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.
引文
1、Worland RL, Johnson GV, A lemparte J, et al. Ten to fourteen year survival and functional analysis of the AGC total knee replacement system. Knee,2002,9 (2):133-137.
2、中华医学会风湿病学分会.类风湿关节炎诊治指南.现代实用医学,2004,16(3),184-188.
3、中华医学会骨科学分会.骨关节炎诊治指南(2007年版).中华关节外科杂志(电子版),2007,1(4),281-284.
4、曾庆馀等.症状性骨关节炎的临床和流行病学探讨.中华内科杂志,1995,34(2),88.
5、李志军,范晓云,陈琳洁,李茂胜.类风湿关节炎合并骨关节炎64例.实用医学杂志,2000,16(9):755-756
6、Stulber BN,Hupfer T. Indications and preoperative planning for total knee orthroplasty. In Petty W editor.Total joint replacement. Philadelphia:Saunders, 1991,3-18.
7、钱文伟,翁习生,林进,金今,赵庆,邱贵兴.一期双膝关节与单膝关节置换术围手术期并发症比较.中华骨科杂志,2008,28(4):298-301
8 Insall JN, Lachiewicz PF, Burstein AH. The posterior stabilized condylar prosthesis:a modification of the total condylar design. J Bone Joint Surg(Am), 1982,64:1317-1323.
9 吕厚山.人工膝关节置换术的进展和现状.中华外科杂志,2004,(42)1,30-32
10 Colizza WA,Insall JN,Scuderi GR,et al. The posterior stabilized total knee prosthesis:Assessment of polyethylene damage and osteolysis after a Ten-year-minimum follow-up.J Bone Joint Surg(Am),1995,77:1713-1720.
11 Brassard MF,Insall JN,Scuderi GR,et al.Does modularity affect clinical success?A comparison with a minimum 10-year followup.Clin Orthop, 2001,(388):26-32.
12 吕厚山,陈坚.关节炎外科学.北京:人民军医出版社,2002,223
13 Robertss on O,Dunbar M,Pehrss on T,et al. Patient satisfacti on after knee arthrop lasty:a report on 27372 knees operated on bet ween 1981 and 1995 in Sweden. Acta Orthop Scand,2000,71:262-267.
14 Shoji H,Yoshino S,Kajino A. Patellar replacement in bilateral total knee arthroplasty. A study of patients who had rheumat oid arthritis and no gross deformity of the patella. J Bone Joint Surg Am,1989,71:853-856.
15 HasegawaM,Ohashi T. Long-term clinical results and radiographic changes in the nonresurfaced patella after total knee arthroplasty:78 knees followed formean 12 years. Acta Orthop Scand,2002,73:539-545.
16 林剑浩,吕厚山.人工全膝关节置换术的假体选择[J].中华骨科杂志,1996,16(5):299-301.
17 高增鑫,翁习生,邱贵兴,费琦,高娜,汪学松.全膝置换术中髌骨置换的适应证探讨.中华外科杂志,2006,44(8):529-531.
18 Barrack RL, Bertot AJ, Wolfe MW, et al. Patellar resurfacing in total knee arthroplasty. A prospective, randomized, double-blind study with five to seven years of follow-up. J Bone Joint Surg Am,2001,83:1376-1381.
19 汤佩飞,顾向军.类风湿关节炎全膝关节置换术后的功能锻炼.现代康复,2001,14(5):136
20 杨静,沈彬,宁宁,等.晚期类风湿关节炎全膝关节置换术后的康复治疗.现代康复,2001,14(5):32-33.
1 Worland RL, Johnson GV, A lemparte J, et al. Ten to fourteen year survival and functional analysis of the AGC total knee replacement system. Knee,2002,9 (2):133-137.
2 Stulber BN,Hupfer T. Indications and preoperative planning for total knee orthroplasty. In Petty W editor. Total joint replacement.Philadelphia:Saunders,1991,3-18.
