急性痛风性膝关节炎关节镜的诊治体会

目的:探讨关节镜诊断与治疗急性痛风性膝关节炎的应用价值。方法:2011年10月至2013年10月应用关节镜微创技术为16例(17个膝关节)急性膝关节痛风性关节炎患者行滑膜刨削切除、半月板及关节软骨表面尿酸盐结晶体刮除,关节冲洗,合并的半月板、关节软骨等关节内结构损伤一并处理。术后常规服用降血尿酸药物、早期功能锻炼。对比患者术前、术后膝关节Lysholm评分。结果:患者术后关节肿痛及功能受限等临床症状均明显缓解或消失,随访6~36个月,效果满意。膝关节Lysholm功能评分平均(90.2±3.2)分。结论:关节镜下关节清理及滑膜切除术是治疗痛风性关节炎见效快、创伤小、效果确切的新型微创治疗方法。膝关节镜技术对急性痛风性膝关节炎的诊断与治疗具有确实可靠的临床效果与应用价值。     

关节镜下行关节腔清理术治疗痛风性膝关节炎的临床研究

目的探讨痛风性膝关节炎在内科治疗后仍反复发作时,采用关节镜辅助下的关节腔清理术对这些患者的治疗效果和手术技巧。方法自2004年1月至2007年1月,对经内科治疗后仍反复发作的31例痛风性膝关节炎患者,行关节镜下的关节腔清理术等。术后坚持正规的降尿酸治疗,对术中难以彻底清除的尿酸盐结晶结合术后短期冲洗,对术前使用糖皮质激素患者比较术后的体温变化情况,比较患者术前和术后12个月的膝关节Lysholm评分。结果痛风性关节炎的关节镜表现为特异性的白色团块状物质沉积在滑膜、软骨和其他关节内结构的表面。术后31例切口甲级愈合,随访12—24个月中全部患者症状均较术前明显缓解,术前曾给予糖皮质激素的患者在术后容易出现体温明显升高,患者术前和术后12月的膝关节Lysholm评分存在显著性统计学差异（t=21．42,P〈0,01）。结论关节镜手术对痛风性膝关节炎具有较高的治疗价值,手术创伤小,术后康复快。术前曾给予糖皮质激素的患者在术后要加强管理。     

关节镜在膝痛风性关节炎诊治中的临床应用分析

[目的]通过对临床应用关节镜治疗膝痛风性关节炎的回顾性分析,评估关节镜技术在膝关节痛风性关节炎诊断和治疗中的临床应用效果。[方法]通过对自2001年8月～2010年7月施行的1 020例膝关节镜手术病人进行回顾性分析,评估其中26例诊断为膝痛风性关节炎患者的治疗过程及效果。结果 26例患者均行膝关节镜下灌洗、炎性滑膜清理,同时清理存在于关节软骨及半月板、韧带表面等部位的尿酸盐结晶,合并的半月板、关节软骨等关节内结构损伤一并处理,术后对确诊患者坚持内科药物治疗。[结果]所有患者术后关节肿痛及功能受限等临床症状均明显缓解或消失,切口甲级愈合,随访6～60个月,取得满意的临床效果。[结论]膝关节镜技术对膝痛风性关节炎的诊断及治疗具有确实可靠的临床效果和应用价值。     

关节镜在诊治急性痛风性关节炎中的价值

目的探讨关节镜诊断和治疗痛风性关节炎的价值。方法应用关节镜微创技术行滑膜组织多点取样病理检查；同时行滑膜刨削切除、关节软骨表面尿酸盐结晶体刮除。结果38例术前诊断急性痛风性关节炎18例（47．37％），漏诊20例（52．63％）。经关节镜下所见及多点滑膜病理检查和滑膜切除。30例得到随访，时间1～10年。采用Lysholm临床评分系统对关节功能进行评估，术后1年平均评分97．6分（95～100分）。结论关节镜微创技术对急性痛风性关节诊断和治疗有极其重要的价值。     

