Infection after anterior cruciate ligament reconstruction

doi:10.3969/j.issn.2095-4344.2013.05.026

Abstract

Abstract:

BACKGROUND: The incidence of infection after anterior cruciate ligament reconstruction is relatively low. However, this infection can lead to disastrous results, and the diagnosis and treatment of this infection have not yet achieved a consensus.
OBJECTIVE: To explore the causes of infection after anterior cruciate ligament reconstruction and how to diagnosis and cure the infection, and to investigate the appropriate treatment program, in order to protect the knee functions.
METHODS: The PubMed database and Wanfang database were searched for articles published between 2007 and 2012 with the key words of “anterior cruciate ligament, reconstruction, infection” in English and Chinese. Infection after anterior cruciate ligament reconstruction was used as the evaluation index. Articles related to infection after anterior cruciate ligament reconstruction were included, and repeated studies were excluded.
RESULTS AND CONCLUSION: Bacterial contaminations of surgical devices or ligament grafts were the most likely causes of infection after anterior cruciate ligament reconstruction, and the fixation method of graft may be related with the infection after reconstruction. The classic clinical symptoms and signs of infection after anterior cruciate ligament reconstruction were similar to general septic arthritis. But classic symptoms of infection were frequently missing. The diagnosis of infection after anterior cruciate ligament reconstruction depended on clinical symptoms and signs, laboratory test such as erythrocyte sedimentation rate and C-reactive protein, and knee aspiration. For the treatment of the infected knee after anterior cruciate ligament reconstruction, culture-specific intravenous antibiotics and surgical joint irrigation with graft retention were considered the overwhelming treatment of choice. Graft removal was recommended if it appeared infected or if there was any difficulty controlling the infection.

Key words: organ transplantation, organ transplantation review, anterior cruciate ligament, reconstruction, infection, graft, diagnosis, treatment, antibiotics, knee joint lavage, knee joint puncture, septic arthritis, internal fixation, laboratory tests

CLC Number:

R318

Xu Chang-ming, Yang Le, Hu Chuan-liang, Hu Yu-hua. Infection after anterior cruciate ligament reconstruction[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(5): 938-944.

