保留部分假体的翻修术治疗慢性髋关节假体周围感染

doi:10.3877/cma.j.issn.1674-134X.2023.03.004

目的

探讨保留部分假体联合硫酸钙抗生素载体的一期翻修术治疗慢性髋关节假体周围感染(PJI)的临床疗效和可行性。

方法

回顾性分析2017年1月至2020年1月期间因髋关节慢性PJI于郑州大学第一附属医院关节外科行一期翻修治疗的33例患者的病历资料。依据美国肌肉骨骼感染协会诊断标准(MSIS)，纳入诊断为THA后PJI，且Tsukayama分型为Ⅳ型的患者，排除再次翻修、不耐受手术者；其中男13例，女20例，年龄55~81岁。根据术前及术中评估假体是否固定牢固及骨长入情况，选择性翻修股骨柄或髋臼杯。翻修术中所有患者均保留牢固假体，常规置换髋臼内衬及股骨头，彻底清创，充分刷洗暴露在骨组织外的保留假体，术中联合植入硫酸钙抗生素颗粒，在局部构建抗生素缓释系统。定期随访感染控制情况、Harris髋关节评分(HHS)、视觉模拟评分(VAS)、健康状况简表评分(SF-36)和并发症发生情况等。术前、术后6个月及术后1年时的HHS、VAS和SF-36评分的比较采用重复测量的方差分析，两两比较用Bonferroni法。计数资料比较采用配对设计Fisher确切概率法检验。

结果

所有患者平均年龄(63±7)岁，术后获平均(32±17)个月随访。1例患者术后6个月出现感染复发迹象，再次手术后8周感染症状消除，至末次随访未见感染复发迹象；感染控制率为97.0%。26例患者选择单纯翻修髋臼杯保留股骨柄，7例患者选择单纯翻修股骨柄保留髋臼杯。HHS评分和SF-36评分分别由翻修术前的(35.3±4.9)分、(374.5±37.3)分提高至术后1年的(84.4±3.5)分、(664.1±23.2)分；VAS评分由翻修术前的(6.9±1.4)分下降至术后1年的(1.2±0.8)分。以上项目翻修术前、术后6月与术后1年比较差异均有统计学意义(F＝1 099.116、930.082、242.621，均为P<0.05)，不同时间段两两比较差异均有统计学意义(均为P<0.05)。

结论

保留部分假体联合硫酸钙抗生素载体的一期翻修术可作为治疗假体固定牢固髋关节慢性PJI的有效方法，早期有效根除感染的同时，减少手术损伤，改善髋关节功能，提高患者生活质量。

关键词: 假体相关感染, 关节成形术，置换, 再手术, 硫酸钙

Objective

To investigate the clinical efficacy and feasibility of antibiotic-loaded calcium sulfate in partial one-stage revision for chronic periprosthetic hip infection.

Methods

A retrospective study was conducted of the 33 patients who had undergone partial single-stage revision for chronic periprosthetic hip infection from January 2017 to January 2020 at the articular surgery department of the First Affiliated Hospital of Zhengzhou University.Inclusion criteria: patients with a diagnosis of PJI after THA and Tsukayama staging type IV were enrolled according to the American Musculoskeletal Infection Society (MSIS)diagnostic criteria; the patients who had revision surgery more than once, and intolerant of surgery were excluded. Thirteen males and 20 females were enrolled, aged from 55 to 81 years. The femoral stem or acetabular cup was selectively revised according to preoperative and intraoperative assessment of whether the prosthesis was firmly fixed and bone ingrowth. During revision surgery, the firm prostheses were retained, the acetabular linings and femoral headswere routinely replaced, thoroughly debridement was performed, andadequately brushed the exposed component. Antibiotic-loaded calcium sulfate were implanted together during the operation to construct a local drug delivery system. Regular follow-up was performed for infection control, Harris hip score (HHS), visual analogue score (VAS), short form health status score (SF-36) and complication occurrence. HHS, VAS and SF-36 scores were compared preoperatively, at six months and one year after the surgery using repeated measures ANOVA, with two-way comparisons using the Bonferroni method. Count data were compared using the Fisher exact probability test in a paired design.

