带抗生素可活动关节骨水泥间隔在全膝关节置换术后感染中的应用

目的总结带抗生素可活动关节骨水泥间隔治疗全膝关节置换术后感染的早期经验。方法2004年6月至2005年4月,采用二期翻修术治疗5例全膝关节置换术后感染患者。男1例,女4例;年龄57～75岁,平均67岁。一期手术彻底清创,取出假体,置入带抗生素可活动关节骨水泥间隔物。术后患者早期部分负重,关节屈曲活动。术后选用敏感抗生素静脉滴注6周,感染控制后再植入高限制性假体。结果患者中3例基础病因为类风湿关节炎,其中2例长期服用激素;余2例基础病因为骨关节炎,都有糖尿病。所有患者术前都曾出现过窦道,其中2例有窦道封闭现象。所有患者均未发现与骨水泥间隔相关的骨折、脱位及不稳定。两次手术间隔期为12～20周,平均15周。在间隔期,5例患者都能扶拐行走和屈曲膝关节,活动度平均为95°,平均膝关节协会评分(kneesocietyscores,KSS)81分。再植入术后平均随访时间为10个月,目前尚未发现复发和新的感染。结论采用带抗生素可活动关节骨水泥间隔可以成功治疗全膝关节置换术后感染,在间歇期能保留关节活动度,最终可有效处理感染并使再植入手术更加方便。     

抗生素骨水泥股骨头临时假体治疗髋关节置换术后感染

目的总结评估Ⅰ期清创后采用自制抗生素骨水泥股骨头假体控制感染,Ⅱ期翻修重建治疗人工髋关节置换术后感染的临床效果。方法自2006年1月至2010年11月共收治11例（12髋）髋关节置换术后感染患者,均采用Ⅱ期翻修。其中男7例8髋,女4例4髋。年龄29～80岁,平均60岁,术前Harris评分17～45分,平均（32±7.63）分。所有患者采用Ⅰ期取出假体,彻底清创,置入自制抗生素骨水泥股骨头假体,间隔4～20个月（平均12个月）,待血沉、C反应蛋白、血白细胞计数正常,伤口局部无感染表现后,行Ⅱ期翻修重建。结果本组患者切口均I期愈合,无伤口并发症发生。所有患者均获得随访,随访时间6～40个月,平均20个月。所有病例在随访时感染均没有复发,感染控制率100%。。患者髋关节疼痛和关节功能均有明显改善。随访时Harris评分65～96分,平均（87±7.72）分,与术前比较有统计学差异（t=38.81,P〈0.01）。结论Ⅰ期清创后用抗生素骨水泥股骨头假体可有效控制髋关节置换术后感染,减少肢体短缩;Ⅱ期翻修重建手术可根据患者的情况选择骨水泥或非骨水泥假体,均可取得良好的临床疗效。     

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。     

术中自制临时关节型抗生素骨水泥占位器治疗人工膝关节置换术后感染

目的:研究术中自制临时关节型抗生素骨水泥占位器治疗人工膝关节置换术后感染的有效性。方法:使用自制压模器术中制备临时关节型抗生素骨水泥占位器。自2002年3月至2007年3月共使用此占位器治疗22例膝关节置换术后感染患者,男10例10膝,女12例12膝,平均年龄59.6岁(33～75岁)。初次置换到感染症状出现时间间隔平均6.7个月(1～14个月)。临床症状,血象、血沉、C-反应蛋白等血液感染指标及膝关节穿刺涂片和培养用以明确假体周围感染,两期手术后均监测感染指标变化,定期随访复查X线片,功能评价使用HSS评分系统。结果:所有患者获得随访,平均占位器植入间隔时间为4.7个月(3～9个月),Ⅱ期术前感染控制率为100%。Ⅱ期术后平均随访时间29.8个月(10～64个月),无感染复发。Ⅰ期术后膝关节HSS评分由术前的平均40.5±5.9提高到65.8±7.5,Ⅱ期术后最近随访时达平均88.7±5.1。9例对治疗结果满意,12例非常满意。结论:此方法制备的膝关节临时关节型占位器具有治疗期间保留较好关节功能、降低Ⅱ期手术难度、无须长期灌注及可靠的感染控制力等优点,治疗人工膝关节置换术后感染效果可靠。     

