服用激素的类风湿关节炎患者人工全膝关节置换术

Total knee replacement in long-term steroid-treated patients with rheumatoid arthritis

目的探讨对长期服用糖皮质激素的类风湿关节炎患者行人工全膝关节置换术的围手术期激素补充疗法的效果。方法自1987年4月～1998年10月,对206例(297膝)类风湿关节炎患者行人工全膝关节置换术,其中63例(84膝)术前有1～23年(平均7年)的激素服用史,对其中的17例(26膝)停药2年以内或术前仍继续服用者,在围手术期行激素补充疗法。结果无1例患者术中及术后发生肾上腺皮质危象。无激素服用史患者感染率明显低于有激素服用史患者(P<0.05)。有激素服用史的患者,围手术期未补充激素的46例(58膝)全膝关节置换术后感染率6.9%与补充激素的17例(26膝)感染率7.7%比较,差异无显著性(P>0.05)。结论长期服用激素的患者在围手术期合理适量的补充激素可预防肾上腺皮质危象的发生,术后感染率也未增加。

Objective To evaluate the effects of perioperative steroid substitution therapy on postoperative complications for long-term steroid-treated patients with rheumatoid arthritis undergone total knee replacement. Methods From April 1987 to October 1998, total knee replacement were performed in 206 patients (297 knees) with rheumatoid arthritis. Of them, 63 patients (84 knees) received long-term steroid treatment ranging from 1 to 23 years (average, 7 years). According to steroid treatment, the patients were divided into three groups. Group A with no any steroid treatment were 143 cases (213 knees); Group B with steroid treatment but withdrawal more than 2 years were 46 cases(58 knees); and group C with steroid treatment but withdrawal within two years or still receiving steroid treatment were 17 cases(26 knees). All of the patients were given antibiotics intravenously three days before operation, and the patients in group C were also received steroid substitution therapy, however the patients in group A and B not. The protocol of steroid substitution therapy included 50 mg cortisol intravenously and original oral dosage one day before operation, 50 mg cortisol intravenously during operation, 50 mg cortisol intravenously immediately after operation, 50 mg cortisol intravenously and original oral dosage one day after operation. All operations of total knee replacement were performed by the same group of surgeon, and the prostheses were fixed with antibiotics cements. Results The perioperative vital signs of the patients were stable without adrenocotical crisis. There were three cases (3 knees) of infection in group A (1.4%), four cases (4 knees) in group B (6.9%), and two cases (2 knees) in group C (7.7%). There was significant difference statistically in postoperative infection rates between the patients with long-term steroid-treated and without steroid-treated. The infection rates between the group B and group C were not significant difference statistically. Of four infections in group B, there were acute infection in 2 cases and late infection in 2 cases. Of two infections in group C, they were all late infection. Each of late infection in group B and C underwent revision, the other infections healed with immobilization, dress change and antibiotics. Conclusion Low-dose steroid substitution for long-term steroid-treated patients with rheumatoid arthritis, who will undergo total knee replacement, can prevent adrenal insufficiency and do not increase postoperative infection rate significantly.