Results

The average age was (63±7)years, and all the patients were followed up for (32±17) months. One patient had signs of infection recurrence at six months after operation, and the infection symptoms were eliminated eight weeks after the re-operation. No sign of infection recurrence was found at the last follow-up, and the infection control rate was 97.0%. Twenty-six patients simply underwent the revision of the acetabular cup and retained the femoral handle, and seven patients only received the femoral handle revision surgery while the acetabular cups were retained. One year after revision surgery, HHS and SF-36 increased from(35.3±4.9)and(374.5±37.3)before the revision to(84.4±3.5)and (664.1±23.2)at one year after the revision. The VAS decreased from (6.9±1.4) preoperatively to (1.2±0.8) one year after revision surgery. There were statistically significant differences in the above items before revision surgery, six months after surgery and one year after surgery (F=1 099.116, 930.082, 242.621, all P<0.05), and there were statistically significant differences in pairwise comparisons at different time periods (all P<0.05).

Conclusions

Partial one-stage revision with antibiotic-loaded calcium sulfate may be used as an effective method for the treatment of chronic periprosthetic hip infection. It reduces surgical injury, improves hip function, and improves patients' quality of life, while effectively eradicating infection at the same time.

Key words: Prosthesis-related infections, Arthroplasty, replacement, Reoperation, Calcium sulfate

图1 硫酸钙抗生素颗粒制备。图A将硫酸钙糊状物压入直径为4.8 mm半球形模具；图B弯曲模具以取出硫酸钙颗粒

Figure 1 Preparation of calcium sulfate antibiotic granules. A shows that calcium sulfate paste was pressed into a 4.8 mm diameter hemispherical mold; B shows that the mold was bended to remove the calcium sulfate particles

图2 术前、术中关节液、组织研磨液和超声裂解液细菌培养结果

Figure 2 Results of microbial culture of joint fluid before operation, joint fluid during operation，tissue abrasive fluid and ultrasonic lysis fluid

图3 保留髋臼假体或股骨柄的一期翻修手术治疗THA(全髋关节置换术)后PJI(假体周围感染)翻修术前后影像。图A为初次左侧髋关节置换术后2年骨盆正位片，示左侧股骨柄下沉，髋臼固定牢固；图B为行一期翻修术后骨盆正位片，示更换全新股骨柄，保留固定牢固髋臼，合并植入硫酸钙抗生素载体；图C为初次单侧髋关节置换术后1年感染，翻修术前骨盆正位片，示髋臼底部出现透亮光线，股骨柄固定牢固；图D为行一期翻修术更换髋臼假体并保留股骨假体术后，骨盆正位片示假体位置良好

Figure 3 Images of PJI after THA with one-stage revision surgery preserving the acetabular prosthesis or femoral stalk. A is anteroposterior views of X rays of pelvis at two years after primary left hip replacement, showing a sunken left femoral stalk with a firmly fixed acetabulum; B is anteroposterior views of X rays of pelvis after one-stage revision, showing a new femoral stalk with a firmly fixed acetabulum and a combined calcium sulfate antibiotic carrier; C is anteroposterior views of X rays of pelvis at one year after primary unilateral hip replacement, showing a translucent region at the base of the acetabulum with a firmly fixed femoral stalk; D is anteroposterior views of X rays of pelvis after one-stage revision surgery for the acetabular prosthesis replacement and the femoral prosthesis preservation, showing prosthesis in good position

表1 一期翻修前、术后6个月和1年PJI患者HHS、SF-36和VAS评分[(n＝33，分，(±s)]

Table 1 HHS, SF-36 and VAS scores of patients with PJI before first-stage revision, six months and one year after surgery

