异体骨植骨重建在髋关节置换感染二期翻修中的应用

[目的]总结髋置换后感染二期翻修中采用异体骨嵌压植骨技术重建骨缺损的病例,分析临床及X线片结果,探讨异体骨植骨重建在髋关节感染二期翻修中应用的安全性及有效性.[方法]本组共4例5髋采用异体骨嵌压植骨重建感染的髋关节,平均随访14.5个月,对临床结果进行Harris评分,并对X线片进行分析.[结果]截至最后1次随访,所有病人均无感染迹象.Harris评分术前平均25.75分,术后平均82.75分,平均改善57分,肢体长度平均矫正3.1cm,术后优良率为50%.所有病例正侧位X线片上均未见假体移位、下沉,无透光线,股骨侧无股骨距处骨吸收.3例病人发生并发症,包括股骨假体穿出、脱位和外展肌无力.[结论]在髋置换感染的二期翻修中采用异体骨植骨重建是一种比较安全和可行的方法,能够获得较满意的感染控制结果和功能结果,但是该方法技术要求高,并发症发生率高,需要医生有丰富的经验和较长期的学习过程.     

二期翻修术治疗人工髋关节置换术后感染的中期疗效

目的探讨二期翻修术治疗人工髋关节置换术后感染的中期疗效。方法 2002年4月-2006年11月,收治12例人工髋关节置换术后感染患者。男5例,女7例;年龄47～72岁,平均59.8岁。人工股骨头置换2例,人工全髋关节置换10例。置换术后1～67个月发生感染。感染根据Segawa分型标准:2型1例,3型2例,4型9例。Harris评分为(36.7±6.1)分。9例C反应蛋白增高,10例红细胞沉降率增高。细菌培养提示阳性8例,阴性4例。一期清创术取出假体、彻底清创,采用抗生素骨水泥自制占位器或感染治疗型临时假体占位,术后抗感染治疗;3～10个月后行二期翻修术。结果 1例一期清创术后感染未控制,再次清创并采用抗生素骨水泥自制占位器治疗后,感染控制。其余患者术后切口均Ⅰ期愈合,无下肢深静脉血栓形成和神经损伤等并发症发生。患者术后均获随访,随访时间3～8年,平均5.4年。随访期间患者无感染复发及关节脱位。末次随访时,2例髋关节活动时有隐痛,3例有轻度跛行;Harris评分为(81.6±4.5)分,与术前比较差异有统计学意义(t=52.696,P=0.000);X线片示假体无松动及明显下沉,植骨处愈合。结论 二期翻修术治疗人工髋关节置换术后感染控制率高,可获较好中期疗效。     

应用抗生素骨水泥占位器与灌注冲洗型占位器治疗全髋关节置换术后感染的疗效比较

目的 比较两种不同抗生素给药方式的关节型占位器在全髋关节置换术后感染治疗中的效果,为全髋关节置换术后感染二期翻修手术中占位器的选择提供依据.方法 自2002年3月～2007年5月,按门诊就诊顺序共收治明确诊断的全髋关节置换术后感染病人36例(40髋),分别应用抗生素骨水泥占位器与灌注冲洗型占位器行二期翻修治疗,其中抗生素骨水泥占位器26例(29髋),灌注冲洗型占位器10例(11髋).记录两种占位器植入手术时间、术中出血量、术后卧床时间、住院时间、下地第1天及二期翻修术前1天髋关节功能、占位器植入次数、重建手术后最近一次随访的感染控制情况等指标.其中髋关节功能采用Harris评分及ROM(range of motion)测量,术前、术后常规摄x片对比.结果 所有患者均获得随访,其中1例因死亡而随访至翻修术后34个月.通过对比发现,抗生素骨水泥占位器较灌注冲洗型占位器平均植入操作时间短(2.52±0.79 h/(3.29±0.33)h,P<0.01),术中出血量少(1208.57±275.64 ml/2131.82±596.84 ml,P<0.01),术后卧床时间短(6.14±1.98 d/45.18±6.11 d,P=0.00),住院时间短(26.00±3.27 d/53.63±3.35 d,P=0.00),占位器植入后感染控制率高(100%/81.82%,P<0.01);而下地第1天两组平均Harris评分相似(56.85±9.61/56.41±6.31),屈伸ROM结果类似(75.31°±6.34°/76.09°±5.49°),翻修术前抗生素骨水泥占位器组平均Harris评分更高(86.78±7.49/80.35±6.37,P<0.05),屈伸ROM差别也不显著(95.16°±4.47°/97.35°±6.22°).结论 在治疗髋关节置换术后感染中,抗生素骨水泥型占位器较灌注冲洗型占位器具有植入操作时间短,术中出血量少,术后卧床时间短,住院时间短,下地后功能更好及无需长期灌注冲洗等优点.     

