本文選題：全膝關(guān)節(jié)表面置換術(shù) + 感染　； 參考：《鄭州大學(xué)》2015年碩士論文

【摘要】：背景與目的:全膝關(guān)節(jié)置換術(shù)(total knee arthroplasty,TKA)對各種原因引起的終末膝關(guān)節(jié)疾病有著確切而顯著的療效,是解決這一終末疾病的終極手段及唯一手段。全膝關(guān)節(jié)表面置換術(shù)能夠明顯改善患者的膝關(guān)節(jié)活動功能,減輕膝關(guān)節(jié)疼痛,矯正膝關(guān)節(jié)的屈曲攣縮或內(nèi)外翻畸形,極度提高生活質(zhì)量。但這種手術(shù)方式有一些不易處理的并發(fā)癥,其中關(guān)節(jié)假體周圍感染是一個“災(zāi)難性”的并發(fā)癥。給患者及家屬帶來了沉重的心理負(fù)擔(dān)及極大的經(jīng)濟(jì)負(fù)擔(dān)。給醫(yī)務(wù)人員也帶來了不必要的心理壓力。假體周圍感染的處理方式有很多,如何選擇最適合病人的治療方式成為關(guān)節(jié)外科界不斷爭論的話題。因擔(dān)心手術(shù)再感染,一期翻修是很多關(guān)節(jié)外科醫(yī)生不愿采用的手術(shù)方式。本文主要研究探討全膝關(guān)節(jié)表面置換術(shù)后感染一期翻修術(shù)適應(yīng)癥選擇及治療效果。材料與方法:以回顧性研究選擇我院從2002年5月至2012年5月10年間,收治人工全膝關(guān)節(jié)表面置換術(shù)后感染的患者,共19例,其中男性患者5例,女性患者14例,年齡平均在(67±7)歲.19例患者均有膝關(guān)節(jié)疼痛癥狀,活動受限,部分局部皮溫增高,部分皮膚顏色異常,血沉(ESR)均大于30mm/h,C反應(yīng)蛋白(CRP)均大于10mg/l。其中9例患者無糖尿病、中重度貧血低蛋白及腫瘤等高危感染因素存在,皮膚條件可,竇道形成少于2個,術(shù)前病原學(xué)檢查5例患者為金黃色葡萄球菌感染,3例表皮葡萄球菌感染,1例為革蘭氏陰性桿菌感染(全部為單一菌群,非混合感染),給予選擇一期翻修手術(shù)。余10名患者選擇二期翻修術(shù)。所有患者術(shù)中發(fā)現(xiàn)假體周圍有炎性肉芽組織和肉眼可見的膿苔,術(shù)中取膿苔再次做細(xì)菌和真菌培養(yǎng)及藥敏試驗。9例一期翻修手術(shù)均徹底清創(chuàng)、取出假體,用雙氧水,碘伏水侵泡及大量生理鹽水脈壓槍沖洗,同時更換器械及手套,加鋪無菌巾,以含有萬古霉素,妥布霉素,慶大霉素的骨水泥固定新假體.術(shù)后靜脈輸入敏感抗生素2周后,改為口服抗生素4-6周。10例二期翻修術(shù)也行徹底清創(chuàng)、取出假體,用雙氧水,碘伏水侵泡及大量生理鹽水脈壓槍沖洗,同時更換器械及手套,加鋪無菌巾,以含有萬古霉素,妥布霉素,慶大霉素的骨水泥填充。術(shù)后定期復(fù)查血常規(guī),血沉(ESR)和C反應(yīng)蛋白(CRP),檢查皮膚狀況及關(guān)節(jié)功能情況。采用HSS膝關(guān)節(jié)評分標(biāo)準(zhǔn)評估臨床治療效果。結(jié)果:9例一期翻修治療的患者,傷口均I期愈合,其中2例在術(shù)后5月左右時感染復(fù)發(fā),再次給予手術(shù),感染得以有效控制。10例二期翻修的患者曠置術(shù)后傷口一期愈合,3-9個月后行二期翻修,其中2例在翻修術(shù)后6月復(fù)發(fā),再次手術(shù)好轉(zhuǎn)。翻修術(shù)后隨訪平均23.8個月。2組研究對象在ESR及CRP的變化趨勢上沒有明顯差別;HSS膝關(guān)節(jié)評分從術(shù)前平均33.6分,提高到最后隨訪時的平均81.2分。2種手術(shù)方式在統(tǒng)計學(xué)無明顯差異(PO.05)。結(jié)論:(1)一期翻修術(shù)在TKA術(shù)后感染的治療是可行的。(2)TKA術(shù)后感染選擇一期翻修術(shù)的適應(yīng)證:單一細(xì)菌感染,非真菌感染,有敏感抗生素治療;骨組織及軟組織條件良好;病人無高危感染因素存在;皮膚竇道形成少于2個。
[Abstract]:Background and purpose: total knee arthroplasty (TKA) has a definite and significant effect on various causes of terminal knee joint disease. It is the ultimate means and the only means to solve this end-end disease. Total knee replacement can significantly improve the function of the knee joint and reduce the pain of the knee. The correction of flexion contracture or valgus deformity of the knee joint greatly improves the quality of life. However, this operation has some unmanageable complications, in which the infection around the prosthesis is a "catastrophic" complication. It brings a heavy psychological burden and a great financial burden to the patients and their families. The necessary psychological pressure. There are many ways to deal with the infection around the prosthesis. How to choose the most suitable treatment for the patient is a constant topic in the joint surgery. For fear of reinfection, a revision is a way that many joint surgeons do not want to use. Materials and methods: a retrospective study was carried out in our hospital from May 2002 to May 2012, 10 years from May 2002 to May 2012. There were 19 cases of total knee replacement after total knee replacement, of which 5 were male and 14 in women. The average