关节镜手术治疗膝关节痛风性关节炎

目的探讨关节镜手术对痛风性膝关节炎病变的手术效果。方法对18例膝关节痛风性关节炎患者关节镜下常规滑膜清理、结晶石清除手术治疗，术后坚持降尿酸治疗。结果术后18例症状均明显缓解，随访6—24个月，有2例出现短暂复发，近期和远期均取得满意疗效。结论关节镜手术对膝关节痛风性关节炎具有较高的诊断治疗价值，是一种创伤小、方法简单、效果好的治疗方法。     

关节镜对痛风性膝关节炎诊治临床分析

目的探讨关节镜对痛风性膝关节炎的诊治价值。方法对19例痛风性膝关节炎患者进行关节镜检查并取滑膜病理送检,同时行关节腔内尿酸盐结晶及痛风石清理,大量生理盐水关节冲洗。术后常规服用治疗痛风的药物及功能锻炼,观察手术疗效。结果 5例术前诊断不明确者术后确诊为痛风性膝关节炎,14例术前初步诊断为痛风性膝关节炎患者术中确诊。术后切口均甲级愈合。随访6~15个月,术后膝关节疼痛VAS平均得分明显低于术前;手术后膝关节功能Lysholm平均得分显著高于术前。手术前后比较,差异均有统计学意义(P<0.05)。结论关节镜对痛风性膝关节炎可作出明确诊断,可明显缓解疼痛及改善膝关节功能障碍,具有临床诊治价值。     

关节镜治疗痛风性膝关节炎合并巨大腘窝囊肿

[目的]探讨膝关节镜下治疗痛风性膝关节炎合并巨大腘窝囊肿的临床疗效。[方法] 15例痛风性膝关节炎合并巨大腘窝囊肿患者,镜下刨刀行关节腔清理,切除增生滑膜组织;刮除关节软骨面、半月板和交叉韧带表面附着的白色尿酸盐结晶,同时行镜下腘窝囊肿内引流联合囊壁切除术。术后配合服用内科药物等。[结果] 15例手术切口均一期愈合,无切口感染,无痛风性膝关节炎合并巨大腘窝囊肿复发。只有1例腘窝囊肿于术后5个月复发。随访10～30个月,平均(18.23±2.34)个月。膝关节Lysholm评分由术前(43.62±2.14)分提高到术后6个月的(90.54±3.27)分,差异有统计学意义(P<0.05)。[结论]关节镜下行关节清理合并腘窝囊肿切除术,可以有效阻止痛风性膝关节炎患者关节内结构进一步侵蚀破坏,具有微创、康复快、不易复发的优点。     

痛风性肩关节炎伴痛风石误诊一例并文献复习

痛风性关节炎是由于尿酸结晶沉积于关节腔或关节周围组织引起的炎症反应,累及肩关节少见。本文报告1例患者,男,49岁,主诉右肩疼痛9个月,加重伴活动受限2周。右肩外旋10°,背手达S5水平,MRI示右肩积液及关节内游离体。以右肩关节游离体、滑膜软骨瘤病可能收入院。关节镜探查见大量尿酸结晶沉积于滑膜、软骨及肩袖组织,行游离体取出及关节清理术。术后病理学检查提示滑膜炎性增生伴尿酸结晶沉积。通过文献回顾分析痛风性肩关节炎的临床特点、诊断及治疗方法。痛风性肩关节炎的临床表现主要为肩关节疼痛及活动受限。含钙盐沉积的痛风结石可以在X线和CT上显影;MRI可显示痛风结石,并能够评估关节内其他病变。痛风性肩关节炎临床表现不典型,影像学上无特异性征象,病理诊断是"金标准"。肩关节镜手术既能明确疾病诊断,又能完成治疗,是痛风性肩关节炎可靠的诊疗方法。     

痛风性膝关节炎的手术治疗现状

临床上痛风性膝关节炎并不少见,药物治疗是主要的治疗措施,但部分患者单纯内科治疗效果欠佳。对这类患者辅助进行外科治疗可以有效的缓解疼痛,改善关节功能,可以采用微创的关节镜手术方式减少痛风沉积,对于晚期痛风性关节炎患者全膝关节置换术是一种良好选择,精细手术操作和良好围手术期管理可以降低围手术期并发症几率。手术不能去除所有的痛风结晶,手术后需要继续坚持长期内科降尿酸治疗。     