自制关节型抗生素骨水泥占位器在人工髋关节置换术后感染二期翻修中的应用

目的 总结使用自制压模器制成的关节型抗生素骨水泥占位器在人工髋关节置换术后感染二期翻修中应用的经验与教训,评价其在髋关节置换术后感染二期翻修中的效果和作用.方法 2005年8月至2009年12月采用二期翻修治疗的髋关节置换术后感染的患者中,127例患者在一期彻底清除后,植入了使用自制压模器术中制成的关节型抗生素骨水泥占位器,待感染控制后行二期翻修.其中106例患者107髋获得随访.观察使用这种占位器控制感染的有效率,制作、植入及取出的方便程度和出现的并发症,特殊情况的使用,观察患者的功能和满意程度.结果 106例患者平均随访时间34.3个月(3～55个月),一次感染控制率为96.3%,经过二期翻修末次随访时感染控制率为94.4%.占位器柄断裂4.7%,脱位率为2.8%,二期翻修时占位器取出困难者14.0%.患者满意率为93.5%.结论 使用自制压模器制成的关节型抗生素骨水泥占位器在人工髋关节置换术后感染的二期翻修治疗中,具有制作简单、重复性好、感染控制率高、保留关节功能好、患者满意率高等优点,通过改进方法后可以减少断裂及取出困难问题,结合使用金属内固定或异体骨不会影响感染的控制率.     

人工全髋关节翻修术治疗假体置换术后感染

目的：探讨全髋关节置换术后假体周围感染的治疗方法。方法：1998年1月～2002年6月共收治7例全髋关节置换术后感染患者。采用一期全髋关节翻修术3例，二期全髋关节翻修术4例，术后平均随访14个月。结果：患者髋关节评分平均提高37．6分(Harris评分)，经随访无一例感染患者复发。结论：人工全髋关节置换术后感染患者经过彻底清创和使用有效抗生素治疗后，可一期或二期进行全髋关节翻修术，治疗假体周围感染，改善患肢关节功能。     

一期抗生素骨水泥翻修治疗髋关节置换术后感染

目的 探讨一期抗生素骨水泥翻修治疗人工髋关节置换术后感染的可行性及效果.方法 对12例髋关节置换术后感染患者采用清创、假体取出后一期行含抗生素骨水泥假体翻修治疗.结果 12例均获随访,时间3～56(40.2±5.6)个月.患者伤口均一期愈合,无感染复发.末次随访时Harris评分由术前的19～67(36±7.8)分提高到63～97(91±6.3)分,患者满意率为92%.结论 髋关节置换术后感染只要诊断明确,彻底清创、合理使用抗生素和抗生素骨水泥,一期翻修同样可以取得满意的临床疗效.     

人工全髋关节翻修术治疗假体置换术后感染

目的:探讨全髋关节置换术后假体周围感染的治疗方法。方法:1998年1月～2002年6月共收治7例全髋关节置换术后感染患者。采用一期全髋关节翻修术3例,二期全髋关节翻修术4例,术后平均随访14个月。结果:患者髋关节评分平均提高37.6分(Harris评分),经随访无一例感染患者复发。结论:人工全髋关节置换术后感染患者经过彻底清创和使用有效抗生素治疗后,可一期或二期进行全髋关节翻修术,治疗假体周围感染,改善患肢关节功能。     

人工全髋关节翻修术治疗假体置换术后感染

目的:探讨全髋关节置换术后假体周围感染的治疗方法.方法:1998年1月～2002年6月共收治7例全髋关节置换术后感染患者.采用一期全髋关节翻修术3例,二期全髋关节翻修术4例,术后平均随访14个月.结果:患者髋关节评分平均提高37.6分(Harris评分),经随访无一例感染患者复发.结论:人工全髋关节置换术后感染患者经过彻底清创和使用有效抗生素治疗后,可一期或二期进行全髋关节翻修术,治疗假体周围感染,改善患肢关节功能.     

