheleft)wasinstalled.Fullreleaseofthepatellarlateralretinaculumandstrengtheningofthepatellarmedialretinaculumwereperformedtocorrectthelateralpatellardislocation.Aftersurgery,thekneeswereingoodalignment.Theankleactivitywasnormal.Onedayaftersurgery,thepatientwasunabletodorsiflextheanklejoints.Thenervusperoneuscommuniswassuspectedtohavebeendamagedbytraction.Thepatientreceivedanoralmethylaminedispersibletabletandperformedjointfunctionalexercises.Oneweekaftersurgery,themovementsofthekneejointrangedfrom5°to90°.Thex-rayimageshowedanappropriateprosthesisposition(Fig.3).  Figure3Postoperativex-rayradiographshowingtheimplantedprosthesis.  Theonlypostoperativecomplicationwasaninjurytotheperonealnerve,whichledtolossofdorsiflexionatbothanklejoints.However,thepatientwasabletowalkwiththeuseofwalkingaids.Thepatientwasregularlyfollowedup,andtheanklemotiondeficitwasfoundtobecompletelyrecovered3monthsaftersurgery.Atthefollow-up6yearsaftertheoperation,thekneeextensionreached180°,kneeflexionreached125°,andtheactivejointfunctionclearlyimproved(Fig.4).TheKSShadimprovedto80atthe2-yearfollow-up,87atthe4-yearfollow-up,and90at6-yearfollow-up.  Figure4Postoperativephotographafter18monthsshowingcompleterecoveryofdorsiflexion.  3.DiscussionAprimaryTKAforavalguskneedeformityof>20°representsachallengefororthopedicsurgeons.[12]Herein,wepresentourexperiencewitha63-year-oldwomanwithaseverevalguskneedeformityangle>90°,whichwasclassifiedasaseveredeformity.Duringsurgery,wereleasedthelateralcollateralligamentsofttissuesandexcisedthemedialandlateralmeniscusandtheremainingcruciateligament.Arotatinghingekneeinstrumentwasusedtocorrecttheboneaxisandstabilizethejoint.TheuseofhingedimplantsinprimaryTKAshouldberestrictedtopatientswithseverebonydeformitiesorligamentousinstability,especiallyinelderlypatients.[14]ConstrainedimplantsarefrequentlyusedforprimaryTKAinpatientswithmoderateandseveregenuvalgum(>10°).[15]ConstrainedTKAiscommonlyperformedtostabilizethejointandcorrecttheboneaxisinpatientswithsevereligamentalinstability,grossdeformity,boneloss,andextremedeviationofthestraightlegaxis.Inthepresentcase,arotatinghingekneeprosthesiswasselected.外翻膝畸形>20°的原发性全膝关节置换术对骨科医生来说是一个挑战[12]。在此，我们报告了一位63岁女性的经验，她的膝关节严重外翻畸形角度>90°，被归类为严重畸形。在手术中，我们松解了外侧副韧带软组织，切除了内侧和外侧半月板以及剩余的交叉韧带。使用旋转铰链膝关节器械矫正骨轴并稳定关节。在原发性全膝关节置换术中使用铰链式植入物应仅限于严重骨畸形或韧带不稳定的患者，尤其是老年患者[14]。限制性假体常用于中度和重度膝外翻（>10°）患者的初次TKA[15]。对于严重韧带不稳、严重畸形、骨质流失和直腿轴极度偏离的患者，通常采用限制性TKA来稳定关节和矫正骨轴。在本病例中，选择了旋转铰链膝关节假体。