初次全髋关节置换术前胶片模板测量与评估

目的：通过胶片模板测量进行全髋关节置换术前计划、术后重复测量评估探讨胶片模板测量在全髋关节置换术前计划中的准确性和重要性。方法：2012年3月至2012年8月,收集我科同一位高年资医师行全髋关节置换病例72例（84髋）作研究对象。术前通过胶片模板测量,决定股骨颈截骨位置,计划髋臼、股骨柄、股骨头假体型号以及植入位置,调整双下肢长度;术后通过重复测量对术前计划进行评估和验证。结果：所有病例股骨颈截骨位置与术前计划相差均在5mm范围内,其中相差小于3mm者占84．5％。术前肢体平均短缩10mm（0～35mm）,术后肢体平均短缩3mm（0-11mm）,差异有统计学意义;术后双下肢长度相差在5mm以内者占90．5％。术前模板测量出的假体型号与实际应用的假体比较,髋臼假体完全符合率65．4％、相差1个型号以内的符合率为94．0％;股骨假体完全符合率为83．3％、相差1个型号以内的符合率为96．4％;股骨头假体完全符合率为63．1％、相差1个型号以内的符合率为98．8％。结论：全髋关节置换术前胶片模板测量对于术中假体型号选择具有较好的预测作用,对于假体位置安放以及双下肢长度调整均具有重要意义。     

Prosthetic Joint Infection Diagnosis Using Broad-Range PCR of Biofilms Dislodged from Knee and Hip Arthroplasty Surfaces Using Sonication

Periprosthetic tissue and/or synovial fluid PCR has been previously studied for prosthetic joint infection (PJI) diagnosis; however, few studies have assessed the utility of PCR on biofilms dislodged from the surface of explanted arthroplasties using vortexing and sonication (i.e., sonicate fluid PCR). We compared sonicate fluid 16S rRNA gene real-time PCR and sequencing to culture of synovial fluid, tissue, and sonicate fluid for the microbiologic diagnosis of PJI. PCR sequences generating mixed chromatograms were decatenated using RipSeq Mixed. We studied sonicate fluids from 135 and 231 subjects with PJI and aseptic failure, respectively. Synovial fluid, tissue, and sonicate fluid culture and sonicate fluid PCR had similar sensitivities (64.7, 70.4, 72.6, and 70.4%, respectively; P > 0.05) and specificities (96.9, 98.7, 98.3, and 97.8%, respectively; P > 0.05). Combining sonicate fluid culture and PCR, the sensitivity was higher (78.5%, P < 0.05) than those of individual tests, with similar specificity (97.0%). Thirteen subjects had positive sonicate fluid culture but negative PCR, and 11 had negative sonicate fluid culture but positive PCR (among which 7 had prior use of antimicrobials). Broad-range PCR and culture of sonicate fluid have equivalent performance for PJI diagnosis.     

术前测量预估DDH患者全髋置换术后股骨柄前倾角方法

目的根据生物型股骨柄设计原理,通过比较全髋置换术(total hip arthroplasty,THA)术前不同CT平面测量所得股骨前倾角与术后股骨柄前倾角,找到术前测量预估发育性髋关节不良(developmental dysplasia of the hip,DDH)患者THA后股骨柄前倾角方法。方法选取2007年9月～2013年5月在上海交通大学医学院附属第九人民医院行初次THA符合DDH诊断的患者21位(28髋),术前及术后均行CT扫描,术前选取头下平面、小粗隆平面和小粗隆平面上1 cm及2 cm 4个平面的前后皮质角平分线与股骨远端内外侧髁最大时后缘连线的夹角,以及大、小粗隆顶点中间平面后侧皮质切线与小粗隆中心上2 cm平面前侧皮质切线的角平分线与股骨远端内外侧髁最大时内外侧髁后方连线夹角(分别记为股骨前倾角1～5)。术后选取股骨柄假体最长水平层面,测量假体前后对称轴线与股骨远端内外侧髁最大时后缘连线的夹角作为术后股骨柄前倾角。同时测量髋臼杯假体前倾角、股骨假体矢状位矢状倾斜角度。比较术前各个股骨前倾角与术后股骨柄假体前倾角并进行相关性分析。结果股骨前倾角1～5分别为17.70°±10.54°、35.59°±7.21°、31.09°±7.98°、24.71°±9.11°、21.94°±10.10°。股骨柄假体前倾角为20.52°±10.90°。术后假体柄前倾角与股骨前倾角1～4之间差值分别为2.82°±6.27°、-15.08°±7.99°、-13.80°±15.68、-4.19°±5.69°、-1.42°±4.07°,髋臼假体前倾角为25.60°±11.65°,术后复合前倾角为46.11°±13.28°,假体矢状倾斜角为1.13°±1.53°。术前股骨前倾角1～4与术后假体前倾角均有统计学差异(P0.05),股骨前倾角5与术后假体前倾角无统计学差异;术前各前倾角与术后假体前倾角相关系数分别为0.829、0.681、0.689、0.853、0.928。结论股骨前倾角5与术后股骨柄前倾角具有高相关性,可作为替代股骨柄前倾角的有效方法。     

