关节镜下前交叉韧带重建术后膝关节感染的临床诊断与治疗

目的 探讨前交叉韧带重建术后膝关节感染的临床诊断与治疗方法.方法 回顾性研究1997年1月至2007年7月关节镜下前交叉韧带重建术后膝关节感染的患者,通过对术后关节感染的发病率、危险因素、临床表现、实验室检查结果、治疗方法及临床预后情况的观察,分析总结临床诊断与治疗方法.结果 关节镜下前交叉韧带重建手术共3638例,术后关节感染者16例,感染率0.44%.临床表现有体温增高,膝关节肿胀、疼痛,关节活动度受限.细菌培养阳性11例,以表皮葡萄球菌最多见.治疗包括静脉抗炎、关节冲洗注药、关节镜下清理术等方法,所有患者均治愈.清创术后1年以上的12例患者中失访3例,9例术后获得随访,随访时间平均19.7个月,膝关节活动度及韧带功能良好.结论 前交叉韧带重建术后膝关节感染的发牛率较低,但可能会导致关节功能障碍、软骨破坏及韧带移植物失效等严重后果.因此早期诊断、早期治疗尤为重要.尽早行关节镜下清理手术,术后结合抗生素治疗,辅以积极有效的功能康复,可以取得很好的临床效果.     

Open debridement of acute gram-positive infections after total knee arthroplasty

Open debridement and retention of components is an attractive, but often ineffective strategy for the treatment of a total knee arthroplasty (TKA) with acute infection. Few studies have stratified the outcomes of debridement specifically according to bacterial species. Thirty-one TKAs with acute gram-positive infections, seen at our institution during the past 10 years, were treated with open debridement, component retention, and antibiotics. The average duration of symptoms before debridement was 9 days (range, 1-40 days), and 78% of debridements were done within 10 days of the onset of symptoms. Eleven (35%) of the 31 patients successfully retained their components at most recent followup, without ongoing infection (mean, 4 years; range, 2-10 years). Only one (8%) of the 13 who had an infection with Staphylococcus aureus was treated successfully, compared with 10 (56%) of 18 patients who had infections, with either Staphylococcus epidermidis or a streptococcal species. The difference between these groups is statistically significant. The success rate of debridement of acute infections in TKA varies significantly depending on the involved pathogen. A high failure rate suggests that immediate component removal should be considered in the presence of acute Staphylococcus aureus infection in TKA. Debridement for acute streptococcal or Staphylococcus epidermidis species has better success, but likely should be done within 2 to 3 days from the onset of symptoms.     

关节镜清理结合灌注冲洗治疗前交叉韧带重建术后关节感染

目的:探讨膝关节前交叉韧带重建术后关节感染的治疗策略。方法:2005年3月至2014年2月关节镜下前交叉韧带重建术后关节感染6例,均为男性,年龄18～36岁。患者术后出现膝关节疼痛肿胀,血沉和C-反应蛋白升高,细菌培养均为表皮样葡萄球菌。采用关节镜清理和置管灌注冲洗。按照Lysholm膝关节评分系统和膝关节活动度对患者进行评价。结果:所有患者的感染均被控制,血沉和C反应蛋白恢复正常,Lysholm膝关节评分85～95分,膝关节活动度120°～135°。结论:前交叉韧带重建术后关节感染,早期采用关节镜清理和置管灌注冲洗获得满意疗效。     

关节镜下月国绳肌腱及生物界面螺钉重建前交叉韧带

目的探讨关节镜下胭绳肌腱及生物界面螺钉重建前交叉韧带的疗效。方法对2007年8月-2009年5月收治的27例前交叉韧带重建病例,采用胭绳肌腱及生物界面螺钉进行重建。男25例,女2例。年龄18±45岁,平均29．6岁。结果22例患者获随访3～24个月,平均8．7月。术后Lysholm评分为91．1±5．3,与术前65．8±5．9比较,差异有统计学意义（P〈0．01）。术后有1例患者发生隐神经损伤,1例出现膝关节化脓性感染,行移植物取出待二期翻修。除感染1例外,其余患者术后患膝活动均正常,不稳感消失。结论胭绳肌腱是修复前交叉韧带的良好移植物,关节镜下界面螺钉固定疗效满意。应避免隐神经损伤和感染等并发症的发生。     

