封闭式负压引流术在全髋关节置换术后深部感染病例中的应用价值

Application of vacuum sealing drainage in patients with deep infection following primary total hip arthroplasty

目的探讨封闭式负压引流术（VSD）在全髋关节置换术（THA）后发生深部感染病例治疗中的应用。方法回顾性研究2014年5月至2015年4月,收治于中南大学湘雅医院关节外科符合纳入、排除标准的13例THA术后深部感染的患者,其中10例为单侧THA,3例为双侧THA,均为单侧深部感染接受翻修术治疗。男性5例,女性8例;年龄49-79岁,平均（63±13）岁。这些患者在初次置换术后2个月至7年内发生感染,平均（3.1±1.1）年。所有病例一期放入抗生素骨水泥占位器旷置,并结合全身用药控制感染,但3周至4个月感染仍未得到控制。取出并更换占位器,开放切口并应用VSD持续冲洗深部组织,待感染控制后置入新的假体。所有病例术前、术后及随访均检测红细胞沉降率（ESR）、C-反应蛋白、白细胞介素6及降钙素原作为检测感染指标,分别对旷置术前及术后7 d、二次翻修术前和末次随访的各指标进行配对t检验。结果 1例患者在经过重复4次清创并VSD引流术后感染仍未得到控制,且组织缺损严重,最终采用肌瓣移植联合外固定架固定处理。其余患者术后切口均愈合,无下肢深静脉血栓及坐骨神经麻痹等并发症的发生。其中12例患者翻修完成后均获10-24个月的随访,随访期间无关节脱位及感染及复发。末次随访中,所有患者切口Ⅰ级愈合,其中3例患者关节活动时有关节疼痛,2例轻度跛行;Harris评分（76±5）分,与术前Harris评分（37±6）分相比差异有统计学意义（t=3.617,P〈0.05）。旷置术前和术后7 d的ESR等四种指标配对t检验结果显示组间差异均有统计学意义（P〈0.05）;二次翻修术前和末次随访四种检验结果比较,组间仅ESR差异有统计学意义（ESR组P〈0.05,其余3组均P〉0.05）。X线片检查未见明显假体松动,2例患者出现股骨柄假体下沉,但尚未发生松动。结论 VSD结合全身使用抗生素对THA术后的深部组织感染治疗具有一定的作用。

Objective To explore the value of using vacuum sealing drainage（ VSD） in patients with deep infection after primary total hip arthroplasty（ THA）. Methods A retrospective study was conducted among 13 patients with deep infection during May,2014 to April,2015,who have met the specific criteria. The patients consisted of five males and eight females,whose age was（ 63 ± 13） years（ ranged from 49 to 79） in average. Ten patients underwent unilateral THA,while the other three underwent bilateral THA. These patients were diagnosed as infection in a mean time（ 3. 1 ± 1. 1） years（ ranged from 2 months to 7 years） after the primary THA. All the cases were operated with a cemented spacer containing antibiotics replacing the former prosthesis. The antibiotics were also applied systematically. But the surgery failed to control the infection after three weeks to four months,then the spacer replaced was with a new one,and VSD was used; the new prosthesis was installed after the infection was controlled. Erythrocyte sedimentation rate（ ESR）,C reactive protein（ CRP）,interlenkin-6（ IL-6）and procalcitonin were examined several times to detect the possibility of infection before and seven days after the replacing surgery as well as. before the revision and each time of the follow-up. Paired t-test was used for data analysis. Results The preoperative Harris score was（ 37 ± 6）. Infection of one case was out of control after four times of debridement and VSD application,of which the soft tissue was obviously defected. The muscular flap transplantation combined with external fixation was used to deal with this situation. The other 12 cases were all followed up for 15. 9 months（ 10- 24 months） on average. No dislocation or recurrence of infection occurred. At the final follow-up,all the incision wounds were restored; three patients complained thigh pain,while two patients suffered claudication. The Harris score（ 76 ± 5） was apparently improved than that before the revision（ t = 3. 617,P〈0. 05）. ESR,CRP,IL-6and procalcitonin showed significant differences before the revision and seven days after the replacing surgery（ P〈0. 05 in all four indicators according to the t value）,while only ESR showed significant difference between the data before revision and at last follow-up（ P〈0. 05 in ESR,while P〉0.05 in other three indicators）. X-ray showed no apparent loosening of prosthesis,while two cases showed subsidence of femoral components. Conclusion The using of VSD combined with antibiotics may provide properly promised effect in controlling the infection.