时间Time	HHS评分HHS score	SF-36评分SF-36 score	VAS评分VAS score
翻修术前before first-stage revision	35.3±4.9	374.5±37.3	6.9±1.4
术后6个月Six months after surgery	73.5±4.6^a	580.9±25.3^a	2.3±1.3^a
术后1年One year after surgery	84.4±3.5^a，b	664.1±23.2^a，b	1.2±0.8^a，b
F值	1099.116	930.082	242.621
P值	<0.001	<0.001	<0.001

表1 一期翻修前、术后6个月和1年PJI患者HHS、SF-36和VAS评分[(n＝33，分，(±s)]

Table 1 HHS, SF-36 and VAS scores of patients with PJI before first-stage revision, six months and one year after surgery

时间Time	HHS评分HHS score	SF-36评分SF-36 score	VAS评分VAS score
翻修术前before first-stage revision	35.3±4.9	374.5±37.3	6.9±1.4
术后6个月Six months after surgery	73.5±4.6^a	580.9±25.3^a	2.3±1.3^a
术后1年One year after surgery	84.4±3.5^a，b	664.1±23.2^a，b	1.2±0.8^a，b
F值	1099.116	930.082	242.621
P值	<0.001	<0.001	<0.001

[1]	Beam E, Osmon D. Prosthetic joint infection update[J]. Infect Dis Clin North Am, 2018, 32(4): 843－859.
[2]	徐一宏，徐卫东. 保留假体清创术治疗假体周围感染疗效的影响因素[J/CD]. 中华关节外科杂志(电子版), 2018, 12(3): 405－410.
[3]	Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030[J]. J Bone Joint Surg Am, 2007, 89(4): 780－785.
[4]	Dobson PF, Reed MR. Prevention of infection in primary THA and TKA[J]. EFORT Open Rev, 2020, 5(10): 604－613.
[5]	Thaler M, Lechner R, Dammerer D, et al. The direct anterior approach: treating periprosthetic joint infection of the hip using two-stage revision arthroplasty[J]. Arch Orthop Trauma Surg, 2020, 140(2): 255－262.
[6]	vanden Kieboom J, Tirumala V, Box H, et al. One-stage revision is as effective as two-stage revision for chronic culture-negative periprosthetic joint infection after total hip and knee arthroplasty[J]. Bone Joint J, 2021, 103－B(3): 515－521.
[7]	林丽能，王辉，孙效棠，等. 一期和二期髋关节翻修术后感染复发率的Meta分析[J/CD]. 中华关节外科杂志(电子版), 2019, 13(1): 73－77.
[8]	Zahar A, Gehrke TA. One-stage revision for infected total hip arthroplasty[J]. Orthop Clin North Am, 2016, 47(1): 11－18.
[9]	He JW, Wang J, Cao L, et al. Serum and synovial vancomycin concentrations in patients with prosthetic joint infection after intra-articular infusion[J]. Eur J Drug Metab Pharmacokinet, 2021, 46(5): 637－643.
[10]	Barrett RJ, Sandquist L, Richards BF, et al. Antibiotic-impregnated polymethylmethacrylate as an anterior biomechanical device for the treatment of cervical discitis and vertebral osteomyelitis: technical report of two cases[J]. Turk Neurosurg, 2014, 24(4): 613－617.
[11]	Risitano S, Sabatini L, Atzori F, et al. Static antibiotic spacers augmented by calcium sulphate impregnated beads in revision TKA: surgical technique and review of literature[J]. J Orthop, 2018, 15(2): 313－318.
[12]	Cooper JJ, Florance H, McKinnon JL, et al. Elution profiles of tobramycin and vancomycin from high-purity calcium sulphate beads incubated in a range of simulated body fluids[J]. J Biomater Appl, 2016, 31(3): 357－365.
[13]	Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society[J]. Clin Orthop Relat Res, 2011, 469(11): 2992－2994.
[14]	Howlin RP, Brayford MJ, Webb JS, et al. Antibiotic-loaded synthetic calcium sulfate beads for prevention of bacterial colonization and biofilm formation in periprosthetic infections[J]. Antimicrob Agents Chemother, 2015, 59(1): 111－120.
