腕部痛风性关节炎的临床分型与治疗体会

Clinical classification and treatment experience of wrist gouty arthritis

目的探讨腕部痛风性关节炎的临床特点、临床分型及相应治疗方法和疗效。方法回顾性分析2011年4月—2020年8月24例明确诊断为腕部痛风性关节炎并有完整随访资料的患者。男21例,女3例;首次发病年龄21~72岁,中位年龄50岁。单纯腕关节发病15例,合并其他关节(手、膝、踝、跖趾关节)受累9例;首发部位为腕关节者19例。排除1例有21年病史患者,其余23例患者发病至确诊时间为7 d~9年,中位时间2个月。依据腕部痛风性关节炎的临床表现、影像学表现、病损范围和术中腕关节镜表现由轻至重分为5型,24例患者中Ⅰ型13例,ⅡA型2例,ⅡB型3例,ⅢA型2例,Ⅳ型3例,Ⅴ型1例。Ⅰ、Ⅱ型患者首次发病至确诊时间为(12.7±40.1)个月,Ⅲ~Ⅴ型患者为(152.0±88.5)个月,差异有统计学意义(t=-4.355,P=0.001)。13例Ⅰ型患者采用保守治疗(包括饮食、运动和生活方式的干预治疗以及药物治疗),11例Ⅱ~Ⅴ型患者接受手术治疗(包括关节镜下滑膜、痛风结晶清理术1例,韧带修复术1例,病灶清理/人工骨植骨填充术5例,腕关节融合术3例,痛风石切除术1例)。治疗前后采用疼痛视觉模拟评分(VAS)评价腕关节疼痛改善情况;评估腕关节掌屈、背伸、桡偏、尺偏活动度。结果 13例保守治疗患者获随访,随访时间10个月~9年,平均2.2年。治疗前及末次随访时VAS评分分别为(6.8±0.7)分和(2.9±0.9)分,差异有统计学意义(t=12.309,P=0.000)。随访期间无1例出现腕骨与腕关节破坏;腕关节活动度基本达到正常,患者末次随访时腕关节掌屈、背伸、桡偏、尺偏活动度均较治疗前显著改善(P<0.05)。11例手术治疗患者获随访,随访时间5个月~9年,平均4.9年。所有患者肿胀、疼痛充分缓解,术前、术后1个月及末次随访时VAS评分分别为(7.3±0.8)、(2.7±0.6)、(2.5±0.6)分,术后较术前显著改善(P<0.05);术后1个月与末次随访间差异无统计学意义(P>0.05)。排除3例接受腕关节融合术患者,其余8例患者末次随访时腕关节掌屈、背伸、桡偏、尺偏活动度均较术前显著改善(P<0.05)。患者对手术结果主观满意度达100%。结论腕部痛风性关节炎容易漏诊而严重影响腕关节的稳定性和功能,早期诊断和治疗可有效遏制病情发展,晚期患者可依据病变分型予以相应手术治疗。

Objective To explore the clinical characteristics, clinical classification, and treatment of wrist gouty arthritis. Methods The clinical data of 24 patients with wrist gouty arthritis and complete follow-up between April 2011 and August 2020 were retrospectively analyzed. There were 21 males and 3 females;the first onset age was 21-72 years,with a median age of 50 years. There were 15 cases of simple wrist joint disease, and 9 cases of other joints(hand, knee,ankle, metatarsophalangeal joint) involvement;19 cases of wrist joint as the first site. Except for 1 patient with a medical history of 21 years, the time from onset to diagnosis in the remaining 23 patients was 7 days to 9 years, with a median time of 2 months. According to the clinical manifestations, imaging manifestations, lesion range, and intraoperative wrist arthroscopy manifestations of wrist gouty arthritis, they were classified into 5 types from mild to severe. Among the 24 patients, 13 were type Ⅰ, 2 were type ⅡA, 3 were type ⅡB, 2 were type ⅢA, 3 were type Ⅳ, and 1 was type Ⅴ. The time from first onset to diagnosis for type Ⅰ and type Ⅱ patients was(12.7±40.1) months, and for type Ⅲ-Ⅴ patients was(152.0±88.5) months, the difference was significant(t=-4.355, P=0.001). Thirteen patients with type Ⅰ received conservative treatment(including diet, exercise, lifestyle intervention, and medication), and 11 patients with type Ⅱ-Ⅴ received surgical treatment(including 1 case of arthroscopic synovial membrane and gout crystal clearing, 1 case of ligament repair, 5 cases of lesion debridement/artificial bone grafting and filling, 3 cases of wrist fusion, and 1 case of tophicectomy). Before and after treatment, the visual analogue scale(VAS) score was used to evaluate the improvement of wrist joint pain;and the range of motion of the wrist joint(including palmar flexion, dorsal extension, radial deviation,and ulnar deviation) was evaluated. Results Thirteen conservatively treated patients were followed up 10 months to9 years, with an average of 2.2 years. The VAS scores before treatment and at last follow-up were 6.8±0.7 and 2.9±0.9,respectively, and the difference was significant(t=12.309, P=0.000). During follow-up, there was no wrist bone and wrist joint damage;wrist joint range of motion basically reached normal. At last follow-up, the wrist joint palmar flexion, dorsal extension, radial deviation, and ulnar deviation significantly improved when compared with the values before treatment(P<0.05). Eleven surgically treated patients were followed up 5 months to 9 years, with an average of 4.9 years. The swelling and pain of all patients fully relieved, and the VAS scores were 7.3±0.8 before operation, 2.7±0.6 at 1 month after operation, and 2.5±0.6 at last follow-up, which significantly improved after operation(P<0.05);there was no significant difference between 1 month after operation and last follow-up(P>0.05). Excluded 3 patients who underwent wrist fusion,the other 8 patients had significantly improved wrist joint palmar flexion, dorsal extension, radial deviation, and ulnar deviation at last follow-up(P<0.05). The patient’s subjective satisfaction with the surgical results reached 100%.Conclusion A missed diagnosis or misdiagnosis of wrist gouty arthritis will greatly damage the wrist stability and functions. Early and proper interventions can effectively retard the progress of the disease. For the late-stage cases, a staged surgical protocol is recommended.