膝关节类风湿关节炎伴重度屈曲畸形患者关节置换术后的中长期随访

Total knee arthroplasty for rheumatoid arthritis with severe knee flexion contracture: mid-long term follow-up study

目的分析膝关节类风湿关节炎(RA)伴重度屈曲畸形行全膝关节置换术(TKA)中长期随访结果,探讨其关键的手术技术和康复措施。方法 1998年1月至2005年12月,18例RA伴重度屈曲畸形患者32膝行TKA,平均年龄38.8岁。RA病程14.2年,畸形时间6.5年;术前畸形67.5°,活动度20.3°,合并内翻畸形3例,外翻11例;术前股四头肌肌力3级7例,4级11例;HSS评分21.1分。术前锻炼股四头肌肌力,术中软组织松解及增加截骨,术后伸直支具及伸膝锻炼。术后1、2、3、6、12个月及以后每年随访,评价关节活动度、生存率、HSS评分等。结果 16例患者获得随访,5～10年随访10例18膝,10年以上6例11膝。最后一次随访,膝关节屈曲畸形3.7°,活动度103.2°,HSS评分为81.4分,与术前相比差异有统计学意义(P<0.05)。2膝翻修,假体生存率93.1%。无感染及侧副韧带损伤。结论通过加强术前术后股四头肌功能训练,术中软组织松解及增加股骨远端截骨,膝关节RA伴重度屈曲畸形患者TKA术后中长期随访效果满意。

Objective To investigate the clinical outcomes of total knee arthroplasty （TKA） for severe knee flexion contracture of rheumatoid arthritis by a five-year follow-up, and explore the technique of TKA and rehabilitation after TKA. Methods From January 1998 to December 2005, 18 patients including 32 knees with rheumatoid arthritis with severe flexion contracture underwent primary bilateral TKA with soft tissue balancing. The average age was 38. 8 years （range, 35 -59 years）. The course of disease was 7 - 30 years （14. 2 years in average ）. The flexion contractnre had existed for 3 - 12 years （6. 5 years on average）. The preoperative flexion contracture angle was 67.5° in average （60° -85°）. The average motion range was 20. 3° （0° -35°）. The HSS score was （21.1 ± 13.9）. During the TKA procedure, based on the correct osteotomy, different methods of soft tissue balancing were used for different degrees of flexion contracture. The patients were followed up in 1, 2, 3, 6, 12 months after surgery and every year later on. The survival rate, range of motion and HSS score were evaluated during the follow-up. Results 10 patients including 18 knees were followed up from five to 10 years, and six patients including 11 knees were followed up for over 10 years after operation. The flexion deformity declined to 3.7° （0° - 10°）, ROM were up to 103.2° （90° - 120°） , and HSS scores was 81.4. There was statistical difference between preoperative results and the reults of the latest follow - up （ P 〈 0.05 ）. One patient was replaced insert because of unstability on two years postoperation, and one patient was revisied because of loosening of femoral prosthesis in 9.4 years after operation. There was no infection or damage of lateral ligaments.Conclusions The soft tissue balancing and osteotomy of the distal femur are crucial procedures for TKA on patients of severe knee flexion contracture with rheumatoid arthritis. The rehabilitation training before and after operation can effectively improve the range of motion and the joint function.