关节置换术后假体周围感染分子生物学诊断研究进展

假体周围感染是关节置换术后的常见并发症,也是灾难性并发症,严重影响患者日常生活质量,加重其社会、经济负担。假体周围感染及时、正确的诊断对后续治疗至关重要。目前常规检查方法有血清学检查、关节液检查及术中组织学检查。多个相关协会和组织亦发布假体周围感染的诊断指南以指导临床工作。但对于细菌培养阴性、之前使用抗生素、生物膜形成及低毒力细菌感染等患者,常规诊断方法效果欠佳。近年来假体周围感染分子生物学诊断的研究大量涌现,本文对此方面的研究进展简要综述。     

白介素-6对于早期诊断关节置换术后假体周围感染的意义

随着关节置换手术的开展,关节置换术后假体感染的患者数量不在少数,而关节置换术后假体周围感染无论对于患者还是医生都是一场灾难,如何能对关节置换术后假体感染进行早期诊断显得尤为重要。目前,C反应蛋白（CRP）和血沉（ESR）被认为是早期诊断假体周围感染的重要血清学手段,本文汇总分析国内外文献,通过C反应蛋白,血沉与白介素-6（IL-6）的对比,发现白介素-6具有较高的特异性,敏感性和准确性,是早期诊断假体周围感染血清学检查的一个有价值的补充。通过对关节置换术后假体周围感染早期诊断的研究进展作出综述,旨在为临床工作提供参考。     

α-防御素在关节假体周围感染诊断中的作用及应用前景

关节假体周围感染是关节置换术后灾难性的并发症。目前对于关节假体周围感染尚缺乏一种可靠、迅捷、高准确率的诊断方法。美国骨肌系统感染协会(Musculoskeletal Infection Society,MSIS)制定的关节假体周围感染诊断标准获得国内外学者的普遍认可,但其诊断指标相对复杂不便于临床应用。临床上常用血沉、血清CRP、IL-6、降钙素原等实验室指标辅助诊断关节假体周围感染,但这些指标的异常并不完全由关节假体周围感染引起,易受其他炎性因素影响。近年来,滑液生物标志物,尤其是滑液α-防御素对关节假体周围感染的诊断价值逐渐受到重视。本文综合分析目前关于滑液α-防御素的临床研究,就其在关节假体周围感染诊断中的研究现状及临床价值做一综述。     

~(18)F-FDG符合线路显像联合滑液CRP检测诊断膝关节假体感染

[目的]探讨~(18)F-FDG符合线路显像联合滑液CRP检测在膝关节假体周围感染的诊断价值。[方法]回顾性分析87例高度疑诊为膝关节假体周围感染患者,术前行~(18)F-FDG显像符合线路显像(~(18)F-FDG显像)及滑液CRP检测,术中采集假体周围5个不同部位的滑液进行细菌培养,培养结果为阴性的延长培养时间至2周,以细菌培养最终检验结果作为诊断标准。分析比较联合检查、单纯~(18)F-FDG显像和单纯滑液CPR的诊断价值及意义。[结果]87例患者中,细菌培养阳性73例,确诊为假体感染(感染组);14例为阴性,排除假体感染(非感染组)。联合检查的敏感性为89.04%,特异性为92.86%,准确性为89.66%;单纯~(18)F-FDG显像的敏感性为87.67%,特异性为71.43%,准确性为85.06%;单纯滑液CPR的敏感性为90.41%,特异性为57.14%,准确性为82.76%。联合检查的特异性和准确性显著高于单纯~(18)F-FDG显像或单纯滑液CRP检测,差异具有统计学意义(P0.05)。[结论]~(18)FFDG符合线路显像联合滑液CRP检测显著改进膝关节假体周围感染诊断的特异性和准确性,可为膝关节假体周围感染诊断提供依据。     

