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.
引文
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