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王志為主任醫(yī)師 北京朝陽醫(yī)院 骨科 沒有更好，只有更適合。選擇單髁置換（UKA）還是全膝置換（TKA）取決于您的病情、年齡、活動水平及膝關(guān)節(jié)受損程度。以下是兩者的主要區(qū)別和選擇依據(jù)：單髁置換（UKA）適用情況：僅膝關(guān)節(jié)內(nèi)側(cè)或外側(cè)單側(cè)間室受損。前交叉韌帶功能正常?；颊咻^年輕，活動量較大。優(yōu)點(diǎn)：保留更多骨量。手術(shù)創(chuàng)傷小，恢復(fù)快。術(shù)后膝關(guān)節(jié)功能更接近自然狀態(tài)。缺點(diǎn)：若其他間室后期出現(xiàn)病變，可能需要再次手術(shù)。技術(shù)要求較高。全膝關(guān)節(jié)置換（TKA）適用情況：多個間室受損或全膝關(guān)節(jié)退變。嚴(yán)重膝關(guān)節(jié)畸形。交叉韌帶功能不全?；颊吣挲g較大，活動量較小。優(yōu)點(diǎn)：適用于廣泛膝關(guān)節(jié)病變。長期效果穩(wěn)定，翻修率低。缺點(diǎn)：創(chuàng)傷較大，恢復(fù)較慢。切除骨量較多。選擇依據(jù)病變范圍：單側(cè)間室病變選UKA，多間室病變選TKA。年齡與活動水平：年輕、活動量大者傾向UKA，老年、活動量小者傾向TKA。膝關(guān)節(jié)穩(wěn)定性：前交叉韌帶功能正常選UKA，功能不全選TKA。畸形程度：畸形輕選UKA，畸形重選TKA。02月02日
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王志為主任醫(yī)師 北京朝陽醫(yī)院 骨科 術(shù)前：1、應(yīng)保持膝關(guān)節(jié)局部皮膚清潔、無皮膚破損，但無需自己買消毒劑消毒。2、如有齲齒、牙周炎、肺炎、尿路感染、身體其他部位的癤腫、足癬等，需向主治醫(yī)生說明情況。3、手術(shù)前3個月內(nèi)膝關(guān)節(jié)不能接受關(guān)節(jié)注射、針灸、小針刀等有創(chuàng)性治療。4、術(shù)前向主治醫(yī)生報告其他手術(shù)情況，尤其是半年內(nèi)的心腦血管介入手術(shù)，并如實(shí)告知用藥情況。術(shù)中：1、麻醉師根據(jù)患者實(shí)際情況選擇全麻還是半麻（椎管內(nèi)麻醉）。2、手術(shù)時間：45分鐘-1小時10分鐘。3、一般無需備血和輸血，也不留置導(dǎo)尿管，使用一次性紙尿褲、保護(hù)患者隱私。4、手術(shù)切口15cm左右，肥胖患者切口會稍長，單髁置換傷口約全膝一半。切口美容閉合，沒有縫針孔瘢痕。術(shù)后：1、因?yàn)樘弁垂芾淼倪M(jìn)步，術(shù)后2-3天內(nèi)，多數(shù)患者無需口服止痛藥。2、術(shù)后當(dāng)日開始指導(dǎo)主動功能鍛煉。醫(yī)生不幫患者彎腿，患者無恐懼感。3、術(shù)后第1天助步器保護(hù)下下地活動，自主如廁。4、一般術(shù)后3-5天，達(dá)到出院標(biāo)準(zhǔn)（膝關(guān)節(jié)屈伸活動和行走距離符合要求）。5、術(shù)后門診復(fù)查時間：1個月、3個月、6個月和1年。6、術(shù)后可以坐飛機(jī)、可以拍磁共振、傷口愈合后也可以泡溫泉。02月01日49
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王志為主任醫(yī)師 北京朝陽醫(yī)院 骨科 現(xiàn)代人工全膝關(guān)節(jié)置換10年假體正常使用率超過95%，20年假體正常使用率93%。即：“10位患者至少有9位能使用超過20年”合理控制體重、避免經(jīng)常性背負(fù)重物、減少高強(qiáng)度高沖擊性運(yùn)動、預(yù)防和治療骨質(zhì)疏松對于延長假體使用壽命有益。誤區(qū)：術(shù)后減少膝關(guān)節(jié)活動量可以延長假體使用壽命這種觀點(diǎn)是不對的，因?yàn)榛顒恿康臏p少會導(dǎo)致骨質(zhì)疏松的進(jìn)展，并可能導(dǎo)致體重的增加，有些患者還會出現(xiàn)“三高”，誘發(fā)其他疾病。02月01日51
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王志為主任醫(yī)師 北京朝陽醫(yī)院 骨科 常見的需要膝關(guān)節(jié)置換的疾病包括骨關(guān)節(jié)炎、類風(fēng)濕性關(guān)節(jié)炎、創(chuàng)傷后關(guān)節(jié)炎、強(qiáng)直性脊柱炎、晶體性關(guān)節(jié)炎等等。但并不是所有患者都適合接受膝關(guān)節(jié)置換手術(shù)的。醫(yī)生在門診通常經(jīng)過詳細(xì)的問詢、查體，再結(jié)合X線片等資料進(jìn)行綜合分析后再做決定。通常來講，如果存在下列情況，那么膝關(guān)節(jié)置換一般能獲得較好效果：1、膝關(guān)節(jié)的疼痛影響到您的日常生活，平路500米內(nèi)（大約公交車一站地）膝關(guān)節(jié)就會出現(xiàn)疼痛或跛行。2、膝關(guān)節(jié)僵硬，逐漸不能完全彎曲或伸直，或者逐漸加重的內(nèi)外翻畸形（O型腿或X型腿）。3、對止痛藥物副作用不能耐受，其他諸如關(guān)節(jié)腔注射、理療或其他非手術(shù)治療無效。4、X線片顯示關(guān)節(jié)間隙明顯狹窄（提示軟骨磨損），并且病變部位與疼痛部位一致。02月01日39
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陳金偉副主任醫(yī)師 上海市第一人民醫(yī)院（北部） 骨科 微創(chuàng)切口單髁膝關(guān)節(jié)置換術(shù)（UKA）作為膝關(guān)節(jié)置換手術(shù)的一類特殊形式，越來越多的被應(yīng)用在膝關(guān)節(jié)退行性變的晚期功能重建。UKA具有創(chuàng)傷小、并發(fā)癥少，術(shù)后關(guān)節(jié)功能恢復(fù)快等優(yōu)點(diǎn)，同時通過保留交叉韌帶，不改變關(guān)節(jié)的穩(wěn)定性，保留了患者的本體感覺。因此，患者術(shù)后膝關(guān)節(jié)運(yùn)動很接近正常膝關(guān)節(jié)運(yùn)動學(xué)。此點(diǎn)區(qū)別于切除了交叉韌帶的全膝關(guān)節(jié)置換，是一種保膝手術(shù)，因此患者術(shù)后恢復(fù)要比傳統(tǒng)的膝關(guān)節(jié)置換手術(shù)快得多。在臨床工作中發(fā)現(xiàn)很多患者在做完UKA手術(shù)后疼痛緩解的很快，下地走路也很好，但不太敢進(jìn)行進(jìn)一步的功能鍛煉。因此在本文中，我將闡述單髁手術(shù)后患者進(jìn)行功能鍛煉的方法。術(shù)后當(dāng)天：術(shù)后當(dāng)天患者從麻醉反應(yīng)中逐漸恢復(fù)，此時膝關(guān)節(jié)已經(jīng)可以進(jìn)行自主的輕度的屈伸活動，此時我們并不要求馬上下地，而是以舒適的姿勢進(jìn)行少量的屈伸活動，同時建議患者將患側(cè)的膝關(guān)節(jié)輕度抬高，適度彎曲以減輕腫脹。此時由于有術(shù)中鎮(zhèn)痛藥物的應(yīng)用，多數(shù)患者不會感覺疼痛，所以可以正常進(jìn)流質(zhì)飲食，飲水并在家人攙扶下下地去洗手間等活動，均不受影響。切勿保持一個固定姿勢而不敢活動，這樣會造成膝關(guān)節(jié)僵硬不適。術(shù)后第1天：第一天早晨在早餐后，醫(yī)生會打開手術(shù)敷貼對創(chuàng)口進(jìn)行換藥處置，同時會繼續(xù)使用繃帶將膝關(guān)節(jié)進(jìn)行適當(dāng)加壓包扎以減少滲出。在第一天上午建議患者使用助行器進(jìn)行適當(dāng)行走，時間為10-20分鐘為宜，此時并不需要膝關(guān)節(jié)過度彎曲，坐在床邊將膝關(guān)節(jié)自然下垂即可，此時我們依然以最舒適的姿勢活動，切勿行走過多而導(dǎo)致腫脹。術(shù)后第2-4天：此時患者膝關(guān)節(jié)的活動量可以適當(dāng)加大，包括屈膝已經(jīng)可以很輕松的達(dá)到90度，下地行走的穩(wěn)定感更好，創(chuàng)面一般不需要再加壓包扎，如愈合良好，沒有明顯的滲出與腫脹，則已經(jīng)可以出院回家了。此時的功能鍛煉應(yīng)該逐漸加量，每天可以行走半小時-1小時左右，出院后需要定期換藥，如果有腫脹發(fā)生，是正常的現(xiàn)象，需要每天冰敷2-3次，以及踝泵運(yùn)動，非常有利于消腫。術(shù)后1周：此時多數(shù)患者還有有輕度的疼痛感，主要與局部愈合過程中產(chǎn)生的反應(yīng)有關(guān)，建議口服的鎮(zhèn)痛藥，如西樂葆，安康信等可以每天口服，對鎮(zhèn)痛效果好，同時注重腿部力量練習(xí)，如直抬腿，走樓梯等都非常適合。鎮(zhèn)痛藥物的服用根據(jù)不同人的疼痛反應(yīng)，一般可以持續(xù)到術(shù)后1個月左右。術(shù)后2周：此時，創(chuàng)面正?？梢圆鹁€了，拆線后預(yù)示著我們的活動量需要進(jìn)一步加大，應(yīng)當(dāng)達(dá)到正?；顒恿康?0%-60%，尤其應(yīng)當(dāng)注重股四頭肌力量的練習(xí)，每天堅持進(jìn)行直抬腿運(yùn)動，每天可以行走半小時以上。術(shù)后2周-2個月：在這個階段，患者應(yīng)當(dāng)大膽的嘗試下蹲和盤腿等動作。尤其坐便更加不受任何影響，這個期間膝關(guān)節(jié)的活動量應(yīng)當(dāng)達(dá)到正常的70%-80%，尤其要調(diào)整好心態(tài)，輕度的疼痛不必過度擔(dān)心，正常的加大鍛煉量，只有關(guān)節(jié)活動開了，以后才能真正不疼。并且可以嘗試脫離助歩器行走。術(shù)后2個月-半年：此時，需要第一次復(fù)查我們的膝關(guān)節(jié)，建議到門診進(jìn)行X光片的拍攝和肢體功能的檢查。同時我會再次對今后的生活與活動進(jìn)行一定的專業(yè)指導(dǎo)。最后還要強(qiáng)調(diào)，手術(shù)后不要忘記補(bǔ)鈣，服用改善骨質(zhì)疏松的藥物與食物。請您記住，好的關(guān)節(jié)需要好的骨骼來支撐，這樣才能用的更長久。01月18日147