膝关节翻修术的现状与未来

近十多年来, 随着加速康复理念的提出、膝关节翻修假体及定制型垫块或假体的研制和应用, 膝关节翻修术进入了快速发展的阶段。但关节外科医生因此面临新的临床挑战, 即假体周围感染的可能。术前应全面检查排除感染, 改善全身情况至最佳状态;全面评估软组织、骨缺损类型和程度;选择合适的手术入路、骨重建策略及假体类型, 最终恢复膝关节的力线、稳定性及活动度。未来需要关注膝关节翻修技术团队的建立, 包括术前规划、3D打印、手术技术、加速康复围手术期管理;还应加强初次膝关节置换术的高质量管理, 从根本上减少膝关节翻修率;更需要加强假体周围感染的防控措施与假体周围骨折的预防, 以及建立高质量的随访体系。     

负压封闭引流结合敏感抗生素治疗假体周围急性感染

目的 :探讨负压封闭引流(vacuum sealing drainage,VSD)结合敏感抗生素治疗假体周围急性感染的疗效。方法:回顾性分析2012年3月至2018年12月采用保留假体的清创、VSD、敏感抗生素治疗11例假体周围急性感染,男7例,女4例;年龄58～88岁,平均72.5岁。髋关节假体周围感染8例,3例出现窦道,膝关节假体周围感染3例。结果:微生物培养阴性2例,阳性9例,金黄色葡萄球菌7例,其中2例耐甲氧西林金黄色葡萄球菌(methicillin-resistant staphylococcus aureus,MRSA),表皮葡萄球菌2例。术后随访8～52个月,平均28个月,1例髋关节假体周围感染清创失败,清创距关节置换时间84 d,行II期人工关节翻修术。10例清创成功。末次随访时,髋关节假体周围感染清创成功患者Harris评分84.1(74～93)分;膝关节假体周围感染者膝关节协会评分(Knee Society score,KSS)84,84,89分。结论:膝关节置换术后1个月内,髋关节置换术后6周内假体周围急性感染,及服用抗凝药物引起假体周围出血伴急性感染,采用保留假体的清创,VSD及敏感抗生素治疗,可获得较满意的效果。     

髋关节置换术后假体周围感染的治疗

目的 探讨髋关节置换术后假体周围感染患者接受清创术、一期翻修术、二期翻修术及旷置术的临床效果.方法 1993年6月至2008年6月因髋关节置换术后假体周围感染接受手术治疗患者46例,男27例,女19例;年龄34～80岁,平均55.8岁.术前诊断感染的方法包括红细胞沉降率、C反应蛋白检查,放射性核素扫描,窦道分泌物及关节穿刺液培养.行保留假体的清创术7例,一期翻修术14例,二期翻修术21例,旷置术4例.术后观察伤口外观,随访时采用Harris评分对髋关节功能进行评估,行实验室检查确定感染控制情况.结果 46例假体周围感染患者中29例培养结果 阳性,表皮葡萄球菌占感染病原体的首位(37.9%),其次为金黄色葡萄球菌(24.2%).35例获得随访,随访时间12～179个月,平均61.6个月.末次随访时Harris评分2～99分,平均76.5分.清创术后假体周围感染的控制率为16.7%,一期翻修术为54.5%,二期翻修术为93.3%,旷置术为100%.二期翻修术后假体周围骨折发生率13.3%,术后脱位率13.3%.11例感染复发,复发时间为感染治疗术后2～127个月,平均39.5个月.其中10例再次接受手术治疗,包括清创术1例、二期翻修术8例、旷置术1例.结论 清创术与一期翻修术的选择应严格把握适应证.二期翻修术感染控制率高,但有发生假体周围骨折和脱位的风险.表皮葡萄球菌及金黄色葡萄球菌足关节感染的主要病原菌.     

