Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program.

BACKGROUND: Deep wound infection (DWI) in total knee (TKA) and total hip (THA) arthroplasty has been shown to highly correlate with superficial surgical site infection (SSSI). Although several studies have reported hospital factors that predispose to SSSI, patient factors have not been clearly elucidated. METHODS: All patients undergoing TKA (n = 1181) and THA (n = 1124) surgery during the period 1977-1995 at our institution were observed at the end of a 30-day post-operative period. Thirty-three patients that developed SSSI during this period constituted the study group. The control group was composed of 64 matched subjects that did not develop SSSI. A chart review was applied to abstract DWI cases during the first 18 post-operative months for the study group and for an average of 6.7 years for the control group (range 5-18.2 years). Potential risk factors for SSSI were used as predictors of SSSI in a logistic regression analysis. RESULTS: During the 18-month observation period 19 out of the 33 study subjects (58%) developed DWI. No DWI was registered in the control group (the difference was significant, p < 0.0001). Of the nine pre-operative, five intra-operative, and five postoperative factors examined, only hematoma formation (odds ratio = 11.8; p = 0.001) and days of post-operative drainage (odds ratio = 1.32; p = 0.01) were significant predictors of SSSI. The cases consumed more health care resources at all stages of the medical process. CONCLUSIONS: Our results (1) confirm the strong correlation between the probability of developing DWI and SSSI; (2) indicate that hematoma formation and persistent post-operative drainage increase the risk of SSSI. We hypothesize that post-operative monitoring of patients for hematoma and persistent drainage enables earlier intervention that may lower the risk of developing SSSI and subsequent DWI.     

Total hip and knee replacement surgery

Total hip and knee replacements are becoming increasingly prevalent and an increasing range of techniques and materials are now available. We review the indications, the key issues regarding surgical and material options and the complications of total joint replacement surgery for the hip and knee.     

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。     

Tissue-sparing surgery: 25 years’ experience with femoral neck preserving hip arthroplasty

Abstract Tissue-sparing surgery is a surgical strategy that aims to preserve, as much as possible, both bone and soft tissue, in order to minimize the invasiveness of the operation and the overall treatment aggression. This is achieved, in the field of hip replacement surgery, by conservation of the femoral neck through the use of “mini-prostheses” such as the Biodynamic and later the CFP. In this paper, we illustrate the biomechanical characteristics and structure of the CFP prosthesis and briefly describe our 25-year experience in conserving the femoral neck during hip replacement surgery. In particular, we report the results of 943 implants, demonstrating a high percentage of excellent results and good clinicoradiographic results (97%) with a survival rate of almost 100%.     

全髋关节及全膝关节置换术后隐性失血的临床影响

目的探讨人工全髋关节置换术（THA）和人工全膝关节置换术（TKA）术后隐性失血的相关机制及对临床的影响.方法2001年3月至2005年5月,行THA 61例,其中男22例,女39例;年龄61～79岁,平均68岁.同期行TKA73例,其中男23例,女50例;年龄65～77岁,平均73岁.所有病例均为初次行单侧关节置换的患者,24h补液总量不超过2000ml.通过Gross方程,根据身高、体重和手术前后的红细胞压积（Hct）计算所有患者的总失血量,减去显性失血部分后即得隐性失血.结果THA组的总失血量平均为1520ml,隐性失血量为482 ml（32%）;TKA组的总失血量平均为1508 ml,隐性失血量为776 ml（52%）,两组的隐性失血量比较差异有统计学意义（P＜0.01）.TKA组中使用引流血回输患者的总失血量平均为1625 ml,隐性失血量为774ml（48%）;未使用引流血回输患者的总失血量平均为1345 ml,隐性失血量为783 ml（58%）,两组的隐性失血量相比差异无统计学意义;THA与TKA肥胖组和非肥胖组的隐性失血量相比差异均无统计学意义.结论TKA隐性失血远较THA高,且使用引流血回输仍不能完全满足机体恢复体循环的需要,应特别注意及时补充血容量.对隐性失血的正确认识有助于提高临床评估能力,帮助关节置换患者度过围手术期.     