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熊奡主任醫(yī)師 北京大學(xué)深圳醫(yī)院 骨關(guān)節(jié)科 在以往啊，做膝關(guān)節(jié)手術(shù)有時需要切除掉完好的韌帶、半月板，甚至是本體感覺神經(jīng)，這樣不僅創(chuàng)傷大，出血多，而且還會讓很多的患者是望而卻步。而隨著醫(yī)學(xué)的發(fā)展，一種節(jié)約化的膝關(guān)節(jié)手術(shù)應(yīng)運(yùn)而生。 張女士今年64歲，從前兩年開始，她就感覺到左邊的膝蓋出現(xiàn)不適，開始只是輕微的癥狀，隨著疼痛加重，后面竟然直接影響到日常的行走，就痛，這這就不能走路了，這個腿就是就得扶著東西走，然后啊，就是這里頭不敢走啊，痛啊，就是很多人都知道，膝蓋一旦出現(xiàn)問題，一到天氣潮濕的時候就痛的厲害，眼看著自己的膝蓋變成天氣預(yù)報，張女士試過多種辦法，包括貼藥膏，擦藥酒也依然無濟(jì)于事。那么張女士的膝蓋到底出現(xiàn)了什么問題？這個患者呢？她的膝關(guān)節(jié)的內(nèi)側(cè)瓣，大家可以看到明顯在磁共振上的，磁共振上顯示一個炎性的信號。 啊，股骨髁，脛骨平臺都有明顯的炎癥，半月板也破也破裂了。 仔細(xì)看，可以看到他這個關(guān)節(jié)軟骨面已經(jīng)磨損了啊，俗話說人老腿先老，特別是對于女性來說，由于經(jīng)常下蹲，上了年紀(jì)之后，相較于男性膝蓋就更容易出現(xiàn)問題，張女士想解決膝蓋疼痛的癥狀，就只能通過手術(shù)，傳統(tǒng)的人工膝關(guān)節(jié)手術(shù)呢，是把我們膝關(guān)節(jié)里頭的所有的表面都進(jìn)行打磨，然后2024年10月28日238
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江晨主治醫(yī)師 南通市海門區(qū)人民醫(yī)院 關(guān)節(jié)與運(yùn)動醫(yī)學(xué)中心 大多數(shù)人聽到“膝關(guān)節(jié)置換”，腦海里浮現(xiàn)出的場景是“把膝關(guān)節(jié)鋸掉，換上一個人工的關(guān)節(jié)”。其實(shí)膝關(guān)節(jié)置換，全名叫膝關(guān)節(jié)表面置換。在我們膝關(guān)節(jié)的表面上有軟骨，隨著年齡增大，磨損增多，慢慢的軟骨就磨掉了。磨掉了以后就會出現(xiàn)膝關(guān)節(jié)疼痛，尤其是行走負(fù)重和上下樓梯，爬山時疼痛會加重，休息后會好轉(zhuǎn)，嚴(yán)重的可引起膝關(guān)節(jié)內(nèi)外翻，就是“O”型腿和“X”型腿。膝關(guān)節(jié)置換就是針對這種軟骨損傷嚴(yán)重，影響生活的人群。膝關(guān)節(jié)置換術(shù)是通過手術(shù)切除已經(jīng)磨損破壞的關(guān)節(jié)面，使用人工生物材料（膝關(guān)節(jié)假體）來置換病變的的膝關(guān)節(jié)軟骨，達(dá)到消除膝關(guān)節(jié)疼痛、矯正膝關(guān)節(jié)畸形、恢復(fù)下肢力線、重建膝關(guān)節(jié)功能的目的。01膝關(guān)節(jié)置換術(shù)適應(yīng)癥膝關(guān)節(jié)置換術(shù)的適應(yīng)癥主要為終末期膝骨關(guān)節(jié)炎、類風(fēng)濕性關(guān)節(jié)炎、創(chuàng)傷性關(guān)節(jié)炎、強(qiáng)直性脊柱炎膝關(guān)節(jié)受累等。對于早期膝骨關(guān)節(jié)炎、類風(fēng)濕性關(guān)節(jié)炎等，可采取減輕體重、佩戴護(hù)具、藥物治療、理療、中西醫(yī)結(jié)合治療等方法，可有效改善關(guān)節(jié)癥狀，并減緩病情進(jìn)展。然而，當(dāng)出現(xiàn)關(guān)節(jié)間隙變窄或消失、關(guān)節(jié)畸形明顯時，則保守治療效果有限。此時，可選擇膝關(guān)節(jié)置換手術(shù)，重建膝關(guān)節(jié)的功能，術(shù)后可早期功能鍛煉，改善生活質(zhì)量。02膝關(guān)節(jié)置換術(shù)的類型單髁關(guān)節(jié)置換術(shù):單髁置換術(shù)主要針對單側(cè)骨關(guān)節(jié)病，單髁置換手術(shù)是用人工關(guān)節(jié)墊片和軟骨替代磨損的部位，屬于保膝手術(shù)，適合單一間室出現(xiàn)磨損的患者，不會損傷前、后交叉韌帶，可保持關(guān)節(jié)穩(wěn)定性和本體感覺，相對會比較好，康復(fù)周期也會短。全膝關(guān)節(jié)置換術(shù)：全膝置換手術(shù)會破壞整個關(guān)節(jié)面，包括韌帶，適合全關(guān)節(jié)嚴(yán)重退化后需要建立表面置換的患者。03膝關(guān)節(jié)置換術(shù)操作步驟1、備體位，消毒2、切開暴露關(guān)節(jié)，軟組織處理3、股骨遠(yuǎn)端截骨4、股骨前后髁和斜面截骨（四合一截骨）5、脛骨近端截骨6、假體試模7、截骨面放置骨水泥并安裝假體8、沖洗，逐層縫合，關(guān)閉切口——關(guān)注我們——2024年08月29日704
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曾紀(jì)洲主任醫(yī)師 北京潞河醫(yī)院 骨關(guān)節(jié)外科 功能對線、運(yùn)動對線、力學(xué)對線等對線技術(shù)的核心理念_MAKO機(jī)械臂系統(tǒng)在全膝關(guān)節(jié)置換術(shù)中具有功能對線的間隙平衡新技術(shù)的初步研究（2024）AnewgapbalancingtechniquewithfunctionalalignmentintotalkneearthroplastyusingtheMAKOroboticarmsystem:apreliminarystudy?TsaiHK,BaoZ,WuD,HanJ,JiangQ,XuZ.AnewgapbalancingtechniquewithfunctionalalignmentintotalkneearthroplastyusingtheMAKOroboticarmsystem:apreliminarystudy[J].BMCSurg,2024,24(1):232.?轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/39143535/轉(zhuǎn)載文章的原鏈接2：https://bmcsurg.biomedcentral.com/articles/10.1186/s12893-024-02524-x?AbstractBackgroundGaptensionisanimportantfactorinfluencingtheclinicaloutcomesoftotalkneearthroplasty(TKA).Traditionalmechanicalalignment(MA)placesimportanceonneutralalignmentandoftenrequiresadditionalsofttissuereleases,whichmayberelatedtopatientdissatisfaction.Conversely,thefunctionalalignmentrequireslesssofttissuereleasetoachievegapbalance.Conventionalgaptensioninstrumentspresentseveralshortcomingsinpractice.TheaimofthisstudyistointroduceanewgapbalancingtechniquewithFAusingthemodifiedspacer-basedgaptoolandtheMAKOroboticarmsystem.間隙張力是影響全膝關(guān)節(jié)置換術(shù)(TKA)臨床療效的重要因素。傳統(tǒng)的機(jī)械對線(MA)重視中性對線，通常需要額外的軟組織松解，這可能與患者的不滿意有關(guān)。相反，功能性對線需要較少的軟組織松解來達(dá)到間隙平衡。傳統(tǒng)的間隙張力儀在實(shí)際應(yīng)用中存在一些不足。本研究的目的是引入一種新的間隙平衡技術(shù)，該技術(shù)使用改進(jìn)的基于間隔器的間隙工具和MAKO機(jī)械臂系統(tǒng)。?MethodsAtotalof22consecutivepatientsunderwentprimaryTKAusingtheMAKOroboticarmsystem.Thegaptensionwasassessedandadjustedwiththemodifiedspacer-basedgaptool改進(jìn)的基于墊片的間隙工具duringtheoperation.Patientsatisfactionwasevaluatedpost-operativelywitha5-pointLikertscale.Clinicaloutcomesincludinglowerlimbalignment,KneeSocietyScore(KSS)andWesternOntarioandMcMasterUniversitiesArthritisIndex(WOMAC)wererecordedbeforesurgery,3monthsand1yearaftersurgery.?ResultsTherangeofmotion(ROM)wassignificantlyincreased(p?2024年08月28日152
