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
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摘要
[目的]研究膝骨性关节炎患者行人工全膝关节置换术时进行滑膜切除与否对术后感染的影响。[方法]选择2008年~2012年860例符合原发性膝骨关节炎诊断标准的患者,年龄48~82岁,分为两组:420例关节置换同时进行滑膜切除,440例未进行滑膜切除。随访3~7年,平均4.8年。观察和测定手术时间,引流量,术前和术后1、3 d,2、6、12周和1年血沉(ESR)、C反应蛋白(CRP)、白细胞总数和感染率评价膝关节术后临床效果。采用VAS评分和AKSS评分评价手术效果。[结果]两组患者术前各项临床指标差异均无统计学意义,基线基本相同。手术时间滑膜切除组较长(76±15)min,非切除组(65±12)min,P<0.001,伤口引流量滑膜切除组(285±105)ml,未切除组(245±103)ml,P<0.001。术后滑膜未切除组患者血液中ESR、CRP水平高于切除组,术后2周CRP恢复到术前水平,而ESR缓慢降低直至术后6周接近正常水平。术后两组患者白细胞总数,未切除组偏高,但差异无统计学意义。术后两组患者VAS评分和AKSS评分差异无统计学意义。在平均4.8年的随访中,切除组出现表浅感染3例,深部感染4例,未切除组表浅感染2例,无深部感染患者。[结论]人工全膝关节置换术滑膜切除组手术时间及伤口引流量均高于未切除组,未切除组术后白细胞总数、ESR,CRP偏高,但感染率低,因此推测膝关节滑膜在抗感染中发挥作用。
[Objective] To study the effects of synovial membrane excision and non- excision on postoperative infection after total knee arthroplasty in patients with knee osteoarthritis. [Methods] From 2012 to 2008,860 patients with primary kneeosteoarthritis,aged 48 to 82 years old( mean,67. 3 years),received total knee arthroplasty and were divided into two groups according to the surgical method. Of them,420 patients were treated with synovial membrane excision as the excision group whilethe other 440 cases,receiving no excision management,served as non- excision group. The operative time,drainage,erythrocyte sedimentation rate( ESR),C- reactive protein( CRP),white blood cell count and infection rate were determined preoperatively and at 1day,3 days,2 weeks,6 weeks,12 weeks and 1 year postoperatively to evaluate the clinical results. The effect of VAS and AKSS were evaluated. [Results] All patients were followed up for 3 ~ 7 years with an average of 4. 8years. Before the operation,the clinical indicators were not significantly different between two groups and the baseline was the same. Intraoperatively,the operative time was longer in the excision group than that in the non- excision group( 76 ± 15 min vs65 ± 12 min,P < 0. 001),and drainage was more as well( 285 ± 105 ml vs 245 ± 103 ml,P < 0. 001). ESR and CRP were found lower in the excision group postoperatively. CRP was reduced to normal 2 weeks postoperatively and ESR slowly returned to normal 6 weeks postoperatively. The white blood cells were lower in the excision group than that in the non- excision group,but there was no significant difference. No significant difference was found for VAS and AKSS score as well. During the average 4. 8years follow- up period,3 cases of superficial infection and 4 cases of deep infection were found in the excision group,while 2cases of superficial infection and no deep infection occurred in another group. [Conclusion] This study indicated that,as the comparison results showing,the operative time and drainage were more in the excision group,while the white blood cells,ESR and CRP were higher in the non- excision group,but infection rate was lower. So,it is speculated that the knee synovial membrane may play a role in prevention of infection.
[Objective] To study the effects of synovial membrane excision and non- excision on postoperative infection after total knee arthroplasty in patients with knee osteoarthritis. [Methods] From 2012 to 2008,860 patients with primary kneeosteoarthritis,aged 48 to 82 years old( mean,67. 3 years),received total knee arthroplasty and were divided into two groups according to the surgical method. Of them,420 patients were treated with synovial membrane excision as the excision group whilethe other 440 cases,receiving no excision management,served as non- excision group. The operative time,drainage,erythrocyte sedimentation rate( ESR),C- reactive protein( CRP),white blood cell count and infection rate were determined preoperatively and at 1day,3 days,2 weeks,6 weeks,12 weeks and 1 year postoperatively to evaluate the clinical results. The effect of VAS and AKSS were evaluated. [Results] All patients were followed up for 3 ~ 7 years with an average of 4. 8years. Before the operation,the clinical indicators were not significantly different between two groups and the baseline was the same. Intraoperatively,the operative time was longer in the excision group than that in the non- excision group( 76 ± 15 min vs65 ± 12 min,P < 0. 001),and drainage was more as well( 285 ± 105 ml vs 245 ± 103 ml,P < 0. 001). ESR and CRP were found lower in the excision group postoperatively. CRP was reduced to normal 2 weeks postoperatively and ESR slowly returned to normal 6 weeks postoperatively. The white blood cells were lower in the excision group than that in the non- excision group,but there was no significant difference. No significant difference was found for VAS and AKSS score as well. During the average 4. 8years follow- up period,3 cases of superficial infection and 4 cases of deep infection were found in the excision group,while 2cases of superficial infection and no deep infection occurred in another group. [Conclusion] This study indicated that,as the comparison results showing,the operative time and drainage were more in the excision group,while the white blood cells,ESR and CRP were higher in the non- excision group,but infection rate was lower. So,it is speculated that the knee synovial membrane may play a role in prevention of infection.