2018年美国关节置换术使用氨甲环酸的临床实践指南解读

2018年美国髋关节和膝关节外科医师协会(AAHKS),美国骨科医师协会(AAOS),髋关节学会(THS),膝关节学会(TKS)及美国局部麻醉与疼痛医学学会(ASRA)共同协作,针对氨甲环酸(TXA)在全关节置换术(TJA)中应用的有效性和安全性进行了循证研究,就氨甲环酸给药的方式、剂量和时机以及在血栓形成高风险患者中的使用等提出了推荐意见,并根据证据支持强度对推荐意见进行了分级。本文对该指南进行解读,旨在为中国的骨科医务工作者、患者、医疗管理人员和指南制定者提供参考。     

人工髋关节置换术后感染二期关节再置换的假体选择

目的 探讨人工髋关节置换术后感染二期关节再置换的假体选择.方法 1999年1月至2007年12月,共32例单侧人工髋关节置换术后感染二期关节再置换的患者,男19例,女13例,平均56岁(32～80岁).髋臼侧Paprosky骨缺损分型:Ⅰ型13例,ⅡA型9例,ⅡC型5例,ⅢA型1例,ⅢB型4例;对Ⅰ～ⅡA型髋臼骨缺损(22例),应用非骨水泥型假体;对ⅡC～ⅢB型髋臼骨缺损(10例),给予植骨、加强环和髋臼网等方法进行充分重建,应用骨水泥型假体.股骨侧Paprosky骨缺损分型:Ⅰ型11例,Ⅱ A型4例,ⅡB型1例,ⅡC型5例,ⅢA型6例,ⅢB型3例,ⅢC型2例;选用骨水泥型假体8例(ⅡC型5例,ⅢB型3例),近端固定生物型假体5例(Ⅰ型),广泛涂层型假体11例(Ⅰ型6例,ⅡA型4例,ⅡB型1例),远端同定型假体8例(ⅢA型6例,ⅢC型2例).结果 术后随访1～10年,平均5年2个月.术后2例患者反复发生感染,因患者拒绝再次取出假体,仅行清创和保守治疗;末次随访时仍存在窦道;Harris评分分别为65和78分.其余30例患者效果满意,Harris评分由二期手术前的平均48分(31～78分)提高到术后平均85分(80～95分).末次随访时X线片与术后当时的X线片对比,30例患者的假体均无下沉、移位和松动.结论 人工髋关节置换术后感染二期关节再置换手术的成功率高,手术重点是确认感染已获得良好控制后,针对骨缺损类型选择相应的假体.     

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。     

下肢关节置换术后感染的危险因素及预防方法

下肢关节置换术如全髋关节置换术和全膝关节置换术是骨科手术中较为成熟的手术方式,术后感染是关节置换术的一项严重的并发症,将引起疼痛、功能受限、治疗费用增加等.控制术后感染的关键在于预防.术前、术中、术后存在多种影响术后感染的危险因素,本综述将对各种术前、术中、术后的危险因素以及相应预防方法作一总结.     

未使用占位器的二期翻修治疗髋关节置换术后感染

目的探讨不使用占位器的二期翻修治疗髋关节置换术后假体周围感染的临床效果。 方法从2009年8月至2017年12月期间,对在西安交通大学第二附属医院接受未使用占位器的二期髋关节翻修治疗的21位既往行人工髋关节置换术后感染的患者(其中男性6例,女性15例,年龄28～78岁)进行随访观察。该组患者均采用一期手术取出髋关节假体旷置(未置放占位器),待临床表现及血液中相关炎性指标降至正常时再进行二期翻修,应用配对t检验以及Wilcoxon秩和检验分别评估患者术前术后的髋关节Harris评分及患肢缩短水平。 结果21例患者术后随访(4.0±2.8)年,术后的末次随访时髋关节Harris评分为(86±4)分,与翻修术前的(48±5)相比,有显著性差异(t ＝ 25.509,P< 0.01),术后患肢短缩为0.1 cm(－0.20, 0.35)cm(负值代表患侧肢体较健侧增加的长度),与术前4.3 cm(3.85,4.90) cm相比,有显著性差异(Z＝－4.016, P < 0.01),术后1例出现再次感染。 结论不使用占位器的二期翻修术治疗髋关节假体周围感染具有较高的感染控制率,同时也不会因为髋关节局部软组织挛缩而引起患肢的明显缩短,可以获得良好的术后髋关节功能。     

