两种术式对类风湿性下尺桡关节紊乱的中远期疗效

Mid-and long-term results of two operative procedures for disorder of distal radioulnar joint of the rheumatoid wrist

目的:评价滑膜切除术中尺骨头切除(Darrach,简称D法)和尺骨头保留(Sauvé-Kapandji,简称S-K法)手术后,对腕关节疼痛和功能的改善及腕部畸形的抑制效果.方法:S-K法或D法滑膜切除术的类风湿性关节炎20例28腕.术后随访6.5～26.5年,平均8.2年.S-K法的下尺桡关节固定:8腕为松质骨螺钉,10腕为自体骨钉+生物可吸收钉.观察项目:腕关节疼痛、前臂的旋转功能、并发症;X线学检查包括:Steinbrocker病期分类和Larsen修正分类用以评价腕关节的破坏程度;腕高比值(CHR);尺侧移位指数(UTI);掌侧半脱位比值(VSR)和桡尺间距(RUD).结果:随访时28腕中的26腕关节疼痛消失.1腕在尺骨截骨近端部有轻微压痛.2例主诉疼痛,复查确认为滑膜炎复发.术后腕关节平均背伸增加,而掌屈减少.前臂的旋前和旋后功能得到明显改善.S-K法和D法术后的病期变化、CHR、UTI和VSR与非手术侧比较,腕骨无明显地塌陷和向掌或尺侧移动.S-K法比D法较好地保持了桡尺骨间的距离.自体骨钉+生物可吸收钉固定的下尺桡关节病例全部达到骨性融合.结论:(1)滑膜切除术可缓解疼痛,但不能阻止腕骨关节的破坏;(2)S-K法和D法都可以改善前臂的旋转功能.但S-K法保持了腕关节的稳定和原有的自然外形;(3)自体骨钉+生物可吸收钉可有效地固定下尺桡关节.

Objective:To evaluate the effect of Sauvé Kapandji(S K)and Darrach(D)procedures for disorders of the distal radioulnar joint(DRUJ),a common problem in the rheumatoid wrist.Method:Twenty eight wrists in 20 patients had dorsal wrist synovectomies with S K or D procedure were investigated in pain,range of motion.The average age of the patients at surgery was 52.1 years.The average follow up period was 8.2 years.Carpale collapse was measured as the carpal height ratio(CHR).Carpal translation was measured as the ulnar translation index(UTI)and volar subluxation rate(VSR).Instability of the excised region of the ulnar was measured as the radio ulnar distance(RUD).The wrist joint destruction grade according to both Steinbrocker and modified Larsen classification.Result:At the follow up,26 of all wrists were pain free,one presented a mild tenderness at the excised region of the ulnar in D procedure.Two patients complained pain after operation because recurrence of the synovitis.The average range of dorsiflexion of the wrist was increased,while volarflexion was decreased.The average rotation of the forearm was improved.From the points of the changes of the CHR,UTI,VSR.And staging,both S K and D procedure were not progressively collapsed and drifted than the none operative side.Union of the DRUJ was obtained uneventfully in all biodegradable materials fixa tioncases.Thinning of the wrist,which was often observed following Darrach procedure,was not observed after S K procedure.Conclusion:Although both the S K and D procedures are useful for the treatment of rheumatoid wrists,which perform sufficient synovectomy,alleviate pain at the DRUJ,and improve supination and pronation of the forearm,the S K procedure should be selected because of keeping the role of the ulnar head to the carpal stability,and natural appearance of wrist.The use of bone peg and biodegradable material is effective for fusion of the DRUJ of the rheumatoid wrist.