畜牧兽医学报  2023, Vol. 54 Issue (9): 3964-3976. DOI: 10.11843/j.issn.0366-6964.2023.09.034    PDF    
胫骨平台水平化截骨术治疗犬前交叉韧带疾病的手术效果和并发症分析
石磊1, 马裔寒1, 袁占奎1,2, 孙艺虹2, 王虓1, 张彬1, 乔康佳2     
1. 北京中农大动物医院有限公司, 北京 100193;
2. 中国农业大学动物医学院, 北京 100193
摘要:旨在评估胫骨平台水平化截骨术(tibial plateau leveling osteotomy, TPLO)治疗犬前交叉韧带疾病(cranial cruciate ligament disease, CCLD)的手术效果和并发症, 分析影响手术效果和并发症的因素。回顾了在中国农业大学动物医院采用TPLO手术治疗犬CCLD的病历记录, 并进行回访。入选病例满足: 回访时间大于5个月; 病例信息记录完整。结果表明: 共纳入85只犬的101例TPLO手术, 包含了20个品种的犬, 主要有杂种犬(n=17, 20.0%)、贵宾犬(n=15, 17.7%)、比熊犬(n=11, 12.9%)、金毛(n=10, 11.8%), 拉布拉多(n=8, 9.4%)。患犬的体重及年龄的中位数分别是14.4 kg(范围, 4~53 kg)和7岁(范围, 1~14岁)。整体并发症发生率为37.6%(38/101), 其中36例(35.6%, 36/101)发生了轻微并发症(包括创口相关并发症和绷带相关并发症), 2例(2.0%)发生严重并发症(包括1例螺钉松脱和1例胫骨结节骨折)。创口相关并发症(23.8%, 24/101)中, 15只舔舐创口的患病动物均出现创口相关并发症, 相比未舔舐创口的犬更易发生创口相关并发症(P < 0.01)。使用绷带的患病动物有34.6%(18/52)出现了相关并发症。2例严重并发症均采取了手术治疗, 术后结果良好。获得回访结果的病例中, 95.6%(86/90)功能恢复良好。未见与手术结果相关的风险因素; 术后使用绷带会增加并发症发生的风险(P=0.047, OR=3.873, 95%CI: 1.015~14.776)。综上: TPLO用于CCLD患犬的治疗具有理想的结果, 严重并发症发生率低; 舔舐会引起伤口相关并发症, 术后应严格防止患犬舔舐创口; 应减少绷带的使用以降低相关并发症。
关键词前交叉韧带疾病    胫骨平台水平化截骨术        手术效果    并发症    
Analysis of Surgical Effect and Complications of Tibial Plateau Leveling Osteotomy for the Treatment of Cranial Cruciate Ligament Disease in Dogs
SHI Lei1, MA Yihan1, YUAN Zhankui1,2, SUN Yihong2, WANG Xiao1, ZHANG Bin1, QIAO Kangjia2     
1. China Agricultural University Veterinary Teaching Hospital, Beijing 100193, China;
2. College of Veterinary Medicine, China Agricultural University, Beijing 100193, China
Abstract: This study aimed to evaluate the surgical effect and complications of tibial plateau leveling osteotomy (TPLO) for cranial cruciate ligament disease (CCLD) in dogs, and analyze factors that affect surgical effect and complications. The medical records of canine CCLD treated by TPLO in China Agricultural University Veterinary Teaching Hospital were reviewed and followed up. The inclusion criteria are: follow-up time more than 5 months; case information record is completed. Results were as follows: 101 TPLO procedures in 85 dogs of 20 breeds were included, including crossbreed (n=17, 20.0%), poodle (n=15, 17.7%), bichon (n=11, 12.9%), golden retriever (n=10, 11.8%) and Labrador retriever (n=8, 9.4%). The median weight and age were 14.4 kg (range, 4-53 kg) and 7 years (range, 1-14 years old), respectively. The overall complication rate was 37.6% (38/101). Thirty-six cases (35.6%, 36/101) had minor complications (including wound-related complications and bandage-related complications), and 2 cases (2.0%) had major complications (including 1case of screw loosening and 1 case of tibial tuberosity fracture). Wound-related complications (23.8%, 24/101) were more likely to occur in dogs with wound licking (P < 0.01), which were found in all the 15 dogs with wound licking. Related complications occurred in 18 (34.6%) of 52 dogs treated with bandage. Two major complications were treated by revision surgery with good results. Among the cases with follow-up results, 95.6% (86/90) cases had good functional recovery. Besides, postoperative bandage increased the risk of complications (P=0.047, OR=3.873, 95%CI: 1.015-14.776). However, no risk factors associated with surgical outcomes were found. In summary, TPLO of dogs with CCLD has desirable results and a low proportion of major complications. Licking can cause wound-related complications, therefore licking wounds should be strictly prevented postoperatively. Moreover, the use of bandages should be reduced to decrease associated complications.
Key words: cranial cruciate ligament disease    tibial plateau leveling osteotomy    canine    surgical effect    complications    