兔关节内植物植入术后金黄色葡萄球菌感染模型的建立

目的探索人工关节置换术后金黄色葡萄球菌假体周围感染感染,可靠动物模型的建立方法,比较细菌数量与模型的关系,观察模型建立后实验动物的生存率,以及后期细菌毒力和基因变异情况。方法60只新西兰大白兔使用定制非骨水泥假体行膝关节置换后,随机分入对照组和实验组（共5组,给予金葡菌液1ml,浓度分别为1×10^4,1×10^5,1×10^6,1×10^7,1×10^8CFU／ml）。采用大体评分、组织学、细菌生化检验、金葡菌遗传学和毒理学分析、扩增片段长度多态性（AFLP）细菌遗传物质分析的方法,验证模型构建的效率、安全性和稳定性,基线齐性检验、动物模型大体评分,浓度梯度分析采用多组间卡方分析,细菌致病基因分析采用和AFLP分析采用组间聚类分析一平均联结法方法。结果动物生存率、感染率不完全相同,组问方差分析显示,各组间存在统计学差异（F=3．695,P〈0．01）;组织学、细菌培养、生化检验和23SrRNA基因、nile基因检测支持金葡菌感染,使用1ml,1×10^5CFU／ml金葡菌膝关节直接接种能够成功构建模型。致病基因分析和AFLP检测显示,细菌在自然繁殖过程中出现变异,但各基因变异率和基因组总体变异率低于10％。结论本研究成功构建了稳定的关节置换术后金葡菌感染动物模型,发现细菌感染初期的基因变异和毒理学改变。该模型可用于关节置换术后假体周围急性感染的相关研究。更远期的变异情况可能导致感染模型的不稳定,需进一步研究。     

Antibiotic bone cement and the incidence of deep infection after total knee arthroplasty

We asked if the use of antibiotic-laden bone cement (ALBC) decreased the deep infection rate after primary total knee arthroplasty as compared to plain bone cement. We surveyed 1625 consecutive patients for relevant covariates. Joint pain and function were assessed at baseline and at 1 year of follow-up with the Western Ontario McMaster University Osteoarthritis Index scores. The incidence of deep infection at 1-year follow-up was recorded. There were no differences in baseline covariates between groups (P > .05). We found a deep infection rate of 2.2% in the ALBC group and 3.1% in the plain bone cement group (P = .27). Adjusted analysis showed that ALBC was not predictive of a lower infection rate at 1 year (P = .84). Antibiotic-laden bone cement did not reduce the incidence of deep infection following primary total knee arthroplasty at 1-year follow-up.     

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.     

Hematogenous infection after knee arthroplasty

Twenty-five hematogenously infected knee arthroplasties in 20 patients (17 with rheumatoid arthritis and 3 with arthrosis) were followed for 3 years. Staphylococcus aureus was the major infecting organism. Three patients with four arthroplasties died of sepsis. Two patients had removal of the arthroplasty, one of which resulted in an above-the-knee amputation. Four out of five arthrodeses fused. Two knees healed after early debridement and two healed without surgery. Ten knees had successful revision arthroplasty.

Rheumatoid arthritis and constrained prostheses increase the risk of hematogenous infection. Any infection and especially cutaneous lesions in a patient with a knee arthroplasty should be treated vigorously.     

