一期双侧胫距跟融合术治疗血友病性踝关节病的临床研究
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摘要
背景:踝关节是血友病最常侵犯的关节之一,对于双侧出现严重关节面破坏的血友病性踝关节病患者,一直未能有很好的治疗方案。目的:探讨应用逆行交锁髓内钉行一期双侧胫距跟融合术治疗双侧终末期血友病性踝关节病的围术期处理方法、手术方法及短中期临床疗效。方法:回顾性分析2012年1月至2016年6月收治的5例双侧终末期血友病性踝关节病患者,甲型血友病3例,乙型血友病2例,均为男性;年龄为22~42岁,平均27.6岁。术前根据美国矫形足踝协会(AOFAS)评分为19~31分,平均25分。入院后由血液内科会诊,通过凝血因子预实验确定围手术期凝血因子替代方案,应用逆行交锁髓内钉行一期双侧胫距跟融合术。结果:单侧融合术用时为60~90 min,平均73 min;术中出血量为10~60 ml,平均24 ml。术后双足完全负重时间为3.5~6.0个月,平均4.2个月。5例患者全部获得随访,随访时间为20~61个月,平均37个月。术后1年随访时X线片示踝关节完全融合,AOFAS评分为83~92分,平均87分。1例术中发生双侧胫骨下段骨折,1足踝前正中切口皮缘愈合不良,1足因1枚交锁螺钉刺激皮肤于术后5周时局部麻醉下取出。结论:在良好的围术期凝血因子替代治疗方案下,采用逆行交锁髓内钉行一期双侧胫距跟融合术治疗双侧终末期血友病性踝关节病变安全有效、医疗费用低、康复周期短。
Background: The ankle is one of the most frequent involved joints in hemophilia patients. But there has been no good treatment for severe bilateral joint surface damages in patients with hemophilic ankle disease. Objective: To investigate perioperative management, operation methods and short-and medium-term clinical outcomes of one-stage bilateral tibiotalocalcaneal arthrodesis in patients with end-stage hemophilic ankle arthropathy by using retrograde interlocking intramedullary nails. Methods: Five patients with bilateral end-stage hemophilic ankle arthritis admitted to our hospital between January 2012 and June 2016 were retrospectively analyzed in this study. There were 3 patients with the hemophilia A and 2 patients with the hemophilia B. They were all male with a mean age of 27.6 years(range, 22-42 years). Preoperative American Orthopedic Foot and Ankle Society(AOFAS) score was 25 on average(range, 19-31). Scheme of alternatives during perioperative period was determined according to preliminary experiment of blood coagulation factors. Retrograde interlocking intramedullary nails were used in the one-stage bilateral tibiotalocalcaneal fusion. Results: The mean unilateral operation time was 73 min(range, 60-90 min) and mean intraoperative blood loss was 24 ml(range, 10-60 ml). The average full weight-bearing time was 4.2 months(range, 3.5-6 months). All the patients were followed up, and the average duration of follow-up was 37 months(range, 20-61 months). X-ray results showed a perfect fusion of the ankle one year postoperatively, and the mean AOFAS score was 87(range, 83-92). Bilateral distal tibial fractures occurred in one patient during operation. Poor healing of anterior median incision was found in one foot. The nail was taken out from one patient under local anesthesia because of skin irritation 5 weeks postoperatively. Conclusions: One-stage bilateral tibiotalocalcaneal arthrodesis using retrograde interlocking intramedullary nails is a safe, effective, low-cost and quick-recovery treatment for end-stage hemophilic ankle arthropathy. Proper supplement of coagulation factors plays an important role during the procedure.
Background: The ankle is one of the most frequent involved joints in hemophilia patients. But there has been no good treatment for severe bilateral joint surface damages in patients with hemophilic ankle disease. Objective: To investigate perioperative management, operation methods and short-and medium-term clinical outcomes of one-stage bilateral tibiotalocalcaneal arthrodesis in patients with end-stage hemophilic ankle arthropathy by using retrograde interlocking intramedullary nails. Methods: Five patients with bilateral end-stage hemophilic ankle arthritis admitted to our hospital between January 2012 and June 2016 were retrospectively analyzed in this study. There were 3 patients with the hemophilia A and 2 patients with the hemophilia B. They were all male with a mean age of 27.6 years(range, 22-42 years). Preoperative American Orthopedic Foot and Ankle Society(AOFAS) score was 25 on average(range, 19-31). Scheme of alternatives during perioperative period was determined according to preliminary experiment of blood coagulation factors. Retrograde interlocking intramedullary nails were used in the one-stage bilateral tibiotalocalcaneal fusion. Results: The mean unilateral operation time was 73 min(range, 60-90 min) and mean intraoperative blood loss was 24 ml(range, 10-60 ml). The average full weight-bearing time was 4.2 months(range, 3.5-6 months). All the patients were followed up, and the average duration of follow-up was 37 months(range, 20-61 months). X-ray results showed a perfect fusion of the ankle one year postoperatively, and the mean AOFAS score was 87(range, 83-92). Bilateral distal tibial fractures occurred in one patient during operation. Poor healing of anterior median incision was found in one foot. The nail was taken out from one patient under local anesthesia because of skin irritation 5 weeks postoperatively. Conclusions: One-stage bilateral tibiotalocalcaneal arthrodesis using retrograde interlocking intramedullary nails is a safe, effective, low-cost and quick-recovery treatment for end-stage hemophilic ankle arthropathy. Proper supplement of coagulation factors plays an important role during the procedure.
