人工全膝关节置换术中保留滑膜对术后感染的预防效果
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摘要
目的探析人工全膝关节置换术(TKA)中保留滑膜对术后感染的预防效果,进一步明确其可行性和临床效果。方法回顾性分析2014年1月—2016年1月248例行单膝TKA原发性膝骨关节炎患者的临床资料,均行TKA治疗,对照组120例术中切除滑膜,观察组128例术中保留滑膜,对比两组患者一般手术情况、感染指标水平变化情况、膝关节功能恢复及感染情况。结果对照组患者手术时间(89.56±26.35)min、术中出血量(472.42±86.18)mL、术后24 h引流量(685.25±92.68)mL及术后输血率29.17%均明显高于观察组[(71.25±21.58)min、(198.56±48.52)mL、(354.26±75.28)mL、10.94%](均P<0.05),两组患者在术后1周关节活动范围、住院时间基本相近(均P>0.05);两组患者各项指标术后1 d、术后7 d均较术前明显增高,于术后14 d降至正常水平。观察组患者WBC、CRP、血沉水平在术前、术后1、7、14 d、术后6、12周、术后6月、术后1年8个不同时间段均稍高于对照组,但经组间t检验均P>0.05;观察组术后12周HSS评分表中功能评分(19.65±2.46)分和总评分(86.06±1.68)分均高于对照组[(18.92±2.36)、(85.06±1.58)分](均P<0.05),其他项评分两组评分基本相近(均P>0.05);术后1年HSS评分表中各项评分和总评分基本相近(均P>0.05);观察组患者术后感染率为0.78%明显低于对照组的5.00%(P<0.05)。结论人工全膝关节置换术中保留滑膜可缩短手术时间、减少出血量和输血量进而预防术后感染的发生,且不影响患者术后膝关节功能恢复,可在TKA手术中广泛开展。
Objective To explore the preventive effect of retained synovial membrane on postoperative infection in total knee arthroplasty( TKA),and further clarify its feasibility and clinical effect. Methods A retrospective analysis was made of clinical data of 248 cases of single knee TKA primary knee osteoarthritis patients,who were treated with TKA from January 2014 to January 2016,120 cases in the control group with synovectomy,and 128 patients in the observation group with preservation of synovial membrane. Comparison was conducted of general surgery,infection index changes,recovery of knee joint function and infection between the two groups. Results The operation time [( 89. 56 ± 26. 35) min],intraoperative blood loss [( 472. 42 ± 86. 18) mL],postoperative 24 h drainage volume[( 685. 25 ± 92. 68) mL]and postoperative blood transfusion rate( 29. 17%) in the control group were significantly higher than those in the observation group [( 71. 25 ± 21. 58) min,( 198. 56 ± 48. 52) mL,( 354. 26 ± 75. 28) mL,10. 94% ]( all P < 0. 05); One week after surgery,the two groups of had similar scope of joint activity and hospitalization time( all P > 0. 05). Each index of the two groups of patients 1 d,7 d after operation was significantly higher than that preoperatively,and decreased to normal level on the 14 th day after surgery. The observation group of patients' WBC,CRP,ESR levels at 8 different time points,including preoperatively,1,7,14 d,6-week,12-week,6-month and 1-year postoperatively,were slightly higher compared with the control group,but the t test between groups showed that P > 0. 05. The functional score [( 19. 65 ± 2. 46) points] and total score [( 86. 06 ± 1. 68) points] in the 12-week HSS scoring table were higher than those in the control group [( 18. 92 ± 2. 36) points,( 85. 06 ± 1. 58) points]( all P < 0. 05),while other scores of the two groups were similar( P > 0. 05). The scores and total score of the 1 year postoperative HSS score were approximately similar( all P > 0. 05). The postoperative infection rate of the observation group( 0. 78%) was significantly higher than 5. 00% of the control group( P < 0. 05). Conclusions Synovial retention in total knee arthroplasty can shorten the operation time,prevent postoperative blood loss and transfusion to reduce the incidence of infection,and doesnot affect the postoperative recovery of knee joint function after surgery,which can be widely carried out in TKA.
