Safety of total hip replacement following an intra-articular steroid hip injection--an audit

The aim of this study was to determine the deep infection rates in patients who underwent a total hip replacement after having had a prior diagnostic steroid injection into the same hip. We identified and reviewed the case notes, relevant radiographs and microbiology reports of all patients who underwent a total hip replacement after a diagnostic steroid hip injection in our unit from 1 January 2007 to 31 April 2009. There were 40 patients. (10 males and 30 females) Their mean age was 68.4 (52-82) years. The mean time interval from the injection to the joint replacement was 6.2 (2-23) months. The mean follow-up was 23.2 (11-37) months. None of the patients in the study group developed a deep infection during this followup period. Diagnostic intra articular steroid and local anaesthetic injection prior to total hip replacement appears to be safe.     

Total hip arthroplasty after ipsilateral intra-articular steroid injection: 8 years follow up

The purpose of the study was to assess the safety of Intra-articular steroid hip injections (IASHI), prior to ipsilateral total hip arthroplasty (THA). We investigated whether there was an excess of infection in such a group 7-10 years after total hip arthroplasty. A database of 49 patients who had undergone IASHI followed by ipsilateral THA was reviewed. The mean length of time between injection and arthroplasty was 12.1 months (5.1-19 months). We found 7 major complications. Ten patients died with no further hip surgery at a mean of 28 months from surgery ; 3 were lost to follow-up. The remaining group (36) were contacted by telephone at a mean of 97.8 (85-117) months from their surgery. No objective signs of joint infection were found. We believe our results show that ipsilateral steroid injection does not confer an increased risk of complications following subsequent THA, over an extended follow up.     

Diagnostic value of routine drain tip culture in primary joint arthroplasty

BACKGROUND: Closed suction drainage after joint arthroplasty is common practice in many institutions. The purpose of this study was to determine the correlation between routine drain tip culture and the diagnosis of superficial or deep postoperative wound infection after primary knee and hip replacement. METHODS: Over a 12-month period, drain tips were retrieved and cultured in all patients who underwent unilateral primary total knee or hip replacement with the use of closed suction drainage. A total of 393 cultures was performed in 387 patients (145 hip replacements, 242 knee replacements). Patients were followed for an average of 8.9 months after surgery to assess for postoperative wound infection. RESULTS: Three patients had a positive drain tip culture, none of which were diagnosed with superficial or deep infection. Four patients (1%) were diagnosed with deep infection, 16 (4.1%) with superficial infection. No patient with either superficial or deep infection had a positive drain tip culture after their index procedure. The sensitivity of routine drain tip culture for the diagnosis of postoperative infection in primary joint replacement was 0% and specificity was 99.2%. CONCLUSIONS: These data do not support the practice of routine drain tip culture after primary hip or knee replacement for the diagnosis of postoperative infection.     

带翼加强杯Ⅰ期治疗髋臼合并同侧股骨颈骨折

目的探讨带翼加强杯在Ⅰ期全髋关节置换治疗髋臼骨折合并同侧股骨颈骨折中的应用。方法对12例合并同侧股骨颈骨折的髋臼骨折行Ⅰ期全髋关节置换术(total hip arthroplasty,THA)。伤后5~18 d接受THA,12例均采用带翼加强杯合并自体植骨行髋臼侧固定,股骨侧均采用生物型固定。根据Harris评分和X线片对其临床效果进行评估。结果 12例患者均得到随访,平均随访时间3年9个月(2年1个月~5年7个月)。2例出现异位骨化,无脱位,未见假体移位及透亮带,无再翻修病例。术后Harris评分平均90分,较术前平均改善51分。所有随访患者髋关节功能均有明显改善,随访期内未发现假体松动。结论应用带翼加强杯行Ⅰ期全髋关节置换术是治疗髋臼骨折合并同侧股骨颈骨折的有效方法,这种方法强调髋臼重建结构的稳定性,避免了切开复位内固定引起的股骨头坏死等严重髋关节并发症,能显著改善关节功能,避免多次手术,减少患者的精神和经济负担。     