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曾紀(jì)洲主任醫(yī)師 北京潞河醫(yī)院 骨關(guān)節(jié)外科 全膝關(guān)節(jié)置換治療膝關(guān)節(jié)夏科氏關(guān)節(jié)病的中長期療效（2024）Mid-toLong-TermResultsofTotalKneeArthroplastyforCharcotArthropathyoftheKnee?OnoiY,MatsumotoT,NakanoN,TsubosakaM,KamenagaT,KurodaY,IshidaK,HayashiS,KurodaR.Mid-toLong-TermResultsofTotalKneeArthroplastyforCharcotArthropathyof?theKnee[J].IndianJOrthop,2024,58(3):308-315.?轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/38425826/?轉(zhuǎn)載文章的原鏈接2：https://link.springer.com/article/10.1007/s43465-023-01094-z?AbstractBackground:Totalkneearthroplasty(TKA)forCharcotarthropathyofthekneeisconsideredcontroversialbecauseofitshighercomplicationratecomparedwiththatofTKAforosteoarthritis.Inthisstudy,weinvestigatedtheclinicaloutcomes,survivalrates,andcomplicationsofprimaryTKAforCharcotarthropathy.全膝關(guān)節(jié)置換術(shù)(TKA)治療膝關(guān)節(jié)Charcot關(guān)節(jié)病被認(rèn)為是有爭議的，因?yàn)榕c骨關(guān)節(jié)炎的TKA相比，其并發(fā)癥發(fā)生率更高。在這項(xiàng)研究中，我們調(diào)查了初次TKA治療Charcot關(guān)節(jié)病的臨床結(jié)果、生存率和并發(fā)癥。?Methods:Weconductedaretrospectiveanalysisofninepatients(12knees)withCharcotarthropathywhounderwentTKA.Themeanageofthepatientswas63.9±9.4years(range,52-83years).Themostfrequentcausativediseasewasdiabetesmellitus(threepatients).Patients'clinicaloutcomes,includingthe2011KneeSocietyScoreandtherangeofmotion,werecomparedbetweenpreoperativeandthemostrecentpostoperativedata.The5-and10-yearsurvivalratesforasepticrevision,revisionduetoinfection,andcomplicationswereexamined.Themeanfollow-upperiodwas7.3±3.9years(range,3-14years).我們對9例Charcot關(guān)節(jié)病患者(12個膝關(guān)節(jié))進(jìn)行了全膝關(guān)節(jié)置換術(shù)的回顧性分析?；颊咂骄挲g為63.9±9.4歲(52~83歲)。最常見的病因是糖尿病(3例)。患者的臨床結(jié)果，包括2011年膝關(guān)節(jié)社會評分和活動范圍，在術(shù)前和術(shù)后的最新數(shù)據(jù)之間進(jìn)行比較。檢查無菌翻修、感染翻修和并發(fā)癥翻修的5年和10年生存率。平均隨訪時間7.3±3.9年(范圍3~14年)。?Results:The2011KneeSocietyScoreandthekneeflexionanglesignificantlyimprovedafterTKAsurgery(P<0.05).The5-yearsurvivalratesforasepticrevision,revisionduetoinfection,andcomplicationswere100%,91.7%,and83.3%,respectively;the10-yearsurvivalratesfortheseparameterswerethesame.Onepatientunderwentrevisionforinsertreplacementduetoperiprostheticinfection,andtheotherpatienthadvarus/valgusinstabilityduetosofttissueloosening.TKA術(shù)后膝關(guān)節(jié)社會評分和膝關(guān)節(jié)屈曲角度均顯著提高(P<0.05)。無菌翻修、感染翻修和并發(fā)癥翻修的5年生存率分別為100%、91.7%和83.3%;這些參數(shù)的10年生存率是相同的。一名患者因假體周圍感染接受假體置換翻修，另一名患者因軟組織松動出現(xiàn)內(nèi)翻/外翻不穩(wěn)定。?Conclusions:Themid-tolong-termresultsofTKAforCharcotarthropathyweregenerallyfavorable.OurfindingsindicatethatTKAmaybeaviabletreatmentoptionforCharcotarthropathy.TKA治療Charcot關(guān)節(jié)病的中長期結(jié)果通常是有利的。我們的研究結(jié)果表明TKA可能是治療Charcot關(guān)節(jié)病的可行選擇。?Keywords:Charcotarthropathy;Constrainedcondylarprosthesis;Neuropathicarthropathy;Rotatinghingeprosthesis;Survivalrates;Totalkneearthroplasty.?IntroductionCharcotarthropathyisadegenerativeneuropathicarthropathythatleadstoseverejointdestructionandinstability,causedbyrepetitiveasymptomaticmicrotraumaduetodecreasedorabsentjointnociception[1].Theglobalincreaseintheincidenceofdiabetesmellitus(DM),themaincausativediseaseofCharcotarthropathy,isexpectedtoleadtoahigherprevalenceofCharcotarthropathy[2,3].BecauseofthenatureofCharcotarthropathy,patientsrarelycomplainofpainduringtheearlydeformitystagesandtypicallyseektreatmentonlyafterseveredeformity,instability,andgaitdisturbancehaveoccurred[4].ThismakesCharcotarthropathyoneofthemostdifficultconditionsfororthopaedicsurgeonstotreat.Charcot關(guān)節(jié)病是一種退行性神經(jīng)性關(guān)節(jié)病，可導(dǎo)致嚴(yán)重的關(guān)節(jié)破壞和不穩(wěn)定，由關(guān)節(jié)痛覺減少或缺失引起的重復(fù)性無癥狀微創(chuàng)傷引起[1]。糖尿病(DM)是Charcot關(guān)節(jié)病的主要致病疾病，隨著全球糖尿病發(fā)病率的增加，預(yù)計將導(dǎo)致Charcot關(guān)節(jié)病的患病率升高[2,3]。由于Charcot關(guān)節(jié)病的性質(zhì)，患者在早期畸形階段很少主訴疼痛，通常只有在發(fā)生嚴(yán)重畸形、不穩(wěn)定和步態(tài)障礙后才尋求治療[4]。這使得Charcot關(guān)節(jié)病成為骨科醫(yī)生最難治療的疾病之一。