髋关节置换术后假体周围感染的治疗

目的 探讨髋关节置换术后假体周围感染患者接受清创术、一期翻修术、二期翻修术及旷置术的临床效果.方法 1993年6月至2008年6月因髋关节置换术后假体周围感染接受手术治疗患者46例,男27例,女19例;年龄34～80岁,平均55.8岁.术前诊断感染的方法包括红细胞沉降率、C反应蛋白检查,放射性核素扫描,窦道分泌物及关节穿刺液培养.行保留假体的清创术7例,一期翻修术14例,二期翻修术21例,旷置术4例.术后观察伤口外观,随访时采用Harris评分对髋关节功能进行评估,行实验室检查确定感染控制情况.结果 46例假体周围感染患者中29例培养结果 阳性,表皮葡萄球菌占感染病原体的首位(37.9%),其次为金黄色葡萄球菌(24.2%).35例获得随访,随访时间12～179个月,平均61.6个月.末次随访时Harris评分2～99分,平均76.5分.清创术后假体周围感染的控制率为16.7%,一期翻修术为54.5%,二期翻修术为93.3%,旷置术为100%.二期翻修术后假体周围骨折发生率13.3%,术后脱位率13.3%.11例感染复发,复发时间为感染治疗术后2～127个月,平均39.5个月.其中10例再次接受手术治疗,包括清创术1例、二期翻修术8例、旷置术1例.结论 清创术与一期翻修术的选择应严格把握适应证.二期翻修术感染控制率高,但有发生假体周围骨折和脱位的风险.表皮葡萄球菌及金黄色葡萄球菌足关节感染的主要病原菌.     

人工关节置换术后假体周围感染治疗策略选择

假体周围感染是人工关节置换术后的灾难性并发症,严重威胁患者的关节功能甚至远期生活质量。目前,假体周围感染尚无理想的治疗方法,常用的治疗策略包括抗生素治疗,清创灌洗+保留假体,一期置换和二期置换。本综述旨在总结这些治疗方法的疗效、进展以及适应证,为假体周围感染的治疗策略选择提供参考。     

人工关节置换术后假体周围感染与术前贫血的研究进展

假体周围感染是人工关节置换术后最严重的并发症。流行病学调查发现,围术期贫血是造成假体周围感染的独立危险因素,其可通过影响细胞机制及自身免疫功能等多个方面发挥重要影响。既往国内外诸多学者对假体周围感染与术后贫血的关系进行研究,但对假体周围感染与术前贫血的相关性探讨较少。术前贫血可使红细胞表面的C3b受体减少,机体免疫功能降低,血源性感染增加,术后康复时间延长,进而诱发假体周围感染。故对于术前合并贫血的患者,除预防性使用抗生素外,术前应补充铁剂、配合促红细胞生成素积极纠正贫血、治疗影响血红蛋白生成的慢性并发症、提高患者自身的免疫状况、对符合输血指征的患者进行相应的输血治疗,从而更好地预防人工关节置换术后假体周围感染的发生,减少二次或多次翻修的概率。     

Effects of joint mobilization on joint stiffness and active motion of the metacarpal-phalangeal joint

Joint mobilization is a common technique used to restore joint motion; however, documentation of its effectiveness is lacking. The purpose of this study was to determine if joint mobilization is effective in counteracting joint stiffness and decreased active range of motion of the metacarpal-phalangeal joint. It was hypothesized that there would be a significant increase in range of motion in those patients who received joint mobilization. Eighteen subjects who had been immobilized for the treatment of metacarpal fractures were randomly assigned to a treatment group that received joint mobilization or a control group that received no treatment. Measurements of active range of motion and torque range of motion prior to and after treatment/rest sessions were obtained for three sessions over a 1 week period. Analyses of variance were performed on the mean changes in excursion between groups and across sessions. The joint mobilization resulted in a significantly greater increase in excursion for subjects in the treatment group over subjects in the control group (p < 0.05). Joint mobilization does appear to be able to counteract the effects of immobilization and alter joint mechanics. J Orthop Sports Phys Ther 1992;16(1):30-36.     

Radioulnar joint fusion for distal radioulnar joint instability

Each one of this small group of patients illustrates a rare indication for the radioulnar joint fusion procedure in distal radioulnar joint instability. The case histories tell of a last ditch effort to salvage function in an extremity crippled by painful radioulnar instability after excision of the distal ulna. The fusions healed slowly and two required repeat surgery to achieve union. Today we would routinely add iliac bone graft to the fusion area to hasten healing. Rarely indicated, this is a salvage procedure that is done after failure of other procedures geared to preserve the rotation of the forearm. These patients all had successful salvage of their extremities for activities of daily living, but only one returned to his labor job. All were worker's compensation cases in physical jobs. Two patients had had prior radiocarpal fusions, making them even more restricted in function. This procedure should be kept in mind to be used in the rare cases of painful instability of the distal radioulnar joint when traditional motion-preserving procedures have failed.     

