全膝关节置换术在类风湿关节炎合并骨关节炎患者中的应用
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摘要
目的：探讨膝类风湿关节炎(rheumatic arthritis, RA)合并骨关节炎(osteoarthritis, OA)患者行全膝关节置换术(total knee replacement, TKR)的手术方式、围手术期相关问题的处理措施及对术后临床疗效的评价。
方法：对自2006年1月至2009年9月期间由同一主刀医师进行的10例14个膝关节TKR手术综合分析。通过术前查体、化验检查及影像资料判定这些膝关节同时符合膝类风湿关节炎和骨关节炎的临床诊断标准,且不能用同一疾病解释所有临床现象；通过术中所见及术后病理结果证实术前诊断。根据公认的全膝关节置换术的指征判定这些患者是否适合行TKR手术。这10例患者中男3例,女7例,平均年龄为58岁(范围55-64岁),其中双膝病变患者4例。对于双膝病变患者通过术前对身体条件的综合评估,并给予积极术前准备,均采用一期完成置换手术。对于术前长期应用抗风湿药物或合并其他疾病患者给予相应处理。全部手术均采用同一手术方式,即采用髌骨旁内侧入路；膝关节内滑膜彻底清理；无水酒精浸泡关节腔3遍灭活残留滑膜细胞；根据术前畸形情况针对性松解相应软组织；采用常规方式截骨；应用的假体全部为后稳定型膝关节假体；术中减少软组织牵拉,避免术后皮肤坏死等并发症。术后积极预防下肢深静脉血栓、感染、失血、刀口愈合不良等并发症。合并有内科疾病的患者在围手术期请相应内科医师协助治疗。根据患者具体病情采用个体化措施促进康复锻炼。
结果：根据术后膝关节HSS评分、膝关节活动度(range of motion, ROM)、并发症发生数量评价临床疗效。所有病人均采用门诊复查随访形式,最短随访时间为3月,最长随访时间为36月,平均随访时间为10月。随访内容包括术后拍片、HSS评分、膝关节活动度及并发症发生情况。术后3个月时10例患者的14膝关节HSS评分平均为78分(范围,75-83分),比术前的30分(范围,19-37分)提高了48分。膝关节活动度从术前的70°(范围,60°-90°)增加到术后的110°(90°-120°)。随访期间置换膝关节拍片均显示假体位置良好。随访中其中1例出现刀口愈合延迟,恰当处理后治愈。1例患者出现轻度的膝关节不稳。其余患者未发现并发症。
结论：对于临床表现符合RA和OA双重标准的患者可根据术中所见及术后病理判定是否为RA合并OA患者。对于符合TKR手术标准的膝关节RA合并OA患者可行关节置换手术治疗,术前适当调整抗风湿药物、积极处理合并疾病、手术采用髌骨旁内侧入路、膝关节内滑膜彻底清理、无水酒精浸泡关节腔3遍灭活残留滑膜细胞、根据术前畸形情况针对性松解相应软组织、采用常规方式截骨、应用的后稳定型膝关节假体、术中减少软组织牵拉以及良好的围手术期处理的方法,可以取得比较满意的临床效果。
Objective To investigate the perioperative managements, surgical technique and clinical results of total knee replacement (TKR) in patients with knee rheumatoid arthritis and osteoarthritis.
Methods Between January 2006 and September 2009,14 TKRs were performed on 10 patients with rheumatoid arthritis combined with osteoarthritis by a single surgeon.The diagnosis are based on criteria presented by American College of Rheumatology (ACR) and Chinese Medical Association (CMA).The diagnosis of OA is made both clinically and radiographically.Three patients were male and seven patients were female.The average age at the time of operation was 58 years (range,55-64 years). Four cases are both knee involved and the TKRs are performed in one surgery.
All of them have knee replacement indications.The surgeries adopted medial parapatellar approach, synovial cleaning,inactivating synovium,standard osteotomy and appropriate soft tissue release with posterior stabilized implants.Intravenous antibiotic therapy went on 1 week after surgery, or suspend until the body temperature drops to normal levels one day.
Results All patients were followed up for for 3 to 36 months.The patients were evaluated according to HSS, and the complications were observed. After a mean follow-up of 10 months (range,3 months-36 months), the average HSS improved from 30 points(range,19-37 points) preoperatively to 78 points (range, 75-83 points) postoperatively. ROM (range of motion) improved from 70°(range,60°-90°) preoperatively to 110°(range,90°-120°) postoperatively. One knee incision had healing problem. One knee had lightly instability at follow-up, no other complications occurred.
