全膝关节置换术治疗血友病膝关节炎

摘要

目的:评价全膝关节置换术治疗血友病膝关节病变的疗效、手术特点、假体选择及凝血因子替代治疗的有效性和安全性.方法:2008年1月至2010年6月,采用全膝关节置换术治疗男性血友病性膝关节炎患者10例(12膝),年龄17～49岁,平均33.6岁,其中8例为甲型血友病,2例为乙型血友病.根据Arnold和Hilgartner影像学分级:7膝为Ⅳ级,5膝为Ⅴ级.Ⅷ因子替代治疗方案为手术当天补充至80％以上,术后3d内60％以上,术后3 d～2周40％以上.Ⅸ因子替代治疗方案为手术当天补充凝血酶原复合物制剂(PCC)使FⅨ活性水平＞40％,术后3d内FⅨ活性水平＞30％,术后3d～2周FⅨ因子活性水平＞20％.观察比较手术前后膝关节HSS评分及各单项评分(包括疼痛、功能、活动度、肌力、屈曲畸形及稳定性).结果:10例(12膝)均获随访,时间6～24个月,平均11个月.术前HSS( 44.9±12.5)分(29 ～62分)改善为术后(84.4±10.2)分(72～96分)；各单项评分包括疼痛、功能、活动度、肌力、屈曲畸形及稳定性均较术前明显提高.同时发现在疼痛方面由术前平均(8.5±4.1)分改善为术后(24.5±4.4)分,TKA缓解疼痛作用明显.结论:在严格围手术期凝血因子的替代治疗下,TKA已成为血友病性膝关节炎一种安全有效的治疗手段,可以有效减轻膝关节疼痛,改善膝关节功能.%Objective:To study the efficacy of total knee anhmplasty (TKA) for the treatment of hemophilic knee arthropathy ,and to explore the operative characteristics,the selection of prothesis.the effectiveness and safety of clotting factor replacement treatment. Methods:From January 2008 to June 2010,10 patients(12 knees)with hemophilic anhropathv underwent TKA. The average age was 33.6 years old (ranged, 17 to 49 years). There was 8 cases of type A hemophilia and 2 cases of type B hemophilia. According to Arnold and Hilgartner classification:7 knees were Ivdegree and 5 knees were V degree. The level of VM factor for replacement treatment was more than 80% on operation day,more than 60% within 3 days after operation, more than 40% from the third day to the second week after operation. Added prothrombin complex concentrate (PCC) to improve the level of IX factor, and the level of DC factor for replacement treatment was more than 40% on operation day, more than 30% within 3 days after operation,more than 20% from the third day to the second week after operation. Functional training was mainly based on continuous passive motion (CPM) device after surgery. Clinical assessment included hospital for special surgery knee score (HSS) and the individual scores (including pain, function, activity, muscle strength, flexion deformity and stability). Results: Ten patients (12 knees) were followed-up, and the average duration was 11 months (ranged, 6 to 24 months). The average preoperati ve HSS score was (44.9±12.5)( ranged, 29 to 62 scores), whereas the average postoperative HSS score was (84.4±10.2) (ranged,72 to 96 scores) (P<0.01). The preoperative individual score including pain,function,activity,muscle strength,flexion deformity and stability were significantly improved compared with pre-operation,the differences between them were statistically significant (P<0.01). TKA had the distinct role in relieving pain from preoperative (8.5±4.1) to postoperative (24.5 ±4.4). Conclusion: Under the strict perioperative coagulation factor replacement therapy, TKA is a safe and an effective treatment for hemophmc anhmpathy of knee joint, whicht can effectively relieve pain and improve joint function.