关节镜术诊治急性期痛风性关节炎

目的：探讨关节镜在诊断和治疗急性发作期痛风性关节炎中的作用。方法：应用关节镜术行滑膜组织活检和滑膜刨削切除治疗急性发作期痛风性关节炎13例。结果：关节镜下表现为滑膜增生，白色絮状物和黄色小结节等，无特异性。7例检出尿酸盐结晶。患者术后症状明显减轻，血尿酸显著下降。12例经过平均4年5个月随访，未见复发。结论：关节镜手术诊断急性期痛风性关节炎有明显的优势且有治疗作用。     

痛风性膝关节炎的关节镜诊断和治疗

目的探讨关节镜对痛风性膝关节炎的诊断价值和近期疗效。方法对22例痛风性膝关节炎患者作膝关节镜检查观察其镜下表现,多点取病变组织做病理检查,将水肿增厚的滑膜和尿酸盐结晶尽可能清除,彻底冲洗。术后观察手术疗效,常规服用治疗痛风的药物。结果术前9例误诊为其他关节炎者术中确诊为痛风性关节炎,13例术前拟诊痛风性关节炎术中得到进一步的证实。22例均获随访,时间3～24个月,膝关节肿胀、疼痛明显减轻,功能改善明显,HHS评分由术前10～58（43±8.3）分到末次随访时提高到80～98（90±4.6）分,疗效评定：优9例,良13例。结论关节镜手术能较直观诊断痛风性关节炎,近期疗效满意。     

Ultrasonography for diagnosing atypical gout. Two case reports

Gout is characterized by the deposition of monosodium urate crystals on the surface of the articular cartilage, within periarticular tissues, and within bone and skin. The diagnosis rests on identification of the crystals in joint fluid or a tophus. However, joint aspiration is not always feasible, and the presentation may be atypical. We describe two cases of chronic gouty arthritis misdiagnosed as psoriatic arthritis. Ultrasonography of the bone and joints disclosed two patterns recently described as highly suggestive of gout, namely, the double-contour appearance of the cartilage and the snowstorm appearance of the synovial membrane. In addition, ultrasonography was useful for guided aspiration of joint fluid or other material containing monosodium urate crystals. Thus, ultrasonography may contribute to improve the diagnosis and treatment of gout.     

膝关节表面置换术治疗重度痛风性膝关节炎的疗效观察

目的探讨重度痛风性膝关节炎行人工全膝关节置换术的特点、疗效和围手术期的注意事项。 方法追踪2008年1月至2014年6月在中山大学附属第一医院关节外科行人工膝关节表面置换术治疗23例28膝经保守治疗不能缓解其疼痛且有明显的影像学改变的痛风性膝关节炎患者,置换后均获得2年以上的随访,记录术前、术后1周、3个月、12个月、24个月的美国膝关节协会评分(KSS评分)及膝关节X光片,各时间点的疗效指标的比较采用重复测量设计资料的方差分析。 结果所有患者置换术中及置换后无严重并发症。术后1周、3个月、12个月及术后24个月随访时疼痛的视觉模拟评分(F＝31.76,P<0.01),KSS评分(F＝106.54,107.85,P<0.01 )、膝关节活动度(F＝104.78,P<0.01)均较术前有明显改善,所有患者置换后X射线片均示假体位置良好,下肢力线满意,无透亮线及任何松动迹象。 结论通过围手术期全面规范处理、快速康复及系统的功能锻炼,人工全膝关节表面置换术治疗晚期痛风性膝关节炎近期疗效满意。     

肌肉骨骼超声技术对风湿性疾病的诊断价值

目的探讨肌肉骨骼超声技术在诊断风湿性疾病病情活动中的应用价值。方法选择2016年1月至2018年9月在我院接受治疗的112例风湿性疾病患者,采用肌肉骨骼超声技术对患者进行关节、骨骼、肌肉及软组织扫描,观察治疗前后滑膜厚度、关节积液、骨面缺损、滑膜血流变化、痛风石、双轨征等影像学表现并进行评分比较,评价肌肉骨骼超声技术对风湿性疾病的诊断价值。结果风湿性疾病患者中,有57例(50. 89%)发生类风湿关节炎,超声表现为关节滑膜增厚,关节积液深度增加,形成血管翳,发生骨侵蚀;有29例(25. 89%)发生痛风性关节炎,超声主要表现为痛风石、多点状强回声和双轨征;有26例(23. 21%)发生骨性关节炎,超声主要表现为关节软骨退化、关节滑膜增厚和关节积液。治疗后超声检查显示,除了骨表面缺损和软骨退化以外,其他主要超声观察指标明显改善(P0. 05)。结论肌肉骨骼超声技术能够全面、细致、动态地检测风湿性疾病的组织病变程度及发展情况,对风湿性疾病的影像学诊断和治疗具有很高的应用价值。     