引文
[1]王学峰,冯建民,孙竞,等.中国血友病骨科手术围术期处理专家共识.中华骨与关节外科杂志,2016,5(5):361-370.
[2]Poenaru DV,P?tra?cu JM,Andor BC,et al.Orthopaedic and surgical features in the management of patients with haemophilia.Eur J Orthop Surg Traumatol.2014,24(5):685-692.
[3]Boehlen F,Graf L,Berntorp E.Outcome measures in haemophilia:a systematic review.Eur J Haematol Suppl.2014,76:2-15.
[4]Rodriguez-Merchan EC.Aspects of current management:orthopaedic surgery in haemophilia.Haemophilia.2012,18(1):8-16.
[5]Li Y,Weng XS,Lin J,et al.Perioperative period of a hemophilia-related osteoarthropathy therapeutic regimen and analysis of complications.Orthop Surg,2016,8(1):60-67.
[6]李晔,翁习生,林进,等.血友病性骨关节病围手术期伤口并发症处理.中华骨与关节外科,2015,8(5):412-416.
[7]高增鑫,邱贵兴,翁习生,等.关节成形术治疗血友病性关节病.中华外科杂志,2008,46(11):809-812.
[8]张凌汉,翁习生,邱贵兴,等.血友病足踝部病变的外科治疗.中国修复重建外科杂志,2013,27(2):160-163.
[9]Rodriguez-Merchan EC.End-stage haemophilic arthropathy of the ankle:ankle fusion or total ankle replacement.Haemophilia,2014,20(1):e106-e107.
[10]Barg A,Elsner A,Hefti D,et al.Haemophilic arthropathy of the ankle treated by total ankle replacement:a case series.Haemophilia,2010,16(4):647-655.
[11]Pasta G,Forsyth A,Merchan CR,et al.Orthopaedic management of haemophilia arthropathy of the ankle.Haemophilia.2008,14 Suppl 3:170-176.
[12]Tsailas PG,Wiedel JD.Arthrodesis of the ankle and subtalar joints in patients with haemophilic arthropathy.Haemophilia,2010,16(5):822-831.
[13]Lane H,Siddiqi AE,Ingram-Rich R,et al.Functional outcomes following ankle arthrodesis in males with haemophilia:analyses using the CDC's Universal Data Collection surveillance project.Haemophilia,2014,20(5):709-715.
[14]Van Meegeren ME,Van Veghel K,De Kleijn P,et al.Joint distraction results in clinical and structural improvement of haemophilic ankle arthropathy:a series of three cases.Haemophilia,2012,18(5):810-817.
[15]李晔,高鹏,翁习生,等.应用带锁髓内钉行胫距跟融合术治疗终末期血友病性踝关节炎的临床研究.中华骨与关节外科杂志,2017,10(2):140-143.
[16]Eckers F,Bauer DE,Hingsammer A,et al.Mid-to longterm results of total ankle replacement in patients with haemophilic arthropathy:A 10-year follow-up.Haemophilia.2018,24(2):307-315.
[17]Hahn ME,Wright ES,Segal AD,et al.Comparative gait analysis of ankle arthrodesis and arthroplasty:initial findings of a prospective study.Foot Ankle Int,2012,33(4):282-289.
[18]Barg A,Morris SC,Schneider SW,et al.Surgical procedures in patients with haemophilic arthropathy of the ankle.Haemophilia,2016,22(3):e156-176.
[19]Dauty M,Gross R,Leboeuf F,et al.Comparison of total ankle replacement and ankle arthrodesis in patients with haemophilia using gait analysis:two case reports.BMC Res Notes,2015,8:768.
