ObjectiveTo evaluate the effectiveness of total hip arthroplasty (THA) with impacted autologous bone grafting and a cementless cup in the treatment of rheumatoid arthritis (RA) with protrusio acetabuli. MethodsBetween January 2001 and April 2009, 18 cases (20 hips) of RA with protrusio acetabuli were treated, including 6 males and 12 females with an average age of 46 years (range, 36-62 years). The disease duration was 3-10 years (mean, 6 years). Preoperative Harris score was 40.25±6.68. The protrusio acetabuli was (5.70±4.26) mm. According to Sotelo-Garza and Charnley classification criterion, there were 12 hips of type 1 (protrusio acetabuli 1-5 mm), 5 hips of type 2 (6-15 mm), and 3 hips of type 3 (>15 mm). All patients received THA with impacting bone graft and cementless prosthesis for recovery of acetabular center of rotation. ResultsThe average operation time was 74 minutes (range, 48-126 minutes); the average blood loss was 350 mL (range, 150-650 mL). Deep venous thrombosis of lower extremity and poor healing of incision occurred in 3 and 2 cases respectively. Other patients achieved primary healing of incisions. The mean time of follow-up was 108 months (range, 60-156 months). According to X-ray films, bone grafting fusion was observed within 6 months after operation. At last follow-up, the Harris score was 87.20±4.21, showing significant difference when compared with preoperative score (t=-27.68, P=0.00); the protrusio acetabuli was (-1.11±0.45) mm, showing significant difference when compared with preoperative value (t=5.66, P=0.00). No loosening of acetabular components was found. ConclusionFor RA patients with protrusio acetabuli, THA with impacted autologous bone grafting and a cementless cup has satisfactory medium term effectiveness.
Objective To evaluate the clinical effectiveness of the first metatarsophalangeal (MTP) joint arthroplasty versus arthrodesis for rheumatoid forefoot deformity. Methods The randomized controlled trials (RCTs) about the first MTP joint arthroplasty vs. arthrodesis for rheumatoid forefoot deformity published by February 2012 were searched in the databases such as CNKI, Ovid, MEDLINE, CBM, EMbase, WanFang Data, The Cochrane Library (Issue 1, 2012), and KJEBM. Two reviewers independently screened studies, extracted data, and evaluated the methodological quality according to the inclusion and exclusion criteria. Then meta-analysis was conducted using RevMan 5.1 software. Results A total of 4 RCTs were included. Among total 206 (269 feet) patients involved in, 98 (130 feet) were in the arthroplasty group, while the other 108 (139 feet) were in the arthrodesis group. The results of meta-analysis showed that the arthrodesis group was superior to the arthroplasty group in the footwear (MD=−0.88, 95%CI −1.55 to −0.22, P=0.01), and the alignment (MD=−5.04, 95%CI −8.94 to −1.14, Plt;0.000 01) with significant differences. But there were no significant differences between the two groups in patient satisfaction, metastatic lesions, pain, activity and weight-bearing of Hallux. Conclusion Based on the current studies, arthrodesis is superior to arthroplasty in treating rheumatoid forefoot deformity. For the quality restrictions and possible publication bias of the included studies, more double blind, high quality RCTs are required to further evaluate the effects.