Objective To explore the preventive effect of retained synovial membrane on postoperative infection in total knee arthroplasty( TKA),and further clarify its feasibility and clinical effect. Methods A retrospective analysis was made of clinical data of 248 cases of single knee TKA primary knee osteoarthritis patients,who were treated with TKA from January 2014 to January 2016,120 cases in the control group with synovectomy,and 128 patients in the observation group with preservation of synovial membrane. Comparison was conducted of general surgery,infection index changes,recovery of knee joint function and infection between the two groups. Results The operation time [( 89. 56 ± 26. 35) min],intraoperative blood loss [( 472. 42 ± 86. 18) mL],postoperative 24 h drainage volume[( 685. 25 ± 92. 68) mL]and postoperative blood transfusion rate( 29. 17%) in the control group were significantly higher than those in the observation group [( 71. 25 ± 21. 58) min,( 198. 56 ± 48. 52) mL,( 354. 26 ± 75. 28) mL,10. 94% ]( all P < 0. 05); One week after surgery,the two groups of had similar scope of joint activity and hospitalization time( all P > 0. 05). Each index of the two groups of patients 1 d,7 d after operation was significantly higher than that preoperatively,and decreased to normal level on the 14 th day after surgery. The observation group of patients' WBC,CRP,ESR levels at 8 different time points,including preoperatively,1,7,14 d,6-week,12-week,6-month and 1-year postoperatively,were slightly higher compared with the control group,but the t test between groups showed that P > 0. 05. The functional score [( 19. 65 ± 2. 46) points] and total score [( 86. 06 ± 1. 68) points] in the 12-week HSS scoring table were higher than those in the control group [( 18. 92 ± 2. 36) points,( 85. 06 ± 1. 58) points]( all P < 0. 05),while other scores of the two groups were similar( P > 0. 05). The scores and total score of the 1 year postoperative HSS score were approximately similar( all P > 0. 05). The postoperative infection rate of the observation group( 0. 78%) was significantly higher than 5. 00% of the control group( P < 0. 05). Conclusions Synovial retention in total knee arthroplasty can shorten the operation time,prevent postoperative blood loss and transfusion to reduce the incidence of infection,and doesnot affect the postoperative recovery of knee joint function after surgery,which can be widely carried out in TKA.
引文
[1]张浩沙强,宁凯,郭瑞,等.全膝关节置换术后早期并发症的原因分析[J].中华全科医学,2015,13(1):27-29,87.
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[8]赵旭红,伍骥,李松林,等.全膝关节置换同时进行滑膜切除术与否对初期骨关节炎患者术后炎性周期及临床结果的影响[J].中国矫形外科杂志,2013,21(3):238-242.
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[10]周宗科,翁习生,曲铁兵,等.中国髋、膝关节置换术加速康复—围术期管理策略专家共识[J].中华骨与关节外科杂志,2016(1):1-9.
[11]张勇,陈建民,王黎明,等.微创全膝关节置换术治疗膝骨性关节炎的早期临床疗效研究[J].中国骨与关节损伤杂志,2013,28(10):963-965.
[12]郝瑞胡,郭林,李丽丽,等.全膝关节置换术治疗膝关节骨性关节炎的临床观察[J].中国骨与关节损伤杂志,2014,29(6):544-546.
[13]MEMTSOUDIS SG,DELLA VALLE AG,BESCULIDES MC,et al.Risk factors for perioperative mortality after lower extremity arthroplasty:a population-based study of 6,901,324 patient discharges[J].J Arthroplasty,2010,25(1):19-26.
[14]PEDERSEN AB,SORENSEN HT,MEHNERT F,et al.Risk factors for venous thromboembolism in patients undergoing total hip replacement and receiving routine thromboprophylaxis[J].J Bone Joint Surg Am,2010,92(12):2156-2164.
[15]PARVIZI J,MILLER AG,GANDHI K.Multimodal pain management after total joint arthroplasty[J].J Bone Joint Surg Am,2011,93(11):1075-1084.
[16]BAE DK,SONG SJ,PARK MJ,et al.Twenty-year survival analysis in total knee arthroplasty by a single surgeon[J].J Arthroplasty,2012,27(7):1297-1304.
[17]KURTZ SM,ONG KL,LAU E,et al.Prosthetic joint infection risk after TKA in the Medicare population[J].Clin Orthop Relat Res,2010,468(1):52-56.
[18]SCHOOF B,JAKOBS O,SCHMIDL S,et al.Fungal periprosthetic joint infection of the hip:a systematic review[J].Orthop Rev(Pavia),2015,7(1):5748.
