双侧髋、膝四关节置换治疗重度晚期炎性关节病的临床疗效

EFFECTIVENESS OF BILATERAL TOTAL HIP AND KNEE ARTHROPLASTY FOR SEVERE INFLAMMATORY ARTHROPATHIES

目的 探讨双侧髋、膝四关节置换在治疗重度晚期炎性关节病变中的应用及其临床疗效分析。方法回顾分析2008年9月-2015年9月,采用双侧髋、膝四关节置换并获完整随访的31例炎性关节病患者临床资料。男22例,女9例;发病年龄5~28岁,平均14岁;首次入院时年龄20~41岁,平均30岁。病因：类风湿性关节炎15例,强直性脊柱炎16例。完全卧床23例,扶双拐短距离行走6例,无需辅助短距离行走2例。下肢髋、膝四关节均融合11例,3个关节融合2例,2个关节融合6例,单髋关节融合1例,无关节融合11例。术前髋关节屈伸活动度为（17.82±28.18）°、膝关节屈伸活动度为（26.45±30.18）;髋关节功能Harris评分为（29.64±11.58）分、膝关节功能美国特种外科医院（HSS）评分为（27.07±11.04）分。观察术后患者髋、膝关节屈伸活动度,采用Harris评分以及美国特种外科医院（HSS）评分评价关节功能。按照病因以及术前关节是否融合进行分组比较。结果患者一期四关节置换1例,二期置换22例,三期置换7例,四期置换1例。总手术时间为325~776 min,手术总失血量为900~3 900 m L,围手术期总输血量为2 220~8 070 m L,总住院时间为21~65 d。31例患者随访时间12~94个月,平均51个月。末次随访时,髋、膝关节屈伸活动度以及Harris评分、HSS评分均较术前显著改善（P〈0.05）。患者主观满意度评定,十分满意16例,一般满意10例,不满意5例。术后2例（3膝）出现假体周围感染,3例（6膝）出现关节僵直,1例单膝关节不稳定,2例双下肢长度相差〉2 cm;1例单膝存在约10°屈曲畸形。末次随访时,强直性脊柱炎组与风湿性关节炎组比较髋、膝关节屈伸活动度及功能评分,差异均无统计学意义（P〉0.05）。末次随访时,各融合组患者髋、膝关节活动度均低于对应的未融合组,比较差异有统计学意义（P〈0.05）;Harris评分和HSS评分明显低于对应的未融合组,但差异无统计学意义（P〉0.05）。结论 双侧髋、膝四关节置换是一种矫正因炎性关节病引起的双下肢关节畸形、缓解疼痛、改善关节功能以及提高生活质量的有效治疗手段,术后膝关节晚期假体周围感染以及关节僵直是影响手术疗效的重要并发症。

ObjectiveTo evaluate the application and effectiveness of bilateral total hip arthroplasty and total knee arthroplasty in the treatment of severe inflammatory arthropathies. MethodsBetween September 2008 and September 2015, 31 patients with severe inflammatory arthropathies were treated with bilateral total hip arthroplasty and total knee arthroplasty. Of 31 cases, 22 were male and 9 were female with an average age of 30 years （range, 20 to 41 years）; there were 15 cases of rheumatoid arthritis and 16 cases of ankylosing spondylitis with an average onset age of 14 years （range, 5-28 years）; all 4 ankylosed joints were observed in 11 cases, 3 ankylosed joints in 2 cases, 2 ankylosed joints in 6 cases, 1 ankylosed joint in 1 case, and no ankylosed joint in 11 cases. Before operation, the hip range of motion （ROM） value was （17.82±28.18）°, and the knee ROM value score was （26.45±30.18）°; the hip Harris score was 29.64±11.58, and the hospital for special surgery （HSS） score was 27.07±11.04. The patients were grouped and compared in accordance with etiology and ankylosed joint. ResultsOne-stage arthroplasty was performed in 1 case, two-stage arthroplasty in 22 cases, three-stage arthroplasty in 7 cases, and four-stage arthroplasty in 1 case. The total operation time was 325-776 minutes; the total blood loss was 900-3 900 mL; the total transfusion volume was 2 220-8 070 mL; and the total hospitalization time was 21-65 days. The patients were followed up 12-94 months （mean, 51 months）. The hip and knee ROM values, Harris score and HSS score at last follow-up were significantly improved when compared with preoperative ones （P 〈 0.05）. The subjective satisfaction degree was good in 16 cases, moderate in 10 cases, and poor in 5 cases. Periprosthetic infection occurred in 2 cases （3 knees）, joint stiffness in 3 cases （6 knees）, joint instability in 1 case （1 knee）, leg length discrepancy of 〉 2 cm in 2 cases, and flexion deformity of 10° in 1 case （1 knee）. The hip and knee ROM values, Harris score and HSS score showed no significant difference between patients with ankylosing spondylitis and patients rheumatoid arthritis at last follow-up （P 〉 0.05）. The hip and knee ROM values of the patients with ankylosed joint were significantly lower than those of patients with no ankylosed joint （P 〈 0.05）; the Harris score and HSS score of the patients with ankylosed joint were lower than those of patients with no ankylosed joint, but no significant difference was found （P 〉 0.05）. ConclusionA combination of bilateral hip and knee arthroplasty is an efficient treatment for severe lower extremities deformity, arthralgia and poor quality of life caused by inflammatory arthropathies. However, the postoperative periprosthetic infection and stiffness of knee are important complications influencing the effectiveness of operation.