前交叉韧带疾病(cranial cruciate ligament disease,CCLD)是最常引起犬后肢跛行的原因[1-2]。前交叉韧带(cranial cruciate ligament,CCL)是犬膝关节的主要稳定结构,其功能丧失导致在负重时产生股骨对胫骨的过度向前的剪切力,导致后肢跛行和骨关节炎[3]。目前兽医临床针对该病有多种手术治疗方案,主要包括囊外技术、囊内技术和截骨术等。胫骨平台水平化截骨术(tibial plateau leveling osteotomy,TPLO)是目前临床用于治疗犬CCLD最广泛的截骨术[4]。TPLO技术1993年由Slocum和Slocum[5]报道,用于解决CCLD引起的膝关节不稳定。TPLO对CCL受损膝关节产生的动态稳定性是通过在胫骨近端进行弧形截骨术,将近端骨块旋转,以减小胫骨平台角(tibial plateau angle,TPA)来实现的。术前测量动物的TPA,计算达到期望的术后TPA需要旋转的距离。中和胫骨前冲所需的旋转量为使术后TPA达到6.5°±0.9°[5]。TPLO手术本身仅解决了动态性膝关节不稳定的问题,术中必须同时检查关节内结构,对半月板损伤或其他异常进行相应的治疗。TPLO手术在大型犬[4]、小型犬和猫[6]以及美洲驼[7]都已经成功实施。TPLO在小型犬的使用越来越广泛[8-11]。国内有一些关于CCLD手术治疗的报道[12],但尚缺乏大病例量的TPLO手术报道。本研究旨在评估TPLO手术治疗犬CCLD的临床效果及并发症,以及分析影响手术效果和并发症的因素。

1 材料与方法 1.1 动物

动物来自于2017—2021年在中国农业大学动物医院确诊CCLD,并通过TPLO手术治疗的犬。共85只患犬,101个患肢,其中左侧48例(47.5%),右侧53例(52.5%)。品种主要包括杂种犬(n=17)、贵宾犬(n=15)、比熊(n=11)和金毛(n=10),具体见表 1。性别方面,雄性33只(38.9%)、雌性17只(20%)、雄性去势14只(16.5%)和雌性绝育21只(24.7%)。患犬的体重及年龄中位数分别是14.4 kg(范围,4~53 kg)和7岁(范围,1~14岁),分布情况详见表 2

表 1 品种分布情况 Table 1 Distribution of breeds
表 2 年龄及体重分布情况 Table 2 Distribution of age and body weight

共88例记录了半月板探查情况,23例(26.1%)发现了半月板损伤,其中14例(60.9%)进行了半月板部分切除。

1.2 TPLO骨板

所使用的TPLO骨板(n=101)包括:瑞士KYON兽用骨科器械有限公司的钛合金TPLO骨板(n=97)、中国拜尔斯医疗科技有限公司的不锈钢TPLO骨板(n=3)、英国维英动物医疗服务有限公司的不锈钢TPLO骨板(n=1)。