[19]ZMISTOWSKI B,RESTREPO C,KAHL LK,et al.Incidence and reasons for nonrevision reoperation after total knee arthroplasty[J].Clin Orthop Relat Res,2011,469(1):138-145.
[20]冯宾,翁习生,林进,等.固定平台全膝关节置换术后10年以上临床随访研究[J].中华骨科杂志,2013,33(5):487-494.
[21]NAMBA RS,INACIO MC,PAXTON EW.Risk factors associated with deep surgical site infections after primary total knee arthroplasty:an analysis of 56,216 knees[J].J Bone Joint Surg Am,2013,95(9):775-782.
[22]HELWIG P,MORLOCK J,OBERST M,et al.Periprosthetic joint infection-effect on quality of life[J].Int Orthop,2014,38(5):1077-1081.
[23]ZNUSRIWSKI B,KARAM JA,DURINKA JB,et al.Periprosthetic joint infection increases the risk of one-year mortality[J].J Bone Joint Surg Am,2013,95(24):2177-2184.
[24]GARRIDO-GOMEZ J,ARRABAL-POLO MA,GIRON-PRIETO MS,et al.Descriptive analysis of the economic costs of periprosthetic joint infection of the knee for the public health system of Andalusia[J].J Arthroplasty,2013,28(7):1057-1060.
[25]周媛.人工全膝关节置换术后感染相关危险因素分析[D].乌鲁木齐:新疆医科大学,2014.
[26]KILICARSLAN K,YALCIN N,CICEK H,et al.The effect of total synovectomy in total knee arthroplasty:a prospective randomized controlled study[J].Knee Surg Sports Traumatol Arthrosc,2011,19(6):932-935.
[27]宁纪斌,田少奇,杨旭,等.滑膜切除对全膝关节置换治疗骨性关节炎的影响[J].齐鲁医学杂志,2014,29(6):519-521.
[28]王华军,李峰,涅喜增,等.全膝关节置换术中滑膜切除对术后功能恢复及失血影响的临床研究[J].中国矫形外科杂志,2015,23(7):610-614.
[29]宋炎成,张慧慧,卢华定,等.CRP、ESR在关节置换手术前后变化及其临床意义[J].中国矫形外科杂志,2008,16(11):823-825.
[30]高玉镭,张寅权,宋方龙,等.切除与不切除滑膜对人工全膝关节置换术后感染影响的比较[J].中国矫形外科杂志,2016,24(5):411-415.
[2]KURTZ S,ONG K,LAU E,et al.Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to2030[J].J Bone Joint Surg Am,2007,89(4):780-785.
[3]TSUNG JD,ROHRSHEIM JA,WHITEHOUSE SL,et al.Management of periprosthetic joint infection after total hip arthroplasty using a custom made articulating spacer(CUMARS);the Exeter experience[J].J Arthroplasty,2014,29(9):1813-1818.
[4]GARVIN KL,KONIGSBERG BS.Infection following total knee arthroplasty:prevention and management[J].Instr Course Lect,2012,61:411-419.
[5]KAPADIA BH,BERG RA,DALEY JA,et al.Periprosthetic joint infection[J].Lancet,2016,387(10016):386-394.
[6]FRANK RM,CROSS MB,DELLA VALLE CJ.Periprosthetic joint infection:modern aspects of prevention,diagnosis,and treatment[J].J Knee Surg,2015,28(2):105-112.
[7]TANAVALEE A,HONSAWEK S,ROJPORNPRADIT T,et al.Inflammation related to synovectomy during total knee replacement in patients with primary osteoarthritis:a prospective,randomised study[J].J Bone Joint Surg Br,2011,93(8):1065-1070.
[8]赵旭红,伍骥,李松林,等.全膝关节置换同时进行滑膜切除术与否对初期骨关节炎患者术后炎性周期及临床结果的影响[J].中国矫形外科杂志,2013,21(3):238-242.
[9]KILICARSLAN K,YALCIN N,CICEK H,et al.The effect of total synovectomy in total knee arthroplasty:a prospective randomized controlled study[J].Knee Surg Sports Traumatol Arthrosc,2011,19(6):932-935.
