雙膝關(guān)節(jié)同期置換術(shù)的利弊分析

蘆浩 王智勇 張志強(qiáng)

（山西醫(yī)科大學(xué)第二臨床醫(yī)院骨關(guān)節(jié)科，太原030002）

雙膝關(guān)節(jié)同期置換術(shù)的利弊分析

蘆浩 王智勇 張志強(qiáng)*

（山西醫(yī)科大學(xué)第二臨床醫(yī)院骨關(guān)節(jié)科，太原030002）

雙側(cè)全膝關(guān)節(jié)同期置換（simultaneous bilateral total knee replacements，SBTKR）較單側(cè)全膝關(guān)節(jié)置換（unilateral totalknee replacement，UTKR）的比例在逐年增加。行初次UTKR的患者中約30%同時(shí)合并對(duì)側(cè)膝關(guān)節(jié)的劇烈疼痛[1]，而且初次UTKR患者中有10%會(huì)在1年內(nèi)行對(duì)側(cè)全膝關(guān)節(jié)置換[2]。雙膝關(guān)節(jié)置換可以分為同期或分期手術(shù)進(jìn)行，所謂同期是指在一次麻醉下行雙膝關(guān)節(jié)置換術(shù)。雙關(guān)節(jié)同期置換的主要標(biāo)準(zhǔn)取決于雙側(cè)關(guān)節(jié)癥狀的嚴(yán)重程度及患者的意愿。在美國，SBTKR較UTKR所占的比例越來越高，1990年到2004年的15年之間，1990年到1994年期間行SBTKR者占20.2%，1995年到1999年占28.7%，而2000年至2004年占51.1%。從1990年到2004年，雙膝關(guān)節(jié)同期置換的人數(shù)增加了一倍，而在女性人群中幾乎增加了兩倍[3]。隨著骨關(guān)節(jié)炎的發(fā)展，TKR的適應(yīng)證趨向?yàn)槟挲g更小、活動(dòng)量及體重更大的患者[4,5]。雙關(guān)節(jié)是否同期置換很大程度上取決于外科醫(yī)生，若其所在醫(yī)院每年關(guān)節(jié)置換量極大，選擇行SBTKR的可能性就大[6]。世界上就如何選擇雙膝同期置換并無統(tǒng)一意見，存在地區(qū)差異。在北美和亞洲，選擇SBTKR的患者人數(shù)最多。而在南美洲，同期雙側(cè)關(guān)節(jié)置換是罕見的。目前伴隨著手術(shù)技術(shù)的提高、假體設(shè)計(jì)及材料的改善和圍手術(shù)期管理的提高，決定SBTKR手術(shù)將顯著增加[7]。本文綜述的目的是對(duì)雙側(cè)關(guān)節(jié)同期置換的利弊進(jìn)行分析。

1 SBTKR的優(yōu)點(diǎn)

1.1 單次麻醉更安全

麻醉嚴(yán)重并發(fā)癥的發(fā)生率極低，但麻醉操作并發(fā)癥（包括全身麻醉中氣管插管、神經(jīng)區(qū)域阻滯和麻醉浸潤操作的并發(fā)癥）和麻醉藥物相關(guān)的潛在風(fēng)險(xiǎn)并不能完全避免。因此，從麻醉程序方面來說，避免二次麻醉，減少麻醉次數(shù)是有益的。在實(shí)施SBTKR時(shí)，無論是選擇全身麻醉、椎管內(nèi)麻醉還是腰硬聯(lián)合麻醉，其并發(fā)癥和死亡率組間無明顯差異性，但椎管內(nèi)麻醉可以顯著降低輸血率[8]。

1.2 手術(shù)時(shí)間縮短

手術(shù)時(shí)間取決于醫(yī)生的手術(shù)技術(shù)及SBTKR實(shí)施的類型。Liu等[9]報(bào)道，SBTKR較分期雙側(cè)全膝關(guān)節(jié)置換（bilateral totalknee replacements，BTKR）手術(shù)和止血帶時(shí)間平均縮短19m in和26m in。這意味著SBTKR降低了止血帶的相關(guān)潛在風(fēng)險(xiǎn)，諸如神經(jīng)麻痹、血管損傷、肌肉損傷、術(shù)后腫脹和僵硬等[9-11]。因止血帶時(shí)間降低，術(shù)中放氣時(shí)引起的心臟驟停、反應(yīng)性充血的發(fā)生率將顯著降低，降低了由于患肢缺氧所導(dǎo)致的早期感染和傷口延遲愈合以及減少術(shù)后的組織灌注等并發(fā)癥[12,13]。

