本科教學(xué)關(guān)節(jié)感染

1、關(guān)節(jié)感染診斷與治療,楊春喜同濟(jì)大學(xué)附屬第十人民醫(yī)院上海市第十人民醫(yī)院 骨科,關(guān)節(jié)感染的定義,細(xì)菌 經(jīng)血循環(huán)或直接經(jīng)皮膚等途徑進(jìn)入關(guān)節(jié)腔， 引起關(guān)節(jié)腔內(nèi)的感染,關(guān)節(jié)感染為何被如此重視？,Infectious arthritis remains a major challenge to physiciansthe enormous potential of certain microorganisms to m

2、odulate 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

3、 frequency of prosthetic joint surgery operations difficulties regarding both early diagnostics and proper treatment,病原學(xué),The overall surgical site infection rate has been estimated by the U.S. Centers for Disease Contro

4、l and Prevention (CDC) to be 2.8% in the United States. Although bacteremia is common—estimated to occur 25% of the time after simple tooth brushings—other etiological factors must be present for an infection to occ

5、ur,,Ross JJ, Saltzman CL, Carling P et al. (2003). Pneumococcal septic arthritis: Review of 190 cases. Clin Infect Dis 36(3):319–327,主要病原體,引起關(guān)節(jié)感染的相關(guān)因素- 患者因素,營(yíng)養(yǎng)狀態(tài)人體測(cè)量 (height, weight, triceps skin fold thickness, and ar

6、m muscle circumference)血清蛋白和細(xì)胞(lymphocytes)皮膚抗體反應(yīng) 42% 的骨科手術(shù)病人可能存在臨床或亞臨床營(yíng)養(yǎng)紊亂 albumin <34 g/L total lymphocyte <1500 cells/mm3 營(yíng)養(yǎng)狀況判定 : [(1.2 ×

7、; serum albumin) + (0.013 × serum transferrin)] ?6.43,免疫狀態(tài)中性粒細(xì)胞反應(yīng)體液免疫細(xì)胞免疫網(wǎng)狀內(nèi)皮細(xì)胞系統(tǒng),引起關(guān)節(jié)感染的相關(guān)因素- 患者因素,與骨科感染相關(guān)狀態(tài),先天性 慢性肉芽腫病   血友病   低丙球蛋白血癥   鐮狀細(xì)胞性血紅蛋白病   補(bǔ)體缺乏癥

8、   淋巴細(xì)胞黏附缺陷,獲得性   糖尿病   肝臟疾病   艾滋病   免疫抑制劑應(yīng)用   器官移植   血管膠原蛋白病   尿毒癥   營(yíng)養(yǎng)不良 

9、;  放射治療,Brennan PJ. Musculoskeletal infections in immunocompromised hosts. Orthop Clin North Am 22:389, 1991.,引起關(guān)節(jié)感染的相關(guān)因素- 患者因素,Skin PreparationOperating Room EnvironmentProphylactic Antibiotic Therapy

10、 golden period,0 hour 2 hours 6 hours,引起關(guān)節(jié)感染的相關(guān)因素- 醫(yī)方因素,關(guān)節(jié)感染的診斷,關(guān)節(jié)感染診斷路線圖,Sambrook P et al (eds). The Musculoskeletal System(Edinburgh: Chruchill Livingstone, 2001),實(shí)驗(yàn)室

11、檢查,A complete blood countESRC-reactive protein increases within 6 hours of infection reaches a peak elevation 2 days returns to normal within 1 week

12、 after adequate treatment has begun,關(guān)節(jié)滑液化驗(yàn),Morrissy RT: Septic arthritis. In Gustilo RB, Genninger RP, Tsukayama DT, eds: Orthopaedic infection: diagnosis and treatme

13、nt, Philadelphia, 1989, Saunders.,Chronic TKA infectionwith loose tibial component,影像學(xué)檢查,骨掃描（ECT）,Three-phase bone scan of osteomyelitis shows increased radiotracer uptake in the proximal tibia on the flow phase (a), bl

14、ood-poolphase (b), and bone phase (c). (Courtesy of C. Palestro),,關(guān)節(jié)感染的治療,,,有效抗菌素的合理應(yīng)用,,髖Lateral Aspiration45-degree angle with the surface inferior and anterior to the greater trochanter Advance the needle med

15、ially 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 surface

16、Advance 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,常見(jiàn)關(guān)節(jié)感染治療,踝Aspir

17、ation,膝關(guān)節(jié)沖洗后治療,立即開(kāi)始關(guān)節(jié)功能康復(fù)鍛煉 股四頭肌肌力練習(xí) 直腿抬高24-48小時(shí)移除引流管 夾板保護(hù)（關(guān)節(jié)鍛煉時(shí)間除外）,化膿性關(guān)節(jié)炎治療的熱點(diǎn)問(wèn)題,Choice and duration of antimicrobial therapy？ 靜脈1W+口服 4-6W

18、Anti-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 arthr

19、itis?Long-term consequences following septic arthritis ?,,,,,膝關(guān)節(jié)感染Spacer治療案例,Radiographs (a.p., lateral) , c,d Radiographs (a.p., lateral) of a temporary replacement with a static spacer. e,f Radiographs (a.p., lateral)

20、 after second stage re-implantation with constraint condylar replacement,,膝關(guān)節(jié)Spacer,Device dimensions and intraoperative photograph obtained after the application of theSpacer-K,感染關(guān)節(jié)一期關(guān)節(jié)置換,病例分析2,患者男性，42歲，左髕骨開(kāi)放性骨折術(shù)后傷口不愈合