髋关节置换术后慢性隐匿性假体周围感染的诊断与治疗

Diagnosis and treatment of delayed occult periprosthetic joint infection after hip arthroplasty

[目的]探讨髋关节置换术后假体周围隐匿性感染的诊断及外科治疗方法。[方法]回顾性分析2011年5月-2014年10月连续收治12例髋关节人工关节置换术后假体周围慢性隐匿性感染患者的临床资料,男10例,女2例;年龄56-75岁,平均60.5岁。12例患者均表现为髋关节疼痛,首发症状距初次关节置换手术的时间6-15个月,平均9.5个月。本组病例无全身和局部感染症状及体征,C反应蛋白和血沉无明显增高,X线片6例关节假体-骨界面可见透光带,2例半髋置换可见明显的髋臼上缘骨质磨损。10例行关节穿刺细菌培养,12例术中均进行关节周围软组织标本细菌培养及冰冻切片快速病理检查。术中行假体取出,抗生素骨水泥间隔体置入及术后全身抗感染治疗,二期关节翻修。[结果]12例患者一期手术假体均顺利取出,术中均未见明显脓性分泌物,但假体柄取出后股骨髓腔内可见炎性坏死组织。术中髋周软组织标本快速冰冻切片结果每高倍视野中性粒细胞计数平均12个（8-15个/高倍视野）,术后病理报告均诊断为化脓性炎症。10例术中标本细菌培养结果为阴性,2例细菌培养为金黄色葡萄球菌。关节翻修术后平均随访时间为16.6个月（5-24个月）,髋关节Harris评分由术前（62.5±8.2）分（59-75分）提高至末次随访时（91.6±3.8）分（88-95分）,差异有统计学意义（t=20.2,P=0.000）。[结论]假体周围隐匿性感染临床表现不典型,常规辅助检查方法不能对假体周围感染提供有价值的诊断依据,术中冰冻病理检查能做出快速、准确诊断。

To investigate approaches to diagnosis and treatment of the delayed occult periprosthetic joint infection. [Methods] A retrospective study was conducted on 12 patients who suffered from delayed occult periprosthetic joint infection after hip arthroplasty from Match 2011 to October 2014. There were 10 males and 2 females with an average age of 60. 5years,ranging from 56 to 75 years. The main manifestation in the 12 patients was persistent local hip pain,which occurred from6 to15 months postoperatively,with an average of 9. 5 months. However,ESR and CRP proved relatively normal in all cases. Radiography showed a continuous radiolucent line in 6 cases and acetabulum wear in 2 cases. Histological examinations were performed in all cases,in which the specimens of periprosthetic tissue were dissected by frozen section and bacterial culture. All of the patients were treated with removal of all implants,complete debridement and using antibiotic loaded cement space in the first stage procedure,followed by systematic antibiotic therapy,and then reimplantation of a new prosthesis in the second stage operation. [Results] Despite no obvious pus,inflamed tissue was easily harvested at the bone- implant interface as the prosthesis removed. Intraoperative frozen section showed 8 to 15 granulocytes per high power field with an average of 12 granulocytes in all of the patients,however,a positive intraoperative culture was obtained in only 2 cases. All patients were followed up for an average of 16. 6 months（ range,5 to 24 months） after revision surgery. Harris hip score improved from（ 62. 5 ± 8. 2）（ 59 to75） preoperatively to（ 91. 6 ± 3. 8）（ 88 to 95） at final follow- up. [Conclusion] Delayed occult periprosthetic infection is atypical in the clinical manifestation,usually presenting just persistent local hip pain. The routine laboratory and radiography examinations cannot provide the valuable information,in contrast,intraoperative frozen section might be helpful to rapid and corrective diagnosis.