1.3 手术方法

根据病例体重和标准膝关节正侧位X线片,按Slocum和Slocum[5]描述的方法,借助vPOP软件(英国维索斯教育有限公司)测量胫骨平台角、制订手术方案和选择合适的骨板及螺钉(图 1);如果膝关节骨刺影响对TPA的测量,则同时借助CT影像测量TPA[13]

1只12岁雌性柴犬,9 kg。图A及B分别为术前拍摄的内外侧位片及尾头侧位片。图C及D分别为使用内外侧位片及尾头侧位片经vPOP软件术前规划得到的相关信息,TPA为32°,使用12 mm的锯片,测得的D1为6 mm,D2为9 mm,旋转距离为5.5 mm,使用KYON的6号TPLO骨板。骨板最近端的螺钉长度为24 mm,最头侧螺钉长度为21 mm,最尾侧螺钉长度为17 mm A 12-year-old female Shiba Inu, 9 kg. Fig. A and B were mediolateral and caudocranial radiographic projections taken preoperatively, respectively. Fig. C and D were obtained using mediolateral and caudocranial radiographic projections by vPOP software, TPA was 32 degrees, 12 mm saw blades were used, D1 was 6 mm, D2 was 9 mm, and the rotation distance was 5.5 mm, using KYON #6 TPLO plate. The screw lengths at the proximal end, cranial and caudal end of the bone plate are 24, 21 and 17 mm respectively 图 1 术前规划 Fig. 1 Preoperative plan

根据麻醉医生偏好,给犬静脉注射布托啡诺0.2 mg·kg-1、右美托咪定3~5 μg·kg-1及舒泰1 mg·kg-1作为麻醉前用药,给药3~5 min后按1~3 mg·kg-1静脉注射阿法沙龙或丙泊酚进行诱导麻醉。之后进行气管内插管,异氟烷或七氟烷吸入麻醉,连接多功能监护仪进行各项生命体征的监护。超过背正中线到手术肢跗关节远端大范围剃毛,用4%葡萄糖氯己定刷洗术部,利多卡因硬膜外麻醉,术前用5%聚维酮碘溶液消毒术区。术前和术中每90 min静脉注射氨苄西林钠50 mg·kg-1

采用膝关节前内侧通路,近端到髌骨近端极水平,远端至胫骨近端约1/4处(根据骨板长度进行调整)。切开缝匠肌远端附着点,并将其向尾侧牵拉。切开腘肌于胫骨尾内侧附着点并钝性分离,显露胫骨内侧面及内侧副韧带。切开关节囊,进行膝关节探查。在韧带完全撕裂或不稳定的部分韧带撕裂情况下清除残余韧带,在稳定的部分韧带撕裂时将完整的韧带部分保留。检查骨关节炎的程度,包括骨赘和软骨病变。利用探勾检查半月板,切除发生撕裂部分的半月板。如果术前存在髌骨内脱,根据检查情况,对出现滑车沟过浅的犬实施楔形或矩形滑车成形术。按术前制定方案标记截骨位置。视情况使用夹具。根据术前规划选择合适规格的弧形锯片截断胫骨近端,按术前计算值旋转近端骨块,并用Kirschner针临时固定。选取合适规格的TPLO骨板放置于胫骨内侧面并固定。大量生理盐水冲洗膝关节和手术部位后,常规缝合关节囊、皮下组织及皮肤。术后拍摄膝关节标准摆位X线片评估手术效果(图 2)。

图 2为图 1中病例术后评估即刻拍摄的X线片。经vPOP软件测得术后TPA为5.5°,D1为6 mm,D2为9 mm(图C) It shows in Fig. 2 the radiographic projections taken immediately after surgery for postoperative evaluation of the case in Fig. 1. Postoperative TPA was 5.5°, D1 was 6 mm, and D2 was 9 mm measured by vPOP software (see Fig.C) 图 2 术后评估 Fig. 2 Postoperative evaluation

