Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, GangNamGu, IrWon Dong 50, Seoul, 135-710, South Korea.
Clin Orthop Relat Res. 2014 Jul;472(7):2201-7. doi: 10.1007/s11999-014-3545-6. Epub 2014 Mar 6.
The treatment of knee arthritis with coexistent bone or joint sepsis is challenging. Despite the condition causing considerable morbidity, there is no generally agreed-upon approach to its treatment.
We used aggressive débridement of the knee and implantation of intraoperatively molded articulating antibiotic cement spacers with 4 g vancomycin and 2 g streptomycin per bag of cement for patients with unknown organisms as a first stage. When the infecting organism was known, organism-specific antibiotics were used. For fungal infections, 400 mg amphotericin B was added per bag of cement. This was followed by TKA as a second stage once soft tissues had healed 2 to 29 months later, (mean, 6 months) and return of laboratory parameters to within a normal range. One patient underwent two débridement and spacer procedures for suspected persistent infection.
To determine whether this approach resulted in adequate control of infection and satisfactory scores for pain and function, we retrospectively reviewed 15 patients who presented with infected arthritic knees between 2001 and 2009; all patients with infected arthritic knees were treated with this same technique during this period. We assessed knee ROM, Knee Society scores, WOMAC scores, and VAS scores preoperatively and during followup. Followup was at a mean of 4 years (range, 2-7 years); No patient was lost to followup before 2 years.
Two of the 15 patients were comfortable with the spacers and declined a more definitive reconstruction, and no patient had a recurrent infection after TKA. Before spacer placement, the mean ROM was 103.° (range, 60°-150°), with the spacers in place it decreased to a mean 87° (range, 60°-135°), and after TKA it improved to a mean of 115° (range, 75°-150°). The mean Knee Society Knee and Function scores progressed from 41 and 43 preoperatively to 85 and 83 at latest followup, respectively. The WOMAC scores improved from 51 initially to 18 after TKA. The mean VAS scores improved from 66 preoperatively to 18 after the TKA.
In this small proof-of-concept series, we found that joint débridement and use of intraoperatively molded articulating antibiotic cement spacers as part of a staged approach to treat the infected arthritic knee before TKA resulted in infection control in all patients at a minimum of 2 years' followup, reduction of knee pain, and restoration of knee function. We suggest that larger, comparative series be performed to further validate these results.
膝关节关节炎合并骨或关节感染的治疗极具挑战性。尽管这种情况会导致相当大的发病率，但对于其治疗方法尚未达成普遍共识。
我们对膝关节进行了积极清创，并在术中使用经模具成型的关节内抗生素水泥间隔物进行植入，每袋水泥中含有 4 克万古霉素和 2 克链霉素，用于治疗未知病原体的患者作为第一阶段。当感染病原体已知时，使用针对特定病原体的抗生素。对于真菌感染，每袋水泥中添加 400 毫克两性霉素 B。在软组织愈合后 2 至 29 个月（平均 6 个月），实验室参数恢复正常范围内后，进行全膝关节置换术（TKA）作为第二阶段。有 1 名患者因疑似持续感染而进行了两次清创和间隔物手术。
为了确定这种方法是否能有效控制感染，并获得满意的疼痛和功能评分，我们回顾性分析了 2001 年至 2009 年间患有感染性关节炎的 15 名患者；在此期间，所有患有感染性关节炎的患者均采用相同的技术进行治疗。我们评估了术前和随访期间的膝关节活动度（ROM）、膝关节协会评分（Knee Society scores）、WOMAC 评分和视觉模拟评分（VAS）。随访时间平均为 4 年（范围 2-7 年）；在随访 2 年之前，没有患者失访。
15 名患者中有 2 名对间隔物感到满意，拒绝了更明确的重建，且在 TKA 后没有患者出现复发感染。在放置间隔物之前，平均 ROM 为 103°（范围 60°-150°），放置间隔物后降至平均 87°（范围 60°-135°），TKA 后改善至平均 115°（范围 75°-150°）。术前 Knee Society 膝关节和功能评分分别从 41 和 43 提高到 85 和 83，术后随访时。WOMAC 评分从最初的 51 分降至 TKA 后的 18 分。VAS 评分从术前的 66 分改善至 TKA 后的 18 分。
在这项小型概念验证系列研究中，我们发现关节清创术和使用术中模具成型的关节内抗生素水泥间隔物作为 TKA 前治疗感染性关节炎膝关节的分期方法的一部分，在至少 2 年的随访中，所有患者均能控制感染，膝关节疼痛减轻，膝关节功能恢复。我们建议进行更大的、对照系列研究，以进一步验证这些结果。
