晚期类风湿关节炎患者的假体选择疗效对比

Comparison of prosthetic selection in patients with advanced rheumatoid arthritis

目的探讨晚期膝关节类风湿关节炎(RA)伴重度内翻屈曲畸形和严重骨质疏松患者行全膝关节置换术(TKA)假体选择及临床效果。方法对2010年1月至2015年12月采用全膝关节置换治疗的晚期RA伴重度内翻屈曲畸形患者21例(27膝)进行回顾性分析。13例17膝采用后稳定型假体,8例10膝采用限制型假体。纳入标准:类风湿性关节炎合并膝关节重度内翻畸形;类风湿性关节炎合并膝关节患者骨密度T-Score<-2.8;无严重心肺疾病。排除标准:合并关节原发性或继发性活动期感染;合并关节外畸形通过单纯截骨无法矫正的患者。采用SPSS 16.0统计软件分析,术前、术后屈曲挛缩度数、关节活动度及胫骨角均值比较采用配对样本t检验。结果本组21例27膝均获得随访,病例随访时间2.0~5.3年,平均(3.8±1.1)年。后稳定组膝关节屈曲挛缩由术前(55.5±12.5)°(65.0°~85.0°)减少到末次随访时(5.5±3.5)°(0°~10.0°)(t=28.868,P<0.01),关节活动度由(32.5±6.5)°(0°~40.0°)提高到末次随访时(105.5±10.5)°(85.0°~130.0°)(t=94.83,P<0.01);股胫角由术前(31.0±3.5)°(23.0°~45.0°)修正为末次随访时(8.5±2.5)°(0°~12.0°)(t=116.913,P<0.01)。限制型假体组膝关节屈曲挛缩由术前(56.5±15.5)°(65.5°~80.0°)减少到末次随访时(6.0±5.0)°(5.0°~15.0°)(t=25.486,P<0.01),关节活动度由(32.0±8.0)°(0°~40.0°)提高到末次随访时(100.0±5.5)°(85.0°~120.0°)(t=141.335,P<0.01);股胫角由术前(31.5±5.5)°(22.0°~45.0°)修正为末次随访时(8.0±4.5)°(0°~12.0°)(t=122.11,P<0.01),均较术前明显改善,手术前后差异有统计学意义。两组之间术前及末次随访比较各指标得知,限制型假体组显著低于后稳定组关节活动度(t=5.716,P<0.01),差异具有统计学意义。结论对晚期RA伴膝关节重度内翻屈曲畸形和严重骨质疏松患者在假体选择方面,后稳定型假体活动度更好,但在纠正内翻屈曲畸形和股胫角疗效比较方面,未见显著差异,所有患者近期疗效满意。

Objective To investigate the clinical outcomes of total knee arthroplasty（ TKA） for severe knee flexion contracture of rheumatoid arthritis（ RA） and severe osteoporosis and explore the technique of TKA and rehabilitation after TKA. Methods From January 2010 to December 2015,21 patients including27 knees with rheumatoid arthritis and severe osteoporosis with severe flexion contracture underwent primary bilateral TKA with soft tissue balancing. Thirteen cases of 17 knees（ the posterior stabilized group） were treated with posterior stabilized prosthesis（ LPS prothesis）,and eight cases with 10 knees（ restrictive group）were treated with limited prosthesis. Inclusion criteria： rheumatoid arthritis with severe varus of knee joint;T-score 〈-2. 8 of the patients with rheumatoid arthritis with knee joint; no serious cardiopulmonary disease.Exclusive criteria： joint primary or secondary active infection; combined deformity of external joint can not be corrected by simple osteotomy. Statistical analysis was carried out with SPSS 16 software. The average values of preoperation,postoperatively flexion contracture degree,joint activity and tibial angle were compared by paired sample t test. Results The duration of follow-up was（ 3. 8 ± 1. 1） years on average. The preoperative knee flexion contracture decreased from（ 55. 5 ± 12. 5） °（ 65. 0°-85. 0°） to the last follow-up（ 5. 5 ± 3. 5） °（ 0°-10. 0°）（ t = 28. 868,P 〈 0. 01）,joint activity improved from（ 32. 5 ± 6. 5） °（ 0°-40. 0°） to the final follow-up（ 105. 5 ± 10. 5） °（ 85. 0°-130. 0°）（ t = 94. 83,P 〈 0. 01） in the posterior stabilized prosthesis group（ LPS prosthesis）; the tibial angle was corrected from preoperative（ 31. 0 ± 3. 5） °（ 23. 0°-45. 0°） to the last follow-up（ 8. 5 ± 2. 5） °（ 0°-12. 0°）（ t = 116. 913,P 〈 0. 01）. In the restrictive group,the preoperative knee flexion contracture decreased from（ 56. 5 ± 15. 5） °（ 65. 5°-80. 0°） to the last follow-up（ 5. 0 ± 5. 0） °（ 5. 0°-15. 0°）（ t = 25. 486,P 〈 0. 01）,joint activity improved from（ 32. 0 ± 8. 0） °（ 0°-40. 0°） to the final follow-up（ 100. 0 ± 5. 5） °（ 80. 0°-120. 0°）（ t = 141. 335,P 〈 0. 01） in the posterior stabilized group; the tibial angle was corrected from preoperative（ 31. 5 ± 5. 5） °（ 22. 0°-45. 0°） to the last follow-up（ 8. 0 ± 4. 5） °（ 0°-12. 0°）（ t = 122. 11,P 〈 0. 01）. All the differences were statistically significant. The indexes were compared between the two groups before and at the follow-up. The range of motion of restriction group was significantly lower than that of the posterior stabilization group（ t = 5. 716,P 〈 0. 01）,and the difference was statistically significant. Conclusion In the advanced RA patients with severe varus flexion deformity of knee joint and severe osteoporosis,the posterior stabilized prosthesis can provide much better activities,but shows no advantage in correction of varus flexion deformity and femor-tibial angle.