手腕部痛风石手术治疗的临床效果

Clinical outcomes of surgical treatment of gout tophi in the hand and wrist

目的观察和评价手腕部痛风石手术治疗的临床疗效。方法回顾性分析2000年8月—2005年3月收治的手腕部痛风石患者29例,病程时间为5～17年,平均[(11.0±5.7)年,x^-±s,下同]。4例为单发非腕部病变,18例为多发非腕部病变,7例为多部位累及腕部病变;其中合并腕管综合征4例,合并感染、皮肤破溃3例。血尿酸浓度增高23例,正常6例。手术采用生理盐水反复冲洗、痛风石病灶清除、刮除植骨及关节融合等方法。术后服用丙磺舒、别嘌呤醇药物治疗。结果手术部位共93处,平均(3.0±1.1)处/例。术后切口Ⅰ期愈合21例,延期愈合5例。术后随访时间为12～42个月,平均(15.0±6.3)个月。术后3个月无高尿酸血症者19例,另外10例平均血尿酸水平较术前下降51%;局部软组织及骨质破坏进程中断,疼痛消除21例,缓解8例;手功能改善23例,腕管综合征症状消失3例,缓解1例;6例指间关节融合者,1年后全部骨性融合。随访1年内痛风石复发,手术部位1例1处,非手术部位2例4处,无复发者26例88处(占89.8%)。术前年均发作次数平均为(5.1±1.5)次,术后平均为(0.6±0.8)次,较术前明显减少。结论手术治疗可及时阻断局部痛风的病理进程,减轻机体总尿酸负荷,改善手部外观,减少痛风急性发作次数,有利于提高患者的生活质量和改善手功能。

Objective To observe and evaluate the clinical outcome of surgical treatment of tophoseous gout in the hand and wrist. Methods Twenty-nine cases of tophoseous gout in the hand and wrist treated during August 2000 and March 2005 were analyzed retrospectively. The course of the disease ranged from 5 to 17 years, with an average of 11.0 ± 5.7 years. Four cases had single joint involvement without affecting the wrist. Eighteen cases had multiple lesions without wrist involvement. Seven cases of multiple lesions involved the wrist, among which there were 4 cases of concomitant carpal ttmnel syndrome and 3 cases of concomitant infection and skin ulcer. Based upon severity and sites of their lesions, varied surgical management was performed including irrigating repeatedly with normal saline, debridement of gout lesions, tophus resection, autologous bone graft and arthrodesis, tendons repair or graft, and carpal tunnel release. Results Ninety-three lesions with 3.0 ± 1.1 sites involved per case were treated. Primary wound healing achieved in 21 cases while 5 cases had delayed healing. All cases were followed-up for 12 to 42 months with an average of 15.0±6.3 months. Three months after the operation, hyperuricemia disappeared in 19 cases and the serum level of uric acid decreased by 51% on average as compared to pre-operative level in the remaining 10 cases. Disruption of local soft and bone tissues was stopped. Pain was completely gone in 21 cases and alleviated in 8 cases. Hand function improved in 23 cases. Symptoms of carpal tunnel syndrome disappeared in 3 cases and alleviated in one case. Bone union was observed in 6 cases with 9 fingers of PIP and DIP joint arthrodesis one year postoperatively. The number of recurrent tophi at the surgical sites was one in one case （accounting for 3.4%）, at the non-surgical sites was 4 in two cases （accounting for 6.8% ）. Twenty-six cases of 88 sites （accounting for 89.8% ） had no recurrence. The incidence of acute recurrent attack was two to eight with an average of 5.10 ± 1.49 annually before the operation and decreased obviously after the operation with an average of 0.55 ± 0.83 within one year. The paired signed rank sum test manifests that the difference between pre-operative incidence and postoperative incidence was significant（ z = -4.75 P = 0.00）. Conclusions Surgical management for patients with gout tophi can block its pathogenic process timely and effectively, reduce systematic uric acid load, amend hand appearance, decrease incidence of acute attack, and improve quality of life and hand function.