应用抗生素骨水泥间隔体二期翻修治疗人工全膝关节置换术后迟发感染

目的探讨应用抗生素骨水泥间隔体二期翻修治疗人工全膝关节置换术后迟发感染的临床疗效。方法 2007年1月-2009年12月,收治23例(23膝)人工全膝关节置换术后迟发感染患者。男15例,女8例;年龄43～75岁,平均65.2岁。置换术后至出现感染时间为13～52个月,平均17.3个月;发生感染至入院翻修时间为15 d～7个月,平均2.1个月。一期清创、取出假体,植入含庆大霉素抗生素骨水泥间隔体;8～10周感染控制后二期植入假体。分别采用美国特种外科医院(HSS)评分及膝关节学会评分系统(KSS)评价翻修前后患膝功能,并统计总体感染控制率。结果术后患者切口均Ⅰ期愈合。2例二期翻修术后发生再感染,余21例感染控制,总体感染控制率91.3%。患者均获随访,随访时间2～5年,平均3.6年。HSS评分由术前(60.6±9.8)分提高至末次随访时(82.3±7.4)分,KSS评分由术前(110.7±9.6)分提高至末次随访时(134.0±10.5)分,手术前后比较差异均有统计学意义(P<0.01)。X线片复查示假体位置良好,无松动、断裂、假体周围透亮影等异常表现。结论应用抗生素骨水泥间隔体二期翻修能有效控制人工全膝关节置换术后迟发感染,并能较好恢复患膝功能。     

定制抗生素骨水泥临时假体在人工髋关节置换术后感染二期翻修中的应用

目的报道应用定制抗生素骨水泥临时假体治疗人工髋关节置换术后感染的手术疗效。方法16例取出人工髋关节假体彻底清创后,放置形状及大小与髋臼及股骨髓腔大小相匹配的抗生素骨水泥临时假体,术后定期复查C反应蛋白和血沉,待结果正常后二期行人工髋关节翻修术。结果抗生素骨水泥临时假体充填后,患者伤口均愈合,1~2周后可扶双拐不负重活动,术后无一例发生骨水泥临时假体断裂及脱位,双下肢长度基本对称,二期翻修时抗生素骨水泥假体均可顺利取出。术后人工关节无一例感染复发、松动及下沉,Harris评分平均81分。结论定制抗生素骨水泥临时假体对感染的人工髋关节进行二期翻修,方法可靠,术后复发率低,能有效地克服髋周软组织挛缩,最大限度地保留下肢功能。     

二期翻修术治疗关节置换术后感染中抗生素使用的策略

[目的]探讨采用二期翻修术治疗关节置换术后感染过程中抗生素使用的有效方法。[方法]采用抗生素骨水泥占位器进行二期翻修治疗了15例髋关节置换术后感染的患者和10例膝关节置换术后感染的患者。其中9例髋关节置换术后感染患者与6例膝关节置换术后感染的患者在一期清创术后及二期翻修术后常规静脉使用抗生素6周，再口服抗生素2个月；另外6例髋关节置换术后感染患者与4例膝关节置换术后感染患者一期清创置入假体后及二期翻修术后只静脉使用抗生素3周，口服抗生素6周：术后定期随访，检测血沉及CRP，应用X线片与Harris评分与HSS评分进行评价。[结果]平均随访时间20．2个月（15～24个月）。两组患者的Harris评分与HSS评分无明显差异，长期使用抗生素组的患者满意率为93．3％，短期使用抗生素组的患者满意率为90％。在最后随访两组均没有感染复发的病例。[结论]在使用抗生素骨水泥占位器的条件下，在二期翻修治疗关节置换术后感染中短期使用抗生素是安全可靠的。     