Althoughtotalkneearthroplasty(TKA)forCharcotarthropathywaspreviouslynotrecommendedbecauseofitshighrateofcomplications,suchasperiprostheticinfection,fracture,anddislocation[5,6],severalrecentstudieshaveshowngoodshort-termclinicaloutcomeswithTKA[2,7].However,thereislimitedliteratureonthemid-tolong-termresultsofTKAforCharcotarthropathy[8,9],andimportantquestionsregardingsurvivalrates,potentialcomplications,andclinicaloutcomesofTKAremainunresolved.ThislackofinformationmaypreventpropermanagementofCharcotarthropathy.Therefore,weaimedtoreportthemid-tolong-termresultsofprimaryTKAforpatientswithCharcotarthropathy.盡管全膝關(guān)節(jié)置換術(shù)(TKA)治療Charcot關(guān)節(jié)病之前不被推薦，因?yàn)槠洳l(fā)癥發(fā)生率高，如假體周圍感染、骨折和脫位[5,6]，但最近的幾項(xiàng)研究表明，TKA的短期臨床效果良好[2,7]。然而，關(guān)于TKA治療Charcot關(guān)節(jié)病的中長期結(jié)果的文獻(xiàn)有限[8,9]，TKA的生存率、潛在并發(fā)癥和臨床結(jié)果等重要問題仍未解決。這種信息的缺乏可能會妨礙對Charcot關(guān)節(jié)病的適當(dāng)治療。因此，我們的目的是報道原發(fā)性全膝關(guān)節(jié)置換術(shù)治療Charcot關(guān)節(jié)病患者的中長期結(jié)果。MaterialsandMethodsPatientsThestudywasapprovedbytheInstitutionalReviewBoardofourinstitution(PermissionNo;1510),andwritteninformedconsentwasobtainedfromthepatients.Weconductedaretrospectiveanalysisof11consecutivepatientswithCharcotarthropathyofthekneewhounderwentprimaryTKAatourinstitutionbetweenAugust2008andMarch2020.TwopatientswereexcludedfromthestudybecausetheydiedwithinoneyearforreasonsunrelatedtoTKA.Theremainingninepatients(12knees),consistingoffourmenandfivewomenwithameanageof63.9?±?9.4years(range,52–83years)atthetimeofTKA,wereenrolledinthestudy.NoneofthepatientshadundergonearthroscopicdebridementorotherkneesurgeriespriortotheTKAs.PriortoTKA,threepatientshadipsilateralanklejointfracturesandunderwentopenreductionandinternalfixation.TheCharcotarthropathy-causativeneuropathywasdiagnosedbyneurologistsusingnerveconductionstudies,electromyography,andclinicalevaluations.Orthopaedicsurgeonsverifiedthediagnosesbyphysicalexaminationandradiographicstudies,revealingfeaturescharacteristicofCharcotarthropathy,includingseveredeformity,instability,andrestrictedrangeofmotion.Theninepatientsincludedinthestudyhadavarietyofcausativediseases.Ofthese,DMwasthemostcommon(threepatients),withameanHbA1cof5.9?±?0.2%(range,5.6–6.1%).Twopatientshadneurosyphilis,onehadCharcot-Marie-Toothdisease,onehadGuillain–Barresyndrome,onehadcervicalossificationoftheposteriorlongitudinalligament,andonehadmeningealaneurysm(Table1).Noneofthepatientswerelosttofollow-up,andthemeanfollow-upperiodwas7.3?±?3.9years(range,3–14years).??Table1Patients’characteristics??OperativeProceduresAllsurgerieswereperformedbyseniorsurgeonswith>?15yearsofexperienceinTKAprocedures.Allpatientsreceivedgeneralanesthesiaandfemoral/sciaticnerveblockwith0.75%ropivacaine(40mL).Afterinflatingtheairtourniquetto250mmHg,thekneeswereexposedbymedialparapatellararthrotomy;osteotomywasperformedusingthemeasuredresectiontechnique.ALegacyconstrainedcondylarkneeprosthesis(LCCK;ZimmerBiomet,Warsaw,IN,USA)wasinsertedintenkneesandarotatinghingekneeprosthesis(RHK;ZimmerBiomet)wasinsertedintwokneespresentinghyperextension.Stemswereusedinboththefemurandtibiaforsevenknees;infourknees,thestemswereusedinthetibiaonly;inoneknee,nostemswereused,followingaprotocoltousestemsinfragilebones.Augmentationwasappliedtoreplacetibialbonedefectsof>5mmineightknees.Allthefemoralandtibialprostheseswerefixedwithcementafterpulsedlavage,drying,andpressurizationofthecement.Patellarresurfacingwasconductedinsevenkneeswithpatellardeformity.Afteralltheprostheseswereimplanted,lateralretinacularreleasewasneededinfourcasesofkneesbasedontheassessmentofpatellartracking.Duringsurgery,nocaseshadsofttissueinjuriessuchasmedialorlateralcollateralligamentsorpatellartendons(Table1).?PostoperativeTherapyTheoperatedkneedidnotwearanybracefromthedayofsurgery.Fromthedayaftersurgery,allpatientswereallowedfullweight-bearingandbeganactivekneemotionexercises,alongwithquadriceps-strengtheningexercisesandstandingatthebedsideorwalkingwithcrutchesorawalkerunderthesupervisionofaphysicaltherapist.Onthe14thpostoperativeday,thewoundstitcheswereremoved.Nopatienthadanyinfectionorwounddehiscenceatthispoint.Twotofourweeksaftersurgery,patientsweredischargedfromthehospital,andphysicaltherapyattheoutpatientclinicwasconductedonceaweekforthreemonthsaftersurgery.Inadditiontotheinpatientrehabilitationprogram,outpatientrehabilitationfocusedonactivitiesofdailylivingexercisessuchasbathing,hillwalking,andstairclimbing,tailoredtoeachpatient'scondition.Forpostoperativeanalgesia,NSAIDswereadministeredupto1monthpostoperativelyandacetaminophenfrom1to3monthspostoperatively.AfterdiagnosisofosteoporosisbydualenergyX-rayabsorptiometry,patientsreceivedoraladministrationof35mgalendronateonceaweekand0.75μgeldecalcitoldaily.?ClinicalandRadiographicEvaluationsClinicalandradiographicevaluationswereperformedforeachpatientpreoperatively,andat3-,6-,and12-monthspostoperatively,andannuallythereafter.The2011KneeSocietyScore(KSS)[10]wasrecordedandassessed.Therangeofmotion(ROM)wasmeasuredthreetimeseachusingagoniometerinthesupinepositionbyseveralseniorphysiotherapistswith>?5yearsofclinicalexperience.Duringradiographicevaluation,thefemorotibialangle(FTA)wasmeasuredinfull-lengthviewsofthelowerextremities,inthestandingposition.ThestageofCharcotarthropathywasclassifiedaccordingtotheKoshinoclassification[11].Prosthesislooseningwasassessedbycomponentsubsidence>2mmorbyacompleteradiolucentlinearoundthecomponent[12].Allradiographicevaluationswereindependentlyanalyzedbytwoinvestigators,whohad>?10yearsofclinicalexperienceandwerenotinvolvedintheoperations.11.Koshino,T.(1991).Stageclassifications,typesofjointdestruction,andbonescintigraphyinCharcotjointdisease.BulletinoftheHospitalforJointDiseasesOrthopaedicInstitute,51(2),205–217.12.Ewald,F.C.(1989).TheKneeSocietytotalkneearthroplastyroentgenographicevaluationandscoringsystem.ClinicalOrthopaedicsandRelatedResearch,248,9–12.?StatisticalAnalysisAllvalueswerenormallydistributedandwereexpressedasmean?±?standarddeviation(SD).AllstatisticalanalyseswereperformedusingthestatisticalsoftwareEZR(SaitamaMedicalCenter,JichiMedicalUniversity,Saitama,Japan)[13].Pairedttestswereusedtocomparethe2011KSSandROMbetweenpreoperativeandthemostrecentdata.Forpatientswhodiedorexperiencedrevisionsurgery,thevaluesatthepre-eventvisitwereconsideredthemostrecentdata.TheKaplan–Meiermethodwasusedtocreatesurvivalcurvesforrevisionandcomplications[14].StatisticalsignificancewassetatP??2mmorprogressiveradiolucentlinesaroundthefemoral,tibial,orpatellarcomponents(Figs.1,2).??Fig.1Radiographsofa61-year-oldmalewithKoshinoclassificationstageIIICharcotarthropathy(No.2inTable1)preoperatively(A,B),immediatelypostoperatively(C,D),andmostrecently,14yearspostoperatively(E,F)??Fig.2Radiographsofa74-year-oldfemalewithKoshinoclassificationstageIIICharcotarthropathy(No.4.1inTable1)preoperatively(A,B),immediatelypostoperatively(C,D),andmostrecently,5yearspostoperatively(E,F)??ImplantSurvival,Revisions,andComplicationsThesurvivalratesforasepticrevision,revisionduetoinfection,andcomplicationsarepresentedinFig.3.The5-yearsurvivalrateswere100%(12/12)forasepticrevision,91.7%(11/12)forrevisionduetoinfection,and83.3%(10/12)forcomplications.The10-yearsurvivalrateswerethesame.Only2outof12patientshadcomplicationsduringfollow-upperiod.??Fig.3Kaplan–Meiercurvesofsurvivalratesforasepticrevision,revisionduetoinfection,andcomplications??Onepatientexperiencedaperiprostheticinfection4yearspostoperatively.Undergeneralanesthesia,thepolyethyleneinsertwasremoved,andthekneejointwasthoroughlydebridementandwashedwith9Lofsalinesolution.Thefemoralandtibialcomponentsshowednosepticlooseningandwerenotreplaced.Anewpolyethylenewasinsertedandthewoundwasclosed.Thedrainplacedinthekneejointwasremovedthedayaftersurgery.ThepathogenicbacteriawasE.coli,andthepatientwastreatedwithceftriaxoneintravenouslyfor6weekspostoperatively,followedbycefditorenpivoxilorallyfor6weeks.Noadditionalrevisionsurgerywasrequiredinthiscase.Theotherpatienthadcoronalplaneinstabilityduetosofttissueloosening1yearpostoperatively.Laterallooseningwassignificant,andalateralthrustwasobserved.Nolateralcollateralligamentinjurywasobservedduringsurgery,however,thesofttissuefragilitywasapparent,probablyduetoincreasedpostoperativeactivityandstress.Thepatientneededtowearahingedkneebracewhenwalking.Noneofthepatientsdevelopedpatellardislocation,periprostheticfracture,deepveinthrombosis,orpatellarcranksyndrome.?DiscussionThemostimportantfindingofthisstudyisthatTKAwasgenerallyasafetreatmentoptionforCharcotarthropathyoftheknee.Clinicaloutcomesincluding2011KSSandROMweresignificantlyimprovedatthelastfollow-up,similartopreviousreports[7,8],andthemid-tolong-termsurvivalrateforasepticrevisioninthisstudywas100%.However,severalpostoperativecomplicationswereobserved.本研究最重要的發(fā)現(xiàn)是TKA通常是膝關(guān)節(jié)Charcot關(guān)節(jié)病的安全治療選擇。最后一次隨訪時，包括2011年KSS和ROM在內(nèi)的臨床結(jié)果均有顯著改善，與既往報道相似[7,8]，本研究無菌翻修的中長期生存率為100%。然而，觀察到一些術(shù)后并發(fā)癥。