AmedialorlateralparapatellarapproachcanbeusedtoperformTKAforvalguskneedeformities.Thelateralpatellarincisioniscommonlyusedinmild-to-moderatevalguskneedeformitiestosimplyreleasethelateralstructure.Giventhepositionofthepatellainthepresentcase,thelateralparapatellarapproachwasnotsuitabletogainadequateexposureofthekneejoint;thus,themedialparapatellarapproachwasused.InjurytotheperonealnerveisacommoncomplicationofTKA.TheperonealnerveinjuryiscommonwhenTKAisperformedtocorrectvalguskneedeformities,withanincidenceof2%to3%.[16–19]Weshouldpaymoreattentiontothetensioninthenerve,whichcouldbealleviatedbycuttingoffthefibularhead,ifnecessaryinosteotomy.Postoperatively,thekneeswereplacedin10°offlexionfor3to4daystopreventstretchingoftheperonealnerve,andactiveandpassiverange-of-motionexercises(rangefrom10°to70°)wereallowed.[20]Inthepresentcase,basedonthepreoperativeevaluationofthesurgicalprocedure,webelievedthattheperonealnervewouldnotbetransected,andthuswedidnotexposetheperonealnerveduringtheoperation.However,postoperatively,thepatientwasunabletodorsiflextheankle.Tractioninjurytothecommonperonealnervemayresultinthelossofanklefunction.Atractioninjurytothecommonperonealnervewaslikelycausedbystraighteningtheknees.Thiscomplicationcouldhavebeenavoidedbypositioningofthekneesinaflexedpositionaftersurgeryandthengraduallystraighteningthekneesbackout.Fortunately,thepatientfullyrecovered3monthsaftersurgery.内侧或外侧髌旁入路可用于外翻膝关节畸形的全膝关节置换术。髌骨外侧切口通常用于轻度至中度膝外翻畸形，以简单地松解外侧结构。考虑到本病例中髌骨的位置，外侧髌旁入路不适合获得足够的膝关节暴露;因此，我们采用内侧髌旁入路。腓神经损伤是TKA的常见并发症。在TKA矫正外翻膝关节畸形时，腓神经损伤是常见的，发生率为2%~3%[16-19]。应注意神经紧张，必要时截骨可切除腓骨头缓解神经紧张。术后，膝关节屈曲10°3-4天，以防止腓神经拉伸，并允许主动和被动活动范围（10°至70°范围）锻炼[20]。在本病例中，基于术前对手术方法的评估，我们认为腓神经不会被横断，因此我们在手术中没有暴露腓神经。然而，术后患者无法踝关节背屈。牵引损伤腓总神经可导致踝关节功能丧失。牵拉伤腓骨总神经可能是伸直膝盖引起的。这种并发症可以通过手术后将膝关节置于弯曲位置，然后逐渐将膝关节拉直来避免。幸运的是，患者在手术后3个月完全康复。Patellardislocationorsubluxationisacommonfindinginvalgusknees.Patellardislocationassociatedwithcongenitaldisordersappearstobeclassifiableintothefollowing3types:conditionsduetosofttissuelaxityandincreasedjointlaxity;conditionsduetopatellarhypoplasiaandskeletaldysplasiaofthefemurandtibia;andconditionsduetosofttissuefibrosisandcontracture.[21]Anabnormalpatellartrajectoryinthemild-to-moderatevalguskneecanbecorrectedafterkneearthroplasty.[22]Inseverevalgusconditions,thelateralpatellarretinaculum,popliteustendon,andthelateralportionofthegastrocnemiusmayrequiredetachmenttorestoretheanatomicalaxisofthelimb.Ananteromedialtibialtubercletransfermaybeperformedtocorrectpatellardislocation.Inthepresentcase,wecorrectedthesevereabnormalpatellartrajectoryandtibialinternalrotationbyreleasingthepatellarlateralsurface,vastuslateralis,andtheintramusculargapoftherectusfemoris.AZ-shapedreleaseofthebicepsfemoriswasalsoperformed.Sincethepatellartrajectorywasstillnotcompletelycorrected,wesubsequentlyreleasedthelateralcollateralligamentbycreatingmultipleneedlepunctures,incisingthevastuslateralis,andextendingitbymalposed-suturetocompletelycorrectthepatellatrajectory.