Successful Two-Stage Exchange Arthroplasty for Periprosthetic Infection Following Total Knee Arthroplasty: The Impact of Timing on Eradication of Infection

Background: Periprosthetic joint infection (PJI) represents a serious complication following total knee arthroplasty. In the setting of chronic infections, the two-staged approach has traditionally been the preferred treatment method. The aim of this study was to determine the optimal period of rest between the first and second stage. Furthermore, we analyzed potentially outcome-relevant parameters, such as general and local conditions and the presence of difficult-to-treat or unidentified microorganisms, with regard to their impact on successful treatment of PJI.Patients and Methods: We performed a retrospective analysis of prospectively collected data for all patients treated for PJI at our institution. Seventy-seven patients who had undergone two-stage revision arthroplasty for PJI of the knee were included into the study. Antibiotic-loaded cement spacers were used for all patients.Results: After a median follow-up time of 24.5 months, infection had reoccurred in 14 (18.7%) patients. A prolonged spacer-retention period of more than 83 days was related to a significantly higher proportion of reinfections. Furthermore, significant compromising local conditions of the prosthetic tissue and surrounding skin, as well as repeated spacer-exchanges between first- and second-stage surgery, negatively influenced the outcome. Neither the patients'' age nor gender exerted a significant influence on the outcome regarding reinfection rates for patients'' age or gender.Conclusions: We observed the best outcome regarding infection control in patients who had undergone second-stage surgery within 12 weeks after first-stage surgery. Nearly 90% of these patients stayed free from infection until the final follow-up. An increased number of performed spacer-exchanges and a bad local extremity grade also had a negative impact on the outcome.     

人工关节置换术后隐性失血对下肢深静脉血栓形成的影响

目的探讨人工髋、膝关节置换术（Total hip arthroplasty，THA；Total knee arthroplasty，TKA）围手术期失血情况对术后下肢深静脉血栓形成（deep vein thrombosis，DVT）的临床影响。方法92例THA、TKA术后DVT发生情况进行分析。THA为51例（56髋），TKA为41例（49膝）。术后7～10d采用彩色多普勒检查双下肢DVT的发生。对临床失血的相关指标与人工关节置换术后DVT的改变进行了分析。结果术后发生DVT患者共计28例，发生率为30．43％（28／92）。发生DVT的患者临床实际失血总量、隐性失血总量、术后失血总量、术后隐性失血量平均值分别为1648．53ml、844．35ml、1016．17ml、735．87ml，与未发生DVT的患者四项指标比较差异有统计学意义（P〈0．05）。结论隐性失血量的增加提高了术后DVT形成的风险。对隐性失血量变化的认识和发生机制的研究有助于人工关节置换术后下肢DVT的防治。     

无柄解剖型人工髋关节置换术临床试验24例报告

目的探讨无柄解剖型人工髋关节置换术的适应症、疗效.方法针对24例临床应用进行临床结果分析和总结.结果无柄解剖型人工髋关节置换术后,经1~2.5年的病案随访观察术后患髋疼痛、关节功能恢复满意,优良92%,可8%.结论无柄解剖型人工髋关节置换术适应征宽,是治疗青壮年股骨头缺血性坏死、股骨头骨折及类风湿性关节炎的有效方法,是有柄人工髋关节置换术的一种补充.无柄解剖型人工髋关节设计符合人体股骨颈自然解剖生理.具有强大的抗压抗弯防旋防松动、低应力高强度的机械力学特征,并且可以达生物愈合的生物力学特性.     