关节镜下前交叉韧带重建术后感染的诊断与治疗要点

目的探讨前交叉韧带（ACL）重建术后关节内感染的诊断标准、预防及治疗关键点。方法回顾性分析2007-01—2012-12关节镜下行ACL重建术后关节内感染5例患者的临床资料。术后关节内感染的诊断标准：膝疼痛在术后再度加重,伴体温升高;膝肿胀、积液或切口红肿;血液白细胞、中性粒细胞比例、ESR、CRP升高;关节液白细胞、中性粒细胞比例升高,葡萄糖浓度降低,以及细菌培养。总结5例感染者诊断、治疗过程及结果并回顾相关文献。结果关节镜下ACL重建术102例中5例术后发生关节内感染（4.9%）,其中仅1例细菌培养阳性（0.98%）。采取清创后持续冲洗引流或间断穿刺冲洗治疗后保留移植韧带4例。结论 ACL重建术后关节内感染的治疗原则：早期干预以提高韧带保留率;清创后持续冲洗引流;使用敏感抗生素足疗程治疗;石膏或支具制动,延迟功能锻炼。     

An unusual epidemic of Staphylococcus-negative infections involving anterior cruciate ligament reconstruction with salvage of the graft and function.

We performed a retrospective study of 13 patients who had postoperative clinical and laboratory signs of infection after autogenous bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstructions. From January 1991 to November 1996 we experienced only 2 infected knees in 1,300 reconstructions, but between December 1996 and February 1997 10 patients in 70 ACL reconstructions developed a postoperative suspected infection. We found the origin of contamination (coagulase-negative Staphylococcus) in the supposedly sterile inflow cannula. When we changed this device, we had only 1 infection in the next 400 reconstructions. The diagnosis in these cases was derived from clinical signs and laboratory results, but only 2 of 11 samples of aspirated synovial fluid tested positive for Staphylococcus. The mean interval between the surgery and the onset of signs of infection and the start of antibiotic therapy was 7.7 days. All the patients had antibiotic association at the highest level. Six knees underwent arthroscopic debridement when the clinical signs indicated resistence to antibiotics. The normal postoperative rehabilitation program was modified but was not discontinued. Although recovery time was longer, overall results were similar to uncomplicated reconstructions. On the basis of our experience, we believe that when there is a notable increase in infection rates, a thorough search for contamination is indicated. Our source of infection was material that was thought to be sterile. Ultimately, early diagnosis and treatment is of critical importance to obtain good results. Even suspicion of infective postoperative complication should be sufficient cause to search for responsible microorganisms and begin antibiotic therapy. Arthroscopic debridement should be proposed to patients with resistence to antibiotics.     

Magnetic resonance evaluation of remodeling process in patellar tendon graft

Several studies have shown the accuracy of magnetic resonance imaging in evaluating the reconstructed anterior cruciate ligament. The purpose of the current study was to clarify the clinical usefulness of magnetic resonance imaging for evaluating the reconstructed anterior cruciate ligament in comparison with using arthroscopy. Sixty-nine patients who had an anterior cruciate ligament reconstruction using a bone-tendon-bone autograft were examined by magnetic resonance imaging and arthroscopy an average of 12 months after surgery. There were 41 males and 28 females with an average age of 25.9 years (range, 15-66 years). The interval from surgery to the magnetic resonance imaging or arthroscopic evaluation was a mean of 12 months (range, 4-32 months). The magnetic resonance imaging findings of the reconstructed anterior cruciate ligament were classified as either high, intermediate, or low intensity. The arthroscopic findings also were classified as either graft impingement at the intercondylar notch or no impingement. In the 47 anterior cruciate ligament grafts that were not impinged, the signal intensity remained low and did not increase during second-look arthroscopy. In contrast, 22 anterior cruciate ligament grafts that were impinged showed an increased signal intensity in the distal area of the graft at the time of the second-look arthroscopy. Furthermore, no significant correlation was observed between the presence of a high signal intensity and postoperative instability. The high signal intensity of the anterior cruciate ligament graft on magnetic resonance imaging was found to be caused by graft impingement. These findings therefore show a clear association between graft impingement and the subsequent appearance of the graft on magnetic resonance imaging.     

