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北京大学学报（医学版） ›› 2021, Vol. 53 ›› Issue (5): 850-856. doi: 10.19723/j.issn.1671-167X.2021.05.007

• 论著 • 上一篇    下一篇

前交叉韧带重建术后膝关节感染的诊断和治疗策略

王成1,孟令宇2,陈拿云1,李玳1,王健全1,敖英芳1,△()   

  1. 1.北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191
    2.北京大学基础医学院,北京 100191
  • 收稿日期:2021-06-02 出版日期:2021-10-18 发布日期:2021-10-11
  • 通讯作者: 敖英芳 E-mail:aoyingfang@163.com

Management algorithm for septic arthritis after anterior cruciate ligament reconstruction

WANG Cheng1,MENG Ling-yu2,CHEN Na-yun1,LI Dai1,WANG Jian-quan1,AO Ying-fang1,△()   

  1. 1. Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
    2. Peking University School of Basic Medical Sciences, Beijing 100191, China
  • Received:2021-06-02 Online:2021-10-18 Published:2021-10-11
  • Contact: Ying-fang AO E-mail:aoyingfang@163.com

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摘要：

目的: 探讨关节镜下前交叉韧带重建术后膝关节感染的临床诊断和治疗策略。方法: 选择2001年1月至2020年12月在北京大学第三医院运动医学科行关节镜下前交叉韧带重建手术且术后发生膝关节感染的病例进行回顾性分析。通过对患者术后关节感染的发病过程、临床特征、试验室检查、治疗方法及随访结果进行分析,探讨最佳的临床诊断和治疗策略。结果: 20年间关节镜下前交叉韧带重建手术共27 867例,术后膝关节感染65例,感染率0.23%。临床表现有体温增高[(38.7±0.5) ℃]、膝关节肿痛、关节活动度受限。细菌培养阳性率 69.2%,其中凝固酶阴性葡萄球菌(占75.6%)、金黄色葡萄球菌(占15.6%)最常见。保守治疗组(16例)和手术治疗组(49例)均能有效控制感染,但保守治疗组体温恢复较慢(保守治疗组5.6 d,手术治疗组1.6 d,P=0.042)。结论: 前交叉韧带重建术后膝关节感染是一种发生率低,但后果严重的并发症,临床诊断建议及早进行关节腔穿刺和病原学检查,一旦确诊,建议尽早进行关节镜清理手术,并给予有效抗生素治疗。

关键词: 前交叉韧带, 重建, 并发症, 关节感染, 诊治策略

Abstract:

Objective: To summarize the experience in the diagnosis and management of septic arthritis after anterior cruciate ligament reconstruction. Methods: A retrospective review was conducted of all the arthroscopic anterior cruciate ligament reconstructions performed at Department of Sports Medicine, Peking University Third Hospital between January 2001 and December 2020. In the study, 65 of 27 867 patients experienced postoperative septic arthritis. The incidence, presentation, laboratory results, treatment, and outcome of all the infected patients were analyzed. The experiences of diagnosis and management of septic arthritis after anterior cruciate ligament reconstruction were summarized. Results: A total of 27 867 anterior cruciate ligament reconstructions were performed at our department between January 2001 and December 2020. In the study, 65 (0.23%) patients were identified with postoperative septic arthritis. The most common symptoms of the infected patients were fever (38.7±0.5) ℃, knee swelling, pain, and restricted motion. The mean peripheral white blood cell count (WBC) was (9.2±2.6)×109/L (range 4.2×109/L-19.4×109/L), with (72.5±6.3) % (range 54.9%-85.1%) polymorphonuclear neutrophils (N). The mean erythrocyte sedimentation rate (ESR) was (59.9±24.1) mm/h (range 9-108 mm/h), C-reactive protein (CRP) was (10.9±5.7) mg/dL (range 1.2-30.8 mg/dL), and fibrinogen (FIB) level was (7.0±1.6) g/L (range 3.7-10.8 g/L). All of the laboratory results were statistically higher in the infection group compared with the normal postoperative group (P<0.001). The synovial white blood cell count (SWBC) of aspirated knee joint fluid was (45.0±29.8)×109/L (range 7.1×109-76.5×109/L). Polymorphonuclear cell percentage (PMNC) was (90.27±7.86) % (range 60%-97%). In the study, 45 patients (69.2%) had positive aspirate cultures. Microbiology showed coagulase-negative Staphylococcus (CNS) and Staphylococcus aureus (SA) were the most common bacterium (34 cases and 7 cases, individually). There were 26 methicillin-resistant Staphylococcus. Both conservative (16 patients) and operative (49 patients) treatments were effective, but conservative group had a longer recovery time (5.6 d vs. 1.6 d, P=0.042). Conclusion: Septic arthritis after arthroscopic anterior cruciate ligament reconstruction is a rare but potentially devastating complication. The correct diagnosis relies on synovial fluid analysis and bacterial culture. Our proposed treatment protocol is arthroscopic debridement and antibiotic therapy as quickly as possible.

