膝关节周围恶性肿瘤保肢术后感染的治疗及影响因素分析

Treatment and influencing factors of infection after limb salvage surgery for malignant tumor around knee joint

目的总结膝关节周围恶性肿瘤保肢术后感染的治疗经验以及对影响感染的因素进行分析。方法以2008年1月—2017年12月因膝关节周围恶性肿瘤行保肢术的212例患者作为研究对象,其中术后发生关节感染14例。2例急性感染给予敏感抗生素治疗;12例慢性感染一期清创并植入抗生素骨水泥占位器,待感染控制后二期行假体翻修(8例)、膝关节融合(2例)、截肢术(2例)。对患者年龄、性别、保肢术前化疗周期、骨髓抑制情况、血清白蛋白、血红蛋白、保肢手术时间,以及保肢术后引流时间、输血量进行分析,筛选保肢术后感染的危险因素;观察感染、肿瘤复发情况,采用Enneking评分系统评价肢体功能。结果单因素分析显示,保肢术前化疗周期、骨髓抑制情况、保肢手术时间以及术后引流时间是保肢术后感染的影响因素(P<0.05);多因素分析显示,保肢手术时间、保肢术前化疗周期以及保肢术后引流时间是保肢术后感染的危险因素(P<0.05)。14例患者中1例于二期术后6个月因交通事故死亡,13例获随访12.2~48.0个月,平均19.9个月。2例急性感染者均治愈。11例慢性感染者中,2例一期术后占位器半脱位;9例感染治愈,2例感染复发。术后12个月,13例患者肢体功能Enneking评分为12~26分,平均20分。1例发生肺转移,余未发现肿瘤转移、复发。结论保肢手术时间、保肢术前化疗周期以及保肢术后引流时间是膝关节周围恶性肿瘤保肢术后感染的危险因素。尽早进行病原学检查及药物敏感性试验是治疗此类术后感染的关键,一期行清创联合抗生素骨水泥占位器可有效治愈感染,挽救患者肢体。

Objective To summarize the experience in the treatment of infection after limb salvage surgery for malignant tumor around knee joint,and explore the risk factor related to infection after limb salvage surgery.Methods A clinical data of 212 patients with malignant tumor around the knee joint underwent limb salvage surgery between January 2008 and December 2017 were retrospectively analyzed.Among them,14 cases had infection after limb salvage surgery.Two cases of acute infection were treated with sensitive antibiotics;12 cases of chronic infection were treated with debridement and antibiotic bone cement occupying device implantation in the first stage,and prosthesis revision(8 cases),knee joint fusion(2 cases),or amputation(2 cases)in the second stage after infection control.The age,gender,preoperative chemotherapy cycle,bone marrow suppression,serum albumin,hemoglobin,operation time,postoperative drainage time,and blood transfusion volume were analyzed to screen the risk factors related to infection after limb salvage surgery.The infection and tumor recurrence were observed,and the limb function was evaluated by Enneking scoring system.Results The univariate analysis showed that the preoperative chemotherapy cycle,bone marrow suppression,operation time,and postoperative drainage time were the influencing factors of postoperative infection(P<0.05).Multivariate analysis showed that the operation time,preoperative chemotherapy cycle,and postoperative drainage time were risk factors of postoperative infection(P<0.05).Among the 14 patients,1 patient died of traffic accident at 6 months after the second stage operation,and 13 patients were followed up 12.2-48.0 months(mean,19.9 months).Two cases of acute infection cured.Among the 11 patients with chronic infection,2 cases of subluxation of the antibiotic bone cement occupying device after the first stage operation occurred;9 cases of infection cured and 2 cases recurred.At 12 months after operation,except 1 case died by accident,the Enneking scores of the other 13 patients were 12-26,with an average of20.At last follow-up,1 case of lung metastasis was still alive,and no tumor metastasis or recurrence was found in the rest.Conclusion The time of limb salvage surgery,preoperative chemotherapy cycle,and drainage time after limb salvage surgery are the risk factors of infection after limb salvage surgery.Early etiological examination and drug sensitivity test is the key to the treatment of infection.One-stage debridement combined with antibiotic bone cement occupying device can effectively cure infection and save patients’limbs.