二期全髋关节置换治疗髋部骨折内固定术后感染

Two-stage total hip arthroplasty using an antibiotic-loaded cement spacer for infected internal fixation of hip fractures

目的探讨应用抗生素骨水泥占位器分二期行全髋关节置换术治疗髋部骨折内固定术后继发髋关节感染的临床应用及其疗效。方法回顾性分析2007年5月至2014年11月解放军总医院骨科收治的行二期人工全髋关节置换术治疗髋部骨折内固定术后感染患者21例，包括股骨颈骨折内固定术后18例，股骨转子间骨折内固定术后3例。其中男15例，女6例；平均年龄45（27-64）岁。术后1、3、6、12个月以及以后每年随访1次，复查血清学炎性指标和X线片评估临床疗效和假体状况，通过Harris评分评估髋关节功能。结果全部患者均在全麻下成功完成两期手术治疗。一期行内固定物取出、清创、自制关节型抗生素骨水泥占位器植入术；二期行占位器取出、清创、人工全髋关节置换术。一期手术时，17例采用标准占位器，4例采用股骨头型占位器；术中1例发生股骨矩劈裂，给予钢丝捆扎固定。平均手术间隔期为21（13-44）周，发生占位器断裂1例。二期关节重建时，20例采用生物固定型假体和1例采用泥固定型假体。所有患者均获得24个月以上随访，平均随访时间为55（25-102）个月。随访过程中，炎性指标均回到正常范围，无感染复发和新发感染出现。患髋Harris功能评分由术前（23．24±11．8）提高至（90．2±3．9），比较差异有统计学意义（P〈0．05）。根据Harris评分标准，髋关节功能获优13髋、良7髋、可1髋，优良率为95％。末次随访时，髋关节正侧位x线片均无连续透光线出现，假体固定良好，无松动表现。无假体脱位、假体周围骨折、异位骨化等并发症发生。结论对于存在关节内活动性感染的髋部骨折内固定术失败的患者，借助临时抗生素骨水泥占位器，分二期行人工全髋关节置换术能够有效地根除髋关节感染、重建关节功能，获得满意的近中期临床结果。

Objective To evaluate the application and clinical results of two-stage total hip arthroplasty in the treatment of the deep hip infection following the internal fixation of hip fractures. Methods From May 2007 to November 2014, 21 patients with active hip infection secondary to internal fixation of hip fractures were treated with two-stage total hip artbroplasty using a temporary antibiotic-loaded cement spacers. Of 21 cases, 15 were males and 6 were females, aged from 27 to 64 years （mean, 45 ） ; there are 18 cases of femoral neck fractures and 3 cases of iutertroehanteric fractures. The serologic examination and X-ray were taken at 1 month, 3 months, 6 months, 12 months and annually thereafter post-operatively to evaluate the clinical results and prosthesis status. Harris hip score system was used to evaluate the joint function. Results All patients were successfully treated with two stage operations under general anesthesia. The operational interval was 12 -44 weeks （mean, 21 ） and 1 spacer breakage. For the arthroplasty, eementless components were used in 20 cases and cemented component was use in 1 case. The patients were followed up 25 - 102 months （ mean, 55 ） and infections were eradicated in all hips. The Harris hip score was improved from 23.24 ± 11.81 pre-operatively to 90. 24 ± 3.92 post-operatively and the difference was statistically significant （ P 〈 0. 05 ）. According to this scoring criteria, the excellent and good rate reached up to 95%. At latest fellow-up, the location of prosthesis were well and the function of hip joint was satisfied. All cases had no dislocation, periprosthetic fracture, ectopic ossification or any other complications at the latest fellow-up. Conclusion By means of an antibiotic-loaded cement spacer, two-stage total hip arthroplasty is an effective salvage procedure eradicating infection and providing functional improvement to the infected internal fixation of hip fractures. The early and mid-term clinical effects are satisfied.