rspНаучно-практическая ревматологияRheumatology Science and Practice1995-44841995-4492IMA-PRESS, LLC10.14412/1995-4484-2019-597-603rsp-2784Research ArticleРЕВМООРТОПЕДИЯ И РЕАБИЛИТАЦИЯORTHOPEDIC RHEUMATOLOGY AND REHABILITATIONУспешное эндопротезирование тазобедренных суставов у пациентов с АНЦА-ассоциированными системными васкулитамиSuccessful total hip arthroplasty in patients with anca-associated systemic vasculitisБекетоваТ. В.BeketovaT. V.

Бекетова Татьяна Валентиновна.

115522, Москва, Каширское шоссе, 34А.

Tatiana Beketova.

34A, Kashirskoe Shosse, Moscow 115522.

tvbek@rambler.ruНарышкинЕ. А.NaryshkinE. A.

115522, Москва, Каширское шоссе, 34А.

34A, Kashirskoe Shosse, Moscow 115522.

АрсеньевЕ. В.ArsenyevE. V.

115522, Москва, Каширское шоссе, 34А.

34A, Kashirskoe Shosse, Moscow 115522.

МакаровМ. А.MakarovM. A.

115522, Москва, Каширское шоссе, 34А.

34A, Kashirskoe Shosse, Moscow 115522.

Научно-исследовательский институт ревматологии им. В.А. НасоновойРоссияV.A. Nasonova Research Institute of RheumatologyRussian Federation201915112019575597603Copyright © Бекетова Т.В., Нарышкин Е.А., Арсеньев Е.В., Макаров М.А., 20192019Бекетова Т.В., Нарышкин Е.А., Арсеньев Е.В., Макаров М.А.Beketova T.V., Naryshkin E.A., Arsenyev E.V., Makarov M.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://rsp.mediar-press.net/rsp/article/view/2784

В ретроспективное исследование вошли 8 пациентов с АНЦА-ассоциированными системными васкулитами (АНЦА-СВ) и поражением тазобедренных суставов (ТБС) с показаниями для выполнения тотального эндопротезирования (ЭП); всего было прооперировано 11 ТБС. Медиана  возраста пациентов к моменту первого ЭП составила 54 [31; 76] года. Продолжительность наблюдения после ЭП варьировала  от 0,5 до 12,5 года (медиана – 3 года). Гранулематоз  с полиангиитом Вегенера был диагностирован у 5 пациентов, микроскопический полиангиит – у двух, эозинофильный гранулематоз с полиангиитом Черджа–Стросс – в одном случае. В дебюте АНЦА-СВ медиана индекса активности ВVAS составляла 12 [6; 26] баллов, у 4 пациентов индекс прогноза  FFS насчитывал  1 балл (предполагаемая 5-летняя  летальность 21%). У 6 пациентов ремиссия АНЦА-СВ была индуцирована анти-В-клеточной терапией ритуксимабом (РТМ).  В общей сложности  выполнено  10 тотальных ЭП по поводу асептического некроза головки ТБС и еще одно ЭП в связи с переломом шейки бедренной  кости. На момент ЭП в 7 случаях наблюдалась полная ремиссия  АНЦА-СВ (BVAS=0), у одного пациента  – неполная ремиссия  (BVAS=3). Все компоненты эндопротезов были стабильны, без признаков остеолиза.  Во всех случаях в результате ЭП отмечен хороший эффект  с увеличением  функциональной активности ТБС и уменьшением болевого синдрома (по данным опросника Харриса в среднем с 54 баллов перед ЭП до 87 баллов через 6 мес после операции). Ни у одного из пациентов не отмечено рецидива АНЦА-СВ или развития  постоперационных осложнений (за исключением необходимости гемотрансфузии). Собственный опыт свидетельствует о потенциально высокой  эффективности и относительной безопасности тотального ЭП ТБС у больных АНЦА-СВ,  в том числе в случаях тяжелого течения заболевания с неблагоприятными факторами прогноза.  Для снижения риска послеоперационных осложнений (прежде всего тромбоэмболий, инфекций, поздней отсроченной нейтропении, индуцированной РТМ) тотальное ЭП следует проводить в период ремиссии  АНЦА-СВ в условиях контроля  коморбидных состояний и тесного сотрудничества ревматологов и хирургов-ортопедов. В последующие рекомендации по ведению пациентов с ревматическими  заболеваниями при плановом  тотальном ЭП ТБС следует включать пациентов с АНЦА-СВ. 

The retrospective study enrolled 8 patients with ANCA-associated  systemic vasculitis (AASV) and hip joint (HJ) injury with indications for total hip arthroplasty (HA); a total of 11 HJs were operated on. The patients’ median age at the time of the first HA was 54 [31; 76] years. The median duration of follow-up after HA was 3 [0.5 to 12.5] years. Wegener’s granulomatosis was diagnosed in 5 patients; microscopic polyangiitis in 2 patients, and eosinophilic granulomatosis polyangiitis (or Churg-Strauss  syndrome) in one case. At the onset of AASV, the median Birmingham Vasculitis Activity Score (BVAS) was 12 [6; 26]; four patients had a 5-year mortality rate of 21% (Five-Factor Score (FFS)  = 1). AASV remission was induced by anti-B cell therapy with rituximab (RTM) in 6 patients. A total of 10 total HAs were performed for aseptic necrosis of the femoral head and another HA was carried out for a femoral neck fracture. At the time of HA, complete remission (BVAS = 0) was observed in 7 cases of AASV; incomplete remission (BVAS = 3) was seen in one patient. All endoprosthesis  components  were stable; there were no signs of osteolysis. In all cases, HA was successful in increasing HJ functional activity and in reducing pain (the Harris hip score averaged 54 before HA and 87 at 6 months after surgery). None of the patients had AASV recurrence  or developed postoperative complications  (except for the need for blood transfusion).

The authors’ own experience suggests that total HA is a potentially highly effective and relatively safe treatment in patients with AASV, including those with severe AASV and unfavorable prognostic factors. To reduce the risk of postoperative complications  (primarily thromboembolism, infections, and RTM-induced late-onset  neutropenia), total HA should be performed in the period of AASV remission under the control of comorbid conditions  and in the close cooperation  of rheumatologists  and orthopedic  surgeons. The following recommendations for the management of patients with rheumatic diseases should include patients with AASV for elective total HA.

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The authors declare that there are no conflicts of interest present.