全膝关节表面置换术后感染一期翻修适应证选择及治疗效果分析

发布时间：2018-05-14 08:24

本文选题：全膝关节表面置换术 + 感染　；参考：《郑州大学》2015年硕士论文

【摘要】：背景与目的:全膝关节置换术(total knee arthroplasty,TKA)对各种原因引起的终末膝关节疾病有着确切而显著的疗效,是解决这一终末疾病的终极手段及唯一手段。全膝关节表面置换术能够明显改善患者的膝关节活动功能,减轻膝关节疼痛,矫正膝关节的屈曲挛缩或内外翻畸形,极度提高生活质量。但这种手术方式有一些不易处理的并发症,其中关节假体周围感染是一个“灾难性”的并发症。给患者及家属带来了沉重的心理负担及极大的经济负担。给医务人员也带来了不必要的心理压力。假体周围感染的处理方式有很多,如何选择最适合病人的治疗方式成为关节外科界不断争论的话题。因担心手术再感染,一期翻修是很多关节外科医生不愿采用的手术方式。本文主要研究探讨全膝关节表面置换术后感染一期翻修术适应症选择及治疗效果。材料与方法:以回顾性研究选择我院从2002年5月至2012年5月10年间,收治人工全膝关节表面置换术后感染的患者,共19例,其中男性患者5例,女性患者14例,年龄平均在(67±7)岁.19例患者均有膝关节疼痛症状,活动受限,部分局部皮温增高,部分皮肤颜色异常,血沉(ESR)均大于30mm/h,C反应蛋白(CRP)均大于10mg/l。其中9例患者无糖尿病、中重度贫血低蛋白及肿瘤等高危感染因素存在,皮肤条件可,窦道形成少于2个,术前病原学检查5例患者为金黄色葡萄球菌感染,3例表皮葡萄球菌感染,1例为革兰氏阴性杆菌感染(全部为单一菌群,非混合感染),给予选择一期翻修手术。余10名患者选择二期翻修术。所有患者术中发现假体周围有炎性肉芽组织和肉眼可见的脓苔,术中取脓苔再次做细菌和真菌培养及药敏试验。9例一期翻修手术均彻底清创、取出假体,用双氧水,碘伏水侵泡及大量生理盐水脉压枪冲洗,同时更换器械及手套,加铺无菌巾,以含有万古霉素,妥布霉素,庆大霉素的骨水泥固定新假体.术后静脉输入敏感抗生素2周后,改为口服抗生素4-6周。10例二期翻修术也行彻底清创、取出假体,用双氧水,碘伏水侵泡及大量生理盐水脉压枪冲洗,同时更换器械及手套,加铺无菌巾,以含有万古霉素,妥布霉素,庆大霉素的骨水泥填充。术后定期复查血常规,血沉(ESR)和C反应蛋白(CRP),检查皮肤状况及关节功能情况。采用HSS膝关节评分标准评估临床治疗效果。结果:9例一期翻修治疗的患者,伤口均I期愈合,其中2例在术后5月左右时感染复发,再次给予手术,感染得以有效控制。10例二期翻修的患者旷置术后伤口一期愈合,3-9个月后行二期翻修,其中2例在翻修术后6月复发,再次手术好转。翻修术后随访平均23.8个月。2组研究对象在ESR及CRP的变化趋势上没有明显差别;HSS膝关节评分从术前平均33.6分,提高到最后随访时的平均81.2分。2种手术方式在统计学无明显差异(PO.05)。结论:(1)一期翻修术在TKA术后感染的治疗是可行的。(2)TKA术后感染选择一期翻修术的适应证:单一细菌感染,非真菌感染,有敏感抗生素治疗;骨组织及软组织条件良好;病人无高危感染因素存在;皮肤窦道形成少于2个。
[Abstract]:Background and purpose: total knee arthroplasty (TKA) has a definite and significant effect on various causes of terminal knee joint disease. It is the ultimate means and the only means to solve this end-end disease. Total knee replacement can significantly improve the function of the knee joint and reduce the pain of the knee. The correction of flexion contracture or valgus deformity of the knee joint greatly improves the quality of life. However, this operation has some unmanageable complications, in which the infection around the prosthesis is a "catastrophic" complication. It brings a heavy psychological burden and a great financial burden to the patients and their families. The necessary psychological pressure. There are many ways to deal with the infection around the prosthesis. How to choose the most suitable treatment for the patient is a constant topic in the joint surgery. For fear of reinfection, a revision is a way that many joint surgeons do not want to use. Materials and methods: a retrospective study was carried out in our hospital from May 2002 to May 2012, 10 years from May 2002 to May 2012. There were 19 cases of total knee replacement after total knee replacement, of which 5 were male and 14 in women. The average age of.19 in the age of (67 + 7) years old had knee joint pain. Symptoms, limited activity, partial skin temperature, partial skin color, ESR were greater than 30mm/h, C reactive protein (CRP) was greater than 10mg/l., 9 patients had no diabetes, moderate to severe anemia, low protein and tumor and other high risk factors of infection, skin conditions, less than 2 sinus formation, 5 patients with preoperative etiological examination as gold. Staphylococcus aureus infection, 3 cases of Staphylococcus epidermidis infection, 1 cases of gram-negative bacilli infection (all single bacteria, non mixed infection) were selected for one period revision operation. The remaining 10 patients chose two stage refurbishment. All the patients found the inflammatory buds and the naked eye moss around the prosthesis during the operation, and the purulent moss was taken again during the operation. .9 cases of bacterial and fungal culture and drug sensitivity test were completely debrided and taken out, taking out the prosthesis, using hydrogen peroxide, iodophor water invading and a large number of physiological saline pulse pressure guns, replacing instruments and gloves, adding sterile towels and fixing new prostheses containing vancomycin, tobramycin and gentamicin. After 2 weeks of antibiotics, 4-6 weeks of oral antibiotics were changed to complete debridement and complete debridement, and the prosthesis was thoroughly debrided. The prosthesis was removed with hydrogen peroxide, iodophor water invading and a large number of physiological saline pulse pressure guns, and the instruments and gloves were replaced, and the sterile towel was added to contain vancomycin, tufomycin and gentamicin. The blood routine was reviewed regularly after the operation. ESR and C reactive protein (CRP), examination of the skin condition and joint function. The effect of clinical treatment was evaluated by the HSS knee score standard. Results: 9 cases of first stage revision were treated with I period, of which 2 cases were relapsed around May, and the operation was given again. The infection was effectively controlled for the two phase revision of.10 cases. After 3-9 months of refurbishment, 2 cases relapsed after refurbishment, of which 2 cases relapsed after refurbishment, and reoperation was improved. There was no significant difference in the changes of ESR and CRP in group.2 for 23.8 months after refurbishment; the HSS knee score was 33.6 points before the operation, and increased to the average of 81.2 at the last follow-up. There was no significant difference in the.2 operation methods (PO.05). Conclusion: (1) the treatment of infection after the first stage revision after TKA was feasible. (2) the indications for the first stage of the infection after the TKA operation: single bacterial infection, non fungal infection, sensitive antibiotic treatment; good bone and soft tissue conditions; and patients without high risk factors. The formation of skin sinus was less than 2.

【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.4

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