1.3 鎮(zhèn)痛藥使用減少

有些學(xué)者認(rèn)為患者接受SBTKR較UTKR痛苦更大和對(duì)麻醉藥物的要求更高[14-16]。Powell等[15]觀察到在術(shù)后72 h SBTKR和UTKR組麻醉藥物的需求沒有多少差異。Shetty等[16]對(duì)50例SBTKR和50例UTKR的前瞻性研究發(fā)現(xiàn)，術(shù)后第1天VAS評(píng)分統(tǒng)計(jì)學(xué)具有差異，而2 d之后無明顯不同。

1.4 經(jīng)濟(jì)成本降低

研究證明，SBTKR具有明顯的經(jīng)濟(jì)成本優(yōu)勢(shì)[17,18]。研究認(rèn)為SBTKR患者住院時(shí)間平均為15 d，而UTKR平均為12 d，意味著雙膝分期手術(shù)住院時(shí)間為24 d[19]，雙膝關(guān)節(jié)同期置換總費(fèi)用高于單膝關(guān)節(jié)置換，但是低于分期手術(shù)的總和?？紤]到重復(fù)進(jìn)行實(shí)驗(yàn)室檢查及支付診療的費(fèi)用，以及需要支付二次手術(shù)、麻醉、麻醉后恢復(fù)、抗生素以及物理治療的費(fèi)用，SBTKR手術(shù)的經(jīng)濟(jì)效益成本更低[20,21]。一些學(xué)者表明，SBTKR較分期BTKR整體手術(shù)的費(fèi)用節(jié)省18%～58%[22]。

1.5 臨床療效和患者滿意度

多項(xiàng)關(guān)于BTKR患者的臨床療效研究報(bào)告認(rèn)為，SBTKR是非常成功的。關(guān)于術(shù)后活動(dòng)范圍、KSS評(píng)分[23]、7年生存率[24]、10年生存率[25]、SF-36[26]和SF-12[24]上，SBTKR患者較UTKR表現(xiàn)出相近或更好的效果。研究指出，SBTKR患者明顯改善了身體和社會(huì)功能，比接受UTKR的患者痛苦少，而軀體和心理上更

健康[26]。對(duì)2050例分期BTKR患者進(jìn)行生存分析[27]，152例間隔1年內(nèi)完成對(duì)側(cè)TKR，1796例患者在5年以上完成對(duì)側(cè)TKR，結(jié)果顯示分期UTKR患者較SBTKR患者KSS評(píng)分明顯降低。研究顯示SBTKR的患者95%表示若再次選擇，他們?nèi)詴?huì)堅(jiān)持雙膝關(guān)節(jié)同期置換，他們對(duì)臨床療效相當(dāng)滿意[24]。

2 SBTKR的缺點(diǎn)

2.1 術(shù)后并發(fā)癥的風(fēng)險(xiǎn)增加

TKR可能發(fā)生各種各樣的并發(fā)癥，但發(fā)生率總比率并不高。并發(fā)癥可以分為全身并發(fā)癥（如下肢深靜脈血栓形成）和手術(shù)操作局部并發(fā)癥。SBTKR與UTKR相比，術(shù)后并發(fā)癥發(fā)生率較高[28]。這種SBTKR并發(fā)癥高的原因可能與全身性炎癥和脂肪碎屑栓塞率高密切相關(guān)[29]。一項(xiàng)關(guān)于BTKR手術(shù)的33篇meta分析中[30]，其中2項(xiàng)研究中觀察到的UTKR組相對(duì)于無論是同期或分期BTKR組并發(fā)癥發(fā)生率高[27-31]，4項(xiàng)研究發(fā)現(xiàn)SBTKR組比UTKR組局部并發(fā)癥發(fā)生率較高[3,27,32,33]，并且2個(gè)研究認(rèn)為分期BTKR組較UTKR組中局部并發(fā)癥發(fā)生率較高[3,32]，1個(gè)研究觀察到分期BTKR組與SBTKR組相比，局部并發(fā)癥的發(fā)生率較高[34]。在全身并發(fā)癥方面，研究顯示SBTKR組較UTKR組全身并發(fā)癥的發(fā)生率更高[32-36]，而1項(xiàng)研究報(bào)告UTKR患者比分期BTKR患者全身并發(fā)癥發(fā)生率更高[31]，2個(gè)研究報(bào)道分期較SBTKR組全身性并發(fā)癥發(fā)生率高[3,34]，1項(xiàng)研究認(rèn)為SBTKR組比分期BTKR患者全身并發(fā)癥的發(fā)生率更高[37]，1項(xiàng)研究中觀察到同期或分期BTKR例均較UTKR患者全身并發(fā)癥發(fā)生率增加[38]。1項(xiàng)關(guān)于手術(shù)并發(fā)癥發(fā)生率的研究顯示，BTKR（12.2%）較UTKR（8.2%）和rTKR（8.7%）相比均較高[39]。