3 吕厚山,陈坚.关节炎外科学[C].北京:人民军医出版社,2002年.
4 Yagishita K,Muneta T,Shinomiya K.Quantitative evaluation of the effect of soft tissue release on soft tissue balance in total knee arthroplasty.J Bone Joint Surg (Br),2001,83:439.
5 Laskin RS.The Insall Award.Total knee replacement with posterior cruiate ligament retention in patients with a fixed varus deformity. Clin Orthop,1996, (331):29-34.
6 Ranawat CS,Rose HA,Rich DS.Toatl condylar knee arthroplasty for valgus and combined valgus-flexion deformity of the knee.Instr Course Lect,1984,33:412-416.
7 王海强,韩一生,朱庆生.全膝关节置换术中的软组织平衡.中华骨科杂志,2004,24(4):241-243.
8 Robertss on O,Dunbar M,Pehrss on T,et al. Patient satisfacti on after knee arthrop lasty:a report on 27372 knees operated on bet ween 1981 and 1995 in Sweden. Acta Orthop Scand,2000,71:262-267.
9 Shoji H,Yoshino S,Kajino A. Patellar replacement in bilateral total knee arthroplasty. A study of patients who had rheumat oid arthritis and no gross deformity of the patella. J Bone Joint Surg Am,1989,71:853-856.
10 HasegawaM,Ohashi T. Long-term clinical results and radiographic changes in the nonresurfaced patella after total knee arthroplasty:78 knees followed formean 12 years. Acta Orthop Scand,2002,73:539-545.
11 林剑浩,吕厚山.人工全膝关节置换术的假体选择[J].中华骨科杂志,1996,16(5):299-301.
12 高增鑫,翁习生,邱贵兴,费琦,高娜,汪学松.全膝置换术中髌骨置换的适应证探讨.中华外科杂志,2006,44(8):529-531.
13 Barrack RL, Bertot AJ, Wolfe MW, et al. Patellar resurfacing in total knee arthroplasty. A prospective, randomized, double-blind study with five to seven years of follow-up. J Bone Joint Surg Am,2001,83:1376-1381.
14 Harris A I, Poddar S, Gitelis S, et al. Arthroplasty w ith a composite of an allograf t and a
prosthesis for knees with severe deficiency of bone【J】. J Bone Joint Surg (Am),1995,77:373-386.
15 张洪美,赵铁军,孙钢,顾力军,陈卫衡,荆琳.初次全膝关节置换术中胫骨近端骨缺损植骨术.中国中医骨伤科杂志,2006,14(增刊):1-3.
16 吕厚山主译.膝关节外科学.北京:人民卫生出版社,2006.1860.
17 吕厚山,王东.全膝关节置换术中胫骨近端倾斜型骨缺损的重建.中华骨科杂志,2003,23(8):466-469.
18 沈奕,王伟力,李晓淼,张炜.应用组合式金属垫块修复胫骨近端AORI Ⅱ型骨缺损的全膝关节置换.中国矫形外科杂志,2009,17(101:728-730.
19 Price AJ,Webb J,Topf H,et al.Rapid recovery after oxford uni-compartmental arthroplasty through a short incision.J Arthroplasty,2001,16:970-976.
20 吴星火,杨述华.微创全膝关节置换术的研究进展.中华骨科杂志,2006,26(4):275-277.
21 Eric JH. Computer-assisted orthopaedic surgery a new paradigm Tech Orthop,2003,18:221-229.
22 裴福兴,李程.计算机导航全膝关节置换系统.中华骨科杂志,2006,26(10):699-702.
23 Haaker RG, Stockheim M, Kamp M, et al. Computer-assisted navi-gation increases precision of component placement in total knee arthroplasty. Clin Orthop Relat Res,2005, (433):152-159.
24 预防骨科大手术后深静脉血栓形成的专家建议—深静脉血栓形成预防座谈会纪要.中华骨科杂志,2005,25(10):636-640.