同期和分期手术在全髋关节置换患者中的应用效果对比

目的：比较同期和分期手术在行全髋关节置换手术临床应用效果,以期为全髋关节置换术式选择提供依据。方法：收集我院2009年10月~2015年6 月行双侧全髋关节置换术患者临床病例资料,对患者治疗效果进行回顾性分析,按照不同手术方式的选择分为同期髋关节置换术（同期组）、分期髋关节置换术（分期组）,比较两组患者手术时间,术中和术后出血量、总输血量,住院费用、住院时间,手术前后Harris评分及术后并发症等方面差异,并进行统计学分析。结果：两组患者在术中和术后出血量、总输血量及手术前后Harris评分无差异,P＞0.05;并发症发病率无差异,P＞0.05;但是同期组患者住院费用、住院时间显著低于分期组患者,P＜0.05。结论：对于双侧全髋关节置换术患者,同期手术与分期手术治疗效果无明显差异,但同期手术可以明显降低患者住院费用、住院时间,减轻患者负担。     

初次髋膝关节置换术中不留置尿管的可行性和安全性研究

目的探讨单侧初次髋或膝关节置换术中不常规留置尿管的可行性及安全性,以减少不必要的导尿,提高患者就医舒适度和满意度。 方法本文回顾性分析中日友好医院骨关节外科2015年11月至2016年10月期间109例无明显尿潴留高危因素、无术前尿路感染、无尿路刺激征及重度肝肾功能不全、且接受单侧初次髋或膝关节置换术、术中不留置尿管(NIC)患者的资料。根据配对条件,与同期行常规术前留置尿管(IC)的单侧初次髋或膝关节置换患者按照1 ∶1进行配对研究,应用SPSS 19.0统计学软件对正态分布计量资料采用配对t检验,非正态分布计量资料采用Wilcoxon符号秩和检验,计数资料采用χ²检验分析比较两组患者术后的尿潴留、二次尿潴留、尿管相关膀胱不适、尿路刺激症、尿路感染、不良事件发生率,以及术后住院时间及患者满意度,分析并评价不留置尿管在单侧初次髋、膝关节置换术中的可行性及安全性。 结果两组患者术后尿潴留、二次尿潴留、尿路感染发生率比较,差异无统计学意义(P>0.05),NIC组术后尿管相关膀胱不适、尿路刺激征、不良事件发生率及术后住院时间均明显低于IC组,而患者满意度高于IC组,两组比较差异有统计学意义(χ²＝10.844,P<0.05),单侧初次髋或膝关节置换术中不必要的导尿高达81.7%。 结论初次髋或膝关节置换术中不常规留置尿管安全可靠,能有效减少尿管相关膀胱不适、尿路刺激征及不良事件的发生,同时可缩短术后住院时间,提高患者早期满意度。     

Relationship of body mass index to early complications in knee replacement surgery

Background The purpose of this study was to evaluate the relationship between body mass index and early complications following knee replacement. Methods Five hundred and twenty-seven patients who underwent primary knee replacement were recruited. All these patients were subjected to a pre-operative assessment and follow-up at 6 weeks and 1 year following surgery. Any complication occurring during this period was recorded. Complications were grouped into systemic and local, minor and major. Results 12.1% (N = 64) patients had an early complication following knee replacement surgery; 9.2% (N = 48) patients had a major complication. Overall BMI did not seem to influence significantly the rate of complication with a P-value of 0.338. A stronger correlation was found between the surgeon and presence of complication with a P-value of 0.004. Conclusions BMI has a weak correlation to early complications following joint replacement surgery. The operating surgeon seems to have a stronger correlation to early complications as compared with BMI. Investigation performed at Hinchingbrooke Hospital NHS Trust, Huntingdon, Cambridgeshire.     