无柄解剖型人工髋关节置换术临床试验24例报告

目的 探讨无柄解剖型人工髋关节置换术的适应症、疗效。方法 针对24例临床应用进行临床结果分析和总结。结果 无柄解剖型人工髋关节置换术后，经1～2．5年的病案随访观察术后患髋疼痛、关节功能恢复满意，优良92％，可8％。结论 无柄解剖型人工髋关节置换术适应征宽，是治疗青壮年股骨头缺血性坏死、股骨头骨折及类风湿性关节炎的有效方法，是有柄人工髋关节置换术的一种补充。无柄解剖型人工髋关节设计符合人体股骨颈自然解剖生理。具有强大的抗压抗弯防旋防松动、低应力高强度的机械力学特征，并且可以达生物愈合的生物力学特性。     

Ruminococcus gnavus Total Hip Arthroplasty Infection in a 62-Year-Old Man with Ulcerative Colitis

We report the case of a total hip arthroplasty infection caused by Ruminococcus gnavus in a 62-year-old man with ulcerative colitis. The bacterium was perfectly identified by matrix-assisted laser desorption ionization–time of flight mass spectrometry.     

快速康复应用于全髋关节置换术的有效性评价

目的 在初次单髋全髋关节置换术中应用快速康复理念,并通过检测患者的各项指标对其有效性进行评价。方法 选取2015年 9月~2016年9月我科进行的单髋全髋关节置换术患者74例,按编号随机分为两组。常规治疗组36例采用改良后外侧切口,使用DePuy CORAIL系统的人工髋关节假体,术后给予选择性非甾体抗炎药（NSAIDs）止痛治疗,并配合康复训练。快速康复组38例在常规治疗组基础上分别在术前、术中及术后进行干预。术后比较两组患者疼痛指数、血红蛋白下降率、影像学评价、并发症、髋关节功能Harris评分、住院天数及住院费用。结果 两组患者在发生严重并发症、髋关节术后X线检查（髋臼杯外展角及前倾角）、术后第1~3 d的静息疼痛VAS评分方面,差异均无统计学意义（P＞0.05）。快速康复组的第1~3 d负重VAS评分、血红蛋白下降率及住院天数、住院费用分别为（2.34±1.21）分、（2.12±1.02）分、（13.21±7.83）%、（9.37±3.13）d及（1.85±0.32）万元,低于常规治疗组的（3.82±1.46）分、（3.06±1.21）分、（17.23±8.45）、（12.43±3.38）d及（2.01±0.37）万元,差异具有统计学意义（P＜0.05）。快速康复组出院当日及术后3个月髋关节Harris评分,高于常规治疗组,差异具有统计学意义（P＜0.05）。结论 快速康复应用于全髋关节置换术,能有效促进患者的功能康复、缩短住院时间、降低住院费用。     

Ceramic Head Fracture in Ceramic-on-Polyethylene Total Hip Arthroplasty

Revision rates of total hip arthroplasty have decreased after introducing total hip arthroplasty (THA) using ceramic component, since ceramic components could reduce components wear and osteolysis. The fracture of a ceramic component is a rare but potentially serious event. Thus, ceramic on polyethylene articulation is gradually spotlighted to reduce ceramic component fracture. There are a few recent reports of ceramic head fracture with polyethylene liner. Herein, we describe a case of a ceramic head component fracture with polyethylene liner. The fractured ceramic head was 28 mm short neck with conventional polyethylene liner. We treated the patient by total revision arthroplasty using 4th generation ceramic on ceramic components.     