术后给予1周的阿莫西林克拉维酸钾(12.5~25 mg·kg-1,BID,PO)、非甾体抗炎药和加巴喷丁。根据医生偏好放置软垫绷带5~7 d。术后前5 d对手术部位冷敷,术后10~14 d拆线。拆线前犬一直佩戴伊丽莎白圈。每6~8周复查1次,并拍摄术部X线片,直至截骨部位愈合。

1.4 并发症及手术效果评估

通过病历记录和电话回访,记录患病动物的并发症(评估标准见表 3)和判断患肢功能情况[14-15]

表 3 并发症评估标准[16] Table 3 Complication assessment criteria[16]
1.5 数据处理

软件:IBM SPSS Statistics 25.0;Microsoft excel 2019。

对于定量正态分布数据,采用“x±s”表示;对于定量偏态分布数据,采用中位数(范围,最小值,最大值)表示。分类变量采用多因素logistic回归和卡方检验,连续变量年龄及体重通过数据处理调整为分类变量。P<0.05表示存在显著性差异,P<0.01表示存在极显著差异。

2 结果 2.1 并发症

整体并发症发生率为37.6%(38/101),36例(35.6%)发生了轻微并发症,2例(2.0%)发生了严重并发症。轻微并发症包括创口相关并发症和绷带相关并发症。24例(23.8%)发生创口相关并发症;舔过伤口病例的创口相关并发症发生率为100%(15/15),未舔过伤口病例的创口相关并发症发生率为10.5%(9/86),经卡方检验可知,两组间的创口相关并发症发生率差异极显著(P<0.01)。术后在52例使用了绷带,18例(34.6%)出现了绷带相关并发症。

2例严重并发症中,1例是术后1周出现了螺钉松脱(图 3),另1例术后3周出现了胫骨结节骨折(图 4)。这2例均采取了手术治疗,结果良好。

1只13岁雄性去势杂种犬,26 kg,使用拜尔斯的3.5 mm不锈钢TPLO锁定骨板。术后1周经X线片发现胫骨近端的3颗骨螺钉均出现了松动,通过手术更换螺钉。图A及B分别为螺钉松脱后拍摄的侧位及正位X线片,C及D分别为翻修后拍摄的侧位及正位X线片 A 13-year-old male castrated crossbreed dog, 26 kg, used a 3.5 mm stainless steel TPLO locking plate from Biortho . Radiographic projections showed that all three screws of proximal tibia were loose one week after surgery, and the screws were replaced. Fig. A and B are mediolateral and caudocranial radiographic projections taken after the screws were loosened, and C and D are mediolateral and caudocranial radiographic projections taken after revision surgery, respectively 图 3 螺钉松脱 Fig. 3 Screw loosening
1只7岁雌性绝育哈士奇,34 kg,术后3周出现胫骨结节骨折,通过1.5 mm的Kirschner针和张力带钢丝技术固定。图A、B为TPLO术后即刻的X线片,C、D为3周时胫骨结节骨折时拍摄的X线片,E、F为张力带钢丝固定后拍摄的X线片,G、H为张力带钢丝固定6个月后拍摄的X线片,可见骨折线已消失,胫骨结节骨折处已愈合。其中A、C、E、G为侧位片,B、D、F、H为正位片 A 7-year-old female sterilized husky, 34 kg, who developed a tibial tuberosity fracture 3 weeks postoperatively, was fixed by a 1.5 mm Kirschner pin and tension band wire. Figures A and B are radiographic projections taken immediately after TPLO surgery, Figures C and D are radiographic projections taken when the tibial tuberosity was fractured at 3 weeks, Figures E and F are radiographic projections taken after tension band wire fixation, Figures G and H are radiographic projections taken after 6 months of tension band wire fixation, it can be seen that the fracture line has disappeared, and the fracture of the tibial tuberosity healed.Figures A, C, E, G are mediolateral radiographic projections, and Figures B, D, F, H are caudocranial radiographs 图 4 胫骨结节骨折 Fig. 4 Tibial tuberosity fracture

