感染后关节的初次人工关节置换术

目的：探讨关节感染后骨关节炎患者行初次人工关节置换术的特点及治疗原则。方法：回顾性研究既往有关节感染史的8例初次全髋和全膝关节置换术病例，其中化脓性感染6例，结核性感染2例。全髋关节置换6例，手术时平均年龄38．1岁(24—51岁)，感染平均静止22．0年(6—30年)。全膝关节置换2例。行关节置换术前，常规进行白细胞计数、血沉、C反应蛋白等检查以除外活动性感染。术后随访2-11年。结果：既往有髋关节感染者患肢均有明显短缩畸形．股骨上段发育异常，并伴有屈曲挛缩畸形。所有患者术前均无活动性感染。化脓性感染的6例，5例感染静止20年以上者均无感染复发：1例感染静止6个月后行全膝关节置换者，术后9个月感染复发，结核感染的2例术后均无感染复发。1例全髋关节置换患者在术后1年出现假体柄无菌性松动，其余患者功能良好，结论：关节感染后骨关节炎患者年龄相对较轻．关节置换手术难度较大，易出现并发症，术前应先排除活动性感染．在感染静止相当一段时间后进行一期置换．可以取得较好的临床效果。     

保留假体的关节清创术结合术后持续灌洗治疗人工关节置换术后急性假体周围感染

[目的]探讨在急性假体周围感染的治疗中,保留假体的关节清创术结合术后持续关节腔灌洗的疗效及影响该治疗方法疗效的因素.[方法]回顾性研究2003年6月～2009年3月间采用保留假体的关节清创术结合持续灌洗治疗人工关节置换术后假体周围急性感染的11例病例.其中髋关节置换术后感染6例,膝关节置换术后感染5例.置换术后早期急性感染(＜4周)7例,急性血行播散性感染4例.保留假体的关节清创术前常规检查血沉、C反应蛋白,所有病例术前均行关节穿刺细菌培养或分泌物细菌培养,术中常规行关节液细菌培养.髋关节清理时应脱出股骨头后彻底清理关节内炎性病灶.膝关节清理时应取出聚乙烯衬垫,彻底清除后关节囊内可疑感染病灶,更换新的聚乙烯衬垫.其中3例关节清创术在发现关节急性感染后的1周内实施.[结果]经平均41.4个月随访,6例患者无感染复发迹象,其中关节置换术后早期感染病例4例,急性血行播散性感染病例2例,感染治愈率为54.5%.[结论]保留假体的关节清创术结合术后持续关节腔灌洗对人工关节置换术后早期急性感染和急性血行播散性感染治疗效果良好,如手术能在症状出现4周内尽早实施,部分患者的感染可得到控制.细菌的种类和毒力是影响该手术方式疗效的重要因素.     

翻修术治疗髋关节置换术后感染

目的探讨髋关节置换术后感染的治疗方法，比较一期翻修与二期翻修的随访结果。方法1999年1月-2005年12月，收治15例髋关节置换术后感染患者。男10例，女5例；年龄54～71岁。左侧8例，右侧7例。初次行人工股骨头置换6例，全髋关节置换9例。术后1个月感染6例，6个月感染9例。患者体温均正常，周围血常规检查白细胞总数、中性多核细胞计数正常，血沉34～80mm／h，平均61mm／h，C反应蛋白11．7mg／L（5,4～21．0mg／L）。术前Harris评分25～40分，平均33分。X线片示患者股骨均有不同程度骨膜反应及骨溶解，假体柄有松动。前次手术距本次翻修术1～41个月，平均7．3个月。细菌培养提示11例阳性，其中8例为表皮葡萄球菌，2例为大肠埃希氏菌，1例为金黄色葡萄球菌。单纯清创或采用庆大霉素骨水泥一期翻修术10例，二期抗生素骨水泥假体翻修术5例。术中采集脓液或关节液进行细菌培养及药敏试验，组织标本行病理学检查。结果术中细菌培养结果与术前一致。病理学检查示均为炎性肉芽组织生长，并有大量多核细胞浸润。翻修术后患者切口均Ⅰ期愈合。患者获随访12～37个月，平均19个月，感染均未复发，局部软组织无肿胀和压痛。14例髋关节疼痛消失，1例行走时有轻微疼痛但不影响行走。Harris评分为79～92分，平均84．2分，与术前比较差异有统计学意义（P〈0．05）。术后6个月X线片示假体固定可靠，无明显松动迹象及骨溶解发生。结论髋关节置换术后感染，只要诊断明确，处理得当，一期翻修与二期翻修均可取得满意的临床疗效。     

