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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2018, Vol. 12 ›› Issue (03) : 324 -331. doi: 10.3877/cma.j.issn.1674-134X.2018.03.005

所属专题： 文献；

临床论著

晚期类风湿关节炎患者的假体选择疗效对比
刘军1, 李旭升1, 甄平1, 高明喧1, 田琦1, 何晓乐2, 谢宏3, 苏琴3, 凌孝臣3, 周胜虎1,†()   
  1. 1. 730050　兰州，中国人民解放军兰州总医院全军骨科中心关节外科
    2. 710032　西安，空军军医大学西京医院老年病科
    3. 261500　高密，解放军94595部队医院
  • 收稿日期:2016-05-04 出版日期:2018-06-01
  • 通信作者: 周胜虎
  • 基金资助:
    国家自然科学基金(81371983); 全军后勤科研计划面上项目(CWH17J009); 甘肃省青年科技基金(1606RJYA300); 甘肃省卫生行业科研计划项目(GSWSKY2018-21); 甘肃省自然科学基金(1606RJZA208)

Comparison of prosthetic selection in patients with advanced rheumatoid arthritis

Jun Liu1, Xusheng Li1, Ping Zhen1, Mingxuan Gao1, Qi Tian1, Xiaole He2, Hong Xie3, Qin Su3, Xiaochen Ling3, Shenghu Zhou1,†()   

  1. 1. Department of Orthopaedics, General Hospital of Lanzhou Command, Lanzhou 730050, China
    2. Department of Gerontology, Xijing Hospital, Air Force Military Medical University, Xi’an 710032, China
    3. 94595 Troops Hospital of PLA, Gaomi 261500, China
  • Received:2016-05-04 Published:2018-06-01
  • Corresponding author: Shenghu Zhou
  • About author:
    Corresponding author: Zhou Shenghu, Email:
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引用本文：

刘军, 李旭升, 甄平, 高明喧, 田琦, 何晓乐, 谢宏, 苏琴, 凌孝臣, 周胜虎. 晚期类风湿关节炎患者的假体选择疗效对比[J]. 中华关节外科杂志(电子版), 2018, 12(03): 324-331.

Jun Liu, Xusheng Li, Ping Zhen, Mingxuan Gao, Qi Tian, Xiaole He, Hong Xie, Qin Su, Xiaochen Ling, Shenghu Zhou. Comparison of prosthetic selection in patients with advanced rheumatoid arthritis[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2018, 12(03): 324-331.

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。

关键词: 关节成形术, 关节炎，类风湿, 膝内翻, 骨质疏松
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 including 27 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.

Key words: Arthroplasty, Arthritis, rheumatoid, Genu varum, Osteoporosis
表1 膝关节表面置换术患者手术前后各指标比较[°，(±s)]
组别 例数(膝) 屈曲挛缩 关节活动度 股胫角
术前 末次随访 t值 P值 术前 末次随访 t值 P值 术前 末次随访 t值 P值
后稳定组 17 55.5±12.5 5.5±3.5 28.868 <0.01 32.5±6.5 105.5±10.5 94.83 <0.01 31.0±3.5 8.5±2.5 116.913 <0.01
限制型假体组 10 56.5±15.5 6.0±5.0 25.486 <0.01 32.0±8.0 100.0±5.5 141.335 <0.01 31.5±5.5 8.0±4.5 122.11 <0.01
t值 ? 1.732 1.054 ? ? 1.732 5.716 ? ? 1.299 1.039 ? ?
P值 ? >0.05 >0.05 ? ? >0.05 <0.01 ? ? >0.05 >0.05 ? ?
图1 典型病例1右下肢术前术后X线片。图A　术前右下肢全长X片(站立位)示右膝关节屈曲挛缩、严重内翻畸形；图B　术前双膝关节正位X片，示患膝关节内侧间隙消失，膝股骨远端关节面相对胫骨平台关节面向外侧水平移位；图C　术前右膝关节侧位X片，示膝股骨及胫骨平台磨损严重；图D　术后右膝关节正位X片，示假体固定在位，内翻畸形纠正；图E　术后右膝关节侧位X片，示假体延长杆填充良好，下肢力线矫正
图2 典型病例2双下肢术前术后X线片。图A　术前双下肢全长X片(站立位)，示双膝关节严重屈曲内翻畸形；图B　术前双膝关节正位X片，示双膝关节间隙消失，膝股骨远端关节面相对胫骨平台关节面向内侧水平移位；图C　术后双膝关节正位X片，示假体在位，挛缩畸形纠正；图D　术后右膝关节侧位X片，示延长杆填充良好，假体位置良好；图E　术后左膝关节侧位X片示假体匹配、位置良好
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