2.2 心臟并發(fā)癥的風(fēng)險(xiǎn)增加

幾項(xiàng)報(bào)道顯示SBTKR患者發(fā)生心臟并發(fā)癥的危險(xiǎn)性顯著增加，SBTKR患者的心肌缺血被認(rèn)為是UTKR患者的4～6倍[27,33-35]。SBTKR心血管并發(fā)癥的風(fēng)險(xiǎn)顯著增高，尤其是存在合并癥，如肺動(dòng)脈高壓、充血性心力衰竭、慢性肺疾病和腎病[36,37]。所謂高風(fēng)險(xiǎn)可能是因?yàn)榛颊呓K末期器官儲(chǔ)備減少，從而代償能力降低[3]。

2.3 包括血栓栓塞癥的肺部并發(fā)癥的風(fēng)險(xiǎn)增加

脂肪栓塞和肺栓塞在SBTKR比UTKR患者的發(fā)生率更高[45]。一些術(shù)者使用槽紋髓內(nèi)桿，緩慢插入技術(shù)，并鉆開股骨髓內(nèi)定位導(dǎo)桿的入口點(diǎn)，以減少脂肪栓塞和肺栓塞發(fā)生率[28,40,41]。然而，一些學(xué)者否認(rèn)這一理論，他們認(rèn)為血栓栓塞的風(fēng)險(xiǎn)與SBTKR手術(shù)操作時(shí)間、各組件的骨水泥硬化時(shí)間、雙下肢手術(shù)創(chuàng)傷及臥床時(shí)間延長等有關(guān)系[18,42]，所有這些都有助于Virchow三角關(guān)系的發(fā)生[43]。有學(xué)者提出了SBTKR肺栓塞（PE）的發(fā)生率較UTKR患者增加了50%[5]。同樣，其他作者報(bào)道的SBTKR組PE風(fēng)險(xiǎn)增高80%[44]。一些研究人員對(duì)SBTKR患者術(shù)中應(yīng)用血流動(dòng)力學(xué)監(jiān)測(cè)、腦電圖監(jiān)測(cè)、頸動(dòng)脈超聲成像顯示止血帶放氣時(shí)脂肪碎屑進(jìn)入動(dòng)脈循環(huán)引起栓塞[66]，觀察顯示脂肪栓塞患者術(shù)后第一天血氧飽和度值顯著降低[33]，遠(yuǎn)大于無脂肪栓塞的患者（P=0.017），然而其顯示SBTKR與UTKR發(fā)生率一致。盡管多數(shù)研究中警告SBTKR患者PE風(fēng)險(xiǎn)明顯增高，但有報(bào)道認(rèn)為SBTKR與UTKR患者無癥狀深靜脈血栓形成發(fā)生率類似，均約為41%[46]。

鑒于大部分研究都發(fā)現(xiàn)包括血栓栓塞肺部并發(fā)癥的風(fēng)險(xiǎn)較高，尤其對(duì)于那些懷疑肺動(dòng)脈高壓較重或右心功能不全，包括睡眠呼吸暫停和那些既往PE病史的，要考慮這些患者的風(fēng)險(xiǎn)較高。這可能因?yàn)橛倚牡膲毫υ黾?，尤其是SBTKR術(shù)后栓塞碎片致肺血管阻力額外增加引起靜脈回流阻力更高[47-49]。肺血管阻力（PVR）與全身血管阻力（SVR）之比在手術(shù)開始時(shí)及術(shù)后1天測(cè)量顯示增長了30%和20%[50]。

2.4 切口潛在感染率增高

文獻(xiàn)觀察SBTKR較UTKR手術(shù)感染率較高[33]，可能因?yàn)槭中g(shù)操作時(shí)間變長或手術(shù)室醫(yī)護(hù)人員數(shù)量增加或者雙膝操作中沒有更換手套和器械。關(guān)于SBTKR中雙膝一組和兩組無菌器械的研究顯示，術(shù)后1年深、淺傷口感染發(fā)生率相似[51]。然而一些學(xué)者認(rèn)為，SBTKR手術(shù)與UTKR比較術(shù)中感染的風(fēng)險(xiǎn)較低。回顧性隊(duì)列研究觀察到的SBTKR（0.3%）與UTKR（0.8%）相比，淺表感染風(fēng)險(xiǎn)顯著降低[27]。同樣，關(guān)于院內(nèi)并發(fā)癥的研究表明，UTKR院內(nèi)感染率為0.2%，較SBTKR的0.1%高[5]。原因可能在于方法選擇學(xué)上UTKR組合并癥較多，如糖尿病，其感染的危險(xiǎn)性增加[52]。此外研究發(fā)現(xiàn)，在術(shù)后6周、3個(gè)月、6個(gè)月、12個(gè)月同期較分期BTKR組院內(nèi)感染顯著減低[34]。