Localization and expression of cartilage oligomeric matrix protein by human rheumatoid and osteoarthritic synovium and cartilage.

Synovium and cartilage from patients with osteoarthritis or rheumatoid arthritis were analyzed for expression of cartilage oligomeric matrix protein. Immunostaining of synovium with antiserum to cartilage oligomeric matrix protein demonstrated positive staining in both diseases. In osteoarthritis, there was positive staining within the synovial cells and immediately subjacent connective tissue, with less intense staining in the deeper connective tissue. In rheumatoid arthritis, there was less intense staining within the synovial cells and marked intense staining in the deeper connective tissue. In situ hybridization performed with an antisense digoxigenin-labeled riboprobe to human cartilage oligomeric matrix protein confirmed the presence of cartilage oligomeric matrix protein mRNA in the cells of the synovial lining in both types of synovium. Quantitative polymerase chain reaction with a cartilage oligomeric matrix protein MIMIC demonstrated increased cartilage oligomeric matrix protein mRNA in rheumatoid cartilage and synovium as compared with osteoarthritic cartilage and synovium, respectively; mRNA levels in rheumatoid synovium were similar to those from osteoarthritic chondrocytes. As a result of the high expression of cartilage oligomeric matrix protein from rheumatoid synovium, inflammatory synovium should be considered as a potential tissue source of cartilage oligomeric matrix protein in any investigation of biological markers of cartilage metabolism. The upregulated expression of cartilage oligomeric matrix protein in inflammatory tissues suggests its in vivo regulation by cytokines.     

A case of familial juvenile gouty nephropathy associated with a right renal tumor

We present a case of familial juvenile gouty nephropathy which was associated with a right renal tumor that was found incidentally. The patient was a 27-year-old woman who initially presented with acute gouty arthritis at the age of twenty years. Her mother and her sister had been attacked with acute gouty arthritis in their early twenties. Progressive deterioration in the renal function was noted in the three family members who had experienced gouty attack. Her mother was maintained on hemodialysis. As image diagnoses could not rule out malignancy in her right renal tumor, in situ non-ischemic enucleation of the right renal tumor using a microwave tissue coagulator(Microtaze) and a renal biopsy were performed. The pathological diagnosis of the renal tumor was tubulopapillary adenoma, and the renal biopsy showed minimal change in the glomeruli and tubules. The post-operative course was uneventful. The serum creatinine and creatinine clearance before and three months after the operation were 2.4 mg/dl and 2.6 mg/dl, 36.7 ml/min and 32.5 ml/min, respectively. The renal biopsy findings that glomerular and tubular changes were minimal and there was no tissue precipitation of uric acid or sodium urate, and the fact that her renal function decreased progressively despite the treatment of hyperuricemia suggested strongly that renal function might have deteriorated due to unknown factors other than hyperuricemia.     

Renal handling of urate and the incidence of gouty arthritis during cyclosporine and diuretic use.

The incidence of gouty arthritis and the role of renal urate handling and diuretic use were studied in 85 cadaveric kidney graft recipients with a graft functioning for at least two years. The incidence of gout was 24% in patients using cyclosporine (CsA, n = 55); no patient using azathioprine (Aza, n = 23) had gout. In patients using CsA, the fractional urate clearance decreased between 1 and 3 months after transplantation, thereafter remaining stable at a significantly lower level than in patients using Aza, pointing toward a specific effect of CsA on tubular urate handling. This impaired fractional urate clearance was not reversible up to 18 months in 7 patients after conversion from CsA to Aza, suggesting irreversible tubular damage. Multiregression analysis showed that the impaired fractional urate clearance and the use of furosemide were significant contributors to the occurrence of gout in patients using CsA.