25 Bengtson S,Knutson K.The infected knee arthroplasty:a 62 year follow-up of 357 cases 【J】. Acta Orthop Scand,1991,62:301.
26 张治国,牛东生.人工全膝关节置换术后关节深部感染的处理及预防[J].中国矫形外科杂志,2007;15(10):755-757.
27 Block J E,Stubbs HA.Reducing the risk of deep wound infection in primary joint arthroplasty with antibiotic bone cement 【J】.Orthopedics,2005,28 (11):1334.
28 Wheatley RQShepherd D,Jackson Ⅱ,et al.Hypoxaemia and pain relief after upper abdominal surgery comparison of i.m. and patient-controlled analgesia.Br J Anaesth 1992; 69:558-61.
29 Russel GB,Graybeal JM.Hypoxemic episodes of patients in a postanesthesia care unit.Chest 1993:104:899-903.
30 赵宏,黄志峰,邱贵兴.全膝关节置换术后不同镇痛方法的效果比较[J].中国临床康复,2005;9(28):12-13.
31 南兴东,贾东林,李水清,张利萍,余家阔,李民.连续股神经阻滞用于全膝关节置换术后康复镇痛的临床观察.中国疼痛医学杂志,2007;13(6):338-341.
32 Pattison E,Protheroe K,Pringle RM,et al. Reduction in haemoglobinafter knee joint replacement surgery 【J】. Am Rheum Dis,1973,32:582-4.
33 王思群,夏军,魏亦兵,吴建国.全膝关节置换术围手术期疼痛综合控制的临床研究.中华关节外科杂志,2008;2(3):32-35.
34 Faris PM,Ritter MA,Keating EM,et al. Unwashed filtered shed blood collected after knee and hip arthroplasties:a source of autolo-gous red blood cells 【J】. J Bone Joint Surg 【Am】,1991,73-A:1169-78.
35 覃健,余存泰,徐中和,等.全髋关节及全膝关节置换术后隐性失血的临床影响[J].中华骨科杂志,2006,26(5):323-326.
36 McManus K T,Velchik M G,Alavi A,et al. Non-invasiveassessment of postoperative bleeding in TKR patients with Tc-99m RNCs 【J】.J Nuclear Med,1987,28:565-567.
37 关振鹏,吕厚山,寇伯龙,等.人工关节置换术后自体引流血回输的观察研究[J].中华外科杂志,1999,17(2):96-98.
38 刘琦,王韶进,戴国峰,等.双侧人工全膝关节同期置换术后自体引流血回输的临床价值[J].山东医药,2003;43(3):21-22.
39 Kreibich DN,VazM,Bourne Rb,et al.What is the best way of assessing outcome after total knee replacement?Clin Orthop & Relat Resea 1996;331:221-5.
40 毕霞,吴岳嵩,成鹏,等.CPM在全膝关节置换术后康复中的应用[J].中国康复医学杂志,2004,19(7):556-557.
41 Denis M, Moffet H, Caron F, et al.Effectivenes s of continuous passive motion and conventional physical therapy after total knee arthroplasty: a randomized clinical trial. Phys Ther 2006;86(2):174-185
42 Beaupre LA, Davies DM, Jones CA, et al.Exercise combined with continuous passive motion or slider board therapy compared with exercise only: a randomized controlled trial of patients following total knee arthroplasty. Phys Ther 2001;81(4):1029-1037
43 Delisa JA.Rehabilitation Medicine.Third edition.New York: Lippincott-Raven publishers 1998:1677-93.
44 陈爱武,宋刘来.全膝置换术后的系统康复.中国康复医学杂志,2007,22(4):362-363.
45 周谋望.人工全膝关节置换的术后康复.中国临床康复,2004,8(2):344-345.
46 周成亮,崔广发,姜勇,白玉和.全膝关节置换治疗重度膝关节畸形术后的个体化康复方案.中国组织工程研究与临床康复,2007,11(41):8368-8371.