人工关节假体周围感染血清学指标的研究现状

随着社会经济的发展、人民生活水平的提高,人工关节置换术在中国各大医院开展的也越来越多。而人工关节假体周围感染是人工关节置换术后严重的并发症之一。人工关节假体周围感染的早期诊断是影响治疗及预后的重要因素,目前临床尚无独立的、可靠的血清学诊断指标。本文筛选了近年来提出的用于人工关节假体周围感染临床诊断的一些血清学检测指标,并予以综述。合理的运用这些指标,将为临床骨科医师对人工关节假体周围感染的早期诊断、治疗及预后判断提供积极作用。     

铰链式全膝关节置换术后假体周围骨折

假体周围骨折是人工关节置换术术后并发症之一,其发生与假体类型及患者自身因素密切相关,并且治疗方法相对复杂,本文针对铰链式全膝关节置换术后假体周围骨折的产生机理及其治疗手段进行回顾性的文献复习,以期对此类骨折的认识及治疗策略的选择有所帮助。     

机器人辅助全髋关节置换术围手术期并发症的特点及危险因素分析

目的：深入研究机器人辅助全髋关节置换术围手术期并发症的特点及危险因素。方法：选择2020年7月至2021年12月采用MAKO机器人辅助全髋关节置换术患者125例,其中男61例,女64例,平均年龄（65.2±7.6）岁。收集并统计患者的性别、年龄、体重指数、糖尿病史、术前血红蛋白水平、围手术期并发症、手术时间及诊断。采用单因素分析及logistic回归分析围手术期并发症的危险因素。结果：17例患者（21例次）发生围手术期并发症,包括髋臼隐匿性假体周围骨折14例次、股骨柄隐匿性假体周围骨折1例次、重度贫血及输血4例次、脑梗死1例次和肺炎1例次。所有隐匿性假体周围骨折患者均正常康复。单因素分析结果提示,并发症组和无并发症组间性别、年龄、高血压病史、糖尿病史、术前血红蛋白水平、体重指数、手术时间和诊断差异无统计学意义;重度贫血组和无重度贫血组术前血红蛋白水平差异有统计学意义（P<0.05）。Logistic回归分析提示,术前血红蛋白水平与术后重度贫血存在显著相关性。结论：机器人辅助全髋关节置换术存在一定的假体周围隐匿性骨折风险,但是该种隐匿性假体周围骨折不影响术后正常康复。同时,术后贫血...     

超声裂解法在诊断假体周围感染的应用

<正>人工关节置换术是一种有效、常用的骨科手术技术,能够改善关节功能,提高患者的生活质量。假体周围感染是人工关节置换术后最严重的并发症。虽然发生率很低,在膝、肩关节置换术后的发生率1%,髋关节置换术后发生率2%[1],但是一旦发生感染给患者带来巨大的痛苦和经济负担。一份来自发展中国家的报告显示[2],假体周围感染患者     

人工髋膝关节置换术后感染治疗进展

假体周围感染作为人工关节置换术后最严重的并发症之一,其治疗方式的选择一直未有明确标准.目前临床上关节置换术后感染的治疗方法,以二期翻修术最为常见,其感染清除率可达到82％～92％,但该术式需要的时间比较长,花费高,而且可能会增加患者术后并发症的发生率和病死率.本文就人工髋关节、膝关节置换术后感染治疗现状进行了综述,旨在...     

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。     

锁定加压接骨板治疗人工关节术后假体周围骨折

目的 报告应用锁定加压接骨板治疗人工关节术后无松动的假体周围骨折的初步临床结果.方法 从2004年11月到2007年7月,治疗人工关节术后无松动的假体周围骨折共8例,其中男3例,女5例,平均年龄66岁(61～72岁).其中全髋置换术后5例,半髋置换术后2例,全膝置换术后1例.按照Vancouver分型,7例髋关节置换术后假体周围骨折中有B1型5例,C型2例;1例膝关节置换术后假体周围骨折为Rorabeck Ⅱ型.选择锁定加压接骨板(单钢板4例,双钢板1例,微创内固定系统3例)作为内固定器进行复位内固定手术.手术后2天开始功能锻炼,12周开始完全负重.结果 随访时间平均14.5个月(4～27个月).术后12周8例骨折均愈合.x线显示假体稳定,无松动表现.髋关节置换术后假体周围骨折Harris评分平均88.75分(84～93分);膝关节置换术后假体周围骨折HSS评分92分.无感染、深静脉血栓形成等并发症.结论 应用锁定加压接骨板,闭合或切开复位内固定治疗人工关节术后假体周围骨折初步临床结果良好.     