Objective To get known about the disease burden and quality of life (QOL) of rheumatoid arthritis (RA) in China by conducting a systematic review. Methods The observational studies about the disease burden and QOL of RA in China were systematically searched in the following databases: CNKI, CBM, VIP, WanFang Data, MEDLINE/Pub Med, EMbase, and Science Citation Index. The retrieval time was from January 1st, 1990 to July 31st, 2010. According to the inclusion and exclusion criteria, the literature was screened, the data were extracted, and the methodological quality of the included studies was assessed. The morbidity of RA was pooled by adopting generic inverse variance model, the meta-analyses on 8 dimensions of SF-36 life quality score (LQS) was conducted by suing RevMan5.0 software, the weighted mean difference (WMD) was regarded as the indicator of intervention effect, and the impact of studies’ quality on the results was assessed by sensitivity analysis. Results A total of 20 studies with medium quality in general were included. The morbidity of RA was 14.7/100 000. The disability adjusted of life years (DALYs) per capita were 4.92. If excluding the cost resulted from DALY, the overall economic cost was RMB 1 250.45 yuan per capita per year; While considering DALY, the cost was RMB 15 717.91 yuan per capita per year. The average cost of outpatient medications was RMB 8 018±17 238 yuan per capita per year. The weighted morbidity was 0.42% (95%CI 0.39% to 0.45%), and it was higher in female than male (Plt;0.05). There was no secular trend and difference between southern and northern (Pgt;0.05), but there were statistical significances in the WMD of 8 dimensions of SF-36 LQS. Sensitivity analyses revealed that the weighted pooled results were stable. Conclusion The epidemiological and economic burden of rheumatoid arthritis are heavier in China, which needs to be concerned by both government and society.
Objective To evaluate the efficacy and safety of adalimumab for rheumatoid arthritis failing to respond to disease-modifying anti-rheumatic drugs (DMARDs). Methods The Cochrane Library, PubMed, EMbase, CBM, CNKI, VIP and Wanfang (from the date of their establishments to June 2010) were searched, and journals of relevant fields were retrieved to identify randomized controlled trials (RCTs). The data were analyzed by using RevMan 5.0 software. Results Four RCTs were included, all of which were from abroad and with good methodological quality. The baseline data of each trial were comparable. Meta-analyses showed that there was a significant difference between the adalimumab and the placebo in terms of ACR20, ACR50, ACR70, tender joint count, swollen joint count, patient assessment of pain, patient global assessment of disease activity, doctor global assessment of disease activity, and disability index of the HAQ. There was no difference between the adalimumab and the placebo in terms of serious adverse events, intractable adverse events and serious infection. Conclusion Adalimumab can treat rheumatoid arthritis failing to respond to DMARDs, but clinically the doctor should balance the benefit and the risk of the adalimumab.
Objective To evaluate the quality of diagnostic studies on detecting anti-cyclic citrullonated peptide antibody to diagnose rheumatoid arthritis. Methods We searched PubMed, EMbase, The Cochrane Library, and CBM to collect studies on using anti-cyclic citrullonated peptide antibody to diagnose rheumatoid arthritis. QUADAS items were used to evaluate the quality of included studies. Results A total of 195 studies were included. Sixty-nine were English studies and 126 were Chinese studies. All studies had good descriptions of the spectrum of patients and little potential for partial verification bias, differential verification bias, and incorporation bias. However, most studies were prone to disease progression bias, review bias, and clinical review bias. One study did not explain the intermediate test results, and another did not report part of the test results. The overall quality of English studies was better than that of Chinese studies. Conclusion The potential bias of the included studies mainly resulted from the absence of blinding when interpreting the test results. The reporting quality of the included studies was poor.
Objective To investigate the effectiveness, safety and cost-effectiveness of leflunomide for rheumatoid arthritis, and formulate an evidence-based treatment plan for a patient with rheumatoid arthritis. Methods We searched the ACP Journal Club, The Cochrane Library (Issue 2, 2007) and MEDLINE (1990 to 2007), and critically appraised the available evidence. Results The available Level A (high quality) evidence showed that the efficacy and adverse events of leflunomide were comparable to those of methotrexate. The total cost of treating patients with leflunomide was significantly higher when compared to methotrexate. The combination of leflunomide and methotrexate in patients with active rheumatoid arthritis unresponsive to methotrexate monotherapy was less costly and more effective than the strategy excluding leflunomide. Given the current evidence, together with our clinical experience and the patient’s preference, methotrexate was administered to the patient. There was an inadequate response after 6 months of treatment. And then, adding leflunomide to methotrexate attained a remarkable response 3 months later. The patient is still being followed up. Conclusion treatment with leflunomide and methotrexate in RA patients can improve the clinical outcomes. Long-term efficacy and toxicity remain to be established.
