膝关节置换术后感染的研究进展

<正>随着生物材料和生物力学的不断发展,全膝关节置换术(total knee arthroplasty,TKA)已成为一种治疗多种膝关节疾病的有效方法,可以彻底缓解患者疼痛,最大限度恢复关节功能。术后感染是TKA最严重的并发症,术后感染使膝关节内解剖结构改变、骨缺损、软组织挛缩等,增大了膝关节翻修手术的难度,治疗十分棘手。TKA术后感染率在1%~3%[1],往往要经历长期的抗生素治疗、     

人工膝关节置换术后感染的临床研究进展

感染是膝关节置换术（total knee arthroplasty，TKA）后一种严重的并发症。由于全膝关节置换术患者的老龄化趋势以及假体在体内留存时间增长所带来的持续性感染风险，未来TKA术后感染的发病率还将有所上升。本文就近年来国际上关于人工膝关节置换术后感染的一些临床研究进展作一综述。     

膝关节置换术后发热的相关因素分析

[目的]分析引起膝关节置换术后发热的相关因素，旨在探讨术后发热与感染等因素的相关性。[方法]回顾性分析1998年8月～2006年4月问本院及华西医院骨科记录完整已行膝关节置换术的200例患者的体温表和病历。列表记录每例患者术前的平均最高体温和手术后7d每天的最高体温，同时记录术前和术后第2d的血色素值以及是否输血、使用导尿管、麻醉方式和基础疾病等。采用SPSS 12．0软件包进行统计分析。[结果]膝关节置换术前和术后7d的患者体温有显著性统计学差异（P〈0．01），78例（39．0％）患者的体温≥38℃。16例患者发展为感染，浅层感染15例，经换药和抗生素治疗治愈，1例深部感染行假体取出，最终关节融合，但其中仅有3例患者的体温增高。术后发热与感染、输血、血色素下降、是否使用导尿管、麻醉方式以及术前发热之间没有明显的相关性（P〉0．05）。[结论]膝关节置换术后1周内发热属正常生理反应，与感染等因素无显著相关性。     

人工全膝关节置换术后感染的临床分析

目的　探讨全膝关节置换术后感染的原因、处理方法及临床效果。　方法　对 1987年～ 1999年 13例全膝关节置换术后感染患者的病因以及清创、一期或二期再置换等治疗方法进行总结分析。 13例患者术前膝关节平均活动度为 5 5°,HSS评分为 36 5分 ;平均随访 3年 5个月。　结果　13例感染患者经治疗后均未复发 ,80 %的患者对手术满意 ;膝关节活动度恢复至平均 85° ,HSS评分为73 5分。　结论　类风湿关节炎 (RA)、服用激素、合并糖尿病、使用铰链式假体及初次置换术前膝关节曾行其它手术是膝关节术后感染的高危因素 ;感染明确后 ,应积极进行清创合并应用敏感抗生素 ;二期置换的临床效果优于单纯清创及一期置换     

人工全膝关节置换术后关节深部感染的处理及预防

自从50年代初以来,人工全膝关节置换术(total kneearthrop lasty,TKA)日益增多。随着假体设计的改进和外科手术技术的提高,术后结果优良率也增加。当然,合并症也象其他手术一样,是一个重要部分。最常见的问题是机械方面的松动,假体下沉,膝关节不稳,假体折断和感染等。然而,感染     

人工膝关节置换术后感染的治疗体会(附4例报告)

目的 总结人工膝关节置换术后感染的原因及治疗体会。方法 对1996年5月至2003年5月4例人工全膝关节置换术后感染在病原学、临床表现、治疗及再次翻修手术进行回顾性分析。结果 经抗感染、清创及二期再置换等处理，3例治愈，1例感染无法控制而截肢。结论 对膝关节置换术后感染，可行单纯清创，抗感染治疗或清创后一期或二期再置换术等治疗，再置换以二期置换效果为好。     

按摩疗法对人工全膝关节置换术术后疼痛的影响

目的 探讨按摩疗法对人工全膝关节置换术（total knee arthroplasty,TKA）术后患者疼痛的影响。方法 选取我院拟行单膝 TKA 患者 142 例,分成对照组和观察组,每组 71 例。对照组患者 TKA 术后行常规术后护理,观察组患者 TKA 术后在常规术后护理基础上行按摩疗法。结果 观察组患者术后 6、12、18 和 24 h 疼痛评分和均显著低于对照组患者（P<0.05）;观察组患者术后6、12 和24 h 焦虑率显著低于对照组患者（P<0.05）;观察组患者术后6、12 和24 h 吗啡用量均显著低于对照组患者（P<0.05）;观察组患者术后满意度评分显著高于对照组患者（P<0.05）。结论 按摩疗法可显著降低 TKA 术后患者疼痛和焦虑感,减少患者镇痛药物使用,提高患者术后满意度。     