Tissue-sparing surgery in total hip arthroplasty: sensible approaches and tested evidence

Minimally invasive total hip arthroplasty was advocated as a surgical procedure resulting in a faster functional recovery when compared with standard-length incision approaches. Currently, the potential benefits of low-surgical dissection are still unproven in well-designed clinical trials. Undoubtedly, smaller incisions and less soft tissue injury than in conventional arthroplasty should be promoted, according to the concept of tissue-sparing surgery. The advantages associated with less invasive surgical procedures must be evaluated carefully against the technical concerns that have the potential to adversely affect primary total hip arthroplasty outcome.     

A new square-contoured acetabulum and straight stem hip replacement

Summary A new hip prosthesis is described in which a square thin cup prevents bone demolition and guarantees against loosening. Deep ring relief diminishes friction. Straight stem, with medialization, diminishes muscular contraction and forcing of the stem against the lateral cortex of femur.

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Résumé Cette nouvelle prothèse totale de hanche est constituée par une cupule dont l'assise quadrangulaire évite une destruction importante de l'acétabulum et donne des garanties contre le descellement.Le frottement est diminué par la présence d'une bande annulaire située au fond de la cupule.Enfin, au niveau de la prothèse fémorale, la présence d'un manche droit implanté en adduction, diminue la contracture musculaire et les forces exercées par l'extrémité de la queue de la prothése au niveau de la corticale externe du fémur.

     

Two-stage arthroplasty for septic arthritis of the hip and knee: A systematic review on infection control and clinical functional outcomes

IntroductionSeptic arthritis of the native hip and knee joint poses particular challenges to orthopedic surgeons. Patients often suffer from several comorbidities, and it could be challenging to find a balance between infection control and adequate function. Two-stage arthroplasty has been addressed as a reliable solution, however the literature on the topic is composed of case series with small sample size. This systematic review aimed to analyze data on infection control and clinical functional outcomes of patients who underwent two-stage arthroplasty for septic arthritis of the hip and knee.MethodsAn electronic search of studies published from January 1st, 2000, to June 1st, 2021, was conducted using eight different databases. Following the Cochrane Handbook of Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Revies and Meta-analysis two authors reviewed the available literature and reference lists to identify papers eligible for inclusion.ResultsA total of 21 studies were included, involving 435 procedures. The mean age was 57.3 ± 6.2 (45.8–71.8) years. The mean follow-up was 53.7 ± 18.6 (12–86.7) months. The mean infection eradication was 93.3 ± 6.4%. Mean Harris Hip Score improved from 32.1 ± 10.6 (11.5–42.9) to 87.5 ± 5.7 (80.6–97.8). Mean Knee Society Score improved from 42.9 ± 7.6 (35.9–58.0) to 86.1 ± 5.4 (80.1–96.0).ConclusionsTwo-stage arthroplasty for hip and knee septic arthritis provided high infection control rate and excellent function. Further high-quality studies should be oriented on providing a validated algorithm for diagnosis and treatment of this condition.Level of evidenceLevel IV, systematic review of Level III and IV studies.     

Randomised controlled trial of triclosan coated vs uncoated sutures in primary hip and knee arthroplasty

BACKGROUND Triclosan-coated vicryl plus suture(Ethicon, Inc.) was developed to reduce microbial colonisation during surgical procedures. However, its effect on wound healing and surgical site infections remain unclear after hip and knee arthroplasty surgery.AIM To determine the effect of triclosan-coated sutures(TCS) vs non-coated sutures on wound healing, following primary hip and knee arthroplasties.METHODS A single-centred, double-blind randomised controlled trial(RCT) was undertaken. We randomly allocated patients to receive either the triclosan-coated sutures(TCS vicryl plus) or non-coated sutures(NCS vicryl) during the closure of unilateral primary hip and knee arthroplasties. We utilised the ASEPSIS wound scoring system to evaluate wound healing for the first 6 weeks post-operatively.RESULTS One hundred and fifty patients undergoing primary total hip or knee arthroplasty over a one-year period were included. Eighty-one were randomised to the TCS group and 69 to the NCS group. Despite no statistically significant difference in the ASEPSIS scores among the study groups(P = 0.75), sensitivity analysis using the Mann Whitney test(P = 0.036) as well as assessment of the wound complications at 6 weeks follow up, demonstrated significantly higher wound complication rates in the TCS group(8 vs 1, P = 0.03).CONCLUSION No clear advantage was demonstrated for using the TCS. However, larger multicentred RCTs are required to validate their use in hip and knee arthroplasty surgery.     

