全膝关节置换术后感染的诊断与外科治疗

Diagnosis and surgical treatment of seven infection cases following total knee arthroplasty

目的探讨单侧膝关节置换术（TKA）后假体周围感染的诊断与外科治疗方法。方法分析2012年4月至2015年12月,兰州大学第二医院关节外科收住的7例骨关节炎患者单侧TKA后感染病例,其中1例为急性感染,5例为亚急性感染,1例为慢性感染。临床资料,纳入标准为有持续的患侧膝关节肿胀、疼痛或有切口窦道,且红细胞沉降率（ESR）、C反应蛋白（CRP）均增高;排除标准为有持续的疼痛但ESR、CRP均低于正常值。男性1例,女性6例,年龄54-70岁,平均（63±6）岁,其中2例行膝关节融合术,4例行Ⅰ期旷置、Ⅱ期翻修术,1例行Ⅰ期清创垫片更换术。手术治疗前后白细胞计数、CRP、ESR、中性粒细胞比率（NE%）等的比较采用配对t检验。结果 2例Ⅰ期关节融合患者与4例Ⅰ期旷置、Ⅱ期翻修术患者感染均得到控制;术前、术后CRP（t=6.87,P〈0.01）、ESR（t=3.75,P〈0.05）、NE%（t=8.34,P〈0.01）的差异有统计学意义;膝关节疼痛明显消除。7例患者翻修术前膝关节平均屈曲度为（73±18）°（45°-90°）,伸直平均角度为（177.86±3.93）°（170°-180°）。末次随访4例Ⅰ期旷置、Ⅱ期翻修患者膝关节平均屈曲度为（75±15）°（60°-95°）,平均伸直角度（178.75±2.50）°（175°-180°）,2例膝关节行关节融合术,关节无活动度。1例Ⅰ期更换垫片患者于术后4个月再次出现膝关节肿胀、疼痛并再次培养出细菌,感染未能完全控制。结论CRP、ESR、NE%可作为诊断膝关节假体周围感染的敏感指标,膝关节融合术及Ⅰ期旷置、Ⅱ期翻修术均可有效控制TKA术后假体周围感染,但前者牺牲了膝关节功能,Ⅰ期旷置、Ⅱ期翻修在治愈感染的同时保留了膝关节的功能,可以作为此类疾病的常规治疗方法。

Objective To investigate the diagnosis and surgical treatment of postoperative infection in the patients of unilateral total knee arthroplast（ TKA）. Methods The clinical data of seven cases of infection followingr unilateral TKA were analyzed in the department of orthopaedics,the second hospital of Lanzhou University,from April 2012 to December 2015,including one case of acute infection,five cases of subacute infection and one case of chronic infection. The inclusion criteria were as follows：continued swelling,pain or sinus of incision,both erythrocyte sedimentation rate（ ESR） and C-reactive protein（ CRP） were higher than normal values. The exclusion criteria included continuing pain,both ESR and CRP were lower than normal values. According to the inclusion and exclusion criteria,one male and six females were included,age 54- 70 years,（ 63 ± 6） years on average. Among the cases,two cases accepted arthrodesis,four cases underwent one-stage exclusion and two-stage revision,one case underwent debridement and gasket replacement surgery. All the data were analyzed using software SPSS 20. 0. The continuous data[e. g. white blood cell count（ WBC）,ESR,CRP and neutrophil ratio（ NE%） ]of preoperation and post-operation were calculated by paired samples t test. The significance was set as P〈0. 05. Results The infection in the two patients of one-stage knee arthrodesis and the four patients of onestage exclusion and two-stage revision were controlled. Significant differences were found in CRP（ t =6. 87,P〈0. 01）,ESR（ t = 3. 75,P〈0. 05） and NE%（ t = 8. 34,P〈0. 01） between the preoperation and post-operation data; the knee pain was obviously relieved. The pre-operative average flexion and extension ranges of the seven cases were 45°- 90°[average（ 73 ± 18） °] and 170°- 180°[average（ 178 ± 4） °]. The average flexion and extension ranges at the latest follow-up of the four cases of one-stage exclusion and two-stage revision were 60°- 95°[average（ 75 ± 15） °]and 175°-180°[average（ 179 ±2） °]. The two patients of knee arthrodesis lost the joint functions of flexion and extension. Swelling and pain occurred in the patient underwent one-stage gasket replacement four months after the operation. The result of bacteria culture was positive,which indicated that the infection was not totally controlled.Conclusions CRP,ESR,NE% can serve as sensitive indices for diagnosis of the prosthetic infection.Both knee arthrodesis and one-stage exclusion and two-stage revision can effectively control the prosthetic infection following TKA,however knee arthrodesis may lead to knee dysfunction. One-stage exclusion and two-stage revision can not only cure the infection but also reserve the function of keen,which should be regarded as a routine treatment for infection after TKA.