Relationship between joint laxity and radio-ulno-carpal joint morphology

The relationships between wrist laxity, ulnar variance, sigmoid notch inclination, and lunotriquetral motion were analysed in 60 normal volunteers. A strong correlation between ulnar length and sigmoid notch inclination was found for the entire group. Joint laxity was found to correlate with ulnar variance and lunotriquetral mobility in women, but not in men. The greater the laxity, the shorter the ulna and the greater the lunotriquetral motion during radial to ulnar deviation. These results support the concept that laxity increases the vulnerability of the wrist to injury.     

Elbow joint

The elbow joint is a key joint for positioning of the hand. Four operations have to be considered for the rheumatoid elbow: removal of rheumatoid nodules and bursectomy, resection of the radial head, synovectomy, and arthroplasty. Synovectomy and arthroplasty are carefully analyzed, both from the point of view of recent international literature as well as personal experience. Synovectomy of the elbow is highly effective even when performed relatively late (stage 3 according to Larsen-Dahle-Eek) insofar as pain relief and swelling are concerned. In long-term disease, deterioration as assessed by radiology can usually not be prevented, but clinical improvement may be the reason for the relatively rare indication for arthroplasty. According to recent literature, the results of elbow arthroplasty vary greatly. Fully constrained hinges should no longer be used, and no decision has been made so far on whether semiconstrained or nonconstrained surface replacement is preferred. We use the semiconstrained GSB Mark II prosthesis, which has provided results in nearly 50 cases that rank among the best reported from the point of view of pain relief, improvement of ROM, and low complication rate. Use of our so-called transtricipital approach to the elbow has proved particularly valuable, especially with regard to lack of extension and muscle strength.     

Endoprosthetic joint replacement of the contracted elbow joint

In a retrospective study 14 patients were reviewed 63 months after the implantation of a semi-constrained total elbow prosthesis in fourteen stiff or ankylosed elbows with a preoperative range of elbow motion of 30 degrees or less. The result, according to the Mayo Elbow Performance score, was excellent for four elbows, good for four, fair for one, and poor for five. The average arc of flexion improved from 7 to 68 degrees postoperatively with an average increase of 34 degrees in flexion, and 27 degrees in extension. There were seven complications affecting seven of the 14 elbows and four of these seven elbows underwent a revision procedure. Replacement for a stiff elbow is the least predictable, has the lowest overall rate of success and highest complication rate, than any other procedure. Nevertheless, these disadvantages must be placed in the context of alternative intervention options. The semiconstrained total elbow arthroplasty seems to be a useful option for patients older than 50 years with intrinsic stiffness involving more than 50% of the articular surface and with an ankylosed or very stiff elbow.     

Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain

Mapping studies of pain elicited by injections into the sacroiliac joints (SIJs) suggest that sacroiliac joint syndrome (SIJS) may manifest as low back pain, sciatica, or trochanteric pain. Neither patient-reported symptoms nor provocative SIJ maneuvers are sensitive or specific for SIJS when SIJ block is used as the diagnostic gold standard. This has led to increasing diagnostic use of SIJ block, a procedure in which an anesthetic is injected into the joint under arthrographic guidance. However, several arguments cast doubt on the validity of SIJ block as a diagnostic gold standard. Thus, the effects of two consecutive blocks are identical in only 60% of cases, and the anesthetic diffuses out of the joint in 61% of cases, often coming into contact with the sheaths of the adjacent nerve trunks or roots, including the lumbosacral trunk (which may contribute to pain in the groin or thigh) and the L5 and S1 nerve roots. These data partly explain the limited specificity of SIJ block for the diagnosis of SIJS and the discordance between the pain elicited by the arthrography injection and the response to the block. The limitations of provocative maneuvers and SIJ blocks may stem in part from a contribution of extraarticular ligaments to the genesis of pain believed to originate within the SIJs. These ligaments include the expansion of the iliolumbar ligaments, the dorsal and ventral sacroiliac ligaments, the sacrospinous ligaments, and the sacrotuberous ligaments (sacroiliac joint lato-sensu). They play a role in locking or in allowing motion of the SIJs. Glucocorticoids may diffuse better than anesthetics within these ligaments. Furthermore, joint fusion may result in ligament unloading.