Fink Bernd, Schlumberger Michael, Oremek Damian
Department of Joint Replacement, General, and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706, Markgröningen, Germany.
Orthopaedic Department, University-Hospital Hamburg-Eppendorf, Hamburg, Germany.
Clin Orthop Relat Res. 2017 Aug;475(8):2063-2070. doi: 10.1007/s11999-017-5334-5. Epub 2017 Mar 28.
The treatment of periprosthetic infections of hip arthroplasties typically involves use of either a single- or two-stage (with implantation of a temporary spacer) revision surgery. In patients with severe acetabular bone deficiencies, either already present or after component removal, spacers cannot be safely implanted. In such hips where it is impossible to use spacers and yet a two-stage revision of the prosthetic stem is recommended, we have combined a two-stage revision of the stem with a single revision of the cup. To our knowledge, this approach has not been reported before.
QUESTIONS/PURPOSES: (1) What proportion of patients treated with single-stage acetabular reconstruction as part of a two-stage revision for an infected THA remain free from infection at 2 or more years? (2) What are the Harris hip scores after the first stage and at 2 years or more after the definitive reimplantation?
Between June 2009 and June 2014, we treated all patients undergoing surgical treatment for an infected THA using a single-stage acetabular revision as part of a two-stage THA exchange if the acetabular defect classification was Paprosky Types 2B, 2C, 3A, 3B, or pelvic discontinuity and a two-stage procedure was preferred for the femur. The procedure included removal of all components, joint débridement, definitive acetabular reconstruction (with a cage to bridge the defect, and a cemented socket), and a temporary cemented femoral component at the first stage; the second stage consisted of repeat joint and femoral débridement and exchange of the femoral component to a cementless device. During the period noted, 35 patients met those definitions and were treated with this approach. No patients were lost to followup before 2 years; mean followup was 42 months (range, 24-84 months). The clinical evaluation was performed with the Harris hip scores and resolution of infection was assessed by the absence of clinical signs of infection and a C-reactive protein level less than 10 mg/L. All patients were assessed before surgery, between stages, every 3 months during the first year after surgery, every 6 months during the second year postoperative, and at latest followup, and were retrospectively drawn from a longitudinally maintained institutional database.
Thirty-four of 35 patients (97.2%; 95% CI, 85.4%-99.5%) appeared free of infection by criteria of Masri et al. and Zimmerli et al. at latest followup. The Harris hip score was 61 ± 13 points after the first operation and 82 ± 16 points 2 years after the second operation.
This technique is a promising treatment option for periprosthetic infections of the hip in which substantial acetabular defects exclude implantation of a normal spacer and a two-stage revision of the femoral component is favored.
Level IV, therapeutic study.
髋关节置换术后假体周围感染的治疗通常涉及单阶段或两阶段（植入临时间隔物）翻修手术。在存在严重髋臼骨缺损的患者中，无论是术前已存在还是假体取出后出现的，都无法安全植入间隔物。在这类无法使用间隔物但仍建议对假体柄进行两阶段翻修的髋关节中，我们将柄的两阶段翻修与髋臼的单阶段翻修相结合。据我们所知，此前尚未有这种方法的报道。
问题/目的：（1）作为感染性全髋关节置换两阶段翻修一部分的单阶段髋臼重建治疗的患者中，2年或更长时间后无感染的比例是多少？（2）第一阶段后以及最终再植入后2年或更长时间的Harris髋关节评分是多少？
2009年6月至2014年6月期间，如果髋臼缺损分类为Paprosky 2B、2C、3A、3B型或骨盆连续性中断且股骨首选两阶段手术，我们对所有因感染性全髋关节置换接受手术治疗的患者采用单阶段髋臼翻修作为两阶段全髋关节置换翻修的一部分。该手术包括在第一阶段取出所有组件、关节清创、确定性髋臼重建（用骨笼桥接缺损并使用骨水泥固定髋臼杯）以及临时骨水泥固定的股骨组件；第二阶段包括重复关节和股骨清创，并将股骨组件更换为非骨水泥型装置。在此期间，35例患者符合这些定义并采用此方法治疗。2年内无患者失访；平均随访42个月（范围24 - 84个月）。采用Harris髋关节评分进行临床评估，通过无感染临床体征且C反应蛋白水平低于10mg/L评估感染是否消除。所有患者在手术前、各阶段之间、术后第一年每3个月、术后第二年每6个月以及最后随访时进行评估，并从纵向维护的机构数据库中进行回顾性提取。
根据Masri等人和Zimmerli等人的标准，35例患者中有34例（97.2%；95%CI，85.4% - 99.5%）在最后随访时无感染。第一次手术后Harris髋关节评分为61±13分，第二次手术后2年为82±16分。
对于髋臼存在大量缺损而排除正常间隔物植入且倾向于对股骨组件进行两阶段翻修的髋关节假体周围感染，该技术是一种有前景的治疗选择。
IV级，治疗性研究。
