全膝关节置换术后假体周围感染的临床诊断与治疗

Clinical diagnosis and treatment of periprosthetic infection after total knee arthroplasty

[目的]探讨全膝关节置换术(TKA)后假体周围感染的临床诊断与治疗策略。[方法]回顾性分析2013年9月~2017年9月在本院收住的28例单侧TKA术后假体周围感染的病例,其中急性感染(Ⅱ型)4例,急性血源性感染(Ⅲ型)5例,慢性感染(Ⅳ型)19例;结合TKA术后假体周围感染的治疗标准及患者的期望和要求,其中11例行膝关节清创术,13例行Ⅱ期翻修术,3例行膝关节融合术,1例行抗结核治疗。评估患者术前与术后实验室检查指标(WBC、CRP和ESR)以及关节液培养作为诊断及治疗标准;并且评估膝关节的活动度(ROM)、VAS评分以及HSS评分。[结果]10例膝关节清创术、12例Ⅱ期翻修术以及3例膝关节融合术的患者感染均得到控制,1例急性血源性感染患者经单纯抗结核治疗后好转;另外2例最终选择截肢术。患者术前CRP和ESR均明显升高,关节穿刺液培养细菌检出率为39%;术后引流液培养均阴性,CRP和ESR值均明显下降。所有患者膝关节活动度明显改善、疼痛感明显减轻,末次随访膝关节HSS评分(82.91±7.49)分。[结论]CRP与ESR以及关节液穿刺培养可作为TKA术后感染的诊断及康复标准;全膝关节置换术后感染的治疗方案需结合假体周围感染的Sagawa分型和患者的期望而定。

[Objective] To investigate the clinical diagnosis and treatment strategy of periprosthetic infection after total knee arthroplasty（TKA）. [Methods] A retrospective study was conducted on 28 patients who were surgically treated in our hospital from September 2013 to September 2017 for unilateral periprosthetic infection, including 4 cases of acute infection（type II）, 5 of acute haematogenous infection（type III） and 19 of chronic infection（type IV）. Combined the guidelines for the diagnosis and treatment of periprosthetic infection with the patient＇s demands, 11 patients were given a through debridement with prosthetic retention, 13 had 2-staged revision, 3 turned to arthrodesis and 1 patient received anti-tuberculosis therapy. The visual analogue scale（VAS） for pain, range of motion（ROM）, Hospital for Special Surgery（HSS） score, as well as laboratory tests,such as white blood cell（WBC） count, C-reaction protein（CRP）, erythrocyte sedimentation rate（ESR）, bacterial cultures and pathological assessment, were used for evaluation of the consequences. [Results] Of them, 10 patients of knee debridement, 12 of the 2-staged revision and 3 of knee arthrodesis achieved complete control of infection, another 1 patient who was of haematogenous infection got subsidence of the infection after mere antituberculosis therapy, whereas the remaining 2 patients were eventually treated by amputation. Before operation all the patients had elevated CRP and ESR, 39% of them had positive bacterial culture results. After operation, all of them got considerable pain relief and significant ROM improvement, with negative culture of the drainage fluid and significant decline of CRP and ESR. At the latest follow up, the HSS score was（82.91±7.49）on average. [Conclusion] CRP and ESR, as well as bacterial culture of synovial fluid can be used as the diagnostic and evaluative criteria for postoperative TKA infection. The concrete surgical procedures should be decided by combined the Sagawa type for periprosthetic infection and patient.s expectation.