age of.19 in the age of (67 + 7) years old had knee joint pain. Symptoms, limited activity, partial skin temperature, partial skin color, ESR were greater than 30mm/h, C reactive protein (CRP) was greater than 10mg/l., 9 patients had no diabetes, moderate to severe anemia, low protein and tumor and other high risk factors of infection, skin conditions, less than 2 sinus formation, 5 patients with preoperative etiological examination as gold. Staphylococcus aureus infection, 3 cases of Staphylococcus epidermidis infection, 1 cases of gram-negative bacilli infection (all single bacteria, non mixed infection) were selected for one period revision operation. The remaining 10 patients chose two stage refurbishment. All the patients found the inflammatory buds and the naked eye moss around the prosthesis during the operation, and the purulent moss was taken again during the operation. .9 cases of bacterial and fungal culture and drug sensitivity test were completely debrided and taken out, taking out the prosthesis, using hydrogen peroxide, iodophor water invading and a large number of physiological saline pulse pressure guns, replacing instruments and gloves, adding sterile towels and fixing new prostheses containing vancomycin, tobramycin and gentamicin. After 2 weeks of antibiotics, 4-6 weeks of oral antibiotics were changed to complete debridement and complete debridement, and the prosthesis was thoroughly debrided. The prosthesis was removed with hydrogen peroxide, iodophor water invading and a large number of physiological saline pulse pressure guns, and the instruments and gloves were replaced, and the sterile towel was added to contain vancomycin, tufomycin and gentamicin. The blood routine was reviewed regularly after the operation. ESR and C reactive protein (CRP), examination of the skin condition and joint function. The effect of clinical treatment was evaluated by the HSS knee score standard. Results: 9 cases of first stage revision were treated with I period, of which 2 cases were relapsed around May, and the operation was given again. The infection was effectively controlled for the two phase revision of.10 cases. After 3-9 months of refurbishment, 2 cases relapsed after refurbishment, of which 2 cases relapsed after refurbishment, and reoperation was improved. There was no significant difference in the changes of ESR and CRP in group.2 for 23.8 months after refurbishment; the HSS knee score was 33.6 points before the operation, and increased to the average of 81.2 at the last follow-up. There was no significant difference in the.2 operation methods (PO.05). Conclusion: (1) the treatment of infection after the first stage revision after TKA was feasible. (2) the indications for the first stage of the infection after the TKA operation: single bacterial infection, non fungal infection, sensitive antibiotic treatment; good bone and soft tissue conditions; and patients without high risk factors. The formation of skin sinus was less than 2.

【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R687.4

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