纳入年龄、体重、性别、患肢、半月板损伤情况、舔舐创口、绷带等构建多因素Logistic回归方程(表 4),可知年龄(P=0.821)、体重(P=0.907)、性别(P=0.415)、患肢(P=0.227)、半月板损伤情况(P=0.220)和舔舐创口(P=0.998)均不是发生术后并发症的风险因素,而术后使用绷带(P=0.047,OR=3.873,95%CI:1.015~14.776)会提高并发症的发生风险,差异具有统计学意义。

表 4 并发症相关风险因素分析 Table 4 Analysis of risk factors associated with complications

有两例(2.0%)拆除了TPLO骨板。患犬为1只5岁雄性比格犬,实施了双后肢TPLO手术(右侧TPLO采用了拜尔斯3.5 mm不锈钢TPLO锁定骨板,左侧采用了KYON钛合金TPLO 9号骨板)。在右侧术后20个月、左侧术后10个月拆除了TPLO骨板(图 5),植入物细菌培养均为阴性。右侧拆除骨板是因为患犬舔舐,导致骨板远端覆盖的皮肤出现溃疡;左侧拆除骨板是由于不明原因的跛行。

1只5岁雄性比格犬,20 kg。图A、B、C、D为右侧X线片,E、F、G、H为左侧X线片。图A、B、E、F为拆植入物前的X线片,未见明显异常;图C、D、G、H为拆植入物后即刻拍摄的X线片,可见胫骨处已愈合 A 5-year-old male beagle, 20 kg. Figures A, B, C, D are the radiographic projections of right hind limb, and Figures E, F, G, H are radiographic projections of left hind limb. Figures A, B, E, and F are radiographic projections before the implant was removed, which no obvious abnormalities can be found; Figures C, D, G, and H are radiographic projections taken immediately after the implant is removed and the tibia has healed 图 5 疑植入物引起不适 Fig. 5 Suspected discomfort caused by implants
2.2 患肢功能恢复情况

电话回访得到90例TPLO手术的患肢功能结果。另外11例中4例无法联系到动物主人;5例动物死亡(2例自然死亡,3例分别因淋巴癌、肠道肿物、肠泄漏死亡);1只患犬(双侧TPLO)因椎间盘疾病导致截瘫,在出现椎间盘疾病症状前(术后3个月)患犬无跛行。90例TPLO手术的回访时间中位数为13个月(范围,5~50个月),其中86例(95.6%)恢复良好,4例(4.4%)存在跛行,跛行病例的具体信息见表 5

表 5 跛行病例信息 Table 5 Lameness cases information

纳入年龄、体重、性别、患肢、半月板损伤情况、舔舐创口、绷带等构建多因素Logistic回归方程(表 6),可知年龄(P=0.322)、体重(P=0.997)、性别(P=0.128)、患肢(P=0.820)、半月板损伤情况(P=0.088)、舔舐伤口(P=0.998)和绷带(P=0.153)等因素均不是影响术后恢复的风险因素。

表 6 影响治疗结果的风险因素分析 Table 6 Analysis of risk factors affecting treatment outcome
3 讨论

TPLO是目前小动物临床最常用于治疗犬CCLD的截骨术[4]。本研究旨在评估TPLO手术治疗犬CCLD的临床效果及并发症,回顾分析了在中国农业大学动物医院进行TPLO的85只患犬的101例手术。TPLO术后的整体并发症为37.6%,其中轻微并发症为35.6%(包括创口相关并发症和绷带相关并发症),严重并发症很少(2%);95.6%的患肢术后功能恢复良好。术后使用绷带会增加并发症发生的风险(P=0.047,OR=3.873,95%CI:1.015~14.776),未见与手术结果相关的风险因素。TPLO手术治疗CCLD患犬具有理想的结果。

