Objective: To investigate the feasibility and effectiveness of high tibial osteotomy (HTO) in treatment of chronic multi-ligament knee injury (MLKI) associated with lower extremity malalignment.
Methods: A clinical data of 14 patients (14 knees) of chronic MLKI associated with lower extremity malalignment, who were treated with HTO between January 2016 and September 2020, was retrospectively analyzed. There were 10 males and 4 females, with an average age of 30.5 years (range, 22-48 years). The causes of injury included traffic accident in 8 cases, bruising by a heavy object in 3 cases, falling from height in 2 cases, and twisting in 1 case. According to Schenck classification of knee dislocation (KD), there were 4 cases of KD-Ⅰ [2 cases of anterior cruciate ligament (ACL) and posterolateral complex (PLC) injuries and 2 cases of posterior cruciate ligament (PCL) and PLC injuries], 7 cases of KD-Ⅲ (all of ACL, PCL, and PLC injuries), and 3 cases of KD-Ⅳ. The preoperative hip-knee-ankle angle (HKA) was (167.1±4.7)°, and the posterior tibial slope angle (PTSA) was (16.3±2.7)°. The knee joint was severely unstable and the patients could not stand and walk normally. Among them, 5 cases of medial compartment cartilage were severely worn out (3 cases of Kellgren-Lawrence grading Ⅱ, 2 cases of grading Ⅲ) causing pain. After admission, 2 cases of KD-Ⅰ underwent HTO and ligament reconstruction in the first stage, 1 case of KD-Ⅲ and 1 case of KD-Ⅳ underwent HTO in the first stage and ligament reconstruction in the second stage; the remaining 10 patients only underwent HTO.
Results: All patients were followed up 12-50 months, with an average of 30 months. The incisions healed by first intention after operation, and no complications such as infection and deep vein thrombosis of the lower extremities occurred. At 12 months after operation, knee range of extension was -5°-0° (mean, -1.2°) and range of flexion was 110°-140° (mean, 125.5°). The Lachman test was negative in 11 cases and positive in 3 cases. The posterior drawer test was negative in 9 cases and positive in 5 cases. The 0/30° varus stress test was negative in 10 cases and positive in 4 cases. The 0/30° valgus stress test was negative in 13 cases and positive in 1 case. The visual analogue scale (VAS) score was significantly lower than that before operation ( P<0.05), and the International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score were all significantly higher than those before operation ( P<0.05). The X-ray film reexamination at 12 months after operation showed that the HKA was (178.2±3.8)° and the PTSA was (8.6±2.4)°, which were significantly different from those before operation ( P<0.05). All osteotomies achieved bone union, and the healing time was 3-11 months, with an average of 6.8 months.
Conclusion: For chronic MLKI associated with lower extremity malalignment, HTO can restore normal lower extremity alignment and improve knee joint function, which is a feasible salvage operation.
目的: 探讨胫骨高位截骨术（high tibial osteotomy，HTO）治疗陈旧性膝关节多发韧带损伤（multi-ligament knee injury，MLKI）合并下肢力线不良的疗效。.
方法: 回顾分析2016年1月—2020年9月14例（14膝）采用HTO治疗的陈旧性MLKI合并下肢力线不良患者临床资料。男10例，女4例；年龄22～48岁，平均30.5岁。致伤原因：交通事故伤8例，重物压伤3例，高处坠落伤2例，扭伤1例。按照 Schenck 分型：KD-Ⅰ型4例，其中2例前交叉韧带（anterior cruciate ligament，ACL）合并后外侧复合体（posterolateral complex，PLC）损伤， 2例后交叉韧带（posterior cruciate ligament，PCL）合并PLC损伤；KD-Ⅲ型7例，均为ACL、PCL、PLC损伤；KD-Ⅳ型3例。术前髋-膝-踝角（hip-knee-ankle angle，HKA）为（167.1±4.7）°、胫骨平台后倾角（posterior tibial slope angle，PTSA）为（16.3±2.7）°。膝关节严重不稳定致不能正常站立行走，其中5例内侧间室软骨严重磨损（Kellgren-LawrenceⅡ级3例、Ⅲ级2例）导致疼痛。入院后2例KD-Ⅰ型行一期HTO、韧带重建，1例KD-Ⅲ型、1例KD-Ⅳ型行一期HTO、二期韧带重建；其余10例仅接受HTO。.
结果: 患者术后均获随访，随访时间12～50个月，平均30个月。术后切口均Ⅰ期愈合，无感染、下肢深静脉血栓形成等并发症发生。 术后12个月，膝关节伸直–5°～0°，平均–1.2°；屈曲110°～140°，平均125.5°。Lachman试验阴性11例，阳性3例；后抽屉试验阴性9例，阳性5例；0/30° 内翻应力试验阴性10例，阳性4例；0/30° 外翻应力试验阴性13例，阳性1例。膝关节疼痛视觉模拟评分（VAS）较术前降低，膝关节功能国际膝关节文献委员会（IKDC）评分、Lysholm评分、Tegner评分均较术前提高，差异均有统计学意义（ P<0.05）。 术后12个月X线片复查示HKA为（178.2±3.8）°、PTSA为（8.6±2.4）°，与术前比较差异均有统计学意义（ P<0.05）。14例截骨均达骨性愈合，愈合时间3～11个月，平均6.8个月。.
结论: 对于合并下肢力线不良的陈旧性MLKI，HTO能恢复正常下肢力线，提高膝关节功能，是一种可行的补救性手术方式。.
Keywords: Knee; chronic injury; high tibial osteotomy; lower extremity malalignment; multi-ligament knee injury.