带蒂腓肠肌内侧头肌瓣转移治疗全膝关节置换术后感染假体外露

A pedicle gastrocnemius muscle flap transposition for salvage of an exposed prosthesis and deep infection of knee joint after total knee arthroplasty

目的回顾分析应用带蒂腓肠肌内侧头肌瓣转移治疗全膝关节置换术后切口坏死、假体外露、关节深部感染的效果。方法回顾分析2015年12月至2019年9月山西省人民医院应用带蒂腓肠肌内侧头肌瓣转移治疗的全膝关节置换术后因切口坏死、假体外露、关节深部感染的7例患者资料。男3例,女4例;年龄(69±4)岁。在接受肌瓣转移治疗前,7例患者中5例施行过至少1次清创手术,均因感染复发而失败,出现假体外露、关节深部感染。创面及关节液细菌培养阳性的4例,关节液为脓性而细菌培养阴性者3例。膝关节X线片检查未见假体周围透亮带,无松动下沉征象。结果7例患者随访7~39个月,平均16.5个月。皮瓣与植皮成活,无疼痛、肿胀、窦道、血肿形成。患肢外形接近正常。1例轻度跛行,其余行走功能接近正常。1例在术后5个月感染复发,取出假体,抗生素骨水泥占位器旷置6个月后行翻修手术,术后随访26个月未见复发。膝关节协会评分标准(KSS)评估,优4例,良2例,一般1例。结论延期带蒂腓肠肌内侧头肌瓣转移是治疗全膝关节置换术后切口坏死、假体外露、关节深部感染的有效方法。对于病程较长、假体未松动的慢性关节深部感染,可以保留假体、闭合创面、控制感染。

Objective To explore the effect of a delayed pedicle gastrocnemius muscle flap transposition for the treatment of a knee joint deep infection secondary to wound necrosis after total knee arthroplasty(TKA).Methods The clinical data of 7 patients treated in Shanxi Provincial People′s Hospital with a delayed pedicle gastrocnemius muscle flap transposition from December 2015 to September 2019 for wound necrosis,exposed prosthesis and deep infection of knee joint after TKA were analyzed retrospectively.Before the muscle flap transplantation,5 of the patients had received at least one debridement but failed for relapse,and resulted in an exposed prostheses and infected knee joint.Four patients were positive in their wounds or joint exudates bacterial culture,while the other 3 patients were negative but only with an obvious purulent secretion.The radiographs in all of the patients had no signs of lucent peripheral to or sink of the prosthesis.Results The patients were followed-up for a mean time of 16.5 months(7-39 months).The flap and skin graft survived uneventfully with no pain,sinus,fistula,edema,and hematoma occurred.The appearances of the legs were normal.Only 1 patient had a mild limp,and the others gained almost a normal gait.One of the patients recurred 5 months after the gastrocnemius muscle flap transposition,and a two-stage revision procedure was applied,that involving a prosthesis remove and vancomycin impregnated cement(4 grams of vancomycin powder mixed with forty grams of polymethylmethacrylate)spacer implanted,and a new prosthesis was re-implanted 6 months later.The assessment of Knee Society Score(KSS)graded as:4 patients classified as excellence,2 as fine,1 as general.Conclusions Delayed pedicle gastrocnemius muscle flap transposition is an effective method for the complication of wound necrosis,deep infection,prosthesis exposure after TKA.This protocol was appropriate for those who have experienced a comparative long time of infection while had no signs of prosthesis loosening,and with which the implant may be salvaged,the defect be closed,and the infection be eradicated.