本科教学关节感染

关节感染诊断与治疗,杨春喜同济大学附属第十人民医院上海市第十人民医院 骨科,关节感染的定义,细菌 经血循环或直接经皮肤等途径进入关节腔， 引起关节腔内的感染,关节感染为何被如此重视？,Infectious arthritis remains a major challenge to physiciansthe enormous potential of certain microorganisms to modulate their genotype and thereby become antibiotic-resistantthe increasing use of immunomodulating treatment that affects the immune responsiveness of the host and thereby undermines microbial clearancethe increasing frequency of prosthetic joint surgery operations difficulties regarding both early diagnostics and proper treatment,病原学,The overall surgical site infection rate has been estimated by the U.S. Centers for Disease Control and Prevention (CDC) to be 2.8% in the United States. Although bacteremia is commonestimated to occur 25% of the time after simple tooth brushingsother etiological factors must be present for an infection to occur,Ross JJ, Saltzman CL, Carling P et al. (2003). Pneumococcal septic arthritis: Review of 190 cases. Clin Infect Dis 36(3):319327,主要病原体,引起关节感染的相关因素- 患者因素,营养状态人体测量 (height, weight, triceps skin fold thickness, and arm muscle circumference)血清蛋白和细胞(lymphocytes)皮肤抗体反应 42% 的骨科手术病人可能存在临床或亚临床营养紊乱 albumin 34 g/L total lymphocyte 1500 cells/mm3 营养状况判定 : (1.2 serum albumin) + (0.013 serum transferrin) 6.43,免疫状态中性粒细胞反应体液免疫细胞免疫网状内皮细胞系统,引起关节感染的相关因素- 患者因素,与骨科感染相关状态,先天性 慢性肉芽肿病 血友病 低丙球蛋白血症 镰状细胞性血红蛋白病 补体缺乏症 淋巴细胞黏附缺陷,获得性 糖尿病 肝脏疾病 艾滋病 免疫抑制剂应用 器官移植 血管胶原蛋白病 尿毒症 营养不良 放射治疗,Brennan PJ. Musculoskeletal infections in immunocompromised hosts. Orthop Clin North Am 22:389, 1991.,引起关节感染的相关因素- 患者因素,Skin PreparationOperating Room EnvironmentProphylactic Antibiotic Therapy golden period,0 hour 2 hours 6 hours,引起关节感染的相关因素- 医方因素,关节感染的诊断,关节感染诊断路线图,Sambrook P et al (eds). The Musculoskeletal System(Edinburgh: Chruchill Livingstone, 2001),实验室检查,A complete blood countESRC-reactive protein increases within 6 hours of infection reaches a peak elevation 2 days returns to normal within 1 week after adequate treatment has begun,关节滑液化验,Morrissy RT: Septic arthritis. In Gustilo RB, Genninger RP, Tsukayama DT, eds: Orthopaedic infection: diagnosis and treatment, Philadelphia, 1989, Saunders.,Chronic TKA infectionwith loose tibial component,影像学检查,骨扫描（ECT）,Three-phase bone scan of osteomyelitis shows increased radiotracer uptake in the proximal tibia on the flow phase (a), blood-poolphase (b), and bone phase (c). (Courtesy of C. Palestro),关节感染的治疗,有效抗菌素的合理应用,髋Lateral Aspiration45-degree angle with the surface inferior and anterior to the greater trochanter Advance the needle medially and close to the bone for 5 to 10 cm,Anterior AspirationPalmpate the femoral artery in line with the inguinal ligamentInsert the needle 2.5 cm lateral and 2.5 cm distal, a 45-degree angle to the skin surfaceAdvance the needle 5 to 7.5 cm medially,膝Aspiration,Arthroscopic drainage,Redrawn from Skyhar MJ, Mubarak SJ: Arthroscopic treatment of septic knees in children, J Pediatr Orthop 7:647, 1987,常见关节感染治疗,踝Aspiration,膝关节冲洗后治疗,立即开始关节功能康复锻炼 股四头肌肌力练习 直腿抬高24-48小时移除引流管 夹板保护（关节锻炼时间除外）,化脓性关节炎治疗的热点问题,Choice and duration of antimicrobial therapy？ 静脉1W+口服 4-6WAnti-inflammatory and anti-bone-resorptive treatment during the course of septic arthritis? Role of local conservative and surgical therapies in the management of septic arthritis ?Mobilization therapy in septic arthritis?Long-term consequences following septic arthritis ?,膝关节感染Spacer治疗案例,Radiographs (a.p., lateral) , c,d Radiographs (a.p., lateral) of a temporary replacement with a static spacer. e,f Radiographs (a.p., lateral) after second stage re-implantation with constraint condylar replac