髋关节置换术后慢性隐匿性假体周围感染的诊断与治疗

[目的]探讨髋关节置换术后假体周围隐匿性感染的诊断及外科治疗方法。[方法]回顾性分析2011年5月~2014年10月连续收治12例髋关节人工关节置换术后假体周围慢性隐匿性感染患者的临床资料,男10例,女2例;年龄56~75岁,平均60.5岁。12例患者均表现为髋关节疼痛,首发症状距初次关节置换手术的时间6~15个月,平均9.5个月。本组病例无全身和局部感染症状及体征,C反应蛋白和血沉无明显增高,X线片6例关节假体-骨界面可见透光带,2例半髋置换可见明显的髋臼上缘骨质磨损。10例行关节穿刺细菌培养,12例术中均进行关节周围软组织标本细菌培养及冰冻切片快速病理检查。术中行假体取出,抗生素骨水泥间隔体置入及术后全身抗感染治疗,二期关节翻修。[结果]12例患者一期手术假体均顺利取出,术中均未见明显脓性分泌物,但假体柄取出后股骨髓腔内可见炎性坏死组织。术中髋周软组织标本快速冰冻切片结果每高倍视野中性粒细胞计数平均12个(8~15个/高倍视野),术后病理报告均诊断为化脓性炎症。10例术中标本细菌培养结果为阴性,2例细菌培养为金黄色葡萄球菌。关节翻修术后平均随访时间为16.6个月(5~24个月),髋关节Harris评分由术前(62.5±8.2)分(59~75分)提高至末次随访时(91.6±3.8)分(88~95分),差异有统计学意义(t=20.2,P=0.000)。[结论]假体周围隐匿性感染临床表现不典型,常规辅助检查方法不能对假体周围感染提供有价值的诊断依据,术中冰冻病理检查能做出快速、准确诊断。     

全膝关节置换术后膝部症状的关节镜下治疗

全膝关节置换后膝关节镜下手术并不常见。本文报道应用关节镜治疗全膝关节置换手术后不同病理改变所致膝部症状的经验。材料及方法:1983年～1989年期间,对53例全膝关节置换术后有膝部症状的病人实行了58次关节镜操作。51例病人(56次手术)得到随访关节镜经标准入路,在全麻下进行。术中及术后给予预防性抗生素24～48小时。每次手术均作录象记录。常规取关节液培养,怀疑感染者作滑膜活检,行组织学检查及培养。检查关节,观察假体故障、松     

初次髋膝关节置换术后假体周围感染危险因素分析

目的探讨初次人工髋膝关节置换术后假体周围感染的相关危险因素,为早期预防假体周围感染提供依据。方法回顾性分析2013年03月至2016年03月鼓楼医院关节疾病诊治中心收治的初次髋膝关节置换患者临床资料,分为病例组和对照组。以初次髋膝关节置换术后发生感染的患者为病例组,未发生感染病例归入对照组。病例组28例,其中髋关节置换13例(全髋11例,半髋2例),膝关节置换15例(1例双膝置换),按1∶2的比例配比同一时期关节置换术后未出现感染的56例患者为对照组,统计两组间病因、病原菌、血型、尿培养及患者身体质量指数(BMI)、手术时间、术后第1天及总引流量、住院时间、患部手术史等的差异。应用SPSS 17.0软件进行统计分析,计量资料组间比较采用独立样本的t检验;计数资料两组比较采用Fisher检验或连续性校正的卡方检验,将有统计学意义的单因素为自变量行多因素Logistic回归分析。结果假体周围感染患者共检出病原菌10株,均以革兰阳性菌感染为主。髋关节置换术后感染以表皮葡萄球菌感染最多,占38.4%,而膝关节假体周围感染以金黄色葡萄菌为主占37.3%;单因素分析显示,BMI大、手术时间长、术后引流多、住院时间长、切口既往手术、使用免疫抑制剂、术前低蛋白血症、无症状细菌尿以及浅表感染情况是初次关节置换术后假体周围感染的危险因素(t=4.73、8.27、5.913、3.461、7.524、3.021、7.721、4.519、2.918,P0.05);多因素Logistic回归分析显示,BMI较大、手术时间长、术后引流多、住院时间长、切口既往手术史、免疫抑制剂使用、术前低蛋白血症、无症状细菌尿以及有表浅感染均是假体周围感染的独立危险因素(P0.05)。结论初次关节置换术后假体周围感染以革兰阳性菌感染为主,BMI大、手术时间长、术后引流较多、住院时间长、切口既往手术史、既往使用过免疫抑制剂、术前低蛋白血症、无症状细菌尿以和有表浅感染的患者术后发生假体周围感染的风险较高。     