晚期强直性脊柱炎髋、膝、踝关节非功能位骨性强直的功能重建

目的探讨晚期强直性脊柱炎髋、膝、踝关节均在非功能位骨性强直患者的关节功能重建。方法1996年1月～1997年5月采用一次麻醉下同侧髋、膝、踝关节同时置换术,对2例晚期强直性脊柱炎3侧髋、膝、踝关节骨性融合在非功能位的患者进行关节功能重建;分别随访22个月和36个月,观察关节活动度恢复情况,进行关节功能评分。结果2例患者膝关节术后平均活动度为76．7。,HSS评分平均提高45分;髋关节术后平均总活动度为145．7°,Harris评分提高37．7分。随访期间患者髋、膝、踝关节活动度基本正常,生活自理。结论对于晚期强直性脊柱炎下肢多关节骨性强直在非功能位的患者,同侧下肢髋、膝、踝三关节同时置换是一种有效的关节功能重建方法。     

Risk of Periprosthetic Infection Following Intra-Articular Corticosteroid Injections After Total Knee Arthroplasty

BackgroundRecent literature has advocated for the effectiveness of postoperative steroid injections following total knee arthroplasty (TKA) for improving pain and range of motion when other correctible causes of these symptoms have been eliminated. The safety of such injections has not been thoroughly evaluated. The aim of this study was to determine the risk of acute infection following intra-articular corticosteroid injection into a preexisting TKA.MethodsThe Humana dataset was used to identify patients who underwent TKA from 2007 to 2017. Patients with ipsilateral knee corticosteroid injections in the postoperative period were then identified and compared to a 2:1 matched control cohort. A diagnosis of infection within 6 months and 1 year following the injection and an ipsilateral procedure for infection at any time postoperatively were then assessed and compared to controls using a multivariate binomial logistic regression analysis.ResultsOf the 166,946 TKA performed during the study period, 5628 patients had a postoperative corticosteroid injection (3.4%). Patients with injections had a significantly higher rate of periprosthetic infection compared to noninjection matched controls at all studied time points.ConclusionIn a large national database, about 3% of patients who undergo TKA have a postoperative steroid injection into their postoperative knee. While there is some existing literature demonstrating improvement in pain and stiffness symptoms after TKA with postoperative injections, the present study demonstrates a significant correlation between postoperative intra-articular corticosteroid injections in patients with preexisting TKA and periprosthetic joint infection compared to matched controls who did not receive an injection.     

髋关节骨性强直或融合后的全髋关节置换术

目的　探讨髋关节骨性强直或融合后行全髋关节置换术的可行性。方法　对 10例髋关节骨性强直或融合患者行全髋关节置换术的临床疗效及手术相关问题进行分析。结果　随访 6～ 30个月 (平均 18个月 ) ,10例 12个髋关节活动度术前为 0° ,术后总的活动度平均 16 3° ,屈髋平均 89°;Har ris评分术前平均 15 6分 ,术后平均 89分。术后髋痛消失 ,膝痛、下腰痛明显改善 ,步态基本恢复正常 ,8例重返工作岗位。结论　髋关节骨性强直或融合后如果发生严重的下腰痛、对侧髋关节、同侧膝关节疼痛或髋关节融合在非功能位上 ,髋关节周围软组织条件好 ,外展肌基本正常 ,应行全髋关节置换术     

复杂性髋臼骨折合并同侧股骨颈骨折及多处骨折的治疗与对策

目的:探索复杂性髋臼骨折(complex acetabular fractures,CAF)合并同侧股骨颈骨折及多处骨折的治疗方法与对策。方法:2000年8月-2005年3月,收治复杂性髋臼骨折合并同侧股骨颈及多处骨折12例,男7例,女5例;年龄24～51岁,平均37.5岁,皆系高能量损伤。合并其他部位骨折23处,平均2.6处。采用改良髋臼入路,应用髋臼三维记忆内固定系统(ATMFS)、空心加压螺钉、Richard钉、交锁髓内钉、天鹅记忆接骨器(SMC)等固定骶髂关节分离、复杂性髋臼骨折、股骨颈、股骨干、胫骨干、肱骨、尺桡骨骨折。结果:术后随访6～31个月,平均13.5个月。12例复杂性髋臼骨折均获解剖复位并达骨性愈合;同侧股骨颈骨折也获解剖复位,10例达骨性愈合。术后3～7个月(平均4.6个月),髋关节功能达到健侧水平;1例出现股骨头缺血性坏死行关节置换;1例股骨头坏死合并异位骨化导致关节骨性融合。4例骶髂关节分离获解剖复位;其他23处骨折,均获骨愈合。根据髋关节功能评分标准:优3例,良6例,一般1例,差2例。结论:采用改良髋臼入路、应用髋臼三维记忆内固定系统固定髋臼骨折,同时固定股骨颈骨折及合并的多处骨折,配合术后早期的功能锻炼,可以使髋关节获得良好的功能。     

