膝关节结核病灶清除术及联合植骨融合外固定术的临床治疗效果观察

Observation of clinical efficacy on debridement and bone graft fusion combined with external fixation in the treatment of knee joint tuberculosis

目的探索膝关节结核病灶清除术及联合植骨融合外固定术的适应证及临床治疗效果。方法回顾性分析2005年10月至2014年10月在我院骨科接受膝关节结核病灶清除术的87例患者（简称“病清组”）与接受膝关节结核病灶清除联合植骨融合外固定术的56例患者（简称“融合组”）的病历资料。通过观察两组患者在术后并发症、术后复发率、术后关节功能改善（Lysholm评分：跛行0～5分，支撑0～5分，交锁0～15分，不稳定0～25分，疼痛0425分，肿胀O～10分，爬楼梯O～10分，下蹲0～5分）、及术后生活质量改善的情况（SN36生活量表），明确两种手术方式的适应证及临床治疗效果。结果病清组术后低蛋白血症发生率为2．3％（2／87），贫血发生率为8．0％（7／87）；融合组术后低蛋白血症发生率为12．5％（7／56），贫血发生率为19．6％（11／56）；融合组术后贫血及低蛋白血症发生率均高于病清组，差异有统计学意义（X2=4．40，P=0．036；X2=4．16，P=0．041）。病清组术后复发率为10．3％（9／87），融合组术后复发率为3．6％（2／56），两组复发率之间差异无统计学意义（y。一1．35，P=0．245）。病清组术前及末次随访时膝关节功能Lysholm评分分别为（43．9±7．3）分、（82．5±7．4）分，差异有统计学意义（￡一16．65，P=0．000），术后膝关节功能平均改善38．5分。末次随访时病清组与融合组的SF-36生活质量均较术前均有明显改善；且病清组末次随访时的SF-36生理健康综合测量评分（84．8±7．6）分及心理健康综合测量评分（89．7±5．4）分）均高于融合组的SF-36生理健康综合测量评分（70．1±5．2）分及心理健康综合测量评分（79．4±5．7）分），差异均有统计学意义（t=4．79，P=0．000；t=3．92，p=0．001）。结论膝关节结核病灶清除术适用于早期关节面无明显破坏的患者，术后关节功能及生活质量能获得明显改善；膝关节结核病灶清除联合植骨融合外固定术适用于晚期膝关节结核患者，患者术后生活质量可以得到改善，但膝关节融合降低了生活质量改善的程度。

Objective To evaluate the operative indications and clinical efficacy on debridement and arthrode- sis in the treatment of knee joint tuberculosis. Methods We analyzed retrospectively the clinical data from 87 cases with knee joint tuberculosis received debridement （as focus debridement group） and 56 cases with knee joint tuberculosis received debridement combined with bone graft fusion （as fusion group）. All patients were admitted in Beijing Chest Hospital, Capital Medical University during Oct. 2005 to Oct. 2014. According to observation of post- operative data including complications, relapsed rates, joint function improvements （Lysholm scores： lameness： 0- 5, surport walking： 0- 5, cross lock walking： 0- 15, unstable walking： 0- 25, pain： 0- 25, swelling： 0- 10, climb stairs： 0-10, and squatting： 0-5）, life quality improvement （SF 36）, the indications and clinical efficacy of two operative methods were determined. Results The incidence of hypoproteinemia and anemia were 2.3% （2/87） and 8.0% （7/87） in the focus debridement group, and 12.5% （7/56） and 19.6% （11/56） in the fusion group, re- spectively. The incidences of hypoproteinemia and anemia in the fusion group were higher than those in the focus de- bridement group with significant difference statistically （X2= 4.40, P= 0. 036;X2 -4.16, P= 0. 041 ）. The postopera- tive relapse rates were 10.3% （9/87） and 3.6% （2/56） in the focus debridement group and in the fusion group without significant difference statistically （X2= 1.35, P=0. 245）. Lysholm scores of joint function improvement were 43.9±7.3 and 82.5±7.4 before surgery and at the last follow-up with significant difference statistically in the fusion group before surgery and at the last follow-up （t= 16.65,P= 0. 000）. The average scores improvement was 38. 5 for postoperative joint function. The life quality improvements of SF-36 at the last follow-up in two groups were significant higher than those before operation in two groups. The scores of comprehensive measurement of physiological health and comprehensive measurement of mental health were 84.8± 7.6 and 89.7± 5.4 in the focus debridement group, and 70.1±5.2 and 79.4±5.7 in the fusion group at the last follow-up. The difference of scores of SF-36 involved in comprehensive measurement of physiological and mental health were significant statistically （t= 4.79,P=0. 000;t= 3.92,P=0. 001）. Conclusion The debridement of knee joint tuberculosis fits patients without apparent damage to the early joint surface and with joint function and life quality improved significantly. The bone graft fusion combined with external fixation of knee joint tuberculosis fits advanced patients with improvements of life quality, but only a little bit.