保留部分假体的翻修术治疗慢性髋关节假体周围感染

Implantation of antibiotic-loaded calcium sulfate in partial one-stage revision for chronic periprosthetic hip infection

目的探讨保留部分假体联合硫酸钙抗生素载体的一期翻修术治疗慢性髋关节假体周围感染(PJI)的临床疗效和可行性。方法回顾性分析2017年1月至2020年1月期间因髋关节慢性PJI于郑州大学第一附属医院关节外科行一期翻修治疗的33例患者的病历资料。依据美国肌肉骨骼感染协会诊断标准(MSIS),纳入诊断为THA后PJI,且Tsukayama分型为Ⅳ型的患者,排除再次翻修、不耐受手术者;其中男13例,女20例,年龄55~81岁。根据术前及术中评估假体是否固定牢固及骨长入情况,选择性翻修股骨柄或髋臼杯。翻修术中所有患者均保留牢固假体,常规置换髋臼内衬及股骨头,彻底清创,充分刷洗暴露在骨组织外的保留假体,术中联合植入硫酸钙抗生素颗粒,在局部构建抗生素缓释系统。定期随访感染控制情况、Harris髋关节评分(HHS)、视觉模拟评分(VAS)、健康状况简表评分(SF-36)和并发症发生情况等。术前、术后6个月及术后1年时的HHS、VAS和SF-36评分的比较采用重复测量的方差分析,两两比较用Bonferroni法。计数资料比较采用配对设计Fisher确切概率法检验。结果所有患者平均年龄(63±7)岁,术后获平均(32±17)个月随访。1例患者术后6个月出现感染复发迹象,再次手术后8周感染症状消除,至末次随访未见感染复发迹象;感染控制率为97.0%。26例患者选择单纯翻修髋臼杯保留股骨柄,7例患者选择单纯翻修股骨柄保留髋臼杯。HHS评分和SF-36评分分别由翻修术前的(35.3±4.9)分、(374.5±37.3)分提高至术后1年的(84.4±3.5)分、(664.1±23.2)分;VAS评分由翻修术前的(6.9±1.4)分下降至术后1年的(1.2±0.8)分。以上项目翻修术前、术后6月与术后1年比较差异均有统计学意义(F=1099.116、930.082、242.621,均为P<0.05),不同时间段两两比较差异均有统计学意义(均为P<0.05)。结论保留部分假体联合硫酸钙抗生素载体的一期翻修术可作为治疗假体固定牢固髋关节慢性PJI的有效方法,早期有效根除感染的同时,减少手术损伤,改善髋关节功能,提高患者生活质量。

Objective To investigate the clinical efficacy and feasibility of antibiotic-loaded calcium sulfate in partial one-stage revision for chronic periprosthetic hip infection.Methods A retrospective study was conducted of the 33 patients who had undergone partial single-stage revision for chronic periprosthetic hip infection from January 2017 to January 2020 at the articular surgery department of the First Affiliated Hospital of Zhengzhou University.Inclusion criteria:patients with a diagnosis of PJI after THA and Tsukayama staging type IV were enrolled according to the American Musculoskeletal Infection Society(MSIS)diagnostic criteria;the patients who had revision surgery more than once,and intolerant of surgery were excluded.Thirteen males and 20 females were enrolled,aged from 55 to 81 years.The femoral stem or acetabular cup was selectively revised according to preoperative and intraoperative assessment of whether the prosthesis was firmly fixed and bone ingrowth.During revision surgery,the firm prostheses were retained,the acetabular linings and femoral headswere routinely replaced,thoroughly debridement was performed,andadequately brushed the exposed component.Antibiotic-loaded calcium sulfate were implanted together during the operation to construct a local drug delivery system.Regular follow-up was performed for infection control,Harris hip score(HHS),visual analogue score(VAS),short form health status score(SF-36)and complication occurrence.HHS,VAS and SF-36 scores were compared preoperatively,at six months and one year after the surgery using repeated measures ANOVA,with two-way comparisons using the Bonferroni method.Count data were compared using the Fisher exact probability test in a paired design.Results The average age was(63±7)years,and all the patients were followed up for(32±17)months.One patient had signs of infection recurrence at six months after operation,and the infection symptoms were eliminated eight weeks after the re-operation.No sign of infection recurrence was found at the last follow-up,and the infection control rate was 97.0%.Twenty-six patients simply underwent the revision of the acetabular cup and retained the femoral handle,and seven patients only received the femoral handle revision surgery while the acetabular cups were retained.One year after revision surgery,HHS and SF-36 increased from(35.3±4.9)and(374.5±37.3)before the revision to(84.4±3.5)and(664.1±23.2)at one year after the revision.The VAS decreased from(6.9±1.4)preoperatively to(1.2±0.8)one year after revision surgery.There were statistically significant differences in the above items before revision surgery,six months after surgery and one year after surgery(F=1099.116,930.082,242.621,all P<0.05),and there were statistically significant differences in pairwise comparisons at different time periods(all P<0.05).Conclusions Partial one-stage revision with antibiotic-loaded calcium sulfate may be used as an effective method for the treatment of chronic periprosthetic hip infection.It reduces surgical injury,improves hip function,and improves patients'quality of life,while effectively eradicating infection at the same time.