Do Intra-Articular Steroid Injections Increase Infection Rates in Subsequent Arthroplasty? A Systematic Review and Meta-Analysis of Comparative Studies

Intra-articular steroid injections are widely used in joint arthritis. The safety of such injections has been questioned as they may increase infection rates in subsequent arthroplasty. We carried out a meta-analysis of studies examining the relation between intra-articular steroid injections and infection rates in subsequent joint arthroplasty. A literature search was undertaken. Eight studies looking at hip and knee arthroplasties were analyzed. Meta-analysis showed that steroid injection had no significant effect on either deep (risk ratio = 1.87; 95% CI 0.80–4.35; P = 0.15) or superficial infection rates (risk ratio = 1.75; 95% CI 0.76–4.04; P = 0.19) of subsequent arthroplasty. Further large cohort studies would be of value in further examining whether steroid injections close to the time of arthroplasty are safe.     

强直性脊柱炎I期双侧人工全髋关节置换术

目的观察强直性脊柱炎同期行双侧人工全髋关节置换术的疗效。方法自2008-05—2011-05对6例强直性脊柱炎患者行双侧人工全髋关节置换术,男5例,女1例;年龄31～42岁,平均37岁;术前双髋关节骨性强直,活动度0度,5例髋关节屈曲挛缩。结果术后6例均获得随访,随访时间6个月～3 a,平均27个月,无关节脱位、感染、松动、深静脉栓塞等并发症发生;Harris评分优良率为83.3%。结论强直性脊柱炎双侧髋关节完全强直,行同期双侧人工髋关节置换有利于患者功能恢复,提高生活质量。     

封闭式负压引流术治疗人工关节置换术后深部感染

目的探讨采用封闭式负压引流术(vacuum sealing drainage,VSD)结合病灶清创治疗人工髋、膝关节置换术后深部感染的方法和疗效。方法 2006年9月-2010年5月,收治13例人工关节置换术后深部感染患者。男5例,女8例;年龄56～78岁,平均62.5岁。置换术后7 d～1年2个月发生感染,中位时间14 d;发生感染至入院时间为8 d～4年6个月,中位时间21 d。均见脓性或脓血性分泌物,5例形成窦道,8例切口、引流口未愈合。分泌物引流口或窦道口皮肤缺损范围为5 mm×3 mm～36 mm×6 mm;分泌物引流通道或窦道深度为21～60 mm。11例取组织行病理检查,提示10例为急性或慢性化脓性感染急性发作,1例为结核。6例取分泌物培养,提示5例金黄色葡萄球菌阳性,1例为阴性。彻底清创后,10例行白天冲洗和晚上持续VSD治疗;3例仅持续VSD治疗。结果 1例人工全髋关节翻修术者VSD治疗时出血较多,停止负压吸引并加压包扎,第3天再次行VSD无大量出血。患者均获随访,随访时间1年～4年5个月,平均2年11个月。10例患者经VSD治疗后7～75 d感染控制,平均43 d;假体均保留,无感染复发,创面愈合良好,疼痛缓解,关节功能良好。1例因负压区疼痛过敏难以忍受拒绝VSD治疗,感染控制无效行大腿中上段截肢;1例感染结核疗效不明显,取出假体后采用骨水泥填塞临时膝关节融合治疗;1例VSD治愈后9个月感染再复发,取出假体旷置、VSD治疗3周,1年4个月未复发。结论 VSD结合病灶清创术使深部创面引流充分,可促进创面愈合,降低感染复发率,最大程度保留假体。     