[15]	Abosala A, Ali M. The Use of Calcium Sulphate beads in periprosthetic joint infection, a systematic review[J]. J Bone Jt Infect, 2020, 5(1): 43－49.
[16]	Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation [J]. J Bone Joint Surg Am, 1969, 51(4): 737－55.
[17]	Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components[J]. Clin Orthop Relat Res, 1990(257): 107－128.
[18]	Osmon DR, Berbari EF, Berendt AR, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America[J/OL]. Clin Infect Dis, 2013, 56(1): e1－e25. DOI: 10.1093/cid/cis803.
[19]	Pivec R, Issa K, Given K, et al. A prospective, longitudinal study of patient satisfaction following total knee arthroplasty using the Short-Form 36 (SF-36) survey stratified by various demographic and comorbid factors[J]. J Arthroplasty, 2015, 30(3): 374－378.
[20]	何斌，章淼锋，沈跃，等. 人工髋关节置换术后初次翻修的原因分析及翻修术疗效评估[J]. 中华骨科杂志，2019, 39(15): 909－917.
[21]	Gristina AG, Costerton JW. Bacterial adherence and the glycocalyx and their role in musculoskeletal infection[J]. Orthop Clin North Am, 1984, 15(3): 517－535.
[22]	Akgün D, Perka C, Trampuz A, et al. Outcome of hip and knee periprosthetic joint infections caused by pathogens resistant to biofilm-active antibiotics: results from a prospective cohort study[J]. Arch Orthop Trauma Surg, 2018, 138(5): 635－642.
[23]	Bjarnsholt T, Ciofu O, Molin S, et al. Applying insights from biofilm biology to drug development- can a new approach be developed？[J]. Nat Rev Drug Discov, 2013, 12(10): 791－808.
[24]	Lee YK, Lee KH, Nho JH, et al. Retaining well-fixed cementless stem in the treatment of infected hip arthroplasty[J]. Acta Orthop, 2013, 84(3): 260－264.
[25]	Chen KH, Tsai SW, Wu PK, et al. Partial component-retained two-stage reconstruction for chronic infection after uncemented total hip arthroplasty: results of sixteen cases after five years of follow-up[J]. Int Orthop, 2017, 41(12): 2479－2486.
[26]	El-Husseiny M, Haddad FS. The role of highly selective implant retention in the infected hip arthroplasty[J]. Clin Orthop Relat Res, 2016, 474(10): 2157－2163.
[27]	纪保超，李国庆，张晓岗，等. 保留部分假体的一期翻修术治疗全髋关节置换术后慢性感染[J]. 中华骨科杂志，2019, 39(15): 918－925.
[28]	Roberts R, McConoughey SJ, Calhoun JH. Size and composition of synthetic calcium sulfate beads influence dissolution and elution rates in vitro[J]. J Biomed Mater Res B Appl Biomater, 2014, 102(4): 667－673.
[29]	Kilgus DJ, Howe DJ, Strang A. Results of periprosthetic hip and knee infections caused by resistant bacteria[J]. Clin Orthop Relat Res, 2002(404): 116－124.
[30]	Lim SJ, Park JC, Moon YW, et al. Treatment of periprosthetic hip infection caused by resistant microorganisms using 2-stage reimplantation protocol[J]. J Arthroplasty, 2009, 24(8): 1264－1269.
[31]	Karlsen ØE, Borgen P, Bragnes B, et al. Rifampin combination therapy in staphylococcal prosthetic joint infections: a randomized controlled trial[J/OL]. J Orthop Surg Res, 2020, 15(1): 365. DOI: 10.1186/s13018-020-01877-2.
[32]	Miller R, Higuera CA, Wu J, et al. Periprosthetic joint infection[J/OL]. JBJS Rev, 2020, 8(7): e19.00224. DOI: 10.2106/jbjs.rvw.19.00224.

