全膝关节置换治疗血友病关节炎围手术期处理及短期疗效评价

 目的 探讨血友病关节炎全膝置换围手术期管理、凝血因子调控及早期临床疗效。方法 回顾性分析2009年3月至2014年3月采用全膝关节置换治疗8例（10膝）血友病膝关节炎患者资料,均为男性患者,年龄31~47岁,平均（38.3±5.0）岁;术前活化部分凝血活酶时间为（63.9±4.0） s,凝血因子活性为2.6%±0.9%;膝关节均有屈曲畸形,伸膝-12.0°±5.9°,屈膝-88.0°±11.4°。其中3例（3膝）合并外翻畸形,外翻角平均-3.0°±5.4°;2例（4膝）合并内翻畸形,内翻角平均-4.5°±6.0°。8例患者中,甲型6例,乙型2例,分别补充冻干人凝血八因子和凝血酶原复合物后手术。骨缺损根据AORI分型方法,T1、T2型采用骨水泥充填,T3包容型采用同种异体骨打压植骨、螺钉支撑内固定修复,T3节段型通过自体骨结构性植骨,并加用胫骨延长杆修复。采用美国特种外科医院（hospital for special surgery, HSS）膝关节评分评价膝关节功能。结果 8例患者均获得随访,随访时间9~26个月,平均14.3个月。末次随访时伸膝0°,屈膝98.5°±6.7°;HSS评分由术前（42.3±10.9）分提高到术后（88.3±4.6）分;X线片示植骨存活,假体、螺钉均未见松动、断裂。结论 全膝关节置换治疗血友病关节炎短期疗效满意,术前的预输试验有助于确定凝血因子的补充剂量。

Perioperative management and short-term clinical evaluation in hemophilia arthritis patients following total knee arthroplasty: a retrospective study

Objective To investigate the perioperative management, coagulation factor regulation in total knee arthroplasty (TKA) for hemophilia arthritis and evaluate its short-term clinical efficacy. Methods A retrospective study was performed in hemophilia arthritis patients who had undergone TKA from March, 2009 to March, 2014. Patients with type A hemophilia received Lyophilized Human Factor Ⅷ, and type B hemophilia patients received Prothrombin Complex. Perioperative accurate dosage of coagulation factor was determined by preliminary test. AORI T1, T2 bone defects were filled with PMMA, and severe contained AORI T3 defects were fixed with impaction allograft and screws, and for non-contained AORI T3 bone defects, structural allografts and stem extension may be considered. Knee function was evaluated by HSS score, and imaging change was evaluated by anteroposterior and lateral radiographs of knee at latest follow-up. Results Eight patients (10 knees) were included with a mean age of 38.3±5.0 years, in which 6 were type A, and the other 2 were type B. Preoperative APTT was 63.9±4.0 s, and coagulation factor activity was 2.6%±0.9%. All the patients had flexion deformity with extension of -12.0°±5.9° and flexion of -88.0°±11.4°. Three patients (3 knees) had valgus deformity with -3.0°±5.4°, and 2 patients (4 knees) had varus deformity with -4.5°±6.0°. All the 8 patients were followed for a mean of 14.3 months. The range of motion was improved with 0°- 98.5°±6.7° at latest follow-up, and the postoperative HSS score was 88.3±4.6 compared with 42.3±10.9 preoperatively. Bone-grafting was survival, and no loosening of prosthesis or screws were detected from X-ray at latest follow-up. Conclusion The early Results of TKA in Hemophilia arthritis patients are satisfactory. Preoperative preliminary test was helpful to determine the accurate dosage of coagulation factor. A stable high level of coagulation factor was vital to control bone-cement bleeding and make prosthesis stable. Tibial bone defects involving<1/3 area and <1 cm in depth could be filled with PMMA, and impaction allograft and screws could be used to fix severe contained bone defects. For segmental bone defects, except of structural allograft, stem extension was recommended to reduce stress and increase stability.