类风湿性关节炎下肢四负重关节置换术手术方案设计及中期疗效分析

Surgical planning and mid-term effectiveness of four major lower extremity arthroplasties in patients with rheumatoid arthritis

目的 探讨类风湿性关节炎(rheumatoid arthritis,RA)患者下肢四负重关节置换术(four major lower extremity arthroplasties,4JA)手术方案设计方法,总结中期疗效。方法 回顾分析2012年6月—2018年9月25例接受分期4JA并获随访3年以上的RA患者临床资料。男3例,女22例;年龄27~80岁,平均48.6岁。身体质量指数16.0~28.4 kg/m2,平均20.48 kg/m2。RA病程2~35年,中位数21年。合并膝外翻8例(12侧),髋臼内陷6例(12侧),髋关节强直5例(10侧)。其中20例均先行髋关节手术,5例先行膝关节手术。髋关节功能评价采用Harris评分、髋关节炎疗效评分(HOOS)、髋关节活动度、Trendelenburg征;膝关节功能评价采用美国特种外科医院(HSS)评分、膝关节活动度及肌力,末次随访时行计时-起立-行走(timed up and go,TUG)测试。X线片观察假体有无松动、移位。结果 25例患者均完成4JA。1例(1侧)术后切口感染、3例(3侧)术中股骨近端骨折,其余患者无并发症发生。患者均获随访,随访时间3.0~8.8年,平均5.8年。末次随访时,髋关节Harris评分、HOOS评分以及关节屈、伸、外展活动度均较术前改善,Trendelenburg征阳性患者减少;膝关节HSS评分以及关节屈、伸活动度均较术前改善;上述指标手术前后比较差异均有统计学意义(P<0.05)。膝关节肌力均为Ⅴ级。TUG试验为7.8~15.3 s,平均10.79 s。X线片复查示假体均未见松动、移位及下沉。结论 RA患者接受4JA时,术前充分评估、合理选择手术时机及手术顺序、术中最大程度恢复下肢力线,能获得较好中期疗效。

Objective To investigate the surgical planning and the mid-term effectiveness of four major lower extremity arthroplasties(4JA) in patients with rheumatoid arthritis(RA). Methods A clinical data of 25 patients with RA, who received 4JA and were followed up more than 3 years between June 2012 and September 2018, was retrospectively analyzed. There were 3 males and 22 females, with an average age of 48.6 years(range, 27-80 years). The body mass index ranged from 16.0 to 28.4 kg/m2, with an average of 20.48 kg/m2. The duration of RA ranged from 2 to 35years(median, 21 years). There were 8 cases(12 sides) of knee valgus, 6 cases(12 side) of acetabular retraction, and 5 cases(10 sides) of hip stiffness. Among them, 20 patients underwent hip surgery first, and 5 patients underwent knee surgery first. Hip joint function was evaluated by Harris score, Hip Disability and Osteoarthritis Outcome Score(HOOS), hip range of motion, and Trendelenburg sign;knee joint function was evaluated by American Hospital for Special Surgery(HSS) score, knee range of motion and muscle strength, and a timed up and go(TUG) test was performed at last followup. X-ray films were used to observe whether the prosthesis was loose or displaced. Results All 25 patients completed4JA. Only 1 patient(1 side) had incision infection after operation, 3 patients(3 sides) had proximal femur fractures during operation. All patients were followed up 3.0-8.8 years, with an average of 5.8 years. At last follow-up, the Harris score,HOOS score, and range of motion of flexion, extension, and abduction of the hip joint significantly improved when compared with those before operation, and the patients with positive Trendelenburg sign decreased. The HSS score and range of motion of flexion and extension of the knee joint also significantly improved when compared with those before operation. There were significant differences in all indexes between pre-and post-operation(P<0.05). The muscle strength was grade V. The TUG test ranged from 7.8 to 15.34 seconds(mean,10.79 seconds). X-ray films showed the prosthesis was not loose or displaced. Conclusion When RA patients receive 4JA, adequate preoperative evaluation,rational selection of the timing and sequence of surgery, and maximal restoration of lower limb alignment can achieve good mid-term effectiveness.