人工全膝关节置换术后深部感染的治疗

目的探讨人工全膝关节置换(total knee arthroplasty,TKA)术后深部感染的处理方法及疗效。方法2004年1月-2010年1月,收治TKA术后深部感染患者32例(32膝)。男13例,女19例;年龄52～79岁,平均64.6岁。TKA手术距发生感染时间为3周～10年。膝关节功能采用膝关节学会评分系统(KSS)为(104.6±9.1)分,疼痛视觉模拟评分(VAS)为(7.8±1.4)分。急性感染3例行关节切开清创后持续冲洗;急性血源性播散感染3例于关节镜下清创;慢性感染26例,其中行关节切开清创后持续冲洗9例,抗生素骨水泥隔体植入4例,二期翻修12例,抗生素保守治疗1例。结果急性感染者治疗均失败,急性血源性播散感染者1例治疗失败,慢性感染者7例清创及1例保守治疗失败;均经对症治疗后治愈。32例患者均获随访,随访时间2～8年,平均4.6年。末次随访时KSS评分为(158.4±8.3)分,VAS评分为(4.1±0.8)分,与术前比较差异有统计学意义(P<0.05)。随访期间再感染3例,均为二期翻修患者。结论TKA术后耐甲氧西林金黄色葡萄球菌急性感染切开清创成功率低;急性血源性播散感染可试行关节镜下清创;慢性感染二期翻修膝关节功能恢复良好,但远期存在再感染风险。     

人工膝关节置换术后康复训练几点体会

近年来 ,随着人们生活水平的提高 ,晚期膝关节病变患者对于提高生活质量的要求越来越高。而人工膝关节置换术(TKA)的出现则可以很好的解决这一问题。作者于 1990年以来共收治 2 1例 ( 2 9膝 ) ,术后进行康复训练 ,取得满意疗效。1　临床资料本组 2 1例 ,男 13例 ,女 8例。年龄 2 3～ 78岁 ,平均 5 1 2岁。类风湿性关节炎 14例 ,骨性关节炎 7例 ;双侧置换 8例 ,单侧置换 13例。屈膝畸形 12～ 90° ,平均 3 5° ,活动度 0～ 90° ,平均 46°。股四头肌肌力Ⅱ级 18膝 ,Ⅲ级 11膝。全部病例均行人工全膝关节置换术。术后早期进行康复训练。结…     

全膝关节置换术后的康复护理

本院开展全膝关节置换术已多年 ,从 1998～ 2 0 0 0年 12月对 36例手术患者进行针对性的康复护理 ,取得了满意的效果 ,现报告如下 :1　临床资料本组 36例 ,男 4例 ,女 32例 ,年龄为 42～ 72岁 ,平均 6 0岁。手术采用膝正中切口 ,即髌上缘以上 7.5ｃｍ处至胫骨结节内侧作膝关节前正中皮肤切开。主要病因 :类风湿性关节炎 2 9例 ,骨性关节炎 5例 ,创伤性关节炎 2例。出院后随访 1年 ,效果满意。假体位置及膝关节功能良好。2　术后康复护理积极防治术后并发症 ,人工关节置换术是人体较大的重建手术 ,术后易发生多种并发症。2 .1　出血　人工全…     

全膝关节置换术围手术期镇痛

目的探讨全膝关节置换术(TKA)围手术期镇痛效果,获得最佳的镇痛方案。方法2005年1月至2006年4月的82例单侧TKA手术患者随机分成两组,采用不同的镇痛方案进行围手术期镇痛治疗。对术后疼痛进行评分分析并观察并发症。结果两种镇痛方法均具有明显的镇痛效果,患者满意率及功能康复效果取得明显改善,并发症发生率较低。结论TKA围手术期采用积极的综合镇痛措施,具有重要意义。     

Evaluation of fever in the immediate postoperative period in patients who underwent total joint arthroplasty

Forty percent to 50% of patients may experience an immediate postoperative fever. Research suggests that these are of aseptic cause due to inflammatory mediators. This is a retrospective analysis of fevers in total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients from 2006 to 2008. Thirty-six percent of THA and 31% of TKA patients developed a fever, with most developing a maximum temperature on postoperative day (POD) 2. The maximum mean temperature between the THA and TKA group was not significantly different. Fevers in the immediate postoperative period are a normal variant in patients undergoing THA or TKA. Urinalysis, urine culture and sensitivity, and chest x-ray are not required during this period because most of these fevers stem from aseptic causes.     

