Netval M, Tawa N, Chocholác D
l. ortopedická klinika 1. LF UK a FN Motol, Praha.
Acta Chir Orthop Traumatol Cech. 2008 Dec;75(6):446-50.
Tuberculous hip arthritis accounts for about 15 % of all orthopaedic forms of tuberculosis and ranks third after spinal and knee joint tuberculosis. The aim of this study was to present the results of total hip arthroplasty (THA) for treatment of post-infectious arthritis or ankylosis, or previous arthrodesis.
A group of patients, 16 women and 10 men, treated at the 1st Department of Orthopaedics, 1st Faculty of Medicine, Charles University in Prague, between 1980 and 2007, was evaluated. All patients had tuberculous hip arthritis in their history and subsequently underwent THA. The average age at the time of THA was 65 years.
Indications for THA following tuberculous coxitis were secondary post-infectious arthritis in 20 patient, ankylosis (fibrous or osseous) in four and conversion from arthrodesis in two. Intra-operative samples were taken for microbiological examination, polymerase chain reaction (PCR) and histological examination. Anti-tuberculous drugs (rifampicin and isoniazid) and cephalosporin were administered intra-operatively following the sample collection and continued post-operatively. Cephalosporin was discontinued on post-operative day 11, rifampicin and isoniazid were administered for further 3 to 5 months with regular laboratory tests.
The average post-operative values for flexion ranged from 0 to 90 degrees, for abduction from 0 to 35 degrees and for both internal and external rotation from 0 to 30 degrees. At the end of treatment all patients walked without aid and with full weight-bearing on the operated leg. No complications were recorded. Intra-operative findings of microbiological, PCR and histological examinations were negative. No recurrent tuberculous disease was found.
A total joint replacement in any post-infectious condition is a complex issue. The average time between achieving a steady state o tuberculous arthritis and the THA procedure was approximately seven years. The outcome was evaluated as good by 75 % of the patients, who would be willing to undergo the surgery again. The clinical picture and radiographic and laboratory findings were within norms at regular follow-ups, which is in agreement with the literature data. Our system of intra- and post-operative administration of anti-tuberculous drugs and antibiotics proved very efficient.
In contrast to arthrodesis or Girdlestone resection arthroplasty, THA results in a marked improvement of painless joint motion. Before any patient is indicated for THA, a thorough medical history with laboratory, internal and pulmonary (including heart and lung radiographs) examination is necessary. When there is more than one tuberculous disease in the patient's medical history, other organ systems such as urinary or reproductive tracts should also be examined. In addition to conventional radiography, examination by computed tomography or magnetic resonance imaging is indicated. The priority is an individual approach of the phthisiology orthopaedist to the indications ensuing from this comprehensive examination, with assessment of both physical and psychic state of the patient in view of post-operative rehabilitation.
结核性髋关节炎约占所有骨科结核形式的15%，在脊柱结核和膝关节结核之后位列第三。本研究的目的是呈现全髋关节置换术（THA）治疗感染后关节炎或关节强直，或既往关节融合术的结果。
对1980年至2007年间在布拉格查理大学医学院第一附属医院骨科一部接受治疗的一组患者进行评估，其中女性16例，男性10例。所有患者既往均有结核性髋关节炎病史，随后接受了全髋关节置换术。全髋关节置换术时的平均年龄为65岁。
结核性髋关节炎后行全髋关节置换术的指征为，20例患者为继发性感染后关节炎，4例为关节强直（纤维性或骨性），2例为关节融合术转换。术中取样本进行微生物学检查、聚合酶链反应（PCR）和组织学检查。样本采集后术中给予抗结核药物（利福平和异烟肼）及头孢菌素，并在术后继续使用。头孢菌素在术后第11天停用，利福平和异烟肼再使用3至5个月，并定期进行实验室检查。
术后屈曲的平均值为0至90度，外展为0至35度，内旋和外旋均为0至30度。治疗结束时，所有患者无需辅助即可行走，患侧下肢完全负重。未记录到并发症。术中微生物学、PCR和组织学检查结果均为阴性。未发现结核复发。
在任何感染后情况下进行全关节置换都是一个复杂的问题。从结核性关节炎达到稳定状态到全髋关节置换手术的平均时间约为7年。75%的患者对结果评价良好，愿意再次接受手术。定期随访时的临床表现、影像学和实验室检查结果均在正常范围内，这与文献数据一致。我们的术中及术后抗结核药物和抗生素给药系统证明非常有效。
与关节融合术或吉德斯顿切除关节成形术相比，全髋关节置换术可显著改善无痛关节活动。在任何患者被建议行全髋关节置换术之前，必须有详尽的病史，并进行实验室、内科和肺部（包括心肺X光片）检查。当患者病史中有不止一种结核疾病时，还应检查其他器官系统，如泌尿或生殖道。除了传统的X光摄影外，还需进行计算机断层扫描或磁共振成像检查。重点是结核科骨科医生针对综合检查结果进行个体化处理，并考虑患者的身体和心理状态以进行术后康复评估。