生物型人工关节假体表面抑菌的研究进展

无菌技术和预防性抗生素应用未能逆转人工关节术后感染的严峻形势,初次置换感染率依旧维持在全髋关节置换术（totalhiparthroplasty,THA）为0．5％～2％,全膝关节置换术（totalkneearthroplasty,TKA）为1％。而感染治疗困难而长期,相当一部分关节难以获得预期功能,甚至不得不面临截肢。其医疗支出显著增加,     

万古霉素骨水泥治疗全髋关节置换术后感染

目的　探讨全髋置换术后感染的治疗方法。方法　本组 15例全髋置换术后感染 ,术前细菌培养 13例阳性 ,应用万古霉素骨水泥进行翻修 ,3例行一期翻修 ,12例行二期翻修 ,术后随访 ,观察疗效。结果　全部病例获得随访 ,平均 16个月 ,所有病例伤口均一期愈合 ,无一例复发。术后髋关节功能明显改善 ,Harris评分为 76～ 93分 ,较术前提高 4 6分。结论　全髋关节置换术后感染采用一期或二期翻修应根据病人具体情况决定 ,局部应用万古霉素骨水泥能提高疗效 ,并有利于关节功能恢复     

采用硫酸钙载抗生素系统联合髋关节翻修术治疗髋关节置换术后假体周围感染的疗效分析

目的 探讨硫酸钙载抗生素联合髋关节翻修术治疗髋关节置换术后假体周围感染（PJI）的临床疗效。方法 回顾性分析2018年1月至2021年10月间常州市武进中医医院骨伤科收治的髋关节置换术后假体周围感染患者12例,其中男8例,女4例;年龄56～76岁（64.9±6.0）岁;其中全髋关节置换术后感染10例,股骨头置换术后感染2例。本组术后出现感染症状距离首次置换时间1～120(15.2±33.4)个月。记录患者术前和术后末次随访时白细胞计数、血沉及C-反应蛋白,改良髋关节Harris评分（mHHS）及髋关节结果（HOS）评分。结果 12例患者随访时间为12～23(17.2±6.7)个月。所有患者术后切口均按期愈合,未出现伤口持续渗液、异位骨化、感染复发等并发症。有1例出现无症状低钙血症。术中组织细菌培养有3例为阴性,9例为阳性,其中3例为金黄色葡萄球菌,3例为表皮葡萄球菌,2例为肺炎克雷伯菌,1例为粪肠球菌。末次随访时白细胞计数、血沉及C-反应蛋白较术前均有显著下降（P<0.05）。末次随访时mHHS评分及HOS评分较术前均有显著上升（P<0.05）。结论 在髋关节置换术后PJI...     