Infection in knee replacements after previous injection of intra-articular steroid

We reviewed 231 patients who had undergone total knee replacement with an AGC (Biomet) implant over a period of 2.5 years. After applying exclusion criteria and with some loss to follow-up, there were 144 patients available for study. These were divided into two groups; those who had received intra-articular steroid in the 11 months before surgery and those who had not. There were three deep infections, all of which occurred in patients who had received a steroid injection. The incidence of superficial infection was not significantly different in the two groups. Five patients had undergone investigation for suspected deep infection because of persistent swelling or pain and all of these had received an intra-articular injection pre-operatively. We conclude that the decision to administer intra-articular steroids to a patient who may be a candidate for total knee replacement should not be taken lightly because of a risk of post-operative deep infection.     

全髋关节置换术治疗髋臼骨折

目的: 探讨全髋关节置换术治疗髋臼骨折的疗效与方法。方法: 回顾全髋关节置换术治疗髋臼骨折患者 17例, 总结分析其手术入路的选择, 异位骨化组织、内固定物以及髋臼骨缺损的处理方法。结果: 17例病人中有14例得到随访, 平均随访时间为 3年 7个月 (1年 2个月~9年 8个月)。出现感染 1例, 脱位 1例, 无菌松动 2例。术后再次异位骨化者 2例, 其中 1例引起坐骨神经症状, 再次行神经松解术。所有随访病例, 髋关节功能均有改善,Harris评分由术前平均 51分, 提高到术后 89分。结论: 选择正确的手术入路, 适当处理异位骨化组织和内固定物,重建髋臼骨缺损, 是全髋关节置换治疗髋臼骨折成功的关键。     

金属对金属大头径微创全髋关节置换术治疗青中年股骨头坏死的临床研究

目的探讨金属对金属（金对金）大头径假体微创全髋关节置换术（THA）治疗青中年股骨头坏死Ⅲ、Ⅳ期的临床疗效。方法本组32例（35髋）青中年股骨头缺血性坏死Ⅲ、Ⅳ期患者,年龄24～59岁,平均45岁,术前髋关节Harris评分平均（37．9±7．5）分;以改良后外侧小切口、肌间隙人路、充分保留关节动力性组织结构为特征的金对金大头径微创THA治疗。术中严格采取正确的假体植入技术,术中保留完整的软骨下骨和髋臼横韧带,击入臼杯时一次性安装成功,正确运用万古霉素预防感染。术后口服利伐沙班片抗凝,术后12h开放负压引流及卧床行功能锻炼,术后第2天拔除引流管后扶拐下地部分负重行走,术后2—3周患者即可弃拐完全负重行走。结果本组32例35髋患者均获随访,随访时间为12个月～6年,平均为4年。所有患者切口均一期愈合,无深静脉血栓形成、关节脱位、坐骨神经损伤、髋臼及股骨疲劳骨折、关节疼痛等严重并发症,X线片示髋关节假体位置均良好,无松动、移位、股骨柄下沉、假体周围骨折等表现。末次随访Harris评分由术前平均（37．9±7．5）分,提高至术后平均（92．2±4．6）分,前后比较有统计学意义（t=44．341,P〈0．05）。所有患者末次随访时髋关节功能明显优于术前,均对治疗效果满意,完全恢复正常生活及工作。结论采用金对金大头径微创THA治疗青中年股骨头坏死Ⅲ、Ⅳ期患者,能够明显降低手术风险,缩短卧床时问,迅速恢复髋关节功能,减少手术并发症,取得了满意的近期临床疗效。随着基础和临床研究的不断深入,金对金大头径髋关节假体的长期疗效还需要进一步探讨。     

Successful reimplantation of total femoral prosthesis after deep infection

A 16-year-old boy developed a deep infection with methicillin-resistant Staphylococcus aureus 6 months after total femoral replacement including knee and hip joints. The deep infection was eradicated by the use of débridement with continuous irrigation and removal of all prosthetic components followed by insertion of an antibiotic-impregnated cement spacer. Six weeks later, the total femoral prosthesis could be successfully reimplanted with both acetabular and tibial components. Two and half years later, the patient remained free of infection. Débridement with continuous irrigation and an antibiotic-impregnated cement spacer can be a feasible technique for the treatment of deep infection after large prosthetic replacement. Furthermore, reimplantation should be performed after a short waiting period. Such treatment should be considered before deciding on amputation.     

