一期病灶清除关节置换治疗活动性髋关节结核的临床研究

Clinical study on one-stage focal debridement and total hip replacement for treating active hip tuberculosis

目的:探讨活动性髋关节结核行一期病灶清除关节置换的治疗方案及临床疗效。方法:回顾性分析2015年6月至2018年6月河北省胸科医院收治的25例行一期病灶清除全髋关节置换手术治疗的活动性髋关节结核患者的临床资料。所有患者术前联合应用抗结核药物治疗,用药时间为4~8周,平均(6.20±1.22)周;所有患者术中均彻底清除髋关节死骨、脓肿、病变滑膜及肉芽组织,骨缺损区植骨选用截除的自体股骨正常骨质,选用非骨水泥生物型假体。术后病理检查均证实为结核,联合应用抗结核药物治疗18个月以上,随访观察切口及病灶愈合、血红细胞沉降率(ESR)及C反应蛋白(CRP)指标变化、假体位置、髋关节功能改善及并发症发生情况。结果:所有患者术后随访时间为24~60个月,平均为(35.62±8.64)个月。术前1 d、术后1个月和末次随访时,患者ESR分别为(41.64±12.10)mm/1 h、(23.36±5.87)mm/1 h和(9.88±2.01)mm/1 h;CRP分别为(43.60±10.35)mg/L、(14.00±3.16)mg/L和(3.80±1.19)mg/L;Harris髋关节疼痛评分分别为(18.40±4.73)分、(41.68±3.15)分和(43.52±1.33)分;Harris髋关节评分总分分别为(33.00±6.01)分、(92.52±3.64)分和(97.36±1.80)分。术后1个月和末次随访时的ESR、CRP水平均明显低于术前1 d(F=103.008,P<0.001;F=270.299,P<0.001),术后1个月和末次随访时Harris髋关节疼痛评分和总分均较术前1 d明显改善(F=432.654,P<0.001;F=1832.393,P<0.001)。所有患者切口均一期愈合,术后未发生血栓形成、肺栓塞、关节脱位及假体周围骨折等并发症。1例患者术后6周出现刀口中下段破溃,形成窦道,经搔刮换药2个月后愈合,其余患者治疗后均无积液和积脓,病灶顺利愈合。随访期内关节假体位置良好,未见病灶复发患者。结论:在规范有效的抗结核药物治疗基础上施行一期病灶清除全髋关节置换术治疗活动性髋关节结核能明显减轻患者髋关节疼痛,改善髋关节功能,临床疗效良好。

Objective:To evaluate the therapeutic plan and clinical effectiveness of one-stage focal debridement and total hip replacement(THR)in treatment of active hip tuberculosis.Methods:A retrospective analysis was done for 25 cases of active hip tuberculosis who were treated with one-stage focal debridement and THR in Hebei Chest Hospital from June 2015 to June 2018.All patients were treated with anti-tuberculosis chemotherapy regularly for 4-8 weeks(average(6.20±1.22)weeks).The abscess,acetabular sequestra and synovium around the joint were cleared in all operations.The removed normal femoral neck issue were used as implants in area of bone defects and cementless THR as artificial arthroplasty.All cases were confirmed as hip tuberculosis by pathological examination.Anti-tuberculosis treatment were applied for at least 18 months after operations.Operative conditions,healing of lesions,the erythroeyte sedimentation rate(ESR),the C-reactive protein(CRP),position of the prostheses,recovery of hip functions and complications were observed.Results:The follow-up period ranged from 24 to 60 months(average(35.62±8.64)months).The average ESR on 1 d preoperative,1 month postoperative and at the last time of follow-up were(41.64±12.10)mm/1 h,(23.36±5.87)mm/1 h and(9.88±2.01)mm/1 h,respectively;the average CRP were(43.60±10.35)mg/L,(14.00±3.16)mg/L and(3.80±1.19)mg/L,respectively;the average Harris hip pain scores were 18.40±4.73,41.68±3.15 and 43.52±1.33,respectively;the average Harris hip total scores were(33.00±6.01),(92.52±3.64),and(97.36±1.80),respectively;The average ESR and CRP on 1 month postoperative and at the last time of follow-up were significantly lower than those on 1 d preoperative(F=103.008,P<0.001;F=270.299,P<0.001).The average Harris hip pain scores and total scores on 1 month postoperative and at the last time of follow-up were significantly improved from 1 d preoperative(F=432.654,P<0.001;F=1832.393,P<0.001).All patients had first intention healing.No deep venous thrombosis,pulmonary embolism,periprostheyic fracture or joint dislocation happened.There were 1 case having incision ruptured into chronic sinus at 6 weeks after surgery,and got lesions healed after dressing and applying ointment for 2 months.Other cases all got recovered with no complications.The joint prosthesis were all well positioned during the follow-up period and no recurrence were observed.Conclusion:Peroperative effective anti-tuberculosis chemotherapy combined with one-stage debridement and THR in treatment of hip joint tuberculosis can significantly decrease hip pain and improve the hip function.