关节置换术后引流管尖端细菌培养结果的临床分析

目的对关节置换术后引流管尖端细菌培养的结果进行统计及分析。方法统计自2010-02—2013-03在南京军区南京总医院骨科进行的关节置换手术1 031例(1 127侧),其中髋关节置换术723例(784髋),膝关节置换术211例(246膝),非感染性关节置换翻修术97例(97髋)。对术后引流管尖端细菌培养结果,结果阳性者的关节置换类型,以及敏感性和特异性进行分析。结果 28侧(2.48%)培养结果为阳性,其中19侧为G+性菌,8侧为G-性菌,1侧为曲霉菌。27侧(2.62%,27/1 030)细菌培养阳性的关节置换为初次关节置换,1侧(1.03%,1/97)为非感染性关节置换翻修术,2组阳性率比较差异无统计学意义(P=0.5050.05)。引流管尖端细菌培养诊断敏感性为3.57%,特异性为97.52%。结论关节置换术后引流管尖端细菌培养结果不宜单独作为诊断感染的重要指标,需综合分析以确诊术后感染。同时建议关节置换术后严格引流管周围皮肤消毒,尽量减少细菌污染,减少培养结果的假阳性。     

Infection after total joint arthroplasty from distal extremity sepsis

At the UCLA Medical Center in three patients treated for hematogenous infection after total joint arthroplasty, the source was apparently an infection in the extremities at a site distal to the joint arthroplasty. In a 72-year-old woman with rheumatoid arthritis infection developed in the right hip after total hip arthroplasty following a Staphylococcus aureus infection at the site of a left metatarsophalangeal arthroplasty. In a 64-year-old man with osteoarthritis the staphylococcal infection that developed after right total hip arthroplasty was seeded from a pyarthrosis of the right knee. In a 61-year-old woman with rheumatoid arthritis the sites of bilateral knee arthroplasties were seeded from a soft tissue infection of the left foot. These cases illustrate the potential for infection from local wound sepsis distal to joint arthroplasty. Such infections, particularly in patients with rheumatoid arthritis, should be treated aggressively to avoid seeding of the more proximal total joint arthroplasty site.     

关节镜下经膝逆行击出股骨侧假体在髋关节翻修术中的应用

目的探讨关节镜下经膝逆行击出法在股骨侧假体翻修术中的应用及疗效。方法对16例患者采用关节镜下经膝逆行击出法取出股骨假体柄、骨水泥,行髋关节翻修手术。结果16例均获随访,时间6-24个月,髋关节功能均良好。Harris评分82-98（92±4.35）分。结论采用关节镜下经膝逆行击打法取出股骨侧假体和骨水泥,手术时间短,创伤小,患者可早期功能锻炼,无需加长柄假体,手术效果良好。     

Patients are more satisfied than they expected after joint arthroplasty

The aim of this study was to compare the preoperative patients' expectations with their postoperative satisfaction after arthroplasties of the hip and knee, using a visual analogue scale. The comparison was made in a group of 44 patients after 44 primary knee and hip joint arthroplasties. A visual analogue scale (VAS) was used for the assessment of expectation and satisfaction. The mean preoperative expectation VAS was 14.8 (SD: 14.3). The mean patient satisfaction at time of follow up was 13.0 (SD : 21.1). We found no agreement in the preoperative patient's expectation satisfaction versus postoperative satisfaction (p = 0.66). Moreover in our study, the patients expected to be less satisfied than they actually were at follow-up, which is shown with the Bland and Altman method. It appears that patients are not capable of predicting the outcome of the joint arthroplasty, which could be influenced by negative preoperative information on complications and risks. Pain and functional disability are probably the most important factors for the patients' satisfaction after arthroplasty surgery.     

Two-stage revision arthroplasty for coagulase-negative staphylococcal periprosthetic joint infection of the hip and knee

BACKGROUND Periprosthetic joint infections(PJIs) are frequently caused by coagulase-negative Staphylococci(Co NS), which is known to be a hard-to-treat microorganism.Antibiotic resistance among causative pathogens of PJI is increasing. Two-stage revision is the favoured treatment for chronic Co NS infection of a hip or knee prosthesis. We hypothesised that the infection eradication rate of our treatment protocol for two-stage revision surgery for Co NS PJI of the hip and knee would be comparable to eradication rates described in the literature.AIM To evaluate the infection eradication rate of two-stage revision arthroplasty for PJI caused by Co NS.METHODS All patients treated with two-stage revision of a hip or knee prosthesis were retrospectively included. Patients with Co NS infection were included in the study, including polymicrobial cases. Primary outcome was infection eradication at final follow-up.RESULTS Forty-four patients were included in the study. Twenty-nine patients were treated for PJI of the hip and fifteen for PJI of the knee. At final follow-up after a mean of 37 mo, recurrent or persistent infection was present in eleven patients.CONCLUSION PJI with Co NS can be a difficult to treat infection due to increasing antibiotic resistance. Infection eradication rate of 70%-80% may be achieved.     