Arthroscopy in acute septic knees. Management in pediatric patients

Arthroscopic evacuation, debridement, and irrigation of acute septic knees in children were effective adjuncts in the treatment of this joint infection. Sixteen knees in 16 pediatric patients were treated with arthroscopic management. Ninety-four percent of the knees had sepsis secondary to Staphylococcus aureus. Two immune-suppressed patients (postrenal transplants) had combined S. aureus and Pseudomonas aeruginosa infections. Twenty-five percent of the patients had a foreign body in the joint that was removed arthroscopically. No postoperative irrigation or drainage systems were used. At an average follow-up period of three years, no evidence of persistent or recurrent infection was noted. Roentgenograms showed no evidence of joint or epiphyseal destruction. Because of the low morbidity associated with the procedure, rapid restoration of joint motion and patient mobility was seen in all patients. Arthroscopic debridement of acute septic knees may be carried out in pediatric patients, given appropriate equipment and arthroscopic skills.     

关节镜下灌洗联合手术切开清创治疗关节镜下肩袖修补术后感染

目的探讨关节镜下灌洗联合手术切开清创治疗关节镜下肩袖修补术后感染的临床疗效。方法回顾性分析2016年1月至2019年6月采用关节镜下灌洗联合手术切开清创治疗4例关节镜下肩袖修补术后感染患者资料,男3例,女1例;年龄55岁(范围,51~61岁)。4例患者均于术后1个月内出现手术部位不同程度的红肿、疼痛等症状,同时伴有发热、脓肿、窦道形成。入院后完善血液学及放射学检查,使用抗生素治疗,并根据微生物培养结果调整使用抗生素。同时采用关节镜下灌洗联合手术切开清创进行治疗。术后继续使用抗生素抗感染治疗。术后复查血常规、红细胞沉降率、C反应蛋白,X线片等,评估感染症状是否缓解及预后情况。术前及随访时均采用视觉模拟评分(visual analogue scale,VAS)和美国肩肘外科协会(American Shoulder and Elbow Surgeons,ASES)评分评估疼痛及肩关节功能。结果4例患者手术均顺利完成,其中1例进行负压吸引1周后再关闭伤口。微生物培养结果显示,4例患者中,2例结核分枝杆菌(+)、1例铜绿假单胞菌(+)、1例金黄色葡萄球菌(+)。经治疗后患者肩部窦道均顺利愈合,患肩红肿、疼痛等症状消失。4例患者随访时间分别为3、4、32、33个月。末次随访时均未出现感染复发,肩关节活动度及评分均较清创术前好转,其中2例术后出现肩关节感染症状1个月的早期清创患者VAS及ASES评分分别由术前的5分及40分、6分及23分,分别提升至1分及80分、1分及73分;另2例术后出现肩关节感染症状病程超过6个月的患者VAS评分及ASES评分分别由术前的6分及28分、6分及32分,分别改善至1分及62分、2分及65分。4例患者均对治疗结果表示满意。结论肩关节感染病程不超过1个月时,采用关节镜灌洗联合手术切开清创的方法治疗关节镜下肩袖修补术后感染可取得较好临床疗效。     

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.     

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.     

Two-stage treatment of chronic staphylococcal orthopaedic implant-related infections using vancomycin impregnated PMMA spacer and rifampin containing antibiotic protocol.

To determine the clinical role of rifampin containing antibiotic combination and modified two-stage exchange arthroplasty with a vancomycin loaded polymethylmethacrylate (PMMA) spacer for the treatment of orthopaedic implant related Staphylococcus epidermidis infections, a prospective study was initiated. A total of 10 patients, with a mean age of 59 years (range: 32 to 78 years) were included in the study. The mean follow up was 23.4 months (range: 16 to 36 months). Six patients had an infected hemiarthroplasty of the hip, three had infected total hip arthroplasty, and one had an infected femoral neck fracture with implant failure and pseudoarthrosis. All had culture-proven Staphylococcus epidermidis infections, six of the isolates were methicillin resistant. Following debridement and implantation of a PMMA spacer, a rifampin-vancomycin antibiotic protocol was initiated until the erythrocyte sedimentation rate and C-reactive protein levels were within normal limits. After reimplantation and discharge from the hospital, oral antibiotics with rifampin-ciprofloxacin were continued for three to six months. At the final follow-up none of the patients had any clinical or laboratory signs of infection. Although this study includes a limited number of patients and relatively short-term follow-up the results indicate that in the presence of orthopaedic implant infection with Staphylococcus epidermidis, modified two-stage exchange arthroplasty using a vancomycin-loaded PMMA spacer and a rifampin-containing antibiotic protocol may be beneficial.     