人工膝关节术后感染的诊断和二期翻修术

目的：对人工膝关节(TKA)术后感染接受二次翻修术的膝关节进行评估。方法：1996年1月～2002年1月实行人工膝关节置换术353膝，其中5个膝关节在术后出现感染，行二期翻修术即一期手术取出原假体，彻底清创，置入抗生素骨水泥间隙垫，术后使用6周以上的敏感抗生素，二期手术作假体翻修术。结果：平均随访2年，无1例翻修的膝关节发生感染或无菌性松动。最近一次随访时平均膝关节功能评分从翻修术前的0分增加到术后的58分(20～100分)，平均膝关节疼痛评分从术前的38分(24～50分)增加到术后的93分(87—100分)。结论：应该尽量采用二期翻修术处理TKA术后感染，以彻底的清除感染灶，使病人获得良好的功能。     

Postoperative numbness of the knee following total knee arthroplasty

Introduction

The infrapatellar branch of the saphenous nerve is often injured during total knee arthroplasty (TKA), leading to numbness in its distribution distal to the incision. This is illustrated in a patient who suffered full-thickness burns to the lateral aspect of the knee from a hot water bottle. However, the proportion of patients who are informed of this phenomenon (as well as the effect of informing the patient of numbness) has not previously been studied according to the authors’ knowledge. The aim of this study was to establish the proportion of patients with whom postoperative numbness was discussed during the consent procedure and whether this discussion was documented.

Methods

A total of 73 patients (103 TKAs) agreed to take part in this study between 16 May and 9 July 2011. Patients were asked about their recollection of numbness being mentioned prior to the procedure as well as whether they experienced postoperative numbness. Statistical analysis was performed using SPSS®.

Results

Subjective numbness was noted in 27% of the patients in this study. The prevalence of numbness decreased with time. Patients whose consent process included a discussion of numbness were 3.3 times more likely to report numbness after TKA (p=0.003).

Conclusions

Patient education regarding postoperative numbness increases the patient’s awareness of any insensate skin that may develop. Numbness after TKA does improve with time but does not resolve completely. It is therefore recommended by the authors that numbness is discussed preoperatively with the patient and that this discussion is documented.     

Surgical factors for total knee arthroplasty in younger patients

With improvements in implant modularity and polyethylene, it is important to assess the contemporary performance of cement vs. cementless fixation in total knee arthroplasty (TKA). Aseptic loosening is the most common indication for revision. Registry data indicates that the type of fixation (cemented, cementless, or hybrid) makes little difference in revision rates for younger patients (<55 years old). Regardless of the type of fixation, there is an opportunity for improvement. Attention to surgical factors, such as coronal alignment and cementing technique, can improve the survivorship of TKA.     

对侧膝关节疼痛对全膝关节置换手术患者的临床影响

目的:评估对侧膝关节疼痛程度对骨性关节炎患者全膝关节置换术(total knee arthroplasty,TKA)后1年手术侧关节功能障碍及治疗满意度的影响。方法:2019年3月至2021年1月行TKA的635例患者,男296例,女339例;年龄(69.33±9.38)岁,病程(1.15±0.44)年。根据术后对侧膝关节疼痛视觉模拟评分(visual analogue scale,VAS)分为轻度或无疼痛(VAS 0～3分)423例,中度疼痛(VAS 4～6分)105例,重度疼痛(VAS 7～10分)107例。分析比较对侧膝关节不同疼痛程度对术后12个月膝关节功能及满意度评分的影响。结果:对侧膝关节疼痛VAS在TKA术后明显降低,年龄大、身体质量指数高、术后手术侧膝关节WOMAC评分高、对侧膝关节中、重度疼痛是患者不满意的危险因素(P<0.05),OR分别为1.285、1.665、2.319、1.863。手术侧膝关节疼痛度高、居家环境为步梯房是患者出院1年后WOMAC评分高的危险因素(P<0.05);出院后坚持锻炼、功能性训练是患者出院1年后WOMAC评分高的保护因素(P...     