本研究中的85只犬中共包含了20个品种,主要包括杂种犬(20.0%)、贵宾犬(17.7%)、比熊犬(12.9%)和金毛(11.8%)等。患犬的体重及年龄的中位数分别是14.4 kg(4~53 kg)和7岁(1~14岁)。Gatineau等[17]的研究中,348只接受TPLO手术的犬中涉及了39个品种,最常见的品种是拉布拉多(25%)、金毛(15.3%)和杂种犬(10%)等;体重和年龄中位数分别是36 kg(16.3~76 kg)和5岁(1~11.5岁)。本研究中,中小型品种比例较大,可能与本地的品种喜好有关。

TPLO手术被广泛应用于各种体型的犬[4, 8-10],在猫[6]和美洲驼[7]也有成功实施的报道。因此,只要有合适的植入物,动物的体型本身并不会限制该技术的使用。多个公司都具有不同规格的TPLO骨板,例如本研究中主要采用的KYON公司的钛合金TPLO骨板,骨板型号为4~12号,所用锁定螺钉为1.5~4.5 mm,适用的动物体型范围非常大。

TPLO对CCL受损膝关节产生的动态稳定性是通过在胫骨近端进行弧形截骨术,将近端骨块旋转,以减小TPA来实现的[5]。术前和术中对截骨术位置的规划会使截骨术的中心位置更精确,并减小胫骨结节骨折的风险[18]。肢体的摆位会影响X线的TPA测量[19-20]。本研究中的所有患犬均进行了镇定或全身麻醉拍片,以获得所需的标准X线影像。在骨刺影响TPA测量时,会结合CT影像进行测量[13]。将获得的X线影像利用vPOP软件进行术前规划。有研究显示,使用DR和计算机测量系统会使TPA测量的差异性减小[21]。规划时采用测量髌腱附着点到计划截骨线上两点的距离(标注为D1和D2)来确定截骨的部位,Mossman等[1]证明这会更精确。

本研究在手术过程中是否使用夹具,取决于手术医生的偏好。整体而言,在体重超过15 kg的犬均使用了夹具,而在体重较小的犬不使用夹具的比例较高。一项研究发现是否使用夹具对TPLO术后TPA、胫骨脊厚度、内翻-外翻畸形或胫骨旋转无明显影响[22]。另一研究发现是否使用夹具,术后TPA、骨块复位或截骨的近远端位置无区别[23]。据作者的经验,使用夹具有助于截骨后对近端骨块进行旋转,对于手术经验不够丰富的医生,夹具可能有助于防止胫骨内翻-外翻畸形或旋转,并在钻入临时固定针时夹具可辅助固定骨块。但是,使用夹具也同样会伴有其他问题,例如,近端夹具针植入到膝关节内,远端夹具针处骨折,使用夹具导致截骨术的位置更靠远端[22]。试验研究发现,使用新型的夹具和锯片引导器以及3D打印锯片引导器会改善截骨术的精确度[24-26],但这对于经验丰富的医生的帮助和对实际手术的意义仍有待进一步研究。

本研究中的病例均采用了锁定骨板系统,包括维英和拜尔斯公司的不锈钢TPLO骨板以及KYON公司的钛合金TPLO骨板。已经有研究显示,使用锁定骨板系统增加了愈合期间TPA的稳定性,且改善了X线骨愈合影像[27],使用锁定骨板结构也降低了感染的风险和整体并发症[28-29]。因此,作者推荐在实施TPLO手术时采用锁定骨板系统。商品化的锁定骨板系统有多种,不同的设计各有特点和使用技巧,医生可根据自己的偏好来选择。无论采用各种系统,在使用前,都应该仔细阅读厂商提供的说明,以减小因使用不当造成的并发症。

本研究的整体并发症发生率为37.6%(n=38),其中36例(35.6%)发生了轻微并发症,2例(2.0%)发生严重并发症。报道的TPLO的整体术后并发症比例为7.2%~28.0%[17, 30-34]。一项前瞻性多中心研究[28]评估了经验丰富的外科医生使用解剖塑形的锁定骨板进行TPLO的X线检查结果和并发症,术后轻微并发症发生率为5.4%,严重和灾难性并发症发生率均为零。许多并发症都是技术错误的结果;因此,并发症的发生率应当会随着医生手术经验的积累而降低。

