彻底清创二期翻修治疗人工髋关节感染的效果

Radical debridement and two-stage revision surgery for treatment of infection after hip arthroplasty

目的探讨彻底清创二期翻修治疗人工髋关节感染的临床疗效。方法回顾分析28例人工髋关节感染行二期翻修患者的资料。26例为首次翻修,1例为第2次翻修,1例为第3次翻修。22例全髋翻修,6例半髋翻修。患者均行一期清创,取出人工髋关节假体并植入自制关节型万古霉素骨水泥假体,术中局部及术后全身抗感染治疗,感染控制后二期植入翻修假体。末次随访根据Harris评分、实验室以及影像学检查对手术效果进行评估。结果患者均获得随访,时间10~72个月。22例全髋关节翻修患者除2例自然死亡外,其余20例未出现感染复发;3例单纯髋臼翻修患者中有1例术后感染复发,3例单纯股骨柄假体翻修患者中有1例感染复发。末次随访时,Harris评分由术前(31.55±2.71)分提高至(75.54±3.44)分,ESR由术前(36.5±5.4)mm/1h下降至(20.4±3.6)mm/1h,CRP由术前(72.4±20.5)mg/L下降至(12.8±8.4)mg/L。至末次随访,Harris评分较术前提高(40.52±1.23)分,ESR较术前下降(15.1±1.6)mm/1h,CRP较术前下降(54.6±9.6)mg/L。除第3次翻修患者术后13个月出现假体松动外,其余患者均未出现明显假体下沉,松动、骨溶解等。结论人工髋关节感染二期翻修时,全髋关节翻修清创彻底,临床效果较好。无明显禁忌时应尽量将假体、骨水泥、感染坏死组织完全取出,必要时可行股骨开窗术,以减少感染复发率。

Objective To explore the clinical effect of radical debridement and two-stage revision for the treatment of hip prosthesis infection.Methods Twenty-eight patients with hip prosthesis infection were retrospectively reviewed.Twenty-six patients underwent revision for the first time,1 case for the second revision,and 1 for the third revision;22 for total hip revision and 6 for half-revision.All patients underwent debridement.The artificial hip prosthesis was removed and implanted with a vancomycin-based prosthesis.The local and postoperative systemic anti-infective treatment was performed.The infection was controlled and implanted in the second stage.The final follow-up was evaluated according to Harris score,laboratory and radiographic examination.Results The patients were followed up for 10~72 months.The 22 patients underwent total hip revision with no recurrence of infection occurred,except 2 patients of natural death.About 1 in 3 patients with pure acetabulum revision had recurrence of infection,and about 1 in 3 patients with pure femoral prothesis stem revision had recurrence of infection.At last follow-up,the Harris score was（31.55±2.71）points up to（75.54±3.44）points,erythrocyte sedimentation rate （ESR） was（36.5±5.4）mm/1h down to（20.4±3.6）mm/1h,C-reactive protein（CRP） was（72.4±20.5）mg/L,down to（12.8±8.4）mg/L.At the last follow-up,the Harris score increased （40.52±1.23）points,ESR decreased （15.1±1.6） mm/1h,and CRP decreased （54.6±9.6） mg/L,compared with the preoperative.No obvious prosthesis subsidence,loosening or osteolysis were found in all patients except for the third revision of prosthesis loosening at 13 months postoperatively.Conclusions In two-stage revision surgery of hip prosthesis infection,complete debridement has good clinical effect.Implant,bone cement and infected necrotic tissue should be removed as far as possible when there is no obvious contraindication,in order to reduce infection recurrence rate,femoral fenestration when necessary.