全髋关节置换术治疗髋臼骨折后创伤性关节炎的疗效观察

目的探讨人工全髋关节置换术治疗髋臼骨折后髋关节创伤性骨关节炎的疗效。方法本组共随访髋臼骨折后髋关节创伤性骨关节炎患者32例32髋,男20例,女12例,平均年龄45.3岁。本组患者全部行人工全髋关节置换术治疗。所有假体均采用生物型假体。采用Harris、UCLA评分对患者术前术后的髋关节功能进行评分,拍摄标准双髋正位片对假体状态进行影像学评估。结果本组患者平均随访26个月,Harris评分由术前42.5分增加到术后93.6分,UCLA评分由术前3.2分增加到术后8.1分,改变有统计学差异。影像学评估显示假体位置良好,无假体松动、关节脱位、感染及明显假体周围骨溶解等并发症。结论全髋关节置换是治疗髋臼骨折后创伤性关节炎的有效治疗手段,术中尽量采用生物型假体,近期随访结果令人满意。     

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.     

全髋关节置换术后假体周围感染的独立危险因素分析

目的探讨全髋关节置换术后假体周围感染的相关危险因素。方法回顾性分析自2014-01—2017-12完成的516例初次全髋关节置换术,观察术后1年内是否发生假体周围感染,然后分为感染组与未感染组。比较2组在性别、年龄、体重指数、术前血红蛋白、心脏病史、呼吸系统病史、糖尿病史、假体类型、手术时间、术中出血量、术中输血量、引流放置情况方面的差异。结果术后1年内有21例(4.07%)发生假体周围感染。单因素分析结果显示,感染组与未感染组在体重指数、心脏病史、糖尿病史、手术时间方面差异有统计学意义(P <0.05);感染组与未感染组在性别、年龄、术前血红蛋白、呼吸系统病史、假体类型、术中出血量、术中输血量、引流放置情况方面差异无统计学意义(P>0.05)。Logistic多元回归分析结果显示,肥胖[OR=0.216,95%CI(0.998,1.006),P=0.009]与手术时间[OR=1.035,95%CI(1.009,1.060),P=0.007]为全髋关节置换术后假体周围感染的独立危险因素。结论肥胖及手术时间延长是初次全髋关节置换术后假体周围感染的危险因素,而假体周围感染与是否合并基础疾病无关。根据患者的体重情况优化手术策略、缩短手术时间可能有利于降低全髋关节置换术后假体周围感染风险。     

Tranexamic Acid Is Associated With Reduced Periprosthetic Joint Infection After Primary Total Joint Arthroplasty

BackgroundPrevious studies have demonstrated preoperative anemia to be a strong risk factor for periprosthetic joint infection (PJI) in total joint arthroplasty (TJA). Allogeneic blood transfusion can be associated with increased risk of PJI after primary and revision TJA. Tranexamic acid (TXA) is known to reduce blood loss and the need for allogeneic blood transfusion after TJA. The hypothesis of this study is that administration of intravenous TXA would result in a reduction in PJI after TJA.MethodsAn institutional database was utilized to identify 6340 patients undergoing primary TJA between January 1, 2013 and June 31, 2017 with a minimum of 1-year follow-up. Patients were divided into 2 groups based on whether they received intravenous TXA prior to TJA or not. Patients who developed PJI were identified. All PJI patients met the 2018 International Consensus Meeting definition for PJI. A multivariate regression analysis was performed to identify variables independently associated with PJI.ResultsOf the patients included, 3683 (58.1%) received TXA and 2657 (41.9%) did not. The overall incidence of preoperative anemia was 16%, postoperative blood transfusion 1.8%, and PJI 2.4%. Bivariate analysis showed that patients who received TXA were significantly at lower odds of infection. After adjusting for all confounding variables, multivariate regression analysis showed that TXA is associated with reduced PJI after primary TJA.ConclusionTXA can help reduce the rate of PJI after primary TJA. This protective effect is likely interlinked to reduction in blood loss, lower need for allogeneic blood transfusion, and issues related to immunomodulation associated with blood transfusion.     

Preoperative Anemia in Total Joint Arthroplasty: Is It Associated with Periprosthetic Joint Infection?

Background  

Anemia is common in patients undergoing total joint arthroplasty (TJA). Numerous studies have associated anemia with increased risk of infection, length of hospital stay, and mortality in surgical populations. However, it is unclear whether and to what degree preoperative anemia in patients undergoing TJA influences postoperative periprosthetic joint infection (PJI) and mortality.     