Figures/Tables 2

2.1 纳入文献基本情况中文文献中仅有1篇文章对前交叉韧带重建术后感染进行了详细的探讨[6]。英文文献对这一问题报道较多，主要探讨了前交叉韧带重建术后感染的原因[8,9]、临床表现[10, 20]、诊断[11,17,21-32]、治疗方法[17,18,33-41]以及预后[11]。 2.2 结果描述 2.2.1 前交叉韧带重建后感染的原因细菌污染手术工具或者韧带移植物是导致前交叉韧带重建术后感染的最常见原因[8-10]。Maria等[11]发现他们的患者前交叉韧带重建术感染率比较高的原因是由于移植物板上的凝固酶隐性葡萄球菌导致的。他们发现尽管消毒是用合格的高压锅进行的，但是移植物板缝合夹的金属部分和橡胶板之间的缝隙并没有得到满意的消毒。异体移植物的应用可能和前交叉韧带重建后感染有关[12]，因为异体移植物在植入关节内之前有一定的污染率，但也有的作者认为这种污染并不一定导致前交叉韧带重建后感染[13]，因而无需特殊处理[14]。也有的作者认为异体移植物的应用并不增加前交叉韧带重建后的感染率[15]。移植物固定的方式和重建后感染之间可能有一定的关系。Fong等[16]发现他们所有患者的膝关节术后感染可能都是由胫骨隧道侧导致的，也就是由关节外到关节内的感染，这是因为不管采用什么方法固定胫骨侧，所有的胫骨隧道都受到了感染。Daniel等[17]发现采用腘绳肌腱重建前交叉韧带的术后感染率较高。他们认为这可能是和移植物的固定方法或者额外的软组织剥离有关，不一定和使用某种移植物之间具有相关性。Barker等[18]则认为采用自体腘绳肌腱重建前交叉韧带的术后感染率要比采用自体或者异体骨-髌腱-骨重建前交叉韧带的术后感染率要高。在采用腘绳肌腱重建的手术中，移植物的长度比较短，这就使得有一部分缝线被留在关节腔内。他们认为较短的移植物和关节内的缝合材料都有可能导致炎性反应。还有的医生对前交叉韧带重建后常规使用引流管和术后感染的相关性进行了研究。Matava等[19]发现那些常规使用引流管的医生的感染率(0.27%)是那些不使用引流的医生的两倍多(0.10%)。考虑到前交叉韧带重建手术后的感染率本来就比较低，所以这个数据不但有很高的临床价值，而且更有统计学意义。 2.2.2 前交叉韧带重建后感染的临床表现典型的前交叉韧带重建术后感染的症状和普通的化脓性关节炎的症状类似。大多数患者会出现化脓性关节炎的典型症状，具体包括：发热，膝关节肿胀、疼痛、局部红肿，切口处有液体渗出，局部皮温增高，有的人还感到全身不适。但是，Maria等[11]发现有的前交叉韧带重建术后感染的病例并没有感染的典型表现，有的患者的情况很容易和普通的重建后改变相混淆。但是，应该注意的是一般的术后疼痛持续几天就会缓解，如果重建后患者疼痛持续时间过长或者术后疼痛并不随时间的推移而逐步改善，这时要考虑化脓性关节炎的可能性[20]。所以Maria等[11]建议：对于那些术后膝关节功能逐步恢复的患者，如果之后又出现了发热、局部疼痛、肿胀、膝关节僵硬、身体不适等情况，应该及时到医院就诊，以明确是否出现了前交叉韧带重建重建后感染。重建移植物引起感染的不良反应："