2.5 圍手術(shù)期死亡率增高

文獻(xiàn)回顧62730例BTKR，術(shù)后30 d分期BTKR死亡率為0.33%，相對(duì)于SBTKR死亡率0.99%，P＜0.05有統(tǒng)計(jì)學(xué)意義[34]。Parvizi等[54]回顧比較19861例UTKR和2679例SBTKR，30 d的死亡率分別為0.17%和0.49，P＜0.05有統(tǒng)計(jì)學(xué)意義。有作者報(bào)道，

分期BTKR 2385例90 d死亡率為0.3%，719例UTKR死亡率為0.7%[55]。關(guān)于死亡率，上述3項(xiàng)研究顯示各組間均存在顯著差異，因此認(rèn)為SBTKR圍手術(shù)期死亡率較高。有2項(xiàng)研究顯示與UTKR組相比，無論是分期還是同期BTKR死亡率均明顯增加[3,19]。而1項(xiàng)研究發(fā)現(xiàn)SBTKR組與UTKR和分期BTKR組相比，只有在年齡超過75歲時(shí)死亡率才升高[56]。

美國國家醫(yī)院分析顯示，BTKR的院內(nèi)死亡率（0.5%）較UTKR的患者死亡率（0.3%）明顯增高[5]。在美國1998年至2006年的所有TKR分析，其中UTKR死亡率為0.14%，而BTKR為0.30%（P＜0.0001）[57]。同一次住院分期BTKR發(fā)病率和死亡率均明顯上升。在一項(xiàng)前瞻性研究中，70例超過70歲的SBTKR患者與312例年輕的UTKR對(duì)比顯示，圍手術(shù)期均無死亡病例，其并不認(rèn)為年事已高是SBTKR的禁忌[55]。

2.6 輸血率增加

顯然，SBTKR較UTKR失血量大。研究顯示，兩組術(shù)前血紅蛋白濃度相近（14.1mg/dl），術(shù)后第1天SBTKR的血紅蛋白濃度為10.2mg/dl，UTKR的為11.0 mg/dl[58]。在住院期間SBTKR輸血4單位，而UTKR為2單位。其他的前瞻性研究也顯示SBTKR具有較高的輸血率。Peak等[59]報(bào)告TKR輸血率為34%，一次住院分期BTKR，其輸血率顯著增加[60]，BTKR術(shù)后貧血的發(fā)生率約為28.6%，而UTKR患者為15.3%[3]。據(jù)報(bào)道SBTKR術(shù)后異體輸血的風(fēng)險(xiǎn)增加約高達(dá)17倍[5]。

2.7 康復(fù)治療率增加

雙側(cè)膝關(guān)節(jié)病變的患者在首次單側(cè)關(guān)節(jié)置換之后，往往存在對(duì)側(cè)關(guān)節(jié)的疼痛，若對(duì)側(cè)關(guān)節(jié)已攣縮也影響其康復(fù)鍛煉。研究報(bào)道SBTKR組術(shù)后需要專項(xiàng)康復(fù)治療的患者為55%，較UTKR組33%比例更高[61]。Wykman和Olsson[62]步態(tài)研究顯示，患者雙側(cè)關(guān)節(jié)炎病變?cè)诘诙P(guān)節(jié)置換之前無法獲得最佳的功能性結(jié)果。Berend等[63]指出SBTKR可為臨床康復(fù)創(chuàng)造更好的條件，因?yàn)殡p膝關(guān)節(jié)同期置換后雙側(cè)疼痛逐漸減輕，因此康復(fù)鍛煉也就同步及更省時(shí)。因此，在最佳康復(fù)和患者滿意度方面，雙膝關(guān)節(jié)同期置換是可取的。為滿足生理和心理需求，分期UTKR需要占用更多的時(shí)間。

綜上，關(guān)于SBTKR的優(yōu)缺點(diǎn)分析，對(duì)于雙膝嚴(yán)重病變的患者，毫無疑問SBTKR是有利的，意味著在一個(gè)住院和康復(fù)周期內(nèi)經(jīng)濟(jì)費(fèi)用更低，誤工時(shí)間更短，同時(shí)術(shù)后康復(fù)鍛煉更有利。至于擔(dān)心SBTKR圍手術(shù)期的并發(fā)癥及死亡率，術(shù)前嚴(yán)格篩選SBTKR手術(shù)的患者是極其重要的。高齡被認(rèn)為是危險(xiǎn)因素，但最重要的是美國麻醉師協(xié)會(huì)（ASA）評(píng)分。我們建議ASA評(píng)分為Ⅰ至Ⅱ級(jí)的患者可行SBTKR，ASA評(píng)分為Ⅲ級(jí)以上的患者是否雙膝同時(shí)置換應(yīng)謹(jǐn)慎。

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2095-9958（2015）04-0 177-05

10.3969/j.issn.2095-9958.2015.02-018

*通信作者：張志強(qiáng)，E-mail：13393430930@163.com