[20]Preis M,Bailey T,Jacxsens M,et al.Total ankle replacement in patients with haemophilic arthropathy:primary arthroplasty and conversion of painful ankle arthrodesis to arthroplasty.Haemophilia,2017,23(4):e301-e309.
[21]Seidel J,Mathew B,Marks J.Bilateral ankle and subtalar joint fusion secondary to Guillain Barré-Induced foot drop.J Foot Ankle Surg,2016,55(2):260-262.
[22]Maenohara Y,Taniguchi A,Tomiwa K,et al.Outcomes of bilateral vs unilateral ankle arthrodesis.Foot Ankle Int,2018,39(5):530-534.
[2]Poenaru DV,P?tra?cu JM,Andor BC,et al.Orthopaedic and surgical features in the management of patients with haemophilia.Eur J Orthop Surg Traumatol.2014,24(5):685-692.
[3]Boehlen F,Graf L,Berntorp E.Outcome measures in haemophilia:a systematic review.Eur J Haematol Suppl.2014,76:2-15.
[4]Rodriguez-Merchan EC.Aspects of current management:orthopaedic surgery in haemophilia.Haemophilia.2012,18(1):8-16.
[5]Li Y,Weng XS,Lin J,et al.Perioperative period of a hemophilia-related osteoarthropathy therapeutic regimen and analysis of complications.Orthop Surg,2016,8(1):60-67.
[6]李晔,翁习生,林进,等.血友病性骨关节病围手术期伤口并发症处理.中华骨与关节外科,2015,8(5):412-416.
[7]高增鑫,邱贵兴,翁习生,等.关节成形术治疗血友病性关节病.中华外科杂志,2008,46(11):809-812.
[8]张凌汉,翁习生,邱贵兴,等.血友病足踝部病变的外科治疗.中国修复重建外科杂志,2013,27(2):160-163.
[9]Rodriguez-Merchan EC.End-stage haemophilic arthropathy of the ankle:ankle fusion or total ankle replacement.Haemophilia,2014,20(1):e106-e107.
[10]Barg A,Elsner A,Hefti D,et al.Haemophilic arthropathy of the ankle treated by total ankle replacement:a case series.Haemophilia,2010,16(4):647-655.
[11]Pasta G,Forsyth A,Merchan CR,et al.Orthopaedic management of haemophilia arthropathy of the ankle.Haemophilia.2008,14 Suppl 3:170-176.
[12]Tsailas PG,Wiedel JD.Arthrodesis of the ankle and subtalar joints in patients with haemophilic arthropathy.Haemophilia,2010,16(5):822-831.
[13]Lane H,Siddiqi AE,Ingram-Rich R,et al.Functional outcomes following ankle arthrodesis in males with haemophilia:analyses using the CDC's Universal Data Collection surveillance project.Haemophilia,2014,20(5):709-715.
[14]Van Meegeren ME,Van Veghel K,De Kleijn P,et al.Joint distraction results in clinical and structural improvement of haemophilic ankle arthropathy:a series of three cases.Haemophilia,2012,18(5):810-817.
[15]李晔,高鹏,翁习生,等.应用带锁髓内钉行胫距跟融合术治疗终末期血友病性踝关节炎的临床研究.中华骨与关节外科杂志,2017,10(2):140-143.
[16]Eckers F,Bauer DE,Hingsammer A,et al.Mid-to longterm results of total ankle replacement in patients with haemophilic arthropathy:A 10-year follow-up.Haemophilia.2018,24(2):307-315.
[17]Hahn ME,Wright ES,Segal AD,et al.Comparative gait analysis of ankle arthrodesis and arthroplasty:initial findings of a prospective study.Foot Ankle Int,2012,33(4):282-289.
[18]Barg A,Morris SC,Schneider SW,et al.Surgical procedures in patients with haemophilic arthropathy of the ankle.Haemophilia,2016,22(3):e156-176.
[19]Dauty M,Gross R,Leboeuf F,et al.Comparison of total ankle replacement and ankle arthrodesis in patients with haemophilia using gait analysis:two case reports.BMC Res Notes,2015,8:768.
[20]Preis M,Bailey T,Jacxsens M,et al.Total ankle replacement in patients with haemophilic arthropathy:primary arthroplasty and conversion of painful ankle arthrodesis to arthroplasty.Haemophilia,2017,23(4):e301-e309.
[21]Seidel J,Mathew B,Marks J.Bilateral ankle and subtalar joint fusion secondary to Guillain Barré-Induced foot drop.J Foot Ankle Surg,2016,55(2):260-262.
[22]Maenohara Y,Taniguchi A,Tomiwa K,et al.Outcomes of bilateral vs unilateral ankle arthrodesis.Foot Ankle Int,2018,39(5):530-534.