Arthroscopic irrigation and debridement of infected total knee arthroplasty: report of two cases

Various methods have been described for the treatment of the acutely infected total knee arthroplasty. These include antibiotic suppression, open debridement and irrigation, exchange arthroplasty, resection arthroplasty, arthrodesis, and amputation. A method not frequently reported is arthroscopic irrigation and debridement. Two cases of acutely infected total knee arthroplasty treated with arthroscopic irrigation and debridement are presented. In both cases there was a benign postoperative course averaging five months. Both infections were secondary to hematogenous seeding from a distant focus of infection. The patients presented within approximately 12 h after the onset of knee symptoms and were taken for arthroscopic irrigation and debridement within 12 h after presentation. Gram-positive organisms sensitive to the antibiotics being used were cultured in both. Postoperative knee function and range of motion returned rapidly and disability was minimal. At average 30-month follow-up both patients were pain free, had full activity of daily living, and had no clinical or radiographic evidence of infection. Arthroscopic irrigation and debridement appears to be an effective method of treatment in select cases of infected total knee arthroplasty.     

人工髋关节置换术后感染的临床经验分析

目的 总结人工髋关节感染的诊断及治疗方法。方法回顾性分析1975年5月至2004年12月收治的人工髋关节置换术后感染患者43例44髋的临床资料,其中男25例26髋,女18例18髋;本院感染病例16例16髋,外院感染病例27例28髋,平均年龄为54岁（24～81岁）。平均随访时间3年3个月（5个月～16年）。治疗包括：I期翻修7例,其中2例失败后行切除成形术;Ⅱ期翻修15例16髋,切除成形13例;保留假体清创5例;抗生素治疗、髋关节融合和截肢各1例。43例患者中40例术前和术中培养阳性,共培养出59株细菌,其中表皮葡萄球菌19株,金黄色葡萄球菌10株。结果术后随访36例,感染均无复发。29例进行术后Harris评分,平均为78．5分（45～98分）。结论人工髋关节置换术后感染诊断治疗均很困难,细菌毒力高、耐药率高,治疗时应予以重视,治疗方法选择应根据具体情况而定,以Ⅱ期翻修较为理想。     

Infektion nach arthroskopischer Kreuzbandersatzplastik: schwerer Behandlungsfehler?

A 28-year-old patient showed clear signs of knee joint infection 8?days after arthroscopic reconstruction of the anterior cruciate ligament. The treating physicians recommended further observation although they stated that a knee joint infection could not be reliably excluded. One week later arthroscopic revision was performed and intraoperative smear tests showed infection by Pseudomonas aeruginosa. Therefore, another 6?days later the obviously infected transplant had to be removed. In the long run painful and limited range of motion of the affected knee joint persisted. The patient complained about medical malpractice concerning management of the complication.The expert opinion stated that due to the fateful course of infection the tendon graft could not be retrieved after the eighth day post surgery anyway. Thus, only flawed delay of treatment was criticized.The arbitration board argued, however, that scientific data concerning the fate of infected tendon grafts do not support the expert opinion and that immediate arthroscopy and antibiotic treatment at least had the potential to influence the course of infection in a positive manner. Evidence clearly shows that survival of an infected tendon graft depends on early diagnosis and emergency treatment rather than just on fate. Due to the fact that, although having in mind the possibility of a knee joint infection, the necessary therapy was delayed for 8 days, the arbitration board considered the described medical malpractice a severe treatment error, leading to reversal of evidence in favour of the patient.     

The effect of bacterial contamination on neointimal hyperplasia in vascular grafts

Neointimal hyperplasia (NH) is the most significant contributing factor to long-term vascular graft failure. Inflammation is known to be important in its development; however, the role of bacterial infection is unclear. We examined the effect of contamination with common organisms on the development of NH in expanded polytetrafluoroethylene grafts. Thirty adult pigs were randomized into one of four groups: no infection, contamination with Staphylococcus aureus, mucin-producing Staphylococcus epidermidis, or Pseudomonas aeruginosa. An expanded polytetrafluoroethylene graft (6 mm x 3 cm) was placed as a common iliac artery interposition graft and was inoculated with 1-2 x 10(8) of the selected organism before closure. Grafts were explanted 6 weeks postoperatively. Microbiologic, histological, and morphometric evaluations were performed. All grafts were patent at the time of euthanasia. The mean areas of NH were 5.45 mm(2) in sterile grafts, 8.36 mm(2) in S. aureus, 7.63 mm(2) in S. epidermidis, and 11.52 mm(2) in P. aeruginosa grafts. Comparison of means via analysis of variance showed that P. aeruginosa grafts had significantly higher formation of NH than sterile grafts (P = 0.025). NH production in infected grafts appears to be organism specific and is significantly higher with P. aeruginosa than common Gram-positive organisms. Increased NH from subclinical infection may be a significant factor contributing to late graft failures.     