Bilateral staged total knee arthroplasty in obese patients

Introduction The purpose of this study was to compare the clinical and functional results and complications associated with staged bilateral total knee arthroplasty (TKA) performed 4–11 days apart during a single hospitalization in patients who were obese and patients who were not obese. Methods We retrospectively evaluated 48 (96 knees) patients who were obese and divided into two groups based on their body mass indices (BMI). Morbidly obese patients (group A1, BMI ≥ 40 kg/m²) consisted of 21 patients (42 knees), and obese patients (group A2, BMI ≥ 30 kg/m²) consisted of 27 patients (54 knees). The control group (group B, BMI < 30 kg/m²) consisted of 20 non-obese patients (40 knees), who were undergoing staged bilateral procedure within the same time frame. All patients had cemented TKAs with use of posterior cruciate sparing prosthesis without patellar resurfacing. If medically stable after the first arthroplasty the patients then underwent the second arthroplasty 4–11 days later. The data on major complications and minor complications were evaluated. Results Although, there was no statistically significant difference in overall complication rates in any of the groups, the non-obese group had fewer wound complications than the other groups (P > 0.05). No significant differences in preoperative or postoperative Knee Society score, and functional score could be demonstrated between the three groups (P > 0.05). Both obese and nonobese patients showed improvements in pain and function from pre-surgery to a minimum 2 years follow-up. Conclusion Results of bilateral staged TKAs in obese patients have low complication and high success rates and increased BMI has no negative effect on the early outcome. Bilateral staged TKA might be a good treatment alternative for the improvement of the patient’s quality of life and functional and clinical outcomes.     

The painful total knee arthroplasty: Keys to diagnosis

As the prevalance of patients living with total knee replacements continues to rise we continue to see a significant portion of patients living with pain following their primary total knee arthroplasty. For some patients, the etiology of their pain following knee replacement is obvious, yet in many cases the cause of pain remains elusive and thus creates a significant burden for the patient and treating physician. In this review article we focus on common sources of pain following knee replacement and discuss keys to diagnosis. We also propose a unique clinical pathway algorithm to guide diagnostic work up and treatment options.     

Intraoperative cutting errors in total knee arthroplasty

Introduction Precise reconstruction of leg alignment offers the best opportunity for achieving good long-term results in total knee arthroplasty (TKA). It was the aim of this study to evaluate the bone-cutting process as a potential source of inaccuracy in TKA.Materials and methods In a consecutive series of 50 computer-assisted TKAs, cutting errors, which were defined as a difference between the cutting block position before sawing and the achieved resection plane afterwards, were measured for the distal femur and proximal tibia resection. Measurements were performed using a CT-based navigation system.Results For the distal femoral cut, there was a mean varus/valgus deviation of 0.6° (SD±0.5°) and a mean flexion/extension deviation of 1.4° (SD±1.3°). For the proximal tibia, varus/valgus alignment showed a mean deviation of 0.5° (SD±0.5°). The mean sagittal variability was 1.0° (SD±0.9°). Differences between the frontal and the sagittal plane were significant.Conclusion To minimize cutting errors, techniques and instruments are needed which enable a more stable fixation of the cutting blocks or even more appropriate preparation instruments. Using a computer-assisted technique, the surgeon is aware of cutting errors occurring at each point of the operation and will therefore be able to correct these errors during surgery, while he is not aware of those errors with the conventional TKA technique.     

超声引导下外侧入路坐骨神经阻滞在全膝关节置换术后镇痛中的应用

目的研究超声引导下外侧入路坐骨神经阻滞在全膝关节置换术(TKA)术后镇痛中的应用情况,并与传统的后入路法比较,评价其临床应用价值。方法选择气管插管全麻下行单侧TKA手术患者60例,男22例,女38例,年龄60～85岁,ASAⅡ或Ⅲ级,所有患者术毕拔管送麻醉恢复室,在超声引导下行单次股神经联合坐骨神经阻滞镇痛,根据坐骨神经入路不同,随机分为2组(n=30):外侧入路组(L组),仰卧位下于转子下股骨干中上段外侧行坐骨神经阻滞镇痛;后入路组(P组),侧卧位下于坐骨结节和股骨大转子间行坐骨神经阻滞镇痛。记录坐骨神经阻滞操作完成时间、穿刺针深度、最低平均电流刺激的强度、穿刺成功率、坐骨神经感觉阻滞起效时间、持续时间和患者对操作满意度评分;收集术后36h内不同时点静息和活动时VAS评分及并发症的发生情况。结果L组操作完成时间明显短于P组(P0.05),进针深度明显浅于P组(P0.05),穿刺的成功率和患者满意度均明显高于P组(P0.05);两组术后不同时点静息和活动时VAS评分、术后镇痛药物使用情况和肌力差异无统计学意义。两组术后36h内均未见局部红肿、感染和神经损伤等麻醉相关并发症。结论与传统的转子间水平后入路法比较,超声联合神经电刺激针引导坐骨神经阻滞镇痛的外侧入路是一种更简单而安全有效的穿刺入路技术。