髌骨脱位或半脱位是外翻膝的常见表现。与先天性疾病相关的髌骨脱位似乎可分为以下3种类型:由于软组织松弛和关节松弛增加引起的情况;髌骨发育不全，股骨和胫骨骨骼发育不良;以及软组织纤维化和挛缩引起的疾病[21]。轻度至中度外翻膝关节的异常髌骨轨迹可以在膝关节置换术后得到纠正[22]。在严重外翻的情况下，髌骨外侧支持带、腘肌肌腱和腓肠肌外侧部分可能需要脱离以恢复肢体的解剖轴。胫骨前内侧结节转移可用于矫正髌骨脱位。在本病例中，我们通过松解髌骨外侧面、股外侧肌和股直肌肌内间隙来纠正严重的异常髌骨轨迹和胫骨内旋。同时进行股二头肌Z形松解术。由于髌骨轨迹仍未完全矫正，我们随后通过多次穿刺从而松解外侧副韧带，切开股外侧肌，并通过错位缝合延长，以完全矫正髌骨轨迹。Insummary,inthisrarecase,wesuccessfullyperformedTKAusingarotatinghingekneeinstrumentforthetreatmentofavalgusdeformityangle>90°associatedwithseverebonydefectsinthefemurandtibia.Thepatellardislocationwascorrectedwithouttheuseofanteromedialtibialtubercletransfer.Postoperatively,thepatientexperiencedbilaterallossofankledorsiflexionduetoatractioninjurytothecommonperonealnerve,which,however,wascompletelyrecoveredin3months.Intraoperativeexplorationofthecommonperonealnerveandpostoperativeflexedpositioningofthekneejointscouldhelppreventnerveinjuries.However,sincethehingeprosthesiswashighlyrestricted,thelifetimeoftheprosthesisisacauseofconcern.Westillneedtoconductlong-termfollow-upsofthepatient.总之，在这个罕见的病例中，我们成功地使用旋转铰链膝关节器械进行了TKA，治疗了角度>90°的外翻畸形，并伴有股骨和胫骨的严重骨缺损。髌骨脱位不采用胫骨前内侧结节转移。术后，由于腓总神经牵拉损伤，患者双侧踝关节背屈丧失，但在3个月内完全恢复。术中探查腓总神经和术后膝关节屈曲定位有助于预防神经损伤。然而，由于铰链假体受到高度限制，假体的使用寿命是一个值得关注的问题。我们还需要对患者进行长期随访。

生理性O型腿/X型腿的特点：1.力线与年龄段相符：2岁以内应该是“O型腿”，2岁以后应该是“X型腿”。2.无论是“生理性O型腿”还是“生理性X型腿”，其双腿力线都是对称的。3.无其它异常表现，如身材矮小、面容异常、鸡胸漏斗胸及家族性疾病等。

生理性O型腿/X型腿：出生时，双下肢都是O型腿，程度随着年龄增大而逐渐变小，到 1.5-2岁完全变直。2 岁之后，下肢力线向X型腿转变，在3-4 岁X型腿最明显。之后，X型腿的程度逐渐变小，到 7 岁左右固定下来并维持到成年，最终的下肢力线通常有轻度X型腿。

10月12日是“世界关节炎日”。关节炎是常见的慢性疾病之一，据统计，全球关节炎患者约有3.55亿人。骨关节炎引起骨关节炎的原因很多，从字面意义上来说，“骨关节炎”就是“关节发炎”了，例如细菌进入无菌的髋关节，可能引起关节严重破坏、导致关节发生严重变形。另外，幼年特发性关节炎（JIA）会同时影响多个关节，引起多关节反复发热、肿痛、变形、僵硬等症状。除此之外，临床更常见的是各种原因引起的关节软骨慢性磨损，是缓慢发展、逐渐加重的过程。例如最常见引起髋关节炎的髋关节发育不良，髋臼-股骨头接触面减小，就像“高跟鞋”一样，关节面软骨磨损速度加快。而目前认为，这种软骨磨损几乎很难修复/逆转，在成人期可能需要接受关节置换手术。对于儿童来说，可能引起骨关节炎的原因众多，如各种先天发育异常、代谢骨病、外伤、感染、肿瘤、退行性改变等等。但是，这些情况在儿童期多数还没有引起关节不可逆性损伤。所以，对于孩子来说，更多的是需要及时针对这些可能引起关节炎的原发病进行及时有效治疗，从而改变这些疾病的“自然转归”，也就是所谓的“保关节”治疗。髋关节髋关节发育不良和很多儿童骨关节发育性疾病的诊治原则类似，对于儿童髋关节发育不良，“早期发现、及时规范治疗”多数能获得良好的治疗效果。实行针对髋关节发育不良的筛查，对于早期检出非常重要，为及时治疗创造了条件。儿童股骨头坏死（Perthes病）儿童股骨头坏死（Perthes病）是另外一种常见髋关节病，早期发现、及时恰当治疗，利用好孩子神奇、强大的修复能力，治疗效果常常会非常理想。专业医生会根据孩子发病时年龄、股骨头缺血范围、是否包容不良等多个重要预后相关因素，制定个性化治疗策略。创伤后股骨头坏死儿童青少年髋部骨折后发生“创伤后股骨头缺血坏死”的风险较高，进展快、预后差，更需及时采用个性化的治疗方案。膝关节膝内翻及膝外翻膝内翻及膝外翻（家长说的O型腿/X型腿）是儿童常见下肢畸形，对于病理性、严重型，如果不及时矫正，会导致膝关节处关节软骨应力异常，需及时矫正，让膝关节面平行地面，以最有利于下肢应力传导。踝关节做好关节“保养”：合理的控制体重：选择良好的饮食习惯。适宜的运动方式：要有“保护关节”的理念，不太适合参加马拉松、爬山等对关节负担比较重的运动，可以综合选择上肢和躯干的运动，例如游泳等低负荷的运动等。适宜的出行方式：可以以骑车或驾驶等方式代替徒步行走。