Digital templating in total knee and hip replacement: an analysis of planning accuracy

Purpose

The aim of this study was to determine how well pre-operative size selection for total knee and hip arthroplasties based on the digital imaging with and without additional referencing correlated with the size actually implanted.

Methods

Size selection planning of total knee arthroplasty by digital templating was documented in 46 cases with reference ball (group A) and in 48 cases without ball (group B). In addition, prospective analysis of pre-operative planning was conducted for 52 acetabular components with reference ball (group C) and 69 without ball (group D) as well as stem planning in 38 cases with ball (group E) and 54 cases without ball (group F). The data were analysed and compared with the size of the final component selected during surgery.

Results

The correlation between planned and implanted size for total knee arthroplasty in group A resulted in femoral anteroposterior (AP) r = 0.8622 and lateral r = 0.8333 and in group B AP r = 0.4552 and lateral r = 0.6950. Tibial in group A was AP r = 0.9030 and lateral r = 0.9074 and in group B AP r = 0.7000 and lateral r = 0.6376. For the acetabular components, the results in group C were r = 0.5998 and group D r = 0.6923. For stems, group E was r = 0.5306 and group F r = 0.5786. No correlation between BMI and the difference between planned and implanted size was found in any of the groups.

Conclusion

In the case of total hip arthroplasty there was a relatively low correlation between planned and implanted sizes with or without reference ball. For total knee arthroplasties the already high precision of size planning was further improved by the additional referencing with a reference ball.     

An evidence-based review of enhanced recovery interventions in knee replacement surgery

IntroductionTotal knee replacement (TKR) is a very common surgical procedure. Improved pain management techniques, surgical practices and the introduction of novel interventions have enhanced the patient’s postoperative experience after TKR. Safe, efficient pathways are needed to address the increasing need for knee arthroplasty in the UK. Enhanced recovery programmes can help to reduce hospital stays following knee replacements while maintaining patient safety and satisfaction. This review outlines common evidence-based pre, intra and postoperative interventions in use in enhanced recovery protocols following TKR.MethodsA thorough literature search of the electronic healthcare databases (MEDLINE^®, Embase™ and the Cochrane Library) was conducted to identify articles and studies concerned with enhanced recovery and fast track pathways for TKR.ResultsA literature review revealed several non-operative and operative interventions that are effective in enhanced recovery following TKR including preoperative patient education, pre-emptive and local infiltration analgesia, preoperative nutrition, neuromuscular electrical stimulation, pulsed electromagnetic fields, perioperative rehabilitation, modern wound dressings, different standard surgical techniques, minimally invasive surgery and computer assisted surgery.ConclusionsEnhanced recovery programmes require a multidisciplinary team of dedicated professionals, principally involving preoperative education, multimodal pain control and accelerated rehabilitation; this will be boosted if combined with minimally invasive surgery. The current economic climate and restricted healthcare budget further necessitate brief hospitalisation while minimising costs. These non-operative interventions are the way forward to achieve such requirements.     

