清创保留假体联合抗生素治疗膝关节置换术后急性感染

doi:10.3877/cma.j.issn.1674-134X.2022.04.019

目的

探讨采用清创保留假体联合抗生素(DAIR)治疗人工膝关节置换术后急性期感染的临床疗效。

方法

回顾性分析解放军联勤保障部队第九四〇医院关节外科自2008年12月1日至2018年11月30日收治的，根据美国肌肉与感染协会(MSIS)诊断标准确诊为急性人工关节感染(PJI)的26例膝关节置换术后急性感染患者的临床资料。所有患者均采用一期彻底清创，更换膝关节聚乙烯衬垫，术后膝关节腔持续冲洗引流及足疗程敏感抗生素治疗。用t检验比较患膝术前、术后的膝关节疼痛视觉模拟评分(VAS评分)，美国特种外科医院膝关节评分(HSS评分)，入院及末次随访红细胞沉降率(ESR)、C反应蛋白(CRP)、白细胞介素-6(IL-6)。

结果

纳入26例患者，失访3例，随访时间平均(44±28)个月。其中治愈17例，感染控制率73.9%。术后的膝关节VAS评分较术前降低(t＝24.815，P<0.05)，术后的HSS评分较术前升高(t＝41.966，P<0.05)。末次随访ESR(t＝14.140)、CRP(t＝3.503)、IL-6(t＝2.999)均较入院时降低(均为P<0.05)。

结论

DAIR治疗人工膝关节置换术后急性感染，严格把握手术时机及手术适应证，可有效控制感染，恢复关节功能，临床效果满意。

关键词: 关节成形术，置换，膝, 感染, 清创术, 假体保留

Objective

To evaluate the clinical efficacy of debridement, antibiotics, and implant retention (DAIR) in the treatment of acute infection after total knee arthroplasty.

Methods

A retrospective analysis of the joint surgery of the 940th Hospital of the Joint Service Support Force of the Chinese People's Liberation Army from December 1, 2008 to November 30, 2018, was diagnosed with acute prosthetic joint infection (PJI) cases according to the diagnostic criteria of the American Society for Musculoskeletal Infection (MSIS), a total of 26 clinical data of patients with infection after acute knee arthroplasty. All the patients were treated with one-stage thorough debridement, replacement of knee joint polyethylene pads, postoperative wound irrigation and drainage, and adequate treatment with sensitive antibiotics. The pain visual analogue scale (VAS), Hospital for Special Surgery (HSS) score of the knee, sedimentation rate (ESR), C-reactive protein (CRP), interleukin (IL) -6 before and after the knee surgery were compared by t test.

Results

Twenty-six patients were enrolled, three cases were lost during the follow-up, and the follow-up time was (44±28) months. Among them, 17 cases were cured, the infection control rate was 73.9%.The postoperative knee joint VAS score was lower than that before surgery (t=24.815, P<0.05), and the postoperative HSS score was higher than that before surgery (t=41.966, P<0.05). ESR(t=14.140), CRP(t=3.503), and IL-6 (t=2.999)at last follow-up were all lower than those at admission (all P<0.05).

Conclusion

Controlling the timing of surgery and the indications for surgery strictly, DAIR can control the acute infections after total knee arthroplasty effectively, restore joint function, and obtain satisfactory clinical results.

Key words: Arthroplasty, Infection, Debridement, Prothesis retention

表1 患者术前及术后VAS评分、膝关节HSS评分比较[n＝26，(±s)]

项目	VAS评分	HSS评分
术前	6.0±1.2	35.6±4.3
末次随访	2.0±0.7	86.4±4.7
t值	24.815	41.966
P值	<0.001	<0.001

表1 患者术前及术后VAS评分、膝关节HSS评分比较[n＝26，(±s)]

项目	VAS评分	HSS评分
术前	6.0±1.2	35.6±4.3
末次随访	2.0±0.7	86.4±4.7
t值	24.815	41.966
P值	<0.001	<0.001

表2 患者术前及术后血清炎性标志物比较[n＝26，(±s)]

项目	ESR(mm/h)	CRP(mg/dL)	IL-6(ng/L)
术前	59.7±21.5	4.0±1.6	26.3±44.7
末次随访	15.6±7.8	1.6±0.5	2.6±1.6
t值	14.140	3.503	2.999
P值	<0.001	0.002	0.009

表2 患者术前及术后血清炎性标志物比较[n＝26，(±s)]

项目	ESR(mm/h)	CRP(mg/dL)	IL-6(ng/L)
术前	59.7±21.5	4.0±1.6	26.3±44.7
末次随访	15.6±7.8	1.6±0.5	2.6±1.6
t值	14.140	3.503	2.999
P值	<0.001	0.002	0.009

图1 典型病例患者左膝骨关节炎行膝关节表面置换术前后情况。图A为术前左膝关节正侧位X线片，示假体在位，无松动表现；图B为术后复查左膝关节正侧位X线片，示假体在位，无松动表现；图C为术后2周左膝关节外观，示局部肿胀伴活动受限；图D术中情况，可见大量坏死组织，感染严重；图E~F为假体周围病变组织病理HE染色(×100)，示化脓性炎症；图G为术后6个月复查膝关节正侧位X线片，示假体在位，无松动表现

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Debridement and implant retention combining antibiotics in treatment of acute infection following total knee arthroplasty

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Debridement and implant retention combining antibiotics in treatment of acute infection following total knee arthroplasty