Laboratoire ICube, équipe MMB, 67400 Illkirch, France.
Département de chirurgie orthopédique, hôpital Sainte-Marguerite, hôpital Universitaire de Marseille, 270, boulevard Sainte-Marguerite, 13009 Marseille, France.
Orthop Traumatol Surg Res. 2021 Nov;107(7):103031. doi: 10.1016/j.otsr.2021.103031. Epub 2021 Jul 31.
the hinge plays a fundamental role in the support and consolidation of a high tibial osteotomy. The objective of this work was to analyse the influence of the end zone of the osteotomy cut and its orientation in relation to the articular joint line (JL) on the risk of hinge fracture.
a specific orientation and end zone of the osteotomy cut can be utilised to decrease the risk of hinge fracture.
a finite element (FE) model was used to reproduce the proximal portion of the tibia and the proximal tibiofibular joint with transverse isotropic elastic bone properties. A 1.27mm thick, complete, anteroposterior saw cut was made with a U-shaped saw blade. Five proximal and lateral tibial zones were used according to Nakamura et al corresponding to the end zones of the osteotomy cut. Three angulations of the cut relative to the JL were defined: 10°, 15°, 20°. The tests consisted of simulating 15 possible situations (3 angulations for each of the 5 end zones) on this model. These simulations made it possible to identify the existence of a local stress concentration (von Mises, in MPa) at the level of the hinge, corresponding to the main judgment criterion.
If we consider only the end zones of the osteotomy cut, regardless of its angulation with respect to the JL, the zone which presents, on average, the lowest local stress concentration is the AM zone (40.3MPa). If we consider only the angulation of the osteotomy cut, with respect to the JL, regardless of the end zone of the cut, the angulation that locally concentrates, on average, the least stress is an angulation at 10° (147.7MPa). Finally, it is important to define the best end zone of the osteotomy cut for each angulation value in relation to the JL: for an angulation of 10°, the end zone must be in AM (38MPa), but also for an angulation of 15° (45MPa), and for an angulation of 20° (38MPa).
DISCUSSION-CONCLUSION: With the inherent caveats of the experimental conditions, the hypothesis is confirmed. An end zone of the osteotomy cut exists (AM) and an orientation (10°) that induces the lowest local stress concentration and therefore the least likely to induce lateral hinge fracture. However, the orientation of the osteotomy cut is also a matter of surgical habit, especially regarding complementary osteotomy of the tibial tuberosity that some may want to avoid. Thus, it is equally important to know the best end zone associated with a given angulation of the cut in relation to the JL, which according to these results is the AM zone for each angulation. This information helps guide the operator in their surgical practices according to their habits.
V, expert opinion.
铰链在支持和巩固高位胫骨截骨术中起着至关重要的作用。本研究的目的是分析截骨切迹的末端区域及其与关节线（JL）的方向对铰链骨折风险的影响。
通过特定的截骨切迹方向和末端区域，可以降低铰链骨折的风险。
使用有限元（FE）模型复制胫骨近端和胫骨近端腓骨关节，采用各向同性弹性骨骼特性。使用 U 形锯片进行 1.27mm 厚的完整前后锯切。根据 Nakamura 等人的研究，将胫骨近端分为 5 个近端和外侧区域，对应于截骨切迹的末端区域。截骨相对于 JL 的三个角度定义为：10°、15°、20°。这些测试在模型上模拟了 15 种可能的情况（5 个末端区域中的每一个都有 3 个角度）。这些模拟使我们能够确定铰链处存在局部应力集中（von Mises，单位为 MPa），这是主要判断标准。
如果我们仅考虑截骨切迹的末端区域，而不考虑其相对于 JL 的角度，则平均呈现最低局部应力集中的区域是 AM 区域（40.3MPa）。如果我们仅考虑截骨相对于 JL 的角度，则平均局部应力集中最小的角度为 10°（147.7MPa）。最后，重要的是要确定与 JL 相关的每个角度值的最佳截骨切迹末端区域：对于 10°的角度，末端区域必须在 AM（38MPa），但对于 15°的角度（45MPa）和 20°的角度（38MPa）也是如此。
讨论-结论：在实验条件的固有局限性下，假设得到证实。存在一个截骨切迹末端区域（AM）和一个方向（10°），可诱导最低的局部应力集中，因此最不可能导致外侧铰链骨折。然而，截骨切迹的方向也是手术习惯的问题，尤其是对于一些人可能希望避免的胫骨结节的补充截骨。因此，同样重要的是要知道与 JL 相关的给定角度的最佳末端区域，根据这些结果，该区域为 AM 区域。这些信息有助于根据他们的习惯指导操作员的手术实践。
V，专家意见。