Total joint arthroplasty in patients with osteopetrosis: a report of 5 cases and review of the literature

Osteopetrosis, an inherited disorder of bone metabolism, is associated with multiple musculoskeletal complications. Two of these problems, osteoarthritis and periarticular nonunions, may be considered for treatment with total joint arthroplasty. However, there is little information on the early and longer-term results, complications, and technical difficulties related to performing arthroplasty in patients with osteopetrosis. We report the results of 3 total hip arthroplasties and 2 total knee arthroplasties in patients with osteopetrosis. These cases in combination with a literature review provide further insight into results, complications, and technical challenges of performing total joint arthroplasty in patients with osteopetrosis.     

Total joint arthroplasty in orthotopic liver transplant recipients

Eight total hip and two total knee arthroplasties were performed from 1986 to 1991 in eight patients who had orthotopic liver transplantation. The indications for joint arthroplasty were avascular necrosis of the femoral head in five hips, pathologic femoral neck fracture caused by osteopenia in three hips, avascular necrosis of femoral and tibial condyles in one knee, and posttraumatic arthritis in one knee. Six patients (75%) had significant osteopenia. The mean interval between liver transplantation surgery and hip or knee joint arthroplasty was 2 years (8–48 months). The patients who had hip arthroplasty were followed for a mean of 4.85 years (2–8 years), and those who had a knee arthroplasty after a hip arthroplasty, for a mean of 3.5 years (2–5 years) after the knee arthroplasty. In the patients who had hip arthroplasty, the mean Harris hip score was improved from 34 to 82 points. In the two patients who had a knee arthroplasty, the mean score was improved to 100 points both for pain and function of the knee and for overall function from mean preoperative knee scores of 49 and 25 points, respectively. Radiographs did not reveal any loosening of the components. None of the patients required reoperation, and there were no serious postoperative complications.     

罗哌卡因复合液关节周围注射对膝关节置换术后镇痛的效果评价

背景：屈曲畸形骨关节炎患者行全膝关节置换术中进行大范围软组织松解,术后存在较严重的急性疼痛,导致早期功能恢复不佳而影响手术效果。目前有多种围手术期镇痛模式,其中关节周围注射复合镇痛药物简单易行,可较好控制置换术后的早期疼痛,减少不良反应。目的：观察罗哌卡因复合液关节周围注射在屈曲畸形骨关节炎患者行全膝关节置换术后的镇痛效果及其对早期功能恢复的作用。方法：60例屈曲畸形骨关节炎患者均接受初次单侧全膝关节置换术,随机分为2组：对照组（n=30）接受术后静脉自控镇痛治疗,实验组（n=30）接受术后静脉自控镇痛治疗,同时术中在关节周围注射复合麻醉药物（盐酸罗哌卡因＋肾上腺素）。评估手术前后患膝静止和活动时的视觉模拟疼痛评分（VAS）及活动范围,比较两组术后早期镇痛效果及早期功能恢复情况。结果：实验组术后4、8、12、24、36h患膝静息时和活动时VAS评分均小于对照组（P〈0.05）,活动范围大于对照组（P〈0.05）;实验组术后48h、3d运动时VAS评分小于对照组（P〈0.05）,静息时VAS评分与对照组比较无显著性差异（P〉0.05）,活动范围大于对照组（P〈0.05）;术后7d两组间VAS评分及活动范围无统计学差异（P〉0.05）。结论：关节周围注射罗哌卡因复合液可减轻屈曲畸形骨关节炎患者行全膝关节置换术后的早期疼痛,提高关节活动度,有助于早期功能恢复。     