急性等容血液稀释在人工关节置换术中的应用

目的评价急性等容血液稀释在人工关节置换术围手术期的治疗效果以及异体血节约程度。方法回顾分析120例初次单侧人工关节置换术患者,对照组60例未进行自体血回输,实验组60例实施自体血回输,对比两组术前以及术后第2天的血红蛋白（Hb）、红细胞压积（Hct）、白蛋白（Alb）水平和术后2 d内录输注红细胞悬液和新鲜冰冻血浆的剂量。结果实验组与对照组在年龄、性别、手术类型间无统计学差异（t年龄=2.123,t性别=2.208,t手术类型=0.138,P均大于0.05）。实验组与对照组的术后Hb、术后Hct、术前Alb间无统计学差异（t术后Hb=-0.233,t术后Hct=0.310,t术前Alb=-1.698,P均大于0.05）。实验组术前Hb（140.58±13.92）g/L、术前Hct（40.43±3.83）高于对照组术前Hb（132.15±14.50）g/L、Hct（37.97±6.19）（t术前Hb=-3.251,t术前Hct=-2.626,P均小于0.05）。实验组术后Alb水平（32.70±2.05）g/L略低于对照组（33.80±3.11）g/L（t术前Alb=-1.698,t术后Alb=2.188,P均小于0.05）。实验组围手术期人均红细胞悬液和新鲜冰冻血浆使用量分别较对照组减少1.77 IU和2.45 IU（P〈0.001）。结论急性等容血液稀释自体血回输治疗在人工关节置换围手术期能够显著降低异体红细胞悬液和新鲜冰冻血浆的用量,同时不影响术后Hb以及Hct的水平。     

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。     

Preoperative use of recombinant human erythropoietin before total joint arthroplasty

BACKGROUND: Previous reports have suggested that the use of recombinant human erythropoietin is effective for decreasing the need for perioperative allogeneic blood transfusion. The purpose of this study was to evaluate the efficacy of erythropoietin in combination with, and compared with, preoperative autologous donation for reducing allogeneic blood requirements for total joint arthroplasty. METHODS: Two hundred and forty patients undergoing primary and revision total hip or knee arthroplasty were enrolled into three groups with different treatment regimens: (1) erythropoietin and preoperative autologous donation (Group 1), (2) erythropoietin alone (Group 2), and (3) preoperative autologous donation alone (Group 3). Patients were evaluated with regard to requirements for allogeneic transfusion, change from the baseline to the lowest postoperative hemoglobin value, postoperative complications, and adverse reactions. RESULTS: The rate of allogeneic transfusion was 11% in Group 1 (erythropoietin and preoperative autologous donation) compared with 28% in Group 2 (erythropoietin alone) and 33% in Group 3 (preoperative autologous donation alone). Within Group 1, patients who had a unilateral primary arthroplasty had an allogeneic transfusion rate of 4% and those who had a bilateral or revision arthroplasty had an allogeneic transfusion rate of 17%. In Groups 2 and 3, the allogeneic transfusion rates were 14% and 15%, respectively, for the patients who had a unilateral primary arthroplasty and 35% and 47%, respectively, for those who had a bilateral or revision arthroplasty. CONCLUSIONS: Preoperative use of erythropoietin in conjunction with preoperative autologous donation reduces the need for allogeneic blood transfusion associated with total joint arthroplasty more effectively than does either erythropoietin or preoperative autologous donation alone.     

Can tranexamic acid change preoperative anemia management during total joint arthroplasty?

AIM: To investigate the postoperative transfusion and complication rates of anemic and nonanemic total joint arthroplasty patients given tranexamic acid (TXA).METHODS: A cross-sectional prospective study was conducted of primary hip and knee arthroplasty cases performed from 11/2012 to 6/2014. Exclusion criteria included revision arthroplasty, bilateral arthroplasty, acute arthroplasty after fracture, and contraindication to TXA. Patients were screened prior to surgery, with anemia was defined as hemoglobin of less than 12 g/dL for females and of less than 13 g/dL for males. Patients were divided into four different groups, based on the type of arthroplasty (total hip or total knee) and hemoglobin status (anemic or nonanemic). Intraoperatively, all patients received 2 g of intravenous TXA during surgery. Postoperatively, allogeneic blood transfusion (ABT) was directed by both clinical symptoms and relative hemoglobin change. Complications were recorded within the first two weeks after surgery and included thromboembolism, infection, and wound breakdown. The differences in transfusion and complication rates, as well as the relative hemoglobin change, were compared between anemic and nonanemic groups.RESULTS: A total of 232 patients undergoing primary joint arthroplasty were included in the study. For the total hip arthroplasty cohort, 21% (18/84) of patients presented with preoperative anemia. Two patients in the anemic group and two patients in the nonanemic group needed ABTs; this was not significantly different (P = 0.20). One patient in the anemic group presented with a deep venous thromboembolism while no patients in the nonanemic group had an acute complication; this was not significantly different (P = 0.21). For nonanemic patients, the average change in hemoglobin was 2.73 ± 1.17 g/dL. For anemic patients, the average change in hemoglobin was 2.28 ± 0.96 g/dL. Between the two groups, the hemoglobin difference of 0.45 g/dL was not significant (P = 0.13). For the total knee arthroplasty cohort, 18% (26/148) of patients presented with preoperative anemia. No patients in either group required a blood transfusion or had an acute postoperative complication. For nonanemic patients, the average change in hemoglobin was 1.85 ± 0.79 g/dL. For anemic patients, the average change in hemoglobin was 1.09 ± 0.58 g/dL. Between the two groups, the hemoglobin difference of 0.76 g/dL was significant (P < 0.001).CONCLUSION: TXA administration results in low transfusion and complication rates and may be a useful adjunct for TJA patients with preoperative anemia.     