[1]	金鑫, 谢卯, 刘芸, 杨操, 杨述华, 许伟华. 个性化股骨导向器辅助初次全髋关节置换的随机对照研究[J]. 中华关节外科杂志(电子版), 2023, 17(06): 780-787.
[2]	邓华梅, 袁札根, 曾德荣, 潘珊珊, 张葆青, 欧爱华, 曹学伟. 全膝关节置换术中气压止血带应用效果与影响因素分析[J]. 中华关节外科杂志(电子版), 2023, 17(06): 788-794.
[3]	张思平, 刘伟, 马鹏程. 全膝关节置换术后下肢轻度内翻对线对疗效的影响[J]. 中华关节外科杂志(电子版), 2023, 17(06): 808-817.
[4]	李培杰, 乔永杰, 张浩强, 曾健康, 谭飞, 李嘉欢, 王静, 周胜虎. 细菌培养阴性的假体周围感染诊治的最新进展[J]. 中华关节外科杂志(电子版), 2023, 17(06): 827-833.
[5]	林文, 王雨萱, 许嘉悦, 王矜群, 王睿娜, 何董源, 樊沛. 人工关节置换登记系统的研究进展[J]. 中华关节外科杂志(电子版), 2023, 17(06): 834-841.
[6]	闫文, 谢兴文, 顾玉彪, 雷宁波, 马成, 于文霞, 高亚雄, 张磊. 微小RNA与全膝关节置换术后深静脉血栓的研究进展[J]. 中华关节外科杂志(电子版), 2023, 17(06): 842-846.
[7]	贺敬龙, 尚宏喜, 郝敏, 谢伟, 高明宏, 孙炜, 刘安庆. 重度类风湿关节炎患者行多关节置换术的临床手术疗效[J]. 中华关节外科杂志(电子版), 2023, 17(06): 860-864.
[8]	孟繁宇, 周新社, 赵志, 裴立家, 刘犇. 侧位直接前方入路髋关节置换治疗偏瘫肢体股骨颈骨折[J]. 中华关节外科杂志(电子版), 2023, 17(06): 865-870.
[9]	王宏宇. 固定与活动平台假体在全膝关节置换术中的应用价值[J]. 中华关节外科杂志(电子版), 2023, 17(06): 871-876.
[10]	李善武, 叶永杰, 王兵, 王子呓, 银毅, 孙官军, 张大刚. 胫骨高位截骨与单髁置换的早期疗效比较[J]. 中华关节外科杂志(电子版), 2023, 17(06): 882-888.
[11]	李辉, 吴奇, 张子琦, 张晗, 王仿, 许鹏. 日间全膝关节置换术早期疗效及标准化流程探索[J]. 中华关节外科杂志(电子版), 2023, 17(06): 889-892.
[12]	姚轶超, 张麒, 滕海茂, 黄攀, 吴雷涛, 韩哲. 膝关节置换术后恐动症与康复效果及社会支持的相关性[J]. 中华关节外科杂志(电子版), 2023, 17(05): 613-618.
[13]	樊绪国, 赵永刚. 全膝关节置换术中髌骨轨迹的研究进展及处理策略[J]. 中华关节外科杂志(电子版), 2023, 17(05): 701-707.
[14]	刘伦, 王云鹭, 李锡勇, 韩鹏飞, 张鹏, 李晓东. 机器人辅助膝关节单髁置换术的研究进展[J]. 中华关节外科杂志(电子版), 2023, 17(05): 715-721.
[15]	王桂冠, 徐杰. 运动学对线在全膝关节置换术中的研究进展[J]. 中华关节外科杂志(电子版), 2023, 17(05): 726-731.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Implantation of antibiotic-loaded calcium sulfate in partial one-stage revision for chronic periprosthetic hip infection

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Implantation of antibiotic-loaded calcium sulfate in partial one-stage revision for chronic periprosthetic hip infection