Key words: Anterior cruciate ligament, Reconstruction, Complication, Septic arthritis, Management algorithm

中图分类号: 

  • R687

表1

24例ACLR正常术后患者和65例术后关节感染患者血液检查结果"

Items Normal Normal postoperative patients Infectious patients P
WBC/(×109/L) 4-10 6.9±1.8
(4.5-10.5) 9.2±2.6
(4.2-19.4) <0.001
N/% 50-70 60.9±5.1
(53.2-69.2) 72.5±6.3
(54.9-85.1) <0.001
ESR/(mm/h) 0-15 27.5±12.8
(7-44) 59.9±24.1
(9-108) <0.001
CRP/(mg/dL) 0-0.8 2.2±1.8
(0.3-5.6) 10.9±5.7
(1.2-30.8) <0.001
FIB/(g/L) 2-4 5.8±1.1
(4.3-8.0) 7.0±1.6
(3.7-10.8) <0.001

图1

感染治疗后各项感染指标变化趋势"

表2

前交叉韧带重建术后膝关节感染的发生率"

Literature Publication year Period /years Total number of ACLR patients Total number of infected cases Infected rate/%
Williams, et al[2] 1997 5 2 500 7 0.28
McAllister, et al[3] 1999 11 831 4 0.48
Viola, et al[4] 2000 6 1 794 14 0.78
Indelli, et al[5] 2002 6 3 500 5 0.14
Schollin-Borg, et al[6] 2003 3 575 10 1.74
Burks, et al[7] 2003 11 1 918 8 0.42
Fong, et al[8] 2004 3 472 7 1.48
Musso, et al[9] 2005 5 1 094 11 1.01
Judd, et al[11] 2006 8 1 615 11 0.68
Van Tongel, et al[13] 2007 9 1 736 15 0.86
Schulz, et al[14] 2007 10 513 4 0.78
Binnet, et al[12] 2007 18 1 231 6 0.49
Katz, et al[15] 2008 5 801 6 0.75
Iorio, et al[16] 2008 6 1 052 8 0.76
Wang, et al[17] 2009 11 4 068 21 0.52
Sajovic, et al[18] 2009 11 1 283 3 0.23
Nag, et al[19] 2009 9 1 152 26 2.26
Barker, et al[21] 2010 5 3 126 18 0.58
Monaco, et al[20] 2010 8 1 232 12 0.97
Benner, et al[22] 2011 27 5 364 13 0.24
Sonnery-Cottet, et al[23] 2011 5 1 957 12 0.61
Vertullo, et al[24] 2012 7 1 135 4 0.35
Schub, et al[25] 2012 11 831 4 0.48
Torres-Claramunt, et al[26] 2013 3 810 15 1.85
Risti c ', et al[27] 2014 1 425 17 1.19
Abdel-Aziz, et al[28] 2014 7 2 560 24 0.94
Boström, et al[29] 2014 8 4 384 43 0.98
Calvo, et al[30] 2014 11 1 564 7 0.45
Schuster, et al[31] 2015 10 7 096 36 0.51
Hantes, et al[33] 2017 12 1 242 7 0.56
Pérez-Prieto, et al[32] 2017 4 810 15 1.85
Our study 2021 20 27 867 65 0.23
Total - - 87 538 458 0.52

图2

ACLR术后膝关节感染诊断和治疗策略"

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