SurvivalratesforasepticrevisionofTKAforCharcotarthropathyhavebeenreportedtobeexcellent,with100%atfiveyearsand88%attenyears[8],andourdatasupportthatresult.However,thepreviousreportshowedahighincidence(16%)ofperiprostheticinfections,whichoccurredatanaverageof3yearspostoperatively(range,1–6years)[8].Inourstudy,theincidenceofperiprostheticinfectionwasslightlylower,affecting1in12knees(8%).Charcotarthropathypatientsareoftenfrailduetotheirunderlyingdisease,andthefrailtyincreasestheincidenceofinfectionafterTKA[15].DM,themostcommondiseasecausativeofCharcotarthropathy,isalsorelatedtoahighincidenceofperiprostheticinfection[16].Inthisstudy,onecaseexperiencedpostoperativevarus/valgusinstability,whichwassimilarlyreportedinpreviousreportsandrequiredrevisionsurgeryinsomecases[6,9].However,thepatientdidnotneedrevisionsurgerybecauseofnosymptomsrelatedtotheinstabilitywithabrace.JointinstabilityisoneofthemostimportantcomplicationsinCharcotarthropathybecauseligamentouslaxityoftenoccursduetoadvancedjointdeformity.RemaininghyperextensionofthekneeafterTKAincreasestheriskofneurovascularinjuryandresidualkneepain.Insuchcases,itisimportanttochooseRHKtorestricttheextensormechanismandavoidrevisionsurgery[17,18],andthishingedprosthesiswasappliedfor2casesintheseriesofthestudy.據(jù)報道，無菌改良TKA治療Charcot關(guān)節(jié)病的生存率非常好，5年生存率為100%，10年生存率為88%[8]，我們的數(shù)據(jù)支持這一結(jié)果。然而，先前的報道顯示假體周圍感染的發(fā)生率很高(16%)，平均發(fā)生在術(shù)后3年(范圍1-6年)[8]。在我們的研究中，假體周圍感染的發(fā)生率略低，影響12個膝關(guān)節(jié)中的1個(8%)。Charcot關(guān)節(jié)病患者往往因其基礎(chǔ)疾病而身體虛弱，這種虛弱增加了TKA后感染的發(fā)生率[15]。DM是Charcot關(guān)節(jié)病最常見的病因，也與假體周圍感染的高發(fā)有關(guān)[16]。在本研究中，1例患者出現(xiàn)了術(shù)后內(nèi)翻/外翻不穩(wěn)，這在之前的報道中也有類似的報道，在一些病例中需要進(jìn)行翻修手術(shù)[6,9]。然而，由于沒有與支具不穩(wěn)定相關(guān)的癥狀，患者不需要翻修手術(shù)。關(guān)節(jié)不穩(wěn)定是Charcot關(guān)節(jié)病最重要的并發(fā)癥之一，因?yàn)橥砥陉P(guān)節(jié)畸形常導(dǎo)致韌帶松弛。全膝關(guān)節(jié)置換術(shù)后膝關(guān)節(jié)持續(xù)過伸會增加神經(jīng)血管損傷和膝關(guān)節(jié)疼痛的風(fēng)險。在這種情況下，選擇RHK來限制伸肌機(jī)制，避免翻修手術(shù)是很重要的[17,18]，本系列研究中有2例使用了這種鉸鏈?zhǔn)郊袤w。InTKAforCharcotarthropathy,variousprostheseshavebeenused,includingcruciate-retaining(CR),posterior-stabilized(PS),LCCK,andRHK.Thechoiceofimplantsisstillamatterofdebate[19,20].Unrestrainedcomponents(e.g.,CR,PS)areofteninappropriateforCharcotarthropathy,becausetheycanleadtopostoperativejointinstabilityduetoseveredeformityandsoft-tissueimbalance[4,19].RHKshouldbeselectedcarefully,becauseexcessiverestraintcanincreasetheriskofasepticlooseningandperiprostheticfractures[18,20].Therefore,somesurgeonsconsiderthatLCCK,whichprovidesgoodstabilitywithminimalrestriction,istheoptimalprosthesisforCharcotarthropathy[7,8].Inourstudy,LCCKwasthepreferredprothesis,withRHKusedonlyinpatientspresentingwithkneehyperextension.Moreover,whenusingconstrainedcomponents,theuseoflongstemsisimportanttodistributetheincreasedstressonthebone[21,22].Inapreviousreport,16%ofCharcotarthropathypatientstreatedwithoutstemsdevelopedasepticlooseningwithin5years[4].Conversely,anotherstudyreportednocasesofasepticlooseningafterfiveyearsandonly6%after10yearsinpatientstreatedwithstems[8].Ofthepatientsincludedinourstudy,stemswereusedin92%ofcases,withnoneofthepatientsshowingasepticlooseningduringthefollow-upperiod.在Charcot關(guān)節(jié)病的TKA中，使用了各種假體，包括交叉關(guān)節(jié)保留(CR)、后穩(wěn)定(PS)、LCCK和RHK。植入物的選擇仍然是一個有爭議的問題[19,20]。無約束假體(如CR、PS)通常不適合用于Charcot關(guān)節(jié)病，因?yàn)樗鼈兛赡軐?dǎo)致嚴(yán)重畸形和軟組織失衡導(dǎo)致術(shù)后關(guān)節(jié)不穩(wěn)定[4,19]。應(yīng)謹(jǐn)慎選擇RHK，因?yàn)檫^度約束會增加無菌性松動和假體周圍骨折的風(fēng)險[18,20]。因此，一些外科醫(yī)生認(rèn)為LCCK具有良好的穩(wěn)定性和最小的限制，是治療Charcot關(guān)節(jié)病的最佳假體[7,8]。在我們的研究中，LCCK是首選的假體，RHK僅用于出現(xiàn)膝關(guān)節(jié)過伸的患者。此外，當(dāng)使用受限組件時，使用長柄對于分配骨上增加的應(yīng)力很重要[21,22]。在先前的報道中，16%的Charcot關(guān)節(jié)病患者在5年內(nèi)發(fā)生無菌性松動[4]。相反，另一項(xiàng)研究報告5年后沒有無菌性松動病例，10年后只有6%的患者接受了莖干治療[8]。在我們的研究中，92%的患者使用了支架，在隨訪期間沒有患者出現(xiàn)無菌性松動。ManagementoflargebonedefectsinCharcotarthropathyisamajorconcern.Treatmentstrategiesforbonedefectsincludeautografts,allografts,metalaugmentation,andtantalumimplants[6,23].However,thebonestructureofCharcotarthropathyisveryweak,andevenifautologousorallogeneicboneisgraftedintothedefect,aboneunionisdifficulttoachieve[9,24].Therefore,inourcases,metalaugmentationwasusedtofillthebonedefect.Immediatelyaftersurgery,fullweightbearingwasallowed;however,nocasesresultedinlooseningorperiprostheticfractures.Charcot關(guān)節(jié)病大骨缺損的處理是一個主要問題。骨缺損的治療策略包括自體移植物、同種異體移植物、金屬隆胸和鉭植入物[6,23]。然而，Charcot關(guān)節(jié)病的骨結(jié)構(gòu)非常薄弱，即使將自體或異體骨移植到缺損處，也難以實(shí)現(xiàn)骨愈合[9,24]。因此，在我們的病例中，我們使用金屬隆胸來填充骨缺損。手術(shù)后立即允許完全負(fù)重;然而，沒有病例導(dǎo)致松動或假體周圍骨折。