大直径球头在全髋关节置换术中的应用

关节脱位是全髋关节置换术后常见的并发症, 而采用大直径球头是减少术后脱位的可能途径之一。作者对有关这方面的最近研究进展进行了综述, 重点综述、讨论了球头直径与超高分子量聚乙烯磨损的关系、大直径球头减少人工髋关节脱位的实验结果及大直径球头在人工关节外科的初步应用。     

全膝关节置换术对膝骨关节炎患者本体感觉的影响

目的 探究膝骨关节炎（knee osteoarthritis, KOA）患者进行全膝关节置换术前后本体感觉的变化。方法 选择34名KOA患者作为实验组,术后根据手术方式分为后交叉韧带保留型全膝关节置换术（CR-TKA）组和后稳固型全膝关节置换术（PS-TKA）组,并对患者进行3个月术后随访,同时纳入20名健康受试者作为对照组。采用Biodex System Ⅲ多关节等速测试系统、自行设计的施力装置、无线表面肌电测试系统采集健康受试者以及患者手术前后的本体感觉（位置觉、运动觉和力觉）数据,并对数据进行处理和分析。结果 与健康受试者相比,KOA患者患侧和对侧膝关节30°、45°和60°位置觉、运动觉、半腱肌力觉显著变差（P<0.05）;术后3个月,CR-TKA组患者患侧股二头肌力觉和对侧半腱肌力觉与健康受试者均存在显著差异（P<0.05）;对CR-TKA组和PS-TKA组患者患侧和对侧的位置觉、运动觉、力觉术后3个月与术前的差值做组间比较,均无统计学差异（P>0.05）。结论 KOA患者膝关节本体感觉较健康受试者明显减退。术后3个月,CR-TKA和PS-TKA两组患者本体感觉未见明显改善。不同手术方式对本体感觉的影响没有差异。研究结果可以为医生的临床诊疗提供一定数据支持,以及为后续的康复方案确定一个方向。     

Actinomyces neuii subsp. neuii Associated with Periprosthetic Infection in Total Hip Arthroplasty as Causative Agent

Actinomyces neuii has until now not been described as a pathogen associated with periprosthetic infection in total joint replacement. The case presented here suggests that A. neuii subsp. neuii is a causative pathogen. The discussion and review of the literature indicate the impact that detection of Actinomyces species could have.     

全膝关节置换术后静脉血栓栓塞的预防研究

静脉血栓栓塞症（VTE）是全膝关节置换术后发生和死亡的主要原因。研究显示,术后发生静脉血栓栓塞症可延长住院时间。在过去15年中,尽管临床上采用了全面的静脉血栓栓塞预防方案,但全膝关节置换术后出现肺栓塞的发生率基本保持不变,约为0.4%。目前VTE预防方案包括早期下地行走、患者评估和药物治疗等。对于具有静脉血栓栓塞症风险的患者,阿司匹林应用越来越广泛。最新研究证实,阿司匹林具有相对较低的出血风险和低成本效益。也有研究认为,新型口服抗凝剂、华法林、低分子肝素,包括Xa因子和直接凝血酶抑制剂均对降低术后VTE有效,但可能与出血和伤口并发症发生率的增加有关。本文主要综述近年来VTE预防的研究进展,旨在为临床医生提供用药指导。     

Meta-Analysis of Sonication Fluid Samples from Prosthetic Components for Diagnosis of Infection after Total Joint Arthroplasty

This meta-analysis included 12 studies that evaluated sonication fluid cultures (SFC) for the diagnosis of prosthetic joint infection (PJI). The pooled sensitivity and specificity were 0.80 (95% confidence interval [CI], 0.74 to 0.84) and 0.95 (CI, 0.90 to 0.98), respectively. Subgroup analyses showed that a 14-day anaerobic culture may improve sensitivity, the use of centrifugation or vortexing may improve specificity, and the use of 400 to 500 ml of Ringer''s solution for containers may improve sensitivity and specificity. The best SFC cutoff was ≥5 CFU. In conclusion, SFC has high sensitivity and very high specificity for diagnosing PJI.     