Cementless two-stage exchange arthroplasty for infection after total hip arthroplasty

We retrospectively reviewed all patients at one center with an infected total hip arthroplasty treated with 2-stage revision using cementless components for the second stage and the PROSTALAC articulated spacer at the first stage. Twenty-nine patients were reviewed and followed for at least 2 years postoperatively. An isolated Staphylococcus species was cultured in 76% (22/29) of patients. Three (10.3%) of 29 patients had recurrent infection at the site of the prosthesis. One of the 3 patients ultimately underwent a Girdlestone arthroplasty. Another patient was managed with irrigation and debridement, whereas the final patient was treated with intravenous antibiotics alone. Treatment of infection at the site of a hip arthroplasty with 2-stage revision using cementless components and an articulated spacer yields recurrence rates similar to revisions where at least one of the components at the second stage is fixed with antibiotic-loaded cement.     

Redefining revision total hip arthroplasty based on hospital admission status

This study examined patient demographics, length of hospital stay, and discharge disposition in those undergoing nonelective revision total hip arthroplasty (rTHA) vs elective rTHA. Data from 23 000 patients with hip revisions from 2005 through 2007 were extracted from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database. We examined patient admission status, demographics, length of stay, and discharge location. We found that patients undergoing nonelective rTHA were older, were female, had more comorbidities, stayed an excess of 1.61 days in the hospital, and required a skilled care facility after discharge compared with those undergoing elective rTHA. We found that rTHA outcomes varied based on patient hospital admission status. Patients who elected to have rTHA had less comorbidities, cost, and likelihood of being discharged into a skilled care facility.     

同期与分期双侧全髋置换术临床比较分析

目的 比较同期与分期双侧全髋置换术围手术期安全性及相关临床指标.方法 同期双侧全髋置换术(THA Ⅰ组)74例(148髋),分期双侧全髋置换术(THA Ⅱ组)54例(108髋),比较两组术前合并症、术后并发症、手术时间、总失血量、输血量、手术前后Harris评分、血红蛋白、血细胞比容、住院天数、总费用等临床指标.结果 两组性别、年龄、术前合并症、手术前后Harris评分、血红蛋白、血细胞比容比较差异均无显著性(P＞0.05).THA Ⅰ组平均手术时间(135.7±33.0)min、总失血量(1 378.6±571.7)ml、输血量(575.8±582.6)ml,THAⅡ组平均手术时间(161±46.1)min、总失血量(1 589.5±628.0)ml、输血量(544.6±582.6)ml,两组差异无显著性(P＞0.05).THA Ⅰ组平均住院天数(15.7±4.1)d、总费用(69 603±27 054.7)元,THAⅡ组平均住院天数(29.2±10.8)d、总费用(107 169±51 697.1)元,两组差异有显著性(P＜0.01).THA Ⅰ组冲经系统并发症(P=0.017)、心血管系统并发症(P=0.012)发生率比THA Ⅱ组高,差异具有显著性;其他系统并发症差异无显著性(P＞0.05).结论 同期双侧髋关节置换术是安全有效的手术方案,并且能够降低住院天数、减少住院费用.     

Conversion total hip arthroplasty: Primary or revision total hip arthroplasty

Total hip arthroplasty (THA) is an increasingly common procedure among elderly individuals. Although conversion THA is currently bundled in a diagnosis related group (DRG) with primary THA, there is a lack of literature supporting this classification and it has yet to be identified whether conversion THA better resembles primary or revision THA. This editorial analyzed the intraoperative and postoperative factors and functional outcomes following conversion THA, primary THA, and revision THA to understand whether the characteristics of conversion THA resemble one procedure or the other, or are possibly somewhere in between. The analysis revealed that conversion THA requires more resources both intraoperatively and postoperatively than primary THA. Furthermore, patients undergoing conversion THA present with poorer functional outcomes in the long run. Patients undergoing conversion THA better resemble revision THA patients than primary THA patients. As such, patients undergoing conversion THA should not be likened to patients undergoing primary THA when determining risk stratification and reimbursement rates. Conversion THA procedures should be planned accordingly with proper anticipation of the greater needs both in the operating room, and for in-patient and follow-up care. We suggest that conversion THA be reclassified in the same DRG with revision THA as opposed to primary THA as a step towards better allocation of healthcare resources for conversion hip arthroplasties.     