Results of arthroscopic treatment of symptomatic loss of extension following anterior cruciate ligament reconstruction

Symptomatic loss of knee extension is an important cause of postoperative morbidity following anterior cruciate ligament reconstruction. In a series of 342 consecutive reconstructions performed by the senior author, 17 knees in 16 patients had symptomatic extension deficits (>5 degrees) refractory to a minimum of 4 months of intensive physical therapy that required arthroscopic debridement. Thirteen knees in 12 patients were available for evaluation at a mean follow-up of 3.9+/-1.7 years and form the treatment group. Twenty-six knees in 26 patients who underwent reconstruction but did not develop arthrofibrosis were matched to the treatment group and served as controls. At a mean of 12+/-8 months following reconstruction, patients in the treatment group underwent examination under anesthesia, arthroscopic debridement, revision notchplasty as necessary, and controlled manipulation. Postoperatively, patients were assigned to a closely supervised rehabilitation protocol emphasizing restoration of knee extension. At final evaluation, knee extension deficits had improved from a preoperative mean of 10 degrees (SD 5 degrees) to 3 degrees (SD 4 degrees) (P<.001). Multiple functional rating scales also were used to evaluate the treatment and control groups. With the numbers available, there was no statistically significant difference in function at final evaluation between the treatment and control groups. The best treatment for loss of knee extension is preventive. Complications are avoided by careful patient selection, appropriate timing of surgery, attention to operative detail, and aggressive rehabilitation. However, patients reaching a plateau in rehabilitation with significant residual extension deficits, patellofemoral symptoms, or both predictably benefit from arthroscopic debridement.     

Treatment of deep infection following thoracic aorta graft replacement without graft removal

Deep infection following thoracic aortic replacement constitutes an extremely serious and life-threatening complication, and its treatment remains a challenge to surgeons. We report our experience involving five patients in whom deep infection occurred around the graft. Four of the five patients were treated by emergency surgery and one was treated by elective surgery. Surgical procedures performed including hemiarch replacement in one case, total arch replacement in one case, suspension of aortic valve and ascending aorta replacement in one case, Bentall procedure in one case, and descending aorta re-replacement in one case. Methicillin-resistant Staphylococcus aureus was detected in four patients, methicillin-resistant Staphylococcus epidermidis in one, and Aspergillus in one patient from purulent discharge at the operative site. Reoperative debridement and irrigation drainage were carried out at an early phase of infection. Intermittent irrigation following the reoperation was performed in all cases. In addition, muscle flap filling or omental translocation was carried out in three patients. Although the reported principle of treatment for arterial graft infection is extraanatomical bypass or rereplacement after removal of the infected graft, such procedures may be technically difficult and have a high risk at the thoracic level. Local anti-septic irrigation, administration of antibiotics, and vascular-rich tissue filling are useful procedures, and it appears that it is not always necessary to remove prosthetic grafts.     

Unsuccessful arthroscopic treatment of pyarthrosis following anterior cruciate ligament reconstruction

Postoperative purulent infection developed in the knee of a patient who had undergone anterior cruciate ligament reconstruction. Initially, arthroscopic lavage and debridement was performed, but was unsuccessful because the infection had spread into the soft tissues of the former surgical wound. Open debridement had to be performed to control the periarticular infection. It is important to stress that the extent of the infection has to be considered when instituting a method of treatment. It should be possible to clinically diagnose this extraarticular infection.     

Treatment of chronic osteomyelitis by free grafts of cancellous autologous bone tissue. A preliminary report.

Chronic osteomyelitis was treated by free grafts of autologous bone tissue in 13 consecutive patients aged 18 to 81 to years. In all patients the osteomyelitis was located in the leg, and Staphylococcus aureus was the causative organism. Seven had an infected non-union. The duration of the osteomyelitis varied from less than 1 year to 75 years. Surgical debridement and grafting of cancellous and cortical cancellous bone were performed at the one operation. The osteomyelitis healed after a single operation in all patients but one, who needed three operations before the infection was eradicated. In one patient a second bone grafting operation was necessary before weight-bearing could be allowed. Although the number of patients is small, the results agree well with larger series published recently. Grafting of autologous bone tissue seems to be a very valuable method of treatment for chronic osteomyelitis.