膝弥漫型色素绒毛结节性滑膜炎四种治疗比较

Comparison of four treatments for diffuse pigmented villonodular synovitis of the knee

摘要:

[目的]比较四种不同治疗方法治疗膝关节弥漫型色素绒毛结节性滑膜炎(pigmented villonodular synovitis, PVNS)的临床疗效。[方法]回顾性分析 2010 年 1 月—2019 年 12 月在本院治疗的 52 例膝关节弥漫型 PVNS 患者的临床资料，根据术前医患沟通结果，8 例采用关节镜滑膜切除(arthroscopic synovectomy, AS)，22 例采用关节镜滑膜切除辅助术后放疗(AS+postop- erative radiotherapy, ASRT)，5 例采用关节镜结合后路开放滑膜切除(AS+posterior open synovectomy, ASPO)，17 例采用关节镜结合后路开放滑膜切除和辅助术后放疗 (AS+posterior open synovectomy+ postoperative radiotherapy, APRT)。比较四组围手术期情况、随访和影像资料。[结果] AS 组与 ASRT 的手术时间、切口总长度、术后引流量、下地行走时间、住院时间均显著优于 ASPO 和 APRT 组(P＜0.05)。所有患者均获随访 25~118 个月，平均(59.8±20.2)个月。AS 组和 ASRT 组恢复完全负重活动早于 ASPO 组和 APRT 组(P＜0.05)。与术前相比，末次随访时四组患者 VAS 评分均显著降低(P＜0.05)，而 Ogilvie-Harris 评分显著增加(P＜0.05)。相应时间点，四组间 VAS 评分的差异无统计学意义(P＞0.05)。末次随访时 Ogilvie-Harris 评分由高至低依次为： ASRT 组＞APRT 组＞AS 组＞ASPO 组，差异有统计学意义(P＜0.05)。MRI 影像评估方面，与术前相比，末次随访时四组关节积液均显著减少 (P＜0.05)；PVNS 复发率，由高至低依次为 ASPO 组 3/5 (60.0%) ＞AS 组 3/8 (37.5%) ＞APRT 组 1/17 (5.9%) ＞ ASRT 组 1/22(4.6%)，差异有统计学意义(P＜0.05)。[结论] 对膝关节弥漫型 PVNS，位于关节内，建议行关节镜手术，侵袭至关节外者，建议行关节镜结合后路开放滑膜切除手术。两者通过术后辅助低剂量放疗，均可降低复发率。

Abstract:

[Objective] To compare the clinical efficacy of four different treatments for diffuse pigmented villonodular synovitis (PVNS) of the knee. [Methods] From January 2010 to December 2019, 52 patients with diffuse PVNS of the knee were retrospectively analyzed. Ac- cording to preoperative doctor-patient communication, 8 patients were treated with arthroscopic synovectomy (AS) , 22 patients underwent AS combined with radiotherapy (ASRT) , 5 patients underwent AS combined with posterior open synovectomy (ASPO) , while the remaining 17 patients were treated with AS combined with posterior open synovectomy and radiotherapy (APRT) . The perioperative, follow-up and im- aging data were compared among the four groups. [Results] The AS group and ASRT group proved significantly superior to the ASPO group and APRT group in terms of operation time, total incision length, postoperative drainage volume, postoperative walking time and hospital stay (P＜0.05) . All patients were followed up for 25~118 months, with an average of (59.8±20.2) months. The AS and ASRT groups returned to full weight-bearing activity significantly earlier than the ASPO and APRT groups (P＜0.05) . At last follow-up, the VAS scores significant- ly decreased (P＜0.05) , while the Ogilvie-Harris score significantly increased in all the 4 groups compared with those preoperatively (P＜ 0.05) . At the corresponding time points, there was no significant difference in VAS score among the four groups (P＞0.05) . At the last followup, the Ogilvie-Harris scores were ranked from high to low ASRT ＞ APRT ＞ AS ＞ ASPO, which was statistically significant (P＜0.05) . In term of MRI assessment, joint effusion was significantly reduced in all four groups at last follow-up compared with those preoperatively (P＜ 0.05) . The recurrence rate of PVNS was ranked up-down as follows: ASPO group 3/5 (60.0%) ＞ AS group 3/8 (37.5%) ＞ APRT group 1/17 (5.9%) ＞ ASRT group 1/22 (4.6%) , which was statistically significant (P＜0.05) . [Conclusion] For diffuse PVNS of the knee, arthroscopic surgery is recommended if it involves intraarticularly only, while arthroscopic combined with posterior open synovectomy is recommended if it involves intraarticularly and extraarticularly. Both of them can reduce the recurrence rate by combined with postoperative adjuvant lowdose radiotherapy.