关节镜下诊治单关节发病的类风湿关节炎

Arthroscopic treatment for the rheumatoid arthritis with solitary joint involvement

目的探讨单关节发病的类风湿关节炎(rheumatoidarthritis,RA)的早期诊断及治疗。方法早期出现单膝关节肿胀、疼痛的患者5例,男1例,女4例;年龄23～47岁,平均36.8岁;左膝3例,右膝2例;自发病到手术时间为6个月～3年,平均16.2个月。检查患者的关节液、血液的同时进行影像学检查和关节镜下探查,并行关节镜下滑膜切除术。对术中所见滑膜形态进行记录、比较,切取滑膜组织做病理检查。手术前、后关节炎症指数、活动范围进行对比。结果关节镜下可见:滑膜呈暗紫色团簇状增生,绒毛呈杵状膨大,软骨面可见血管翳爬行,有坏死纤维素沉积。病理学诊断均符合RA。术后患者疼痛缓解率为100%,肿胀消失率为60%,活动范围平均增加19°。5例患者在随访过程中逐渐出现多关节发病,症状及体征均符合美国风湿病协会(ARA)诊断标准。由单膝症状到典型症状出现的时间为3～25个月,平均10.9个月。本组5例患者术后无一例出现并发症。结论关节镜下滑膜形态的特异性表现可早期诊断RA。关节镜下滑膜切除术对膝关节RA的治疗和控制病情发展是一种有效的方法。

Objective One of the characteristics of rheumatoid arthritis was multiple joints involved symmetrically. The purpose was to study the method of early diagnosis and treatment for the atypical rheumatoid arthritis involving solitary joint. Methods From April 1997 to December 2002, 5 cases which were 1 male and 4 female patients with an average age of 36.8 years (range, 23 to 47 years), suffered from the swelling and pain of knee joint, and were diagnosed as early rheumatoid arthritis. The interval of the onset to surgical treatment ranged from 2 months to 3 years with a mean of 16.2 months. The patients were evaluated with serum test, joint fluids examination and radiological imaging. They were treated by the synovectomy under the arthroscopy, while the appearances of the joint under arthroscopy were recorded, and the synovial tissue was sent to the pathological examination. The improvements of the joints symptoms and the range of motion were assessed at final follow up. Results During the operation, the light green and little muddy joint fluids were found in all patients. ESR of the patients ranged from 29 to 51 mm/1h with an average of 32.2 mm/1h, all of which were higher than normal value, whereas, 3 cases had positive rheumatoid factor and 4 cases showed significant higher β2-MG. The radiographic findings were osteoporosis in 3 cases, soft tissue swelling in 4 cases and narrowed joint space in 1 case. The synovium were proliferated and enlarged in dark violet, there were creeping pannus and necrosis fibrin deposition in the cartilage. All of the patients were diagnosed as rheumatoid arthritis confirmed by pathological changes of the synovium. The patients were followed up from 4 months to 5 years (mean, 18.7 months). Pain released in 5 cases, swelling reduced in 3 cases, the range of motion improved by 19 degrees. Unfortunately, all of the patients developed later into typical rheumatoid arthritis after the mean interval of 10.9 months (range, 3 to 25 months), the symptoms were consistent with the criteria of American Rheumatoid Association . Conclusion Solitary joint with rheumatoid arthritis is rare and may be the early status of rheumatoid arthritis. The specific appearance under the arthroscopy prompt the early diagnosis of the knee rheumatoid arthritis, and synovectomy by arthroscopy may be benificial to release the symptoms of rheumatoid arthritis.