Outcomes of Salvage Endoprostheses in Revision Total Knee Arthroplasty for Infection and Aseptic Loosening: Experience of a Specialist Centre

BackgroundWe aimed to evaluate the clinical and radiographic outcomes of complex salvage knee revision arthroplasty (rTKA) using endoprostheses with segmental bone loss.MethodsA consecutive study of patients who underwent salvage distal femoral replacement (DFR) or proximal tibial replacement (PTR) with a minimum 2- year follow-up (2005–2018). Patients who had acute DFR for periprosthetic fractures were excluded. Clinical outcomes, complications, reoperations, revision for any cause, loosening and mortality data were collected. Knee Society Score (KSS) at final follow up was used as a patient-reported-outcome-measure.ResultsThirty three consecutive patients were included; average age 79.6 years (range 58–89); 15 males/18 females. All had AORI-III massive bone defects and were reconstructed using DFRs; 6 patients had concurrent PTRs. The indication for salvage rTKA was infection in 16/33 (48.5%) and aseptic-loosening in the remaining 17 patients (51.5%). Complications rate was 12.1%; two patients had significant extensor lag; 1 patella dislocation and one recurrent infection. Median follow-up was 5 years (range 2–15) with median arc of flexion- extension of 100° (range 60–120). KSS was available for 29/33 patients with an average of 73.2 (range 51–86). Patients with infection as their indication had poorer KSS scores (66.1 vs. 81.6; P < 0.0001). Eleven patients have died at median 4 years postoperatively (range 2–7) for unrelated causes, none of the components have been revised to date with overall 80% patients’ survivorship at 5 years.ConclusionsThe use of endoprostheses in salvage knee arthroplasty led to satisfactory medium-term clinical outcomes with an acceptable complication rate for this challenging group of patients with poorer functional scores for infection compared to aseptic loosening.Level of evidenceLevel IV.     

两种入路方式全髋关节置换术的疗效观察

目的 探究THA中DAA和PA的临床疗效及对髋关节功能的影响。方法 选择2017年1月~2018年1月收治的102例行THA者作研究对象,随机分成研究组和对照组,各51例。对照组患者行PA治疗,研究组患者行DAA治疗,比较两组患者术中出血量、下床时间、住院时间、髋臼前倾角、并发症及髋关节评分等情况。结果 研究组术中出平均血量（124.13±29.47）ml、术后下床及住院时间均优于对照组（P＜0.05）;研究组术后1个月、2个月的Harris评分（82.51±4.29）分、（86.37±5.13）分均高于对照组（P＜0.05）;研究组与对照组并发症总发生率未显示高度差异（P＞0.05）。结论 与经PA行THA治疗相比,经DAA行THA治疗术后住院时间更短,且髋关节功能恢复更佳。     

Easy Identification of Mechanical Axis during Total Knee Arthroplasty

Purpose

We devised an intraoperatively identifiable mechanical axis (IIMA) as a reference of alignment in total knee arthroplasty (TKA).

Materials and Methods

Between February 2010 and January 2011, primary TKAs were consecutively performed on 672 patients (1007 knees) using an IIMA as a reference in the coronal plane.

Results

The alignment of the lower extremity improved from a mean of 11.4±6.7° (-10.3-34.4°) of varus preop. to 0.7±3.5° (-5.2-8.6°) immediately after surgery. Mean alignment of the femoral component in the coronal plane was 89.3±2.3° (83.4-97.2°) postop. and mean alignment of the tibial component was 90.4±2.2° (85.1-94.2°) postop.

Conclusion

This study showed that IIMA could be of considerable value as a new guider of alignment that is easily accessible and highly effective during total knee arthroplasty.     

Prevalence of Osteoporosis in Female Patients with Advanced Knee Osteoarthritis Undergoing Total Knee Arthroplasty

This study sought to demonstrate bone mineral density (BMD) conditions in elderly female patients with knee osteoarthritis (OA) undergoing total knee arthroplasty (TKA). In addition, we sought to determine whether their BMD conditions differ from those of community-based females without knee OA. Finally we sought to determine whether clinical statuses are related to BMD in the knee OA patients. BMD conditions in 347 female patients undergoing TKA and 273 community-based females were evaluated. Additionally, comparative analyses of BMD between age and body mass index-matched knee OA groups (n=212) and the control groups (n=212) were performed. In the pre-matched knee OA group, regression analyses were performed to determine whether preoperative clinical statuses were related to BMD. Considerable prevalence of coexistent osteoporosis (31%) was found in the pre-matched knee OA patients undergoing TKA. We found no significant differences of the BMD T-scores and the prevalence of osteoporosis between the age and body mass index-matched knee OA and control groups. In the pre-matched knee OA patients, poorer preoperative clinical scores were related to poorer BMD T-scores in the proximal femur and/or lumbar spine. Our study suggests that more attention should be paid to identify and treat osteoporosis in elderly female patients with advanced knee OA undergoing TKA.