【Abstract】 Objective To explore the effectiveness of multiple joint arthroplasty in treating lower limb joint disease. Methods Between January 2000 and December 2007, 5 patients with lower limb joint disease (three or more joints were involved) were treated with total hip and knee arthroplasty. There were 3 males and 2 females, aged from 27 to 59 years (mean, 41.8 years). Two patients had ankylosing spondylitis and 3 had rheumatoid arthritis, whose hip and knee joints were involved. Four patients lost the ability of walking preoperatively, 1 patient could only walk with crutch. The Harris score was 24 ± 24 and the Hospital for Special Surgery (HSS) score was 28 ± 15. All patients underwent multiple joint arthroplasty simultaneously (2 cases) or multiple-stage (3 cases). Results Wounds healed by first intention in all patients. In 1 patient who had dislocation of the hip after operation, manipulative reduction and immobilization with skin traction were given for 3 weeks, and no dislocation occurred; in 2 patients who had early sign of anemia, blood transfusion was given. All patients were followed up 46-140 months with an average of 75 months. The patients could walk normally, and had no difficulty in upstairs and downstairs. The stability of the hip and knee was good, and no joint infection or loosening occurred. The Harris score was 88 ± 6 at last follow-up, showing significant difference when compared with the preoperative score (t=8.16, P=0.00); the HSS score was 86 ± 6, showing significant difference when compared with the preoperative score (t=13.96, P=0.00). Conclusion Multiple joint arthroplasty is an effective treatment method in patients with lower limb joint disease, which can significantly improve life quality of patients.
Objective To evaluate the surgical treatment and effectiveness of rheumatoid forefoot reconstruction with arthrodesis of the first metatarsophalangeal joint and arthroplasty of lesser metatarsal heads. Methods Between January 2007 and August 2009, 7 patients with rheumatoid forefoot were treated by reconstruction with arthrodesis of the first metatarsophalangeal joint and arthroplasty of lesser metatarsal heads. They were all females with an average age of 62 years (range, 56-71 years) and with an average disease duration of 16 years (range, 5-30 years). All patients manifested hallux valgus, hammer toe or mallet toe of 2-5 toes, 5 feet complicated by subluxation of the second metatarsophalangeal joint. The improved American Orthopaedic Foot amp; Ankle Society (AOFAS) score was 36.9 ± 6.4. The hallux valgus angle was (46 ± 5)°, and the intermetarsal angle was (12 ± 2)° by measuring the load bearing X-ray films preoperatively. Results All incisions healed by first intention after operation. The X-ray films showed bone fusion of the first metatarsophalangeal joint at 3-4 months after operation. Seven patients were followed up 2.9 years on average (range, 2-4 years), gait was improved and pain was rel ieved. The hallux valgus angle decreased to (17 ± 4)° and the intermetarsal angle was (11 ± 2)° at 3 months postoperatively, showing significant differences when compared with preoperative values (P lt; 0.05). The improved AOFAS score was 85.3 ± 5.1 at 2 years postoperatively, showing significant difference when compared with preoperative score (t=4.501, P=0.001). One patient had recurrent metatarsalgia at 4 years after operation. Conclusion Arthrodesis of the first metatarsophalangeal joint and arthroplasty of lesser metatarsal heads for rheumatoid forefoot reconstruction can correct hallux valgus, remodel the bearing surface of the forefoot, and rel ieve pain, so it can be considered as a procedure that provides improvement in the cl inical outcome.