多关节置换治疗晚期下肢关节疾患

目的探讨下肢多关节置换治疗晚期关节疾患的有效性。方法回顾分析2000年1月-2007年12月行下肢3个或以上关节置换的5例患者临床资料。男3例,女2例,年龄27～59岁,平均41.8岁。强直性脊柱炎2例,类风湿性关节炎3例;均为下肢髋、膝关节受累。4例完全丧失行走功能,1例患者扶拐可自行活动。髋关节功能根据Harris评分标准为(24±24)分,膝关节功能根据美国特种外科医院(HSS)评分标准为(28±15)分。一期多关节置换2例,二期置换2例,三期置换1例。结果术后患者切口均Ⅰ期愈合。1例术后发生髋关节脱位,手法复位后给予下肢制动皮牵引3周,无关节再脱位发生。2例术后2 d内出现贫血,给予积极扩容补充红细胞后改善。5例患者均获随访,随访时间46～140个月,平均75个月。患者基本能正常行走及上、下楼梯。髋、膝关节稳定性好,无关节感染及松动发生。末次随访时,髋关节功能根据Harris评分为(88±6)分,与术前比较差异有统计学意义(t=8.16,P=0.00);膝关节功能根据HSS评分为(86±6)分,与术前比较差异有统计学意义(t=13.96,P=0.00)。结论下肢多关节置换是治疗晚期关节疾患的有效方法,可显著提高患者生活质量。     

Postoperative blood salvage using the Cell Saver after total joint arthroplasty

The purpose of this study was to investigate whether the salvage in the recovery room of blood from the drainage tubes of patients who had total joint arthroplasty was both feasible and efficacious. The cases of seventy-four patients who had seventy-six consecutive total hip or knee arthroplasties were studied prospectively. Intraoperative salvage of blood was performed using the Cell Saver. After closure of the fascial layer or joint capsule, the drainage tubes were connected to the Cell Saver in the operating room and remained connected in the recovery room for a mean of 2.9 hours. Blood that was collected in the recovery room was then processed and transfused back to the patient. The average amount of blood that was salvaged after different types of arthroplasty varied. The addition of bone cement to the acetabular side during primary total hip replacement decreased the amount of postoperative bleeding and of salvaged blood (p = 0.018), whereas cementing the femoral component had no statistically significant effect. Revision total hip replacement also resulted in more bleeding and in the collection of more blood in the recovery room than did primary total hip replacement (p = 0.03), especially if cement was not used (p less than 0.001). There were no statistical differences in the amount of blood that was collected in the recovery room after unilateral, bilateral, primary, or revision total knee replacement.(ABSTRACT TRUNCATED AT 250 WORDS)     

Total joint arthroplasty in patients surgically treated for morbid obesity

The results of 20 total hip and knee arthroplasties performed in patients with morbid obesity who were treated with bariatric surgery before arthroplasty are reviewed. Bariatric surgery was successful in reducing the Quetelet ratio (weight in kilogram divided by height in square meters) of patients from a mean of 49 kg/m(2) (range, 38-56 kg/m(2)) to a mean of 29 kg/m(2) (range, 25-32 kg/m(2)). The average time from bariatric surgery to arthroplasty was 23 months (range, 7-65 months). The cumulative Knee Society score had improved significantly from a mean of 103.6 (range, 45-165) before arthroplasty to a mean of 148.9 (range, 66-185) at final follow-up in 12 knees undergoing total knee arthroplasty (P<.01). The Harris hip score also had increased significantly from a prearthroplasty mean of 40 (range, 25-55) to 67.5 (range, 50-95) at final follow-up in 8 hips receiving total hip arthroplasties (P<.05). All but 1 patient with continuing patellofemoral pain were satisfied with the result of the arthroplasty at final follow-up. One hip was revised at 5 years for aseptic loosening of the femoral component; no knee revisions were required. All other prostheses were stable with no evidence of radiographic loosening or wear at final surveillance. Morbidly obese individuals, with severe degenerative joint disease, who are considered unsuitable for arthroplasty because of excess weight should be considered for bariatric surgery. Total joint arthroplasty after surgical treatment of obesity has an excellent outcome with an acceptable complication rate.