Conclusions The techniques of medial parapatellar approach, synovial cleaning, inactivating synovium, standard osteotomy and appropriate soft tissue release, posterior stabilized implants, intravenous antibiotic therapy, management of complications can provides excellent results very successfully in patients with knee rheumatoid arthritis and osteoarthritis undergoing primary total knee replacement.
方法：对自2006年1月至2009年9月期间由同一主刀医师进行的10例14个膝关节TKR手术综合分析。通过术前查体、化验检查及影像资料判定这些膝关节同时符合膝类风湿关节炎和骨关节炎的临床诊断标准,且不能用同一疾病解释所有临床现象；通过术中所见及术后病理结果证实术前诊断。根据公认的全膝关节置换术的指征判定这些患者是否适合行TKR手术。这10例患者中男3例,女7例,平均年龄为58岁(范围55-64岁),其中双膝病变患者4例。对于双膝病变患者通过术前对身体条件的综合评估,并给予积极术前准备,均采用一期完成置换手术。对于术前长期应用抗风湿药物或合并其他疾病患者给予相应处理。全部手术均采用同一手术方式,即采用髌骨旁内侧入路；膝关节内滑膜彻底清理；无水酒精浸泡关节腔3遍灭活残留滑膜细胞；根据术前畸形情况针对性松解相应软组织；采用常规方式截骨；应用的假体全部为后稳定型膝关节假体；术中减少软组织牵拉,避免术后皮肤坏死等并发症。术后积极预防下肢深静脉血栓、感染、失血、刀口愈合不良等并发症。合并有内科疾病的患者在围手术期请相应内科医师协助治疗。根据患者具体病情采用个体化措施促进康复锻炼。
结果：根据术后膝关节HSS评分、膝关节活动度(range of motion, ROM)、并发症发生数量评价临床疗效。所有病人均采用门诊复查随访形式,最短随访时间为3月,最长随访时间为36月,平均随访时间为10月。随访内容包括术后拍片、HSS评分、膝关节活动度及并发症发生情况。术后3个月时10例患者的14膝关节HSS评分平均为78分(范围,75-83分),比术前的30分(范围,19-37分)提高了48分。膝关节活动度从术前的70°(范围,60°-90°)增加到术后的110°(90°-120°)。随访期间置换膝关节拍片均显示假体位置良好。随访中其中1例出现刀口愈合延迟,恰当处理后治愈。1例患者出现轻度的膝关节不稳。其余患者未发现并发症。
结论：对于临床表现符合RA和OA双重标准的患者可根据术中所见及术后病理判定是否为RA合并OA患者。对于符合TKR手术标准的膝关节RA合并OA患者可行关节置换手术治疗,术前适当调整抗风湿药物、积极处理合并疾病、手术采用髌骨旁内侧入路、膝关节内滑膜彻底清理、无水酒精浸泡关节腔3遍灭活残留滑膜细胞、根据术前畸形情况针对性松解相应软组织、采用常规方式截骨、应用的后稳定型膝关节假体、术中减少软组织牵拉以及良好的围手术期处理的方法,可以取得比较满意的临床效果。
Objective To investigate the perioperative managements, surgical technique and clinical results of total knee replacement (TKR) in patients with knee rheumatoid arthritis and osteoarthritis.
Methods Between January 2006 and September 2009,14 TKRs were performed on 10 patients with rheumatoid arthritis combined with osteoarthritis by a single surgeon.The diagnosis are based on criteria presented by American College of Rheumatology (ACR) and Chinese Medical Association (CMA).The diagnosis of OA is made both clinically and radiographically.Three patients were male and seven patients were female.The average age at the time of operation was 58 years (range,55-64 years). Four cases are both knee involved and the TKRs are performed in one surgery.
All of them have knee replacement indications.The surgeries adopted medial parapatellar approach, synovial cleaning,inactivating synovium,standard osteotomy and appropriate soft tissue release with posterior stabilized implants.Intravenous antibiotic therapy went on 1 week after surgery, or suspend until the body temperature drops to normal levels one day.
Results All patients were followed up for for 3 to 36 months.The patients were evaluated according to HSS, and the complications were observed. After a mean follow-up of 10 months (range,3 months-36 months), the average HSS improved from 30 points(range,19-37 points) preoperatively to 78 points (range, 75-83 points) postoperatively. ROM (range of motion) improved from 70°(range,60°-90°) preoperatively to 110°(range,90°-120°) postoperatively. One knee incision had healing problem. One knee had lightly instability at follow-up, no other complications occurred.
Conclusions The techniques of medial parapatellar approach, synovial cleaning, inactivating synovium, standard osteotomy and appropriate soft tissue release, posterior stabilized implants, intravenous antibiotic therapy, management of complications can provides excellent results very successfully in patients with knee rheumatoid arthritis and osteoarthritis undergoing primary total knee replacement.
引文
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