Graphical Abstract

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Use of Fine-Needle Aspiration for Diagnosis of Mycobacterium ulcerans Infection

Noninvasive methods for the bacteriological diagnosis of early-stage Mycobacterium ulcerans infection are not available. It was recently shown that fine-needle aspiration (FNA) could be used for diagnosing M. ulcerans infection in ulcerative lesions. We report that FNA is an appropriate sampling method for diagnosing M. ulcerans infection in nonulcerative lesions.Mycobacterium ulcerans infection (Buruli ulcer) is one of the 13 most neglected tropical diseases (9) and the third most common mycobacterial infection after tuberculosis and leprosy in immunocompetent humans (2, 6, 13-14). In general, this skin disease initially manifests as a painless nodule or papule, plaque, or edema (2). Without early intervention, these symptoms evolve into painless ulcers with undermined edges. The epidemiological, scientific, and management aspects of this disease have been well described (12). Over recent years, the management of Buruli ulcer patients has considerably changed with advances in antibiotherapy (3, 5).Laboratory diagnosis of this mycobacterial infection is based on detection of acid-fast bacilli (AFB) through the direct examination of samples, isolation of mycobacteria by culture, histological analysis, and detection of M. ulcerans DNA by PCR (12). Ulcerative lesion specimens are collected using swabs (12). Swabbing from the undermined edges of ulcers may sometimes be difficult and painful. Collecting specimens from patients with nonulcerative lesions necessitates invasive procedures, such as incisional, excisional, or punch biopsies, which require hospital infrastructure not available in remote rural areas in Africa where M. ulcerans infection is endemic. Two studies recently reported that fine-needle aspirates could be used to diagnose M. ulcerans infection in ulcerative lesions. In both studies, the number of patients enrolled was not large enough to draw conclusions on the effectiveness of this technique in diagnosing nonulcerative forms.First, we compared the diagnostic sensitivities of fine-needle aspiration (FNA) and swabbing in 64 patients with ulcerative lesions. These patients had skin lesions consistent with active M. ulcerans infection, based on the clinical definition of the World Health Organization (12). For each patient with ulcerative lesions, two swab samples were taken from beneath the undermined edges of the ulcers and one FNA sample was taken from the edge of the lesion. The FNA procedure was similar to that described previously (4, 11); however, we used 20-gauge, 25-mm needles (attached to 5-ml syringes) instead of the 21-gauge and 23-gauge needles used in other studies. All samples were placed in sterile Venosafe tubes (Terumo) and sent, at room temperature, to the bacteriology unit of Angers University Hospital, France, within 7 days of collection for processing.Significant differences were observed in the efficacies of the two sampling methods. PCR using FNA samples detected M. ulcerans DNA in 56 of the 71 patients (diagnostic sensitivity of 79%), and PCR using swab samples detected M. ulcerans DNA in 68 of 71 patients (sensitivity of 95%) (Table ​(Table1).1). Chi-square tests showed that the number of positive smears (direct smear examination) was significantly different (P < 0.0001) between swab (50.7%) and FNA (9.9%) samples. The number of positive FNA PCR results was not significantly lower than those for swab samples (P < 0.46). However, there was a significant difference in the number of negative PCR results between fine-needle aspiration (21.1%) and swab (4%) samples (P < 0.007). Overall, these comparisons showed that PCR analysis of swab samples was more accurate than that of FNA samples for diagnosing ulcerative forms. For each swab collection and FNA, the patient''s response to pain was assessed according to standard pain assessment methods (15). Twenty adults (aged 15 to 35 years) and 20 children (aged 5 to 12 years) presenting ulcerative lesions (5 to 15 cm in diameter) localized on right or left limbs were enrolled. The analysis of results clearly demonstrated that FNA was less painful and thus more comfortable for the patient than swabbing (Fig. ​(Fig.11).Open in a separate windowFIG. 1.Pain assessment during swabbing and FNA.

TABLE 1.

Results of direct smear examination and M. ulcerans DNA detection from swabs and fine-needle aspirations from ulcerative and nonulcerative lesions