本研究中的轻微并发症主要包括创口相关并发症和绷带相关并发症。23例(22.8%)发生创口相关并发症;15例曾舔舐创口的犬均出现了创口相关并发症,而未舔过伤口病例组的创口相关并发症发生率为9.6%(8/83),两组间的创口相关并发症发生率差异极显著(P<0.01)。因此,在术后一定要督促动物主人戴好脖圈或嘴套,严格防止动物舔舐伤口。本研究中,术后给一周的阿莫西林克拉维酸钾(12.5~25 mg·kg-1,BID,PO)。许多研究表明术后使用抗生素的确减少了TPLO术后手术部位感染(surgical site infection,SSI)的发生率[29, 33, 35-36]。研究发现,50 kg以上的犬SSI的发生率增加[37]。如果处置得当,SSI与长期功能性结果无关[38],本研究也表明了这一点。在术后采用了绷带的52例中,18例(34.6%)出现了绷带相关并发症。虽然术后采用绷带有助于缓解术部肿胀和疼痛、限制膝关节活动等优点,但也具有妨碍对伤口进行观察和进行局部治疗等缺点,结合绷带引发的并发症比例较高,作者不推荐在TPLO术后常规使用绷带。尽管本研究中轻微并发症的发生率要高于之前的报道,但如之前报道[30]所称,不需要手术干预即可解决;通过加强医患沟通和术后管理,以及避免术后使用绷带,可以极大地减少轻微并发症。

本研究中的2例(2.0%)严重并发症中1例为术后1周发生了胫骨近端3颗螺钉松脱,另1例是术后5周出现了胫骨结节骨折。发生螺钉松脱的是1只13岁雄性去势杂种犬,为双侧CCL断裂,采用的是3.5 mm锁定螺钉,发生螺钉松脱的原因不明。进行手术翻修,并同时进行左侧TPLO手术,患犬恢复良好。发生胫骨结节骨折的患犬为1只7岁雌性绝育哈士奇犬,事发前曾与家中另一只犬打闹,采用1.5 mm的Kirschner针和张力带钢丝进行胫骨结节固定,恢复良好。在以往报道中,腓骨或胫骨骨折是潜在的更严重的并发症,在TPLO术中或术后可能会发生。报道的TPLO术后胫骨结节骨折的比例为1%~6%[30-32]。在一项涵盖了168例的TPLO病例中,5.4%的病例发生腓骨骨折[39]。355例TPLO的研究显示腓骨骨折率为15%[40]。在本研究中并未出现腓骨骨折的病例。TPLO术后胫骨结节骨折的风险因素包括双侧TPLO、术后胫骨结节的平均厚度小以及在康复期间TPA增加[41-42]。本研究中发生胫骨结节骨折的犬的术后胫骨结节厚度大约为胫骨近端总厚度的25%,因此,作者推断发生胫骨结节骨折的主要原因是犬过早进行了剧烈运动。术后一定要反复强调控制活动的重要性,在X线检查显示截骨部位完全愈合之前,都应该避免患犬做剧烈运动,尤其在多宠物家庭。

2例怀疑存在植入物引起不适的TPLO手术同为1只5岁雄性比格犬。患犬右侧TPLO采用拜尔斯3.5 mm不锈钢TPLO锁定骨板,术后患肢功能恢复良好,但在术后20个月出现舔舐右侧患肢内侧的表现,在骨板远端对应皮肤上出现脓疱,手术移除了骨板和皮肤病变。左侧TPLO手术在右侧手术后10个月,采用了KYON钛合金TPLO骨板,术后恢复良好,截骨部位愈合良好;在术后39个月患犬出现跛行,用非甾体抗炎药无效,怀疑与植入物有关,进行了骨板拆除,之后患肢恢复正常。两侧的植入物拆除后的细菌培养均为阴性。已报道了TPLO术后在胫骨近端出现肿瘤[43],无法确认特定植入物与骨肿瘤形成之间的直接关联。从该犬的X线片和拆骨板术中并未见肿瘤迹象。综合来看,作者推断患犬的症状是由于植入物引起不适。