引文
[1]Guermazi A,Zaim S,TaouliB,et al.MR findings in knee osteoarthritis[J].Eur Radiol,2003,13(6):1370-1386.
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[3]Lybck CO,Belt EA,Savolainen HA,et al.Previous synovectomy or epiphyseal stapling and the influence on knee replacement in juvenile chronic arthritis[J].Int Orthop,2004,28(3):134-137.
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[5]丁汉飞,肖李冰,陆启祥.类风湿关节炎早期切除50例[J].中国骨伤,2002,15(2):179.
[6]O’Connell JX.Pathology of the synovium[J].Am J Clin Pathol,2000,114(5):773-784.
[7]Attur M,Samuels J,Krasnokutsky S,et al.Targeting the synovial tissue for treating osteoarthritis(OA):where is the evidence[J].Best Pract Res Clin Rheumatol,2010,24(1):71-79.
[8]Hunter DJ.Imaging insights on the epidemiology and pathophysiology of osteoarthritis[J].Rheum Dis Clin North Am,2009,35(3):447-463.
[9]Kanbe K,Takemura T,Takeuchi K,et al.Synovectomy reduces stromal-cell-derived factor-1(SDF-1)which is involved in the destruction of cartilage in osteoarthritis and rheumatoid arthritis[J].J Bone Joint Surg Br,2004,86(2):296-300.
[10]MasońA,Witoński D,Pieszyński I,et al.Early clinical results of open and arthroscopic synovectomy in knee inflammation[J].Orthop Traumatol Rehabil,2007,9(5):520-526.
[11]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
[12]宋炎成,张慧慧,卢华定.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.
[13]Demey G,Servien E,Pinaroli A,et al.The influence of femoral cementing on perioperative blood loss in total knee arthroplasty:a prospective randomized study[J].J Bone Joint Surg Am,2010,92(3):536-541.
[14]Prasad N,Padmanabhan V,Mullaji A.Blood loss in total knee arthroplasty:an analysis of risk factors[J].Int Orthop,2007,31(1):39-44.
[15]Steffin BI,Green-Riviere E,Giori NJ.Timing of tourniquet release in total knee arthroplasty when using a postoperative blood salvage drain[J].J Arthroplasty,2009,24(4):539-542.
[2]Jones EA,Crawford A,English A,et al.Synovial fluid mesenchymal stem cells in health and early osteoarthritis:detection and functional evaluation at the single-cell level[J].Arthritis Rheum,2008,58(6):1731-1740.
[3]Lybck CO,Belt EA,Savolainen HA,et al.Previous synovectomy or epiphyseal stapling and the influence on knee replacement in juvenile chronic arthritis[J].Int Orthop,2004,28(3):134-137.
[4]Tanaka N,Sakahashi H,Sato E,et al.Influence of the infrapatellar fat pad resection in a synovectomy during total knee arthroplasty in patients with rheumatoid arthritis[J].J Arthroplasty,2003,18(7):897-902.
[5]丁汉飞,肖李冰,陆启祥.类风湿关节炎早期切除50例[J].中国骨伤,2002,15(2):179.
[6]O’Connell JX.Pathology of the synovium[J].Am J Clin Pathol,2000,114(5):773-784.
[7]Attur M,Samuels J,Krasnokutsky S,et al.Targeting the synovial tissue for treating osteoarthritis(OA):where is the evidence[J].Best Pract Res Clin Rheumatol,2010,24(1):71-79.
[8]Hunter DJ.Imaging insights on the epidemiology and pathophysiology of osteoarthritis[J].Rheum Dis Clin North Am,2009,35(3):447-463.
[9]Kanbe K,Takemura T,Takeuchi K,et al.Synovectomy reduces stromal-cell-derived factor-1(SDF-1)which is involved in the destruction of cartilage in osteoarthritis and rheumatoid arthritis[J].J Bone Joint Surg Br,2004,86(2):296-300.
[10]MasońA,Witoński D,Pieszyński I,et al.Early clinical results of open and arthroscopic synovectomy in knee inflammation[J].Orthop Traumatol Rehabil,2007,9(5):520-526.
[11]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
[12]宋炎成,张慧慧,卢华定.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.
[13]Demey G,Servien E,Pinaroli A,et al.The influence of femoral cementing on perioperative blood loss in total knee arthroplasty:a prospective randomized study[J].J Bone Joint Surg Am,2010,92(3):536-541.
[14]Prasad N,Padmanabhan V,Mullaji A.Blood loss in total knee arthroplasty:an analysis of risk factors[J].Int Orthop,2007,31(1):39-44.
[15]Steffin BI,Green-Riviere E,Giori NJ.Timing of tourniquet release in total knee arthroplasty when using a postoperative blood salvage drain[J].J Arthroplasty,2009,24(4):539-542.