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.

The choice of prosthesis in the second stage revision with infectious of artificial hip replacement

Objective To study surgical technique and choice of prosthesis in the second stage revision with infections of artificial hip replacement. Methods From January 1999 to December 2007, 32 patients with infections after unilateral hip replacement underwent the second stage revision, including 19 males and 13 females, with a mean age of 56 years (32-80 years). Bone defect in acetabular side by Paprosky classification were 13 cases(type Ⅰ), 9 cases(Ⅱ A), 5 cases(Ⅱ C), 1 cases(ⅢA), 4 cases(Ⅲ B). Cemeritless prosthesis was applied in 22 cases with type Ⅰ-Ⅱ A bone defect. Cemented prosthesis was applied in 10 cases with type Ⅱ C-Ⅲ B bone defect followed by acetabular reconstruction by allograft, mesh and cage or ring. Bone defect in femoral side by Paprosky classification were 11 cases(Ⅰ), 4 cases(Ⅱ A), 1 case (Ⅱ B), 5 cases(Ⅱ C), 6 cases(Ⅲ A), 3 cases(Ⅲ B), 2 cases(Ⅲ C). Cemented prosthesis was applied in 8 cases with type Ⅱ C (5 cases) and Ⅲ B(3 cases) bone defect. Cementless prosthesis was applied in the other cases, including proximal fixation(5 cases with type Ⅰ ), extensive prouscoating(6 cases with Ⅰ, 4 cases with Ⅱ A, 1 case with Ⅱ B) and distal fixation (6 cases with Ⅲ A, 2 cases with Ⅲ C). Results All cases were followed up i-10 years. Among them, 2 patients suffered recurrent infections, and underwent debridement and conservative treatment, with sinus tract at final follow-up. Harris score were 65 and 78, respectively. The other 30 cases got satisfactory results. Harris score was increased from average 48 (31-78) preoperatively to 85 (80-95) postoperatively. At final follow-up, 30 prosthesis had no subsidence, migration and loosening on X-ray images. Conclusion The success rate of two stage revision with infections of artificial hip replacement is satisfactory. The key point of revision is to choose proper prosthesis according to bone defect type after the infection is under better control.