研究发现,TPA>30°、体重大和CCL部分或完全断裂与术后并发症发生率有关[33-34, 37]。同时进行双侧TPLO增加了并发症发生率[31]。在本研究中并未发现体重与并发症有关(P=0.509),可能与本研究中体重小于15 kg的犬比例较高(n=44,51.8%)有关。Hans等[37]的研究显示,在体重大于50 kg的犬,TPLO手术的严重并发症高达27.8%。本研究中仅有一只犬的体重大于50 kg(手术时体重为53 kg),但由于术后失联,手术并发症和结果未知。本研究也发现年龄(P=0.821)、体重(P=0.907)、性别(P=0.415)、患肢(P=0.227)、半月板损伤情况(P=0.220)和舔舐创口(P=0.998)均不是发生术后并发症的风险因素。术后使用绷带的并发症概率较高[44],本研究的结果也显示,术后使用绷带(P=0.047,OR=3.873,95%CI:1.015~14.776)会增加并发症的发生风险。

在大型和小型犬,报道的TPLO结果的主观和客观研究都比较理想,对CCLD手术治疗的文献分析强烈支持TPLO可以使犬恢复正常功能[45]。临床评估的主观研究如跛行评分、X线骨赘评分和客户调查问卷[32, 41, 46-47];客观评估是通过压力板和动力学分析[48-49]。本研究通过病历记录和电话回访,发现95.6%的手术肢功能恢复良好;4个(4.4%)患肢在回访时仍存在不同程度的跛行。统计结果未发现年龄(P=0.996)、体重(P=1.000)、性别(P=0.828)、患肢(P=0.887)、半月板损伤情况(P=0.996)、术前髌骨内脱情况(P=0.998)、舔舐伤口(P=0.996)、创口相关并发症(P=0.999)、术后绷带(P=0.997)、并发症(P=1.000)等因素对手术结果存在影响。Priddy等[31]的报道显示,在151只犬的TPLO术后,78.8%的动物主人称犬不存在跛行,15.9%的动物主人认为犬存在间歇性跛行,5.3%的动物主人表示犬存在持续性跛行;93%的动物主人对手术结果满意或非常满意。通过压力板和动力学分析,发现TPLO后在早期阶段恢复迅速,尤其是与外侧籽骨-胫骨缝合固定相比[48-49]。在小型犬的TPLO也见地面反应力度改善大于外侧籽骨-胫骨缝合固定[11]。Cosenza等[9]的研究中,采用1.5/2.0 mm锁定骨板成功实施了小型犬的TPLO手术。Aminoto等[10]的研究中,基于压力板步态分析,12只体重小于15 kg的犬在TPLO术后后肢功能明显改善,结果良好。本研究中体重小于15 kg的犬占到了51.8%,术后均获得了比较理想的结果。

本研究属于回顾性研究,存在一定的局限性。首先是手术由不同的医生操作完成,术中很多细节,例如是否使用夹具、软组织的分离情况等都存在一定差异,这些对术后恢复速度和手术结果的影响有待进一步评估。第二,本研究中对动物患肢恢复结果的长期评估主要通过对动物主人进行电话回访获得,尽管存在一定的主观性,但已有研究证明动物主人对骨科手术后功能结果的评估是有效且可靠的[50]。若能通过压力板步态测试对患肢的功能进行评估,将会得到更客观的结果。

4 结论

本研究包含了101例TPLO手术,整体并发症发生率达37.6%,但主要为轻微并发症,严重并发症仅为2%,对所有并发症进行适当治疗后未影响最终结果。95.6%的患肢术后功能恢复良好。据此可以得出结论,TPLO用于CCLD患犬具有理想的结果,严重并发症发生率低;术后要防止动物舔舐创口和减少绷带的使用,以降低并发症的发生率。

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