类风湿关节炎髋关节终末期受累髋臼内陷临床特征和相关因素分析

Protrusio acetabuli in rheumatoid arthritis patients with end-stage hip involvement:clinical characteristics and related factors

目的:评估合并终末期髋关节受累的类风湿关节炎(RA)患者髋臼内陷的发生率及其相关因素。方法:回顾性评估入院待行全髋关节置换术(THA)的RA患者,通过查询人工关节登记中心的电子数据库和线上问卷形式收集人口学参数、临床参数、实验室检查和影像学参数。通过术前骨盆正位X线片,依据Sotello-Garza和Charnley提出的标准,评估是否合并髋臼内陷。比较髋臼内陷组和非髋臼内陷组上述各参数的差异,并建立logistic回归模型,计算髋臼内陷相关因素风险比(OR)和95%置信区间(CI)。结果:共178例(204髋)纳入本研究,50髋(24.5%)符合髋臼内陷诊断标准,其中1级35髋(17.2%),2级15髋(7.4%)。髋臼内陷组发病年龄45.0(39.8,50.0)岁,手术年龄58.5(53.8,65.0)岁,显著高于非髋臼内陷组的发病年龄37.0(23.5,47.5)岁和手术年龄53.0(39.5,63.0)岁(P=0.003,0.005)。术前传统合成改善病情抗风湿药物(cs DMARDs)使用率为38.0%,生物型改善病情抗风湿药物(b DMARDs)+靶向合成改善病情抗风湿药物(ts DMARDs)的使用率为4.0%,显著低于非髋臼内陷组的57.1%和18.8%(P=0.019,0.011)。髋臼内陷组红细胞沉降率为43.0(27.0,77.0)mm/1h,血小板计数水平为289.0(223.0,378.8)×109/L,显著高于非髋臼内陷组红细胞沉降率33.0(15.5,54.5)mm/1h和血小板计数水平247.0(207.0,310.0)×109/L(P=0.003,0.011)。髋臼内陷组颈干角(NSA)为134.5°±8.6°,显著低于非髋臼内陷组的139.4°±9.3°(P=0.001)。髋臼内陷组外侧缘中心角(CEA)为59.8°±14.9°,显著高于非髋臼内陷组的46.6°±17.8°(P<0.001)。Logistic回归分析显示,与髋臼内陷相关的显著性因素包括NSA(OR=0.948,P=0.015)和CEA(OR=1.044,P<0.001)。结论:髋臼内陷是RA终末期髋关节受累病例的一种常见的影像学表现,并与疾病活动度和抗风湿药物的使用存在一定关联性。髋臼内陷的存在将不可避免地对后续THA手术重建造成诸多技术挑战,关节外科医师务必在术前完善相关应对措施。

Objective: To judge the incidence of protrusio acetabuli(PA) in rheumatoid arthritis(RA) patients with end-stage hip involvement and identify all possible related factors predisposing to PA. Methods: Inpatients with RA ready for THA were retrospectively evaluated. The demographics, clinical, laboratory and radiographic parameters were collected from electronic database of our hospital for arthroplasty registration and online questionnaire. The diagnosis of PA was established based on anteroposterior radiographs of the pelvis according to the criteria proposed by Sotello-Garza and Charnley. The intergroup differences were compared between PA group and non-PA group. A multivariate logistic regression model was used in assessment of related factors predisposing to PA in this special patient population and the odds ratio(ORs) and 95% confidence intervals were determined. Results: A total of 204 hips ready for THA were enrolled in this study. 50(24.5%) hips met the criteria for PA: grade 1 in 35(17.2%) hips, grade 2 in 15(7.4%) hips. The age at disease onset and THA were 45.0(39.8, 50.0) years and 58.5(53.8, 65.0) years in PA group and 37.0(23.5, 47.5) years and 53.0(39.5, 63.0) years in non-PA group(P=0.003,0.005). The percentage of use of conventional synthetic disease-modifying antirheumatic drugs and use of biological disease-modifying antirheumatic drugs plus targeted synthetic disease-modifying antirheumatic drugs were38.0% and 4.0% in PA group and 57.1% and 18.8% in non-PA group(P=0.019, 0.011). The erythrocyte sedimentation rate and platelet were 43.0(27.0, 77.0) mm/1h and 289.0(223.0,378.8) ×109/L in PA group and 33.0(15.5, 54.5) mm/h and 247.0(207.0,310.0)×109/L in non-PA group(P=0.003, 0.011). The neck shaft angle(NSA) and center-edge angle were 134.5°±8.6°and 59.8°±14.9°in PA group and 139.4°±9.3°and 46.6°±17.8° in non-PA group(all P<0.01). The multivariate logistic regression model revealed that significant parameters for PA were NSA(OR=0.948;P=0.015) and CEA(OR=1.044;P<0.001). Conclusions: PA is a common radiographic finding in RA patients with end-stage hip involvement and correlates with general disease activity and clinical use of antirheumatic drugs. The presence of PA may inevitably present technical challenges to THA, and surgeons should take special reconstruction techniques into considerations before surgery.