Hematogenous infection after knee arthroplasty

Twenty-five hematogenously infected knee arthroplasties in 20 patients (17 with rheumatoid arthritis and 3 with arthrosis) were followed for 3 years. Staphylococcus aureus was the major infecting organism. Three patients with four arthroplasties died of sepsis. Two patients had removal of the arthroplasty, one of which resulted in an above-the-knee amputation. Four out of five arthrodeses fused. Two knees healed after early debridement and two healed without surgery. Ten knees had successful revision arthroplasty. Rheumatoid arthritis and constrained prostheses increase the risk of hematogenous infection. Any infection and especially cutaneous lesions in a patient with a knee arthroplasty should be treated vigorously.     

Treatment strategies for infection after reverse shoulder arthroplasty

Introduction

Infection after reverse shoulder arthroplasty (RSA) is a disastrous complication. No clear guidelines describing specific management strategies for infection after RSA are available.

Methods

We retrospectively analyzed 20 patients treated for deep infection after RSA. Initial irrigation and debridement and exchange of the polyethylene inlay were performed in seven patients, and initial two-stage revision was performed in 12 and initial resection arthroplasty in one patient. Patient charts were reviewed for risk factors, clinical symptoms and investigations of those symptoms, pre- and postoperative X-rays, interval until revision surgery, causative bacteria, complications, final clinical outcome and patient satisfaction.

Results

The mean overall postoperative Constant–Murley Score (CMS) was 42.6 points, the mean UCLA score was 20.8, the mean simple shoulder test (SST) was 5.5, and the mean VAS was 1.5. When comparing the CMS, UCLA score and the SST between the revision RSA group and the resection group, significant differences between the groups were found (p < 0.05). Irrigation, debridement and exchange of the polyethylene inlay were successful only in two of the four patients with acute infection. The three patients with subacute infections were treated with initial irrigation and debridement and exchange of the polyethylene inlay, which were not successful.

Conclusion

The relatively high patient satisfaction can be explained by the low pain level once the patient is free from infection. However, functional results are poor in most cases, and this possible outcome must be discussed with the patient in the preoperative setting.     

人工关节置换术后感染的Ⅱ期翻修术

随着材料技术和加工技术的进步 ,目前人工全髋关节置换术后感染发生率已降到 1%以下〔1〕。临床上治疗以Ⅱ期翻修术较常用 ,现就有关内容综述如下。1　人工关节置换术后感染的发生人工关节置换术后感染发生与否取决于细菌数量、毒力及机体抵抗力。细菌以凝固酶阴性表皮葡萄球菌和金黄色葡萄球菌多见 ,两者所占比例超过5 0 % 〔2〕,革兰阳性杆菌、β 溶血性链球菌、肠球菌和厌氧菌次之〔3〕,布氏杆菌、真菌等极少见〔4〕。术中细菌残留、术后细菌经血液播散是感染发生的基本途径〔5〕。据临床统计 ,手术室空气中细菌坠落污染是最主要来源 ,占…     

Aspergillus infection after total knee arthroplasty

The literature includes little information about the treatment protocol for Aspergillus infection after total knee arthroplasty. In this article, we describe the case of a nonimmunocompromised patient who lacked predisposing risk factors and who initially presented with aseptic loosening of a total knee prosthesis that postoperatively had grown Aspergillus niger. Intraoperative culture and frozen-section results for the pseudocapsule were negative. Two days postoperatively, culture results showed heavy growth of A niger. The patient was treated with a 6-week course of amphotericin B followed by oral antifungal therapy. She was doing well and had no symptoms 12 months after surgery.     

Mycobacterium farcinogenes infection after total hip arthroplasty

Atypical mycobacterium infection after total hip arthroplasty is a very rare but a potential cause of implant failure. We present the first report of Mycobacterium farcinogenes infection in human beings. Although the treatment of atypical mycobacterium infection after total hip arthroplasty is controversial, we successfully treated the infection in this case, after consultation with a microbiologist regarding infection management, with both surgery and chemotherapy. It is important to maintain a high index of suspicion for atypical mycobacterium infection, particularly when standard culture findings are negative despite strong clinical evidence of prosthesis infection.