Intra-articular bupivacaine hip injection in differentiation of coxarthrosis from referred thigh pain: a 10 year study

The authors conducted a retrospective study to validate the specificity of intra-articular injection of local anaesthetic to identify the source of pain in patients with coxarthrosis but ill-defined clinical and radiological features. Forty-seven patients received intra-articular injection of the hip joint as a diagnostic procedure. Twenty-four patients showed a positive response with relief of pain. All of them underwent total hip replacement and remained pain free following surgery. In twenty-three patients intra-articular injection did not relieve the pain; three of these underwent successful total hip replacement two years later. Other negative responders were further evaluated and appropriately managed. This study confirms that intra-articular injection of local anaesthetic is a valuable tool in diagnostic dilemma. The calculated sensitivity of 88% and specificity of 100% is similar to other published series.     

生物型加长柄髋关节置换治疗高龄不稳定型股骨转子间骨折

目的探讨生物型加长柄人工髋关节置换治疗高龄不稳定型股骨转子间骨折的临床疗效。方法对51例高龄不稳定型股骨转子间骨折患者采用经髋关节外侧切口前方入路生物型加长柄人工髋关节置换治疗。结果患者均顺利完成手术,术后发生急性深静脉血栓2例,经积极治疗恢复正常。死亡2例,1例术后6个月死于心肌梗死,1例术后10个月死于肺部感染。49例获得随访,时间12~36个月。骨折愈合时间4~10个月,无人工关节脱位、假体周围感染、假体松动等并发症。术后12个月按Harris评分评定患髋关节功能:优18例,良25例,可5例,差1例,优良率87.8%。结论生物型加长柄人工髋关节置换是治疗高龄不稳定型股骨转子间骨折的一种安全有效方法。     

The benefit of radiologically-guided steroid injections for trapeziometacarpal osteoarthritis

INTRODUCTION

Osteoarthritis of the trapeziometacarpal joint (TMJ) is a common condition causing significant disability. Conservative treatments include intra-articular steroid injections.

PATIENTS AND METHODS

This clinical, observational study prospectively reviewed the longevity of benefit of steroid injections into the TMJ. Eighty-three patients were recruited with a median age of 62 years and injected with steroid and local anaesthetic under radioscopic guidance. They were followed up until the analgesic effects ceased with a questionnaire including visual analogue scores.

RESULTS

Two-thirds of patients were improved at 2 months, with nearly half having a 3-month improvement. One in six patients had a 6-month benefit, with some patients still improved 2 years after injection. Previously injected patients had a reduced duration of benefit compared to their previous injection. Severity of osteoarthritis did not affect the injection efficacy.

CONCLUSIONS

Based on this study, we recommend steroid injections in all degrees of TMJ osteoarthritis.     

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.     

A procedure-specific systematic review and consensus recommendations for analgesia after total hip replacement

Total hip replacement is a major surgical procedure usually associated with significant pain in the early postoperative period. Several anaesthetic and analgesic techniques are in common clinical use for this procedure but, to date, clinical studies of pain after total hip replacement have not been systematically assessed. Using the Cochrane protocol, we have conducted a systematic review of analgesic, anaesthetic and surgical interventions affecting postoperative pain after total hip replacement. In addition to the review, transferable evidence from other relevant procedures and clinical practice observations collated by the Delphi method were used to develop evidence-based recommendations for the treatment of postoperative pain. For primary total hip replacement, PROSPECT recommends either general anaesthesia combined with a peripheral nerve block that is continued after surgery or an intrathecal (spinal) injection of local anaesthetic and opioid. The primary analgesic technique should be combined with a step-down approach using paracetamol plus conventional non-steroidal anti-inflammatory drugs, with strong or weak opioids as required.