全膝关节置换术后假体周围感染的手术方式及预后

Treatment options and prognosis of infection after total knee arthroplasty

目的 探讨全膝关节置换术后假体周围感染的手术方式及预后。方法 2000年1月至2016年11月经手术治疗的全膝关节置换术后假体周围感染患者62例,男17例,女45例;年龄37~85岁,平均（66.0±10.2）岁。初次手术诊断为骨关节炎49例、类风湿关节炎9例、化脓性关节炎后继发性强直2例、血友病性关节炎2例。初次手术为单侧全膝关节置换术41例、双侧全膝关节置换术21例。统计感染类型、有无窦道、病原学证据、感染后处理方式及预后。结果 治疗方案包括保留假体的开放清创术24例（38.7%）,其中清创成功14例,清创距初次关节置换术的中位时间为33 d,关节腔内组织或关节液细菌培养出苯唑西林耐药的金黄色葡萄球菌1例,合并窦道形成1例;清创失败10例,清创距初次关节置换术的中位时间为270 d,细菌培养结果为耐药菌4例,合并窦道形成6例,1例放弃治疗、1例行关节融合术、8例接受全膝关节翻修术。全膝关节翻修46例（74.2%）,其中一期翻修9例,翻修距初次关节置换术时间（15.9±14.5） d,细菌培养耐药菌3例,合并窦道形成1例;二期翻修37例,翻修距初次关节置换术时间60~4 934 d,平均（1 045.7±1 044.1） d,培养出耐药菌15例,合并窦道形成12例。随访时间4~177个月,平均（73.9±48.2）个月,所有患者末次随访时感染均已治愈。开放清创术成功者末次随访时膝关节协会评分（85.9±4.3）分、一期翻修者（78.5±3.3）分、二期翻修者（65.7±7.4）分,组间差异有统计学意义。结论 对全膝关节置换术后3周内出现的假体周围感染,若细菌培养无耐药菌且无窦道形成,可首先考虑保留假体的开放清创术;对3周至1个月内出现的感染或清创术中发现假体不稳者,可选择一期翻修术;1个月之后出现的、软组织条件差、细菌培养为耐药菌、有窦道形成的假体周围感染,可采用二期翻修术。

Objective To investigate surgical interventions for periprosthetic joint infection （PJI） after total knee arthroplasty and characteristics of prognosis. Methods Sixty-two patients with PJI after total knee arthroplasty from January 2000 to November 2016 were reviewed retrospectively, included with 17 males and 45 females. The mean age was 66.0±10.2 years old （37-85）. Fourty-nine patients were diagnosed with osteoarthritis, 9 with rheumatoid arthritis, 2 with secondary ankyloses after suppurative arthritis and 2 with hemophilia arthritis. Forty-one patients underwent unilateral total knee arthroplasties, and 21 bilateral total knee arthroplasties. Characteristics of PJI, including infection types, existence of sinus tract, infectious pathogen, surgical intervention and patients＇ prognosis, were collected. Results Twenty-four patients underwent open debridement with prothesis retention. In the 14 successful cases, medial time interval between primary total knee arthroplasty and debridement was 33 days. One case of positive Methicillin resistant Staphylococcus aureus culture of joint aspiration, and 1 case formed sinus tract. In 10 cases of failed debridement, the medial time interval was 270 d. Intra-articular culture presented 4 cases of antibiotic resistant bacteria, and 6 cases formed sinus tract. Except for one patient gave up treatment and another received arthrodesis, the other 8 failed cases were all treated with revisions. In 46 revisions, nine patients underwent one-stage revisions. The mean time interval between primary total knee arthroplasty and revision was 15.9±14.5 d. Intra-articular culture presented 3 cases of antibiotic resistant bacteria, and 1 case formed sinus tract. In the other 37 two-stage revisions, the mean time interval was 1 045.7±1 044.1 d. Intra-articular culture showed 15 cases of antibiotic resistant bacteria, and 12 cases formed sinus tract. The mean follow-up duration was 73.9±48.2 months. At the last follow-up, all patients were free of antibiotics treatment. The mean Knee Society Score （KSS） was 85.9±4.3 after successful open debridement with prothesis retention. The KSS of one-stage revision patients was 78.5±3.3, while that of two stage revision patients was 65.7±7.4. Statistical difference was found among groups （P〈0.05）. Conclusion For PJI within 3 weeks after total knee arthroplasty without sinus tract or intra-articular culture of antibiotic resistant bacteria, open debridement with prosthesis retention could be recommended. One stage revision could be applied in infectious cases which appeared between 3 weeks to 1 month after primary surgery or in cases with unstable prostheses found in open debridement. For infectious cases longer than 1 month after primary procedure or those with sinus tract, severe soft tissue deficiency, intra-articular culture of antibiotic resistant bacteria, two-stage revision could be recommended.