Objective To analyse the results of posterior cruciate l igament-retained mobile-bearing total knee arthroplasty (TKA) in treatment of rheumatoid arthritis (RA) and to solve the problems often encountered during surgery. Methods From February 1999 to August 2005, the cl inical data from 73 patients with RA undergoing TKA were analysed retrospectively. In 73 patients, 38 patients were treated with posterior cruciate l igament-retained mobile-bearing prosthesis (group A), while 35 patients were treated with posterior stabil ized fixed-bearing prosthesis (group B). Another 70 patients with osteoarthritis (OA) treated with an posterior cruciate l igament-retained mobile-bearing prosthesis served as controls (group C). In group A, there were 8 males and 30 females with an average age of 56.5 years and an average diseasecourse of 16.8 years. In group B, there were 6 males and 29 females with an average age of 57.3 years and an average disease course of 17.1 years. In group C, there were 37 males and 33 females with an average age of 65.4 years and an average disease course of 10.8 years. There was no significant difference (P gt; 0.05) in general data between groups A and B, but there were significant differences (P lt; 0.05) when compared with group C. Results In groups A and B, 2 cases (5.3%) and 1 case (2.9%) had poor heal ing of incision, respectively; in group C, all cases had good heal ing of incision. There were significant differences in heal ing rate of incision between groups A, B and group C (P lt; 0.05). All patients were followed up 7.6 years on average (range, 3.5-10.5 years). Deep infection occurred in 1 case respectively in 3 groups, showing no significant difference (P gt; 0.05). Posterior instabil ity occurred in 1 case (2.6%) 5 years after operation in group A and 2 cases (2.9%) 9 years after operation in group C, and no posterior instabil ity occurred in group B; showing significant differences between groups A, C and group B (P lt; 0.05). There were significant differences (P lt; 0.05) in knee score, Feller patellar score, and anterior knee pain score between pre- and postoperative values among groups A, B, and C. There were significant differences (P lt; 0.05) in the function scores between pre- and post-operative values in 3 groups, between groups A, B and group C pre- and post-operatively. Conclusion Posterior cruciate l igament-retained mobile-bearing TKA can yield satisfactory cl inical results in treatment of RA at intermediate-term followup. This mobile-bearing prosthesis has a low prevalence of posterior instabil ity and a good outcome for anterior knee function without patellar resurfacing.
Objective To explore the technique of the soft tissue balancing in the total knee arthroplasty (TKA) for the patients of rheumatoid arthritis with flexion contracture. Methods From November 1997 to May 2006, 38 patients with rheumatoid arthritis with flexion contracture underwent primary bilateral TKA and balancing of the soft tissues, among whomthere were 8 males and 30 females, aged 48-71 years old (58.2 on average). The course of disease was 28 months-16 years (7.6 years on average). The preoperative flexion contracture was (38.2 ± 11.3)°. The average range of motion (ROM) and HSS score were (49.1 ± 17.8)° and 23.9 ± 16.9, respectively. According to the preoperative flexion-contracture degree of the knees, these patients were divided into 3 levels: 5 patients with ≤ 20°, 26 patients with 20-60° and 7 patients with ≥ 60°. During the TKA procedure, based on the correct osteotomy, different methods of soft tissue balancing were used for different degrees of flexion contracture. The TKA soft tissue treatment was summed up as the releasing of posterior structures and the balancing between medial collateral ligaments (MCL) and lateral collateral ligaments (LCL), etc. Results The flexion contractures in 38 cases were all improved after the operation, among which 33 patients had a complete correction and only 5 patients had a residual flexion contracture of 5-10°. Eight knees suffered from complications within 1 week after operation, among which 3 had subcutaneous superficial infection and 5 had deep vein thrombus (DVT). These patients obtained good heal ing after active treatment. All the 38 patients were followedup for 10 months to 8 years with the median time of 37 months. The postoperative flexion deformity declined to (2.4 ± 5.7)°, and the ROM and HSS scores were (96.3 ± 14.6)° and 81.7 ± 10.4, respectively. There was statistical difference (P lt; 0.05). According to the HSS score, 27 patients (71.05%)were rated as excellent, 6 good (15.79%) and 5 fair (13.16%), and the choiceness rate was 86.84%. Conclusion The balancing of the soft tissue is a major treatment for correction of the flexion contracture, which can avoid bone over-resection during the surgery of TKA. The proper balancing of the soft tissue can not only achieve an obvious correction of the flexion contracture but also effectively improve the range of motion and the functional recovery of the knee joint after TKA.