膝骨关节炎合并化脓性关节炎患者感染控制后行全膝关节置换术的疗效观察

Curative effect of total knee arthroplasty after controlling suppurative infection in patients with knee osteoarthritis complicated with pyogenic arthritis

目的探讨膝骨关节炎合并化脓性关节炎患者感染控制后行全膝关节置换术(TKA)的临床治疗效果。方法选择2012年1月至2017年6月新乡市第一人民医院关节外科收治的12例膝骨关节炎合并化脓性关节炎患者为研究对象。患者给予开放清创联合敏感抗生素骨水泥珠链置入方法治疗膝关节化脓性感染,于清创术后3 d及1、2、6周和2、3个月时行血常规、红细胞沉降率(ESR)及C-反应蛋白(CRP)等炎症指标检测。连续3个月ESR、CRP及血常规结果基本正常,2次关节液培养均阴性后行TKA手术。TKA术后给予患者抗感染治疗。记录患者清创术前后白细胞计数(WBC)、中性粒细胞百分比(Neu%)、ESR、CRP等指标变化情况;采用纽约特种外科医院(HSS)膝关节评分评估患者行TKA手术前后膝关节功能;应用视觉模拟评分(VAS)评估患者TKA手术前后膝关节疼痛程度;观察患者的临床疗效。结果患者TKA术后3个月WBC、Neu%、CRP及ESR均显著低于清创术前(P<0.05)。患者TKA术后的VAS评分显著低于清创术前,HSS评分显著高于清创术前,膝关节活动度显著优于清创术前(P<0.05)。所有患者随访10~56个月,TKA术后11例患者切口Ⅰ期愈合,1例换药后Ⅱ期愈合,均无皮肤坏死,无血管及神经损伤,无假体周围骨折、血栓形成等并发症。术后复查X线片显示,下肢力线均纠正,无内、外翻畸形,无假体松动。1例患者术后出现膝前痛,予以依托考昔片治疗,于术后3个月疼痛逐渐缓解。1例患者术后功能锻炼配合欠佳,出现膝关节僵硬,经麻醉后再次手法松解,膝关节活动度恢复。结论对膝骨关节炎合并化脓性关节炎患者,早期进行彻底清创,置入敏感抗生素骨水泥珠链可有效控制感染,并可常规行膝关节置换,术后膝关节功能恢复良好。

Objective To explore the clinical therapeutic effect of total knee arthroplasty(TKA)after controlling suppurative infection in patients with knee osteoarthritis complicated with pyogenic arthritis.Methods Twelve patients with knee osteoarthritis complicated with pyogenic arthritis in the Department of Joint Surgery of Xinxiang First People's Hospital from January 2012 to June 2017 were selected as the research objects.All patients were given open debridement combined with sensitive antibiotic bone cement bead chain implantation for treatment of pyogenic infection of knee joint.Blood routine,erythrocyte sedimentation rate(ESR),C-reactive protein(CRP)and other inflammatory indexes were measured at 3 days,1,2,6 weeks and 2,3 months after debridement.The patients underwent TKA after the results of ESR,CRP and blood routine examination were basically normal for 3 consecutive months and the twice joint fluid cultures were negative.All patients were given antiinfective treatment after TKA operation.The changes of white blood cell count(WBC),neutrophilic granulocyte percentage(Neu%),ESR and CRP of patients were recorded before and after debridement;the knee joint function was evaluated by the knee joint score of New York Hospital for Special Surgery(HSS)before and after TKA operation;the degree of knee joint pain was evaluated by visual analogue scale(VAS)before and after TKA operation;and the clinical efficacy of patients was observed.Results The WBC,Neu%,CRP and ESR of patients at 3 months after TKA were significantly lower than those before debridement(P<0.05).The VAS score after TKA was significantly lower than that before debridement,the HSS score was significantly higher than that before debridement,and the range of motion of knee joint was significantly better than that before debridement(P<0.05).All patients were followed up for 10-56 months.After TKA,the incision of 11 patients was one-stage healing and the incision of 1 case was Ⅱ healing after dressing change.All patients had no skin necrosis,vascular and nerve injury,periprosthetic fracture,thrombosis and other complications.The postoperative X-ray film showed that the force lines of the lower limbs were corrected without varus and valgus deformity and prosthesis loosening.One patient had anterior knee pain after operation,and then was treated with etocoxib tablets;the pain gradually relieved at 3 months after operation.One patient appeared stiffness of knee joint due to poor coordination of postoperative functional exercise and the range of motion of knee joint of this patient recovered after giving manipulation release under anesthesia.Conclusion For patients with knee osteoarthritis complicated with purulent arthritis,early thorough debridement and placement of sensitive antibiotic bone cement beads in knee joint cavity at the same time can effectively control the infection,and can perform the routine TKA.The function of knee joint recovered well after surgery.