Routine Postoperative Complete Blood Counts Are Not Necessary After Most Primary Total Hip and Knee Arthroplasties

BackgroundRoutine postoperative complete blood count tests are commonplace after total joint arthroplasty. The goal of this study was to identify if these result in any clinically meaningful action and if it would be safe to forego this testing in a population without known risk factors for transfusion.MethodsA retrospective review of 1060 patients undergoing a total knee or total hip arthroplasty at a single institution was performed. Data points including patient demographics, preoperative and postoperative laboratory results, tranexamic acid use, preoperative and postoperative medication for venous thromboembolism prophylaxis and anticoagulation, as well as 90-day readmission related to anemia were collected.ResultsThe transfusion rate for all patients was 0.66% (7/1060) and there was only one transfusion for a patient with a preoperative hemoglobin (Hb) greater than 12 g/dL (1/976; 0.1%). There was no difference in the change from preoperative to postoperative day 1 Hb levels in patients treated with aspirin compared with those on direct oral anticoagulation (P = .73). There were no 90-day readmissions related to acute blood loss anemia.ConclusionsThis study demonstrates that routine postoperative complete blood count testing is not absolutely necessary and does not provide additional value in the vast majority of patients with preoperative Hb levels equal to or greater than 12 g/dL when tranexamic acid is administered. This could avoid unnecessary testing in patients and increased savings to the health care system.Level of EvidenceLevel 3, retrospective cohort.     

Patients With Infected Total Hip Arthroplasty Undergoing 2-Stage Exchange Arthroplasty Experience Massive Blood Loss

Background

Two-stage exchange arthroplasty is the preferred treatment for chronic periprosthetic joint infection following total hip arthroplasty (THA). These patients are at high risk of substantial blood loss and perioperative blood transfusion. Our study aimed at determining risk factors for blood transfusion during a 2-stage exchange for infected THA.

Blood management in two-stage revision knee arthroplasty for deep prosthetic infection.

Treatment of infected total knee arthroplasty requires aggressive management to treat the infection and restore joint function. For patients with infected knee arthroplasties, a two-stage procedure is used that involves resection of the joint and placement of an antibiotic impregnated cement spacer followed by implantation of a new prosthetic 6 weeks later. Patients undergoing the two-stage procedure typically endure high allogeneic blood transfusion rates (82% to 88%) and progressive anemia because the two surgeries are spaced closely and because the infection precludes the use of alternatives to allogeneic blood. Records were reviewed of 75 patients who underwent two-stage total knee arthroplasty to characterize perioperative hemoglobin levels and blood transfusion needs in this patient group. Although transfusions were administered only when warranted by clinical symptoms and were not based on predetermined hematologic values, 62 (82%) patients received a mean of 2.3 units of blood at first-stage surgery, and 60 (80%) patients received a mean of 2.1 units of blood at the second stage. Overall, only 12% of patients did not have allogeneic blood transfusion. At the first stage before resection, mean hemoglobin concentration was 11.6 g/dL and reached a mean nadir of 8.6 g/dL 3 days after surgery. At the second stage before reimplantation, hemoglobin concentration averaged 11.1 g/dL and reached a mean nadir of 8.2 g/dL 3 days after surgery. After the first stage, allogeneic blood transfusion failed to improve postoperative hemoglobin levels enough to prevent transfusions associated with the second-stage. Patients undergoing two-stage total knee arthroplasty have anemia, and a substantial proportion of these patients require allogeneic blood transfusion at both stages. Thus, novel blood management practices are required to improve hemoglobin levels and reduce allogeneic transfusion rates in this patient population.