One-stage revision of infected total hip arthroplasty with bone graft

There are many different opinions in the literature regarding the best procedure for revision of infected hip arthroplasty and hence in achieving long-term stabilization of a new implant. Thirty-two patients with 32 loose and infected total hip arthroplasties underwent revision with a bone graft in a 1-stage procedure. The bone graft was used in the acetabulum and femur in 25 patients, in the acetabulum alone in 4 patients and in the femur alone in 3 patients. A metal mesh was necessary in 15 patients to contain the morselized bone graft. At the time of surgical revision, 9 patients had a draining sinus, 6 had a closed sinus, and 17 had never had sinuses in the surgical wound. Antibiotic therapy was administered intravenously and orally for 6 months. Mean follow-up was 103 months (range, 63-183 months), and infection recurred in 2 (6.2%) cases. Further studies are necessary, and continuation of this method is justified.     

Two-stage revision for the infected total knee arthroplasty: The gold standard

Infection in total knee arthroplasty is a devastating complication requiring the surgeon to weigh duration of symptoms, host factors, and the characteristics of the afflicting agent when devising a management strategy. Due to its well-documented success rate, most centers in North America prefer a two-stage revision strategy. This approach allows for higher likelihood of foreign material removal and eradication of the infecting pathogen. Although the success of single-stage exchange arthroplasty has been noted in the literature, its use should be relegated to a highly selective patient population.     

Results of Wagner SL revision stem with impaction bone grafting in revision total hip arthroplasty

Background:

As the number of total hip arthroplasties (THAs) performed increases, so do the number of required revisions. Impaction bone grafting with Wagner SL Revision stem is a good option for managing bone deficiencies arising from aseptic osteolysis. We studied the results of cementless diaphyseal fixation in femoral revision after total hip arthroplasty and whether there was spontaneous regeneration of bone stock in the proximal femur after the use of Wagner SL Revision stem (Zimmer, Warsaw, IN, USA) with impaction bone grafting.

Materials and Methods:

We performed 53 hip revisions using impaction bone grafting and Wagner SL Revision stems in 48 patients; (5 cases were bilateral) for variety of indications ranging from aseptic osteolysis to preiprosthetic fractures. The average age was 59 years (range 44-68 years). There were 42 male and 6 female patients. Four patients died after surgery for reasons unrelated to surgery. 44 patients were available for complete analysis.

Results:

The mean Harris Hip Score was 42 before surgery and improved to 86 by the final followup evaluation at a mean point of 5.5 years. Of the 44 patients, 87% (n=39) had excellent results and 10% (n=5) had good results. The stem survival rate was 98% (n=43).

Conclusion:

Short term results for revision THA with impaction bone grafting and Wagner SL revision stems are encouraging. However, it is necessary to obtain long term results through periodic followup evaluation, as rate of complications may increase in future.     

Dislocation and infection after revision total hip arthroplasty: comparison between the first and multiply revised total hip arthroplasty

Dislocation and infection are common complications of total hip arthroplasty (THA). This study evaluated the correlation between the number of revision THAs and the incidence of these complications. Data were obtained from 749 revision THAs. Average follow-up was 13.2 ± 5.9 years. Patients were grouped as first, second, third, and fourth or greater revision THA. Dislocation rates (5.68%, 7.69%, 8.33%, and 27.45%) and infection rates (1.35%, 1.92%, 2.5%, and 7.84%) in the first, second, third, and fourth or greater groups, respectively, correlated directly with the revision number and were highest (P < .001) in the fourth or greater group. Dislocation and infection are exponentially correlated with the number of revision THA. From the fourth revision onward, those risks are multiplied.     

Techniques in the treatment of the infected total knee arthroplasty

Infection of the total knee arthroplasty can be a devastating complication. Appropriate management can significantlydecrease morbidity and cost. This article outlines the management of the infected total knee arthroplasty. To optimize patient outcome adherence to strict guidelines and meticulous technique will greatly improve the results.