2.2.3 前交叉韧带重建后感染的诊断和鉴别诊断如果前交叉韧带重建后出现关节感染的典型临床症状，那么诊断前交叉韧带重建术后感染并不困难。但是很多作者注意到，前交叉韧带术后感染的诊断并不一定很容易，典型的膝关节感染的症状常常会被一些术后反应所掩盖。为了排除化脓性关节炎，Maria等[11]推荐患者作实验室检查(比如C-反应蛋白和血沉)。在那些膝关节或者髋关节感染的患者中，这两个实验室指标都被发现明显增高。由于手术创伤，那些没有并发术后感染的前交叉韧带重建患者在术后短期血沉和C-反应蛋白也会出现增高[17]，重建后2周时C-反应蛋白恢复至正常水平，而血沉在重建后4周内一直保持轻度增高的状态。这种情况可能会干扰感染的早期诊断。膝关节穿刺是诊断术后感染的最好方法[21]。关节液外观、白细胞计数和革兰氏染色是早期正确诊断感染的可靠手段[22]。发生前交叉韧带重建后感染时，关节液外观一般为混浊脓性、稠厚，有时呈黄色，关节液中往往有多形核白细胞浓聚，这些结果强烈提示化脓性感染。如果关节液中能培养出致病菌，那么可以确定患者为前交叉韧带重建术后化脓性感染。导致前交叉韧带重建术后化脓性感染的常见病菌有：金黄色葡萄球菌(Staphylococcus aureus) [18, 23, 24]。表皮葡萄球菌(Staphylococcus epidermidis)。胨链球菌(Peptostreptococcus)。肠杆菌属(Enterobacter)[17,25]。其他致病菌还有：耐甲氧西林的金黄色葡萄球菌(methicillinresistant Staphylococcus aureus)。丹毒丝菌(Erysipelothrix rhusiopathiae)[26]。丙酸杆菌(Propionibacteriaceae)。小韦荣菌(Veillonella parvula)。产气荚膜梭菌(Clostridium perfringens)[8,27]。结核菌（Mycobacterium tuberculosis）[28]。真菌（Fungi）[29,30]。分枝杆菌(Mycobacterium fortuitum)[31]。里昂葡萄球菌(Staphylococcus lugdunensis)[32]。但是由于抗生素的使用、培养条件的限制以及致病菌的活性等原因，关节液的培养不一定会有阳性结果。如果关节液培养阴性，那么可以根据粒细胞计数增高、血沉、 C-反应蛋白水平以及感染的临床表现来诊断感染[22]。 2.2.4 前交叉韧带重建后感染的治疗前交叉韧带重建术后化脓性关节炎的治疗目标是：第一，保护关节软骨。第二，保护移植物[33]。目前，85%的外科医师选择静脉使用敏感的抗生素、膝关节灌洗并保留移植物作为自体移植物重建前交叉韧带术后感染的首选治疗方法[34]，对于异体移植物，有64%的医生采用同样的处理方法[18]。如果初次治疗后效果不明显，仍然有39%的医生继续静脉使用敏感抗生素结合关节灌洗、保留移植物作为最常用的治疗方法。合适的抗生素治疗是非常重要的治疗措施。一个动物试验的结果显示：金黄色葡萄球菌导致的膝关节化脓性关节炎，如果在感染症状出现后7 d内仍然没有进行合理的治疗，那么关节软骨将会丢失一半以上的黏多糖和胶原蛋白[35-37]。Daniel等[17]则报道：实验室检查完善后，按照感染科医生的会诊意见，所有患者都根据经验给予静脉抗生素治疗，选择头孢唑啉或万古霉素。在他们的11例患者中有6例患者初期使用的抗生素是细菌耐药的。11例患者中，仅1例患者的细菌对头孢唑啉敏感，其余10例患者的细菌对万古霉素敏感。抗生素使用的疗程因患者的实验室结果而不尽相同。Viola等[38]报道，抗生素治疗后一般5-30 d(平均14.4 d)时临床体征首先缓解，而实验室结果稍晚些时候才变得正常。实验室检查结果正常后两三天，停用抗生素。除了抗生素治疗之外，为了减少严重并发症的发生(比如退变性关节炎、骨髓炎)，还需要对感染的膝关节作适当的减压治疗[39-41]。对于化脓性关节炎，Daniel等[17]建议采用关节镜灌洗和关节镜下清创术。关节镜可以很容易地达到膝关节的所有部位，同时可以使膝关节减压，充分清创，对移植物的完整性以及有无感染迹象作评估，破坏膝关节内的纤维粘连，从而减少术后出现膝关节强直的可能。关节镜术中往往可以看到移植物的表面一般都有一薄层的纤维覆盖，其他并没有什么明显的异常，移植物的张力一般比较好[42-43]。以往有的医生认为前交叉韧带移植物可能是感染的发源地[44]，所以他们认为如果经治疗后感染的症状和体征一直存在，那么在第二次手术时应该将移植物取出。2011年Demira?等[45]报道他们采用长期抗生素(6周)、关节镜下清创、保留移植物和内固定物以及适当康复治疗处理前交叉韧带重建后发生感染的7例患者，获得了满意的疗效。感染控制后所有膝关节的Lachman试验均为阴性，轴移试验：3例为阳性，4例为阴性。和健腿相比，单腿纵向跳跃距离是对侧的78%(63%-100%)，单腿水平跳跃距离是对侧的72%(88%-93%)。Monaco等[46-47]采用类似的方法也取得了良好的临床效果，而且他们的所有患者都恢复到术前和感染前的运动水平。 2.2.5 预后 Maria等[11]对他们的两组患者进行对比发现，每个感染的膝关节的评分等于或者小于对照组的没有感染的膝关节的评分。感染的患者有更多的主观症状，具体包括[48-50]：活动受限，膝关节屈曲受限。他们还发现感染患者的膝关节功能差的不是由移植物失败导致的，而是由于感染导致关节软骨破坏引起的。"

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