Thisstudyhadsomelimitations.First,itwasaretrospectivecaseserieswithalimitednumberofpatients.Thislimitedtheabilitytoperformsubgroupanalysisbasedoncausativedisease,Charcotstage,orimplanttype.Toperformsubgroupanalysis,alargernumberofpatientsisneeded.Second,alongerfollow-upperiodisdesirabletoaccuratelyevaluatetheefficacyoftheTKAprocedureinCharcotarthropathy.這項(xiàng)研究有一些局限性。首先，這是一個回顧性病例系列，患者數(shù)量有限。這限制了基于病因、Charcot分期或植入物類型進(jìn)行亞組分析的能力。為了進(jìn)行亞組分析，需要更多的患者。其次，為了準(zhǔn)確評估TKA手術(shù)治療Charcot關(guān)節(jié)病的療效，需要更長的隨訪期。Inconclusion,ourmid-tolong-termresultsofTKAforCharcotarthropathyweregenerallyfavorable.Patientsinthisstudyachieveddefiniteimprovementinkneepain,function,andmobility,andthe5-and10-yearsurvivalratesforasepticrevisionwereexcellent.Therefore,TKAmaybeaviabletreatmentoptionforCharcotarthropathywhilethecomplicationssuchasperiprostheticinfectionandinstabilityshouldbekeptinmind.總之，TKA治療Charcot關(guān)節(jié)病的中長期結(jié)果總體上是有利的。在這項(xiàng)研究中，患者在膝關(guān)節(jié)疼痛、功能和活動方面得到了明確的改善，無菌翻修術(shù)的5年和10年生存率非常好。因此，TKA可能是Charcot關(guān)節(jié)病的一種可行的治療選擇，但應(yīng)注意假體周圍感染和不穩(wěn)定等并發(fā)癥。2024年08月15日132
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曾紀(jì)洲主任醫(yī)師 北京潞河醫(yī)院 骨關(guān)節(jié)外科 生物膜相關(guān)性全膝關(guān)節(jié)置換感染:預(yù)防、診斷和治療(2024)BiofilmRelatedTotalKneeArthroplastyInfection:Prevention,DiagnosisandTreatment?Rodriguez-MerchanEC.BiofilmRelatedTotalKneeArthroplastyInfection:Prevention,DiagnosisandTreatment[J].ArchBoneJtSurg,2024,12(7):531-534.轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/39070877/轉(zhuǎn)載文章的原鏈接2：https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11283302/?AbstractBiofilmrelatedimplantinfectionisundoubtedlyarelevantchallengeinTKAwithourcomprehensionsteadilyprogressingandnovelmanagementapproachesbeingdeveloped.Theaimofthisarticlewastoreviewthemostimportantadvancesinapproachestocombatinfectionsduetobiofilm-formingbacteriainTKA.Themainconclusionswerethefollowing:1)FundamentalmanagementtechniquesforinfectedTKAincludeopenDAIR(debridement,antibiotics,andimplantretention),andoneandtwo-stagerevisionTKA;2)Continuouslocalantibioticperfusion(CLAP)appearstodiminishtheriskofPJI;3)RestraintofquorumsensingseemstoavertPJIafterTKA;4)ArecentinvitrostudyshowedpromisingresultsinthepreventionandmanagementofPJIafterTKAusingPMMA[poly(methylmethacrylate甲基丙烯酸甲酯)]loadedwithupto100mgofrifampin.生物膜相關(guān)的種植體感染無疑是TKA的一個相關(guān)挑戰(zhàn)，我們的理解正在穩(wěn)步進(jìn)步，新的管理方法正在開發(fā)中。本文的目的是回顧在TKA生物膜形成細(xì)菌感染的治療方法的最重要的進(jìn)展。主要結(jié)論如下:1)感染TKA的基本管理技術(shù)包括開放式DAIR(清創(chuàng)、抗生素和植入物保留)和一期和二期翻修TKA;2)持續(xù)局部抗生素灌注(CLAP)似乎可以降低PJI的風(fēng)險;3)群體感應(yīng)的抑制似乎可以避免TKA后的PJI;4)最近的一項(xiàng)體外研究顯示，使用PMMA[聚(甲基丙烯酸甲酯甲基丙烯酸甲酯)]加載多達(dá)100毫克的利福平，在TKA后PJI的預(yù)防和管理方面有希望的結(jié)果。?KeyWords:Biofilms,Diagnosis,Periprostheticjointinfection,Prevention,Totalkneearthroplasty,Treatment?IntroductionTKAisthetreatmentofchoiceforindividualswithsevereosteoarthritisofthekneeandintensepain.OveronemillionTKAsarecarriedouteveryyeargloballywithupto143%growthbyyear2050forecast.1ArecentclinicalstudyshowedthatkneePJIswereprincipallyattributedtoinfectionwithST59methicillin-resistantStaphylococcusaureus(MRSA)andrisingtrendsforinfectionwithST8andotherSTtypesofMRSAsinPJIindividualswerefoundfrom2016to2019.TheidentificationofMRSAgenotypesinPJIsmightbeusefulforthetreatmentofPJIs.2Forthepurposesofthisreview,on1January2024abibliographicsearchwasperformedonPubMedutilizingthesearchstring:[biofilmtotalkneearthroplasty],resultingin123articles,ofwhich20paperswerefinallyanalyzedbecausetheyweredirectlyrelatedtonovelstrategiestopreventandtreatbiofilm-formingbacteriaonTKAandwerepublishedin2022,2023and2024.?MainbodyCurrentDiagnosticandTreatmentMethodsRecentpublicationsonthediagnosisofPJIinTKAareshownin[Table1].3-11inacomputertomography(CT)-basedcadaverstudyitwasshownthatcementremovalofpolymethylmethacrylate(PMMA)usingultrasoundswasnearlyfull.12??Table1RecentpublicationsonthediagnosisofPJIinTKAAUTHORS[REFERENCE]?YEAR?????FINDINGSTsikopoulosetal32022??????Inthismeta-analysisnodifferencewasfoundbetweenthesonicationandchemical-basedbiofilmdislodgmentmethods.Rodriguez-Merchan42022?Thesonicationtechniqueprovedtobereliable.Itssensitivityandspecificityweregreaterthanconventionalculturesoftheperiprosthetictissue.PolyethylenelinerssonicationhasbeenpublishedtobeenoughfordiagnosisofPJIFisheretal52022?????ProteomicprofilingutilizingasmallproteinpanelwasabletomakeadistinctionbetweenPJIandnon-infectiousarthroplastyfailuresonicatesamplesandrenderedabettercomprehensionoftheimmuneresponseduringTKAfailure.Azadetal62022???????ThisstudyshowedthattheclinicalsensitivityoftheInvestigationalUseOnly(IUO)BioFireJointInfection(JI)Panelwasexcellentforon-panelbacteria.However,overallsensitivityforPJIdiagnosiswaslowduetotheabsenceofStaphylococcusepidermidis.Flurinetal72022Thisstudyanalyzedtheaccuracyofa16SrRNA(rRNA)gene-basedPCRfollowedbySangersequencingand/ortargetedmetagenomicsequencingapproach(tMGS)carriedoutonsynovialfluidforPJIdiagnosis.Itwasfoundthatthesequencing-basedmethodwasnotbetterthatculturefordiagnosisofPJI,butproducedpositiveresultsinsomeculture-negativesamples.Hongetal82023??????The16SribosomalRNA(rRNA)gene-basedtargetedmetagenomicsequencing(tNGS)methodhasshownsimilarperformancecharacteristicsthanshotgunmetagenomicsequencing(sNGS)forPJIbacteriarecognitioninsonicatefluidfromfailedTKAsinculture-negativecases.Brooksetal92023????Implantsurfaceculture(ISC)successfullyrecognizedbacterialgrowthwithhighsensitivitywhilealsodisclosingthatbiofilmgrowthwasusuallylocalizedtoparticularlocations.Dragoetal102023???Theantibiofilmpre-treatmentofsynovialfluidswithdithiotreitol(DTT)demonstratedthecapacitytoraisethesensitivityofmicrobiologicalexaminationinthesynovialfluidofindividualswithPJI.Fisheretal112023???Inapilotstudyproteomicprofilingofsonicatefluidutilizingliquidchromatography-tandemmassspectrometry(LC-MS/MS)wasabletodistinguishbetweenS.aureusPJIandnon-infectedarthroplastyfailure.?OpenDAIR(debridementantibioticimplantretention)Arecentstudyhassuggestedthatdebridementantibioticpearlsandretentionoftheimplant(DAPRI)couldbeagoodalternativetotheDAIRtechnique.13?One-stagerevisionTKA(rTKA)AccordingtoJietal(2022)one-stagerTKAusingintraarticularinfusionofantibioticscandiminishbiofilmformation.14?Two-stagerTKAIn2023Shichmanetalanalyzedthecharacteristicsof90individualswhohavehadrecurrentinfectionaftertwo-stagerTKAforPJI.Themostfrequentpathogendetectedwascoagulase-negativeStaphylococci.Persistenceofbacteriawasseenin14(22.2%)ofrecurrentPJIs.Almostonethirdoftheindividualsattainedinfectioncontrolaftertreatmentofafailedtwo-stagerTKAduetoPJI.15?StrategiestoReduceRiskofInfectionHowtodecreasetheriskofPJIbefore,duringandaftersurgeryisshownin[Table2].Inastudy,eightindividualsaccomplishedresolutionoftheinfectionusingcontinuouslocalantibioticperfusion(CLAP)andintravenousantibiotics.ThestudysuggestedthatCLAPcanbeausefulmanagementalternativeforPJIafterTKA.16??Table2FactstokeepinmindtoreducetheriskofPJIbefore,duringandafterTKA?Table2.Continued?PREOPERATIVEPHASEBodymassindex(BMI)oflessthan35OptimizationofdietGoodlevelsofhemoglobinandfructosamineStopsmokingMRSA(methicillin-resistantStaphylococcusaureus)nasalscreening?INTRAOPERATIVEPHASEAppropriateantibioticprophylaxisAdequatefluidresuscitationSkinpreparationwithbetadineandchlorhexidineIrrigationwithdilutedpovidoneiodinesolutionAdministrationoftranexamicacidUtilizationofmonofilamentbarbedtriclosan-coatedsuturesfortheclosureofsofttissues?POSTOPERATIVEPHASEEarlyPJIinfectionmustbesuspectedwhenerythrocytesedimentationrate(ESR),C-reactiveprotein(CRP),D-dimer,andinterleukin(IL)-6arenotnormal6weeksaftertheprocedure?NovelTechniquestoPreventandTreatPJIQuorumsensing(QS)canreducebacterialvirulence.Infact,inhibitionofbacterialcommunicationwithsodiumsalicylate(NaSa)水楊酸鈉hasshowntobeeffective.17Asystematicreviewandmeta-analysisstatedthatrifampin利福平seemedtoconferaprotectiveeffect.ThismanagementeffectwasparticularlypronouncedinthecontextofrTKA.18ArecentinvitrostudyshowedpromisingresultsinthepreventionandmanagementofPJIafterTKAusingPMMAloadedwithupto100mgofrifampin.19InaclinicalstudyonPJIwithcoagulase-negativeStaphylococcusaureus凝固酶陰性的金黃色葡萄球菌itwasfoundthatthesuccessratewas47%at1-yearfollow-up.OpenDAIRhadthehigherfailurerate(60%).Two-stagerTKAhada46.7%failurerate.20?ConclusionEssentialtreatmentapproachesforinfectedTKAincludeOpenDAIRandoneandtwo-stagerTKA;continuouslocalantibioticperfusion(CLAP)seemstoreducetheriskofPJI;restraintofQS(imsteadofquorumsensing)appearstoavertPJIafterTKA;arecentinvitrostudyhasshownpromisingresultsinthepreventionandtreatmentofPJIafterTKAusingPMMAloadedwithupto100mgofrifampin.感染TKA的基本治療方法包括開放式DAIR和一期和二期rTKA;持續(xù)局部抗生素灌注(CLAP)似乎可以降低PJI的風(fēng)險;抑制QS(而不是群體感應(yīng))似乎可以避免TKA后的PJI;最近的一項(xiàng)體外研究顯示，使用含有高達(dá)100毫克利福平的PMMA在TKA后預(yù)防和治療PJI方面有希望的結(jié)果。2024年08月13日46
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