晚期色素沉着绒毛结节滑膜炎全膝置换是否放疗△

Total knee arthroplasty for knee advanced pigmented villonodular synovitis with or without radiotherapy

摘要:

[目的] 探讨全膝关节置换术 （total knee arthroplasty,TKA） 辅助关节外放疗治疗晚期色素沉着绒毛结节性滑膜炎 （Pigmented Villonodular Synovitis, PVNS）的临床效果。[方法]回顾性分析 2007 年 6 月—2019 年 6 月收治的 39 例晚期 PVNS 患者的临床资料。根据医患沟通结果，20 例行滑膜全切和 TKA，术后辅助关节外放疗 （放疗组），另外 19 例单纯行滑膜全切和 TKA（未放疗组）。比较两组围手术期、随访及影像资料。[结果]两组手术时间、切口总长度、术中失血量、术后 5 d 疼痛 VAS 评分、下地行走时间、住院时间的差异均无统计学意义（P＞0.05）。随访平均时间（36.0±2.2）个月，随时间推移，两组 VAS 评分显著减少（P＜0.05），HSS、KSS 功能评分和 KSS 临床评分、膝关节活动度显著增加（P＜0.05）。末次随访，放疗组的 VAS 评分 [(1.7±0.5) vs (2.6±0.6), P＜0.001]、HSS 评分 [(93.6±2.2) vs (87.1±2.1), P＜0.001]、KSS 功能评分 [(93.3±2.0) vs (87.3±1.9), P＜0.001]、KSS 临床评分 [(93.9±1.4) vs (87.7±1.8), P＜0.001]，以及膝伸屈 ROM [(144.4±6.1)° vs (136.9±3.8)°, P＜0.001] 均显著优于未放疗组。至末次随访，放疗组复发率显著低于未放疗组（0% vs 21.1%, P=0.047）。影像方面，术后两组髌上囊积液厚度及髌上滑膜厚度较术前均显著减少 （P＜0.05）。末次随访时，放疗组髌上囊积液厚度 [(1.4±0.5) mm vs (2.6±0.7) mm, P＜0.001] 及髌上囊滑膜厚度 [(0.9±0.2) mm vs (1.8±0.5) mm, P＜0.05] 均显著小于未放疗组。相应时间点，两组骨密度 T 值的差异无统计学意义（P＞0.05）。[结论]对于严重骨质破坏的膝关节 PVNS 患者行 TKA，术后辅助放疗，能有效预防复发，安全性好，近期临床效果较未辅助放疗好。

Abstract:

[Objective] To investigate the clinical outcomes of total synovectomy and total knee arthroplasty (TKA) with or without radio- therapy in the treatment of knee advanced pigmented villonodular synovitis (PVNS). [Methods] A retrospective study was done on 39 pa- tients who received treatment for knee advanced PVNS from June 2007 to June 2019. According to the doctor-patient communication, 20 pa- tients received total synovectomy and TKA, followed by postoperative extra-articular radiotherapy (the RT group), while the remaining 19 pa- tients received total synovectomy and TKA only (non-RT group). The perioperative, follow-up and imaging data of the two groups were com- pared. [Results] There were no significant differences in operation time, total incision length, intraoperative blood loss, pain VAS score 5 days after surgery, walking time and hospital stay between the two groups (P＞0.05). As time went during the follow- up period lasted for (36.0±2.2) months in a mean, the VAS scores significantly reduced (P＜0.05), whereas the HSS, KSS functional scores, KSS clinical scores and knee range of motion (ROM) significantly increased in both groups (P＜0.05). The last follow-up, the RT group proved significantly supe- rior to the non-RT group in terms of VAS [(1.7±0.5) vs (2.6±0.6), P＜0.001], HSS [(93.6±2.2) vs (87.1±2.1), P＜0.001], KSS functional score [(93.3±2.0) vs (87.3±1.9), P＜0.001], KSS clinical score [(93.9±1.4) vs (87.7±1.8), P＜0.001] and knee ROM [(144.4±6.1)° vs (136.9±3.8)°, P＜ 0.001]. By the latest follow-up, the RT group was significantly better than the non-RT group in recurrence rate (0% vs 21.1%, P＜0.047). Re- garding imaging, the thickness of suprapatellar effusion and suprapatellar synovial were significantly reduced in both groups after operation (P＜0.05). At the last follow-up, the RT group proved significantly superior to the non-RT group in terms of effusion thickness of suprapatel- lar bursae [(1.4±0.5) mm vs (2.6±0.7) mm, P＜0.001] and synovial thickness of suprapatellar bursae [(0.9±0.2) mm vs (1.8±0.5) mm, P＜ 0.001]. However, there was no significant difference in the T value of bone mineral density between the two groups at any time points accord- ingly (P＞0.05). [Conclusion] For knee advanced PVNS with severe bone destruction, total synovectomy and TKA with postoperative adju- vant radiotherapy does effectively prevent recurrence, with good safety, and achieve considerably better short-term clinical outcome over the counterpart without adjuvant radiotherapy.