人工髋关节置换术治疗内固定失败的髋部骨折

目的探讨挽救性人工髋关节置换术的疗效。方法1995年1月至2007年12月，对11例髋部骨折内固定治疗失败的患者（股骨颈骨折7例，股骨粗隆问骨折4例）进行回顾性研究，分析其内固定治疗失败的原因，总结这11例患者行人工髋关节置换术的疗效。结果髋部骨折内固定治疗失败的主要原因是复位不良、内固定技术错误。10例患者获平均12个月（2～27个月）随访。无感染、脱位、假体松动下沉及假体周围骨折等并发症发生。10例患者髋关节功能均有改善，Harris评分由术前平均34.5分提高到术后84.2分。结论骨折复位不良、错误的内固定技术是髋部骨折治疗失败的重要原因。进行挽救性的人工髋关节置换手术对恢复患者髋关节功能临床疗效满意。     

严重屈膝畸形的人工膝关节表面置换术

为探讨重度屈膝畸形（屈曲角度≥６０度）如何进行人工全膝关节表面置换术（ＴＫＲ）,作者于１９８７年４月～１９９４年５月对２３例患者、３７个膝关节行ＴＫＲ,均获得了较好的临床治疗效果。术后患者疼痛明显减轻,屈曲角度由术前的平均７７．９７度降至术后的平均６．７度,其中６２．１％膝关节屈曲角度＜５度,关节屈伸活动度也由术前的平均２５．６度增至术后的平均８３．６度。膝评分优良者占７３．８３％,膝功能评分优良者占１３％。作者认为,重度屈膝畸形并非ＴＫＲ的绝对禁忌证,关键在于术中对后关节囊、侧副韧带等挛缩组织的彻底松解和平衡,必要时应切除后交叉韧带并适当多切除股骨髁及胫骨平台骨质。     

关节感染后继发性骨关节炎人工关节置换治疗的初步探讨

目的探讨关节感染后继发骨关节炎患者行初次人工关节置换术的特点及治疗原则。方法回顾性分析既往有关节感染史的15例初次全髋和全膝关节置换术病例,其中化脓性感染5例,结核性感染10例。全髋关节置换7例,全膝关节置换8例,手术时平均年龄（53．5±7．7）岁,感染平均静止（41．5±35．8）个月。行关节置换术前常规进行白细胞计数、血沉、c反应蛋白检查,并穿刺取关节液、滑膜组织等进行细菌培养以明确感染活动状态。结果所有病例术前白细胞计数、血沉、c反应蛋白正常,关节液、滑膜组织细菌培养阴性,组织学检查明确关节无活动性感染。采用一期关节置换,无论膝关节还是髋关节,均获得满意的关节功能恢复,术后随访（2．6±1．6）年,随访过程中均未出现感染复发。结论关节感染后继发骨关节炎病例,通过血清免疫学检查、关节液、滑膜组织细菌培养、组织学检查排除活动性感染,保持静息状态相当一段时间后行一期关节置换,可明显改善关节活动功能,取得较好的临床效果。     

后外侧入路小切口微创人工全髋关节置换术初步报告

[目的]探讨后外侧入路小切口微创（minimally invasive surgery，MIS）人工全髋关节置换的手术方法和初期临床治疗效果。[方法]采用后外侧入路MIS技术为68例72髋实施人工全髋关节置换术。股骨头坏死34例，其中双侧3例；股骨颈骨折25例；髋关节骨性关节炎9例，其中双侧1例。[结果]手术切口长7．5～11cm，平均9．28cm；术中出血量200～480ml，平均280ml；术后3个月时Harris评分平均为93分。在以往采用传统后外侧入路行人工全髋关节置换的病例中，选择病种、性别，年龄、术前Harris评分相近的患者68例72髋做为对照组，对两组进行对比：（1）切口MIS组明显短于传统组；（2）术中出血量少于传统组；（3）3个月时的Harris评分高于传统组（P〈0．001）。[结论]采用MIS人工全髋关节置换技术，手术切口短，创伤小，出血少，术后功能恢复快，较传统的全髋置换术有明显的优势，但应有严格的手术指征和熟练的操作技术。