臨床整形外科44巻2号

2009年02月発行

誌上シンポジウム 膝骨壊死の病態と治療

特発性膝骨壊死に対するOpening Wedge High Tibial Osteotomy

著者： 竹内良平¹ 荒武正人¹ 尾藤晴彦¹ 齋藤泉¹ 熊谷研¹ 林陸¹ 佐々木洋平¹ 齋藤知行¹

所属機関： ¹横浜市立大学整形外科

ページ範囲：P.151 - P.159

　大腿骨顆部骨壊死(膝骨壊死)は突然発症し，進行すると重度の変形性膝関節症(OA)に至る．膝骨壊死に対する外科的治療法には徐圧術，高位脛骨骨切り術(HTO)，人工膝関節単顆置換術(UKA)，人工膝関節全置換術(TKA)などがあるが，近年HTOの数は減少し，TKAに取って代わられた．膝骨壊死の病態は急性に発症するものであり，長期間を要して悪化する変形性膝関節症とは異なり，膝関節機能が良好に保たれていることが多い．骨壊死巣が大きく保存的治療が功を奏さない症例では関節拘縮が出現しやすく，また下肢のアライメントが内反である症例では壊死巣が圧潰して病気が進行する可能性が高い．このような症例に対しては早期の関節温存手術を行うことが好ましいと考える．本稿ではわれわれが行っているopening wedge high tibial osteotomyを紹介する．

参考文献

1) Aglietti P, Insall JN, Buzzi R, et al:Idiopathic osteonecrosis of the knee. Aetiology, prognosis and treatment. J Bone Joint Surg Br 65:588-597, 1983

2) Cruess RL:Steroid-induced osteonecrosis:A Review. Can J Surg 24:567-571, 1981

3) Forst J, Forst R, Heller KD, et al:Spontaneous osteonecrosis of the femoral condyle:causal treatment by early core decompression. Arch Orthop Trauma Surg 117:18-22, 1998

4) Griffin T, Rowden N, Morgan D, et al:Unicompartmental knee arthroplasty for the treatment of unicompartmental osteoarthritis:a systematic study. ANZ J Surg 77:214-221, 2007

5) Hernigou P, Medevielle D, Debeyre J, et al:Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study. J Bone Joint Surg Am 69:332-54, 1987

6) Karachalios T, Zibis A, Papanagiotou P, et al:MR imaging findings in early osteoarthritis of the knee. Eur J Radiol 50:225-230, 2004

7) Kobayashi Y, Kimura M, Higuchi H:Juxta-articular bone marrow signal changes on magnetic resonance imaging following arthroscopic menisectomy. Arthroscopy18:238-245, 2002

8) 腰野富久，土屋弘吉，富田和夫・他：膝の特発性骨壊死の臨床所見とX線学的所見．日整会誌　49：189-201，1975

9) Koshino T:The treatment of spontaneous osteonecrosis of the knee by high tibial osteotomy with and without bone-grafting or drilling of the lesion. J Bone Joint Surg Am 64:47-58, 1982

10) Koshino T, Murase T, Saito T:Medial opening-wedge high tibial osteotomy with use of porous hydroxyapatite to treat medial compartment osteoarthritis of the knee. J Bone Joint Surg Am 85:78-85, 2003

11) 腰野富久：膝診療マニュアル．医歯薬出版，1992

12) Langdown AJ, Pandit H, Price AJ, et al:Oxford medial unicompartmental arthroplasty for focal spontaneous osteonecrosis of the knee. Acta Orthop 76:688-692, 2005

13) Lobenhoffer P, Agneskirchner JD:Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 11:132-138, 2003

14) Mont MA, Rifai A, Baumgarten KM, Sheldon M, et al:Total knee arthroplasty for osteonecrosis. J Bone Joint Surg Am 84:599-603, 2002

15) Mont MA, Tomek IM, Hungerford DS:Core decompression for avascular necrosis of the distal femur:long term followup. Clin Orthop 334:124-130, 1997

16) Pape D, Seil R, Fritsch E, et al:Prevalence of spontaneous osteonecrosis of the medial femoral condyle in elderly patients. Knee Surg Sports Traumatol Arthrosc 10:233-240, 2002

17) Parrate S, Argenson JNA, Dumas J, et al:Unicompartmental knee arthroplasty for avascular osteonecrosis. Clin Orthop 464:37-42, 2007

18) Saito T, Takeuchi R, Mitsuhashi S, et al:Use of joint fluid analysis for determining cartilage damage in osteonecrosis of the knee. Arthritis Rheumatism 46:1813-1819, 2002

19) Staubli AE, De Simoni C, Babst R, et al:TomoFix:a new LCP-concept for open wedge osteotomy of the medial proximal tibia―early results in 92 cases. Injury 34:55-62, 2003

20) 鈴木英一，竹内良平，斎藤知行・他：SLEに合併したステロイド性大腿骨顆部骨壊死3例の長期経過．臨整外30：977-985，1995

21) 竹内良平，岡本連三，腰野富久・他：大腿骨顆部骨壊死に対して保存療法を行った3例の成績．臨整外25：103-111，1990

22) Takeuchi R, Aratake M, Bito H, et al:Simultaneous bilateral opening-wedge high tibial osteotomy with early full weight-bearing exercise. Knee Surg Sports Traumatol Arthrosc 16:1030-1037, 2008

23) Takeuchi R, Ishikawa H, Aratake M, et al:Medial opening wedge high tibial osteotomy with early full weight bearing. Arthroscopy 25:46-53, 2009

24) Takeuchi R, Aratake M, Bito H, et al:Clinical results and radiological evaluation of opening wedge high tibial osteotomy for spontane osteonecrosis of the knee. Knee Surgery Sports Traumatology Arthroscopy, 2009 (in press)

25) Todd CJ, John AE, James AG, et al:Osteonecrosis of the knee after arthroscopic surgery for meniscal tear and chondral lesions. Arthroscopy 16:254-261, 2000

26) Wang CJ:Treatment of focal articular cartilage lesions of the knee with autogenous osteochondral grafts. Arch Orthop Trauma Surg 122:169-172, 2002