[10]周宗科,翁习生,曲铁兵,等.中国髋、膝关节置换术加速康复—围术期管理策略专家共识[J].中华骨与关节外科杂志,2016(1):1-9.
[11]张勇,陈建民,王黎明,等.微创全膝关节置换术治疗膝骨性关节炎的早期临床疗效研究[J].中国骨与关节损伤杂志,2013,28(10):963-965.
[12]郝瑞胡,郭林,李丽丽,等.全膝关节置换术治疗膝关节骨性关节炎的临床观察[J].中国骨与关节损伤杂志,2014,29(6):544-546.
[13]MEMTSOUDIS SG,DELLA VALLE AG,BESCULIDES MC,et al.Risk factors for perioperative mortality after lower extremity arthroplasty:a population-based study of 6,901,324 patient discharges[J].J Arthroplasty,2010,25(1):19-26.
[14]PEDERSEN AB,SORENSEN HT,MEHNERT F,et al.Risk factors for venous thromboembolism in patients undergoing total hip replacement and receiving routine thromboprophylaxis[J].J Bone Joint Surg Am,2010,92(12):2156-2164.
[15]PARVIZI J,MILLER AG,GANDHI K.Multimodal pain management after total joint arthroplasty[J].J Bone Joint Surg Am,2011,93(11):1075-1084.
[16]BAE DK,SONG SJ,PARK MJ,et al.Twenty-year survival analysis in total knee arthroplasty by a single surgeon[J].J Arthroplasty,2012,27(7):1297-1304.
[17]KURTZ SM,ONG KL,LAU E,et al.Prosthetic joint infection risk after TKA in the Medicare population[J].Clin Orthop Relat Res,2010,468(1):52-56.
[18]SCHOOF B,JAKOBS O,SCHMIDL S,et al.Fungal periprosthetic joint infection of the hip:a systematic review[J].Orthop Rev(Pavia),2015,7(1):5748.
[19]ZMISTOWSKI B,RESTREPO C,KAHL LK,et al.Incidence and reasons for nonrevision reoperation after total knee arthroplasty[J].Clin Orthop Relat Res,2011,469(1):138-145.
[20]冯宾,翁习生,林进,等.固定平台全膝关节置换术后10年以上临床随访研究[J].中华骨科杂志,2013,33(5):487-494.
[21]NAMBA RS,INACIO MC,PAXTON EW.Risk factors associated with deep surgical site infections after primary total knee arthroplasty:an analysis of 56,216 knees[J].J Bone Joint Surg Am,2013,95(9):775-782.
[22]HELWIG P,MORLOCK J,OBERST M,et al.Periprosthetic joint infection-effect on quality of life[J].Int Orthop,2014,38(5):1077-1081.
[23]ZNUSRIWSKI B,KARAM JA,DURINKA JB,et al.Periprosthetic joint infection increases the risk of one-year mortality[J].J Bone Joint Surg Am,2013,95(24):2177-2184.
[24]GARRIDO-GOMEZ J,ARRABAL-POLO MA,GIRON-PRIETO MS,et al.Descriptive analysis of the economic costs of periprosthetic joint infection of the knee for the public health system of Andalusia[J].J Arthroplasty,2013,28(7):1057-1060.
[25]周媛.人工全膝关节置换术后感染相关危险因素分析[D].乌鲁木齐:新疆医科大学,2014.
[26]KILICARSLAN K,YALCIN N,CICEK H,et al.The effect of total synovectomy in total knee arthroplasty:a prospective randomized controlled study[J].Knee Surg Sports Traumatol Arthrosc,2011,19(6):932-935.
[27]宁纪斌,田少奇,杨旭,等.滑膜切除对全膝关节置换治疗骨性关节炎的影响[J].齐鲁医学杂志,2014,29(6):519-521.
[28]王华军,李峰,涅喜增,等.全膝关节置换术中滑膜切除对术后功能恢复及失血影响的临床研究[J].中国矫形外科杂志,2015,23(7):610-614.
[29]宋炎成,张慧慧,卢华定,等.CRP、ESR在关节置换手术前后变化及其临床意义[J].中国矫形外科杂志,2008,16(11):823-825.
[30]高玉镭,张寅权,宋方龙,等.切除与不切除滑膜对人工全膝关节置换术后感染影响的比较[J].中国矫形外科杂志,2016,24(5):411-415.