臧澤林，李鵬飛，曹海泉

(南充市中心醫(yī)院重癥醫(yī)學(xué)科，四川 南充637000)

高齡髖膝關(guān)節(jié)置換術(shù)后致假體周圍感染的相關(guān)因素分析

臧澤林，李鵬飛，曹海泉

(南充市中心醫(yī)院重癥醫(yī)學(xué)科，四川 南充637000)

目的 分析高齡髖膝關(guān)節(jié)置換術(shù)后致假體周圍感染發(fā)生的相關(guān)因素，以期為高齡患者術(shù)后感染的控制提供依據(jù)。方法 選取2013年1月至2015年10月我院重癥醫(yī)學(xué)科收治的31例高齡髖膝關(guān)節(jié)置換術(shù)后假體周圍感染患者為觀察組，同期的31例未發(fā)生感染患者為對照組，比較兩組患者的年齡、BMI值、手術(shù)時(shí)間、血清白蛋白水平、基礎(chǔ)疾病并發(fā)率、其他感染病灶存在率、引流管留置時(shí)間及髖膝部位創(chuàng)傷史率，同時(shí)以Logistic回歸分析上述指標(biāo)與感染的關(guān)系。結(jié)果 觀察組患者的年齡、BMI值、手術(shù)時(shí)間、基礎(chǔ)疾病并發(fā)率、其他感染病灶存在率、引流管留置時(shí)間及髖膝部位創(chuàng)傷史率分別為(78.42±5.21)歲、(25.16±2.32)kg/m2、(2.56±0.30)h、58.06%、35.48%、(31.64±2.76)h及32.26%，均高于對照組的(72.60±4.81)歲、(22.87±2.14)kg/m2、(1.98±0.22)h、32.26%、12.90%、(24.08±2.53)h及12.90%，血清白蛋白水平為(31.82±3.85)g/L，低于對照組的（37.67±4.25）g/L，差異均有統(tǒng)計(jì)學(xué)意義(P＜0.05)，且經(jīng)Logistic回歸分析結(jié)果顯示，上述指標(biāo)均為術(shù)后假體周圍感染發(fā)生的危險(xiǎn)因素(P＜0.05)。結(jié)論 年齡、BMI值、手術(shù)時(shí)間、血清白蛋白水平、基礎(chǔ)疾病并發(fā)率、其他感染病灶存在率、引流管留置時(shí)間及髖膝部位創(chuàng)傷史率均是高齡髖膝關(guān)節(jié)置換術(shù)后假體周圍感染發(fā)生的相關(guān)因素，臨床上應(yīng)給予充分的重視，及時(shí)采用干預(yù)措施。

高齡；髖膝關(guān)節(jié)置換術(shù)；假體；感染；相關(guān)因素

髖膝關(guān)節(jié)置換術(shù)是近年來臨床中應(yīng)用較廣泛的治療方式，關(guān)于本治療方式的研究較多，其中關(guān)于高齡髖膝關(guān)節(jié)置換患者術(shù)后感染，尤其是假體周圍感染的臨床研究并不少見[1-2]，但是有關(guān)高齡患者術(shù)后導(dǎo)致假體周圍感染的相關(guān)因素研究卻較少，相關(guān)研究指標(biāo)的差異也較大[3]。為此，本文就高齡髖膝關(guān)節(jié)置換術(shù)后假體周圍感染發(fā)生的相關(guān)因素進(jìn)行分析，以期為高齡患者術(shù)后感染的控制提供依據(jù)，現(xiàn)將結(jié)果報(bào)道如下：

1 資料與方法

1.1 一般資料 選取2013年1月至2015年10月我院重癥醫(yī)學(xué)科收治的31例高齡髖膝關(guān)節(jié)置換術(shù)后致假體周圍感染患者為觀察組，同期的31例未發(fā)生感染患者為對照組。對照組患者中，單側(cè)置換者27例，雙側(cè)置換者4例；骨關(guān)節(jié)炎者25例，其他患者6例。觀察組患者中，單側(cè)置換者26例，雙側(cè)置換者5例；骨關(guān)節(jié)炎者24例，其他患者7例。兩組患者的置換位置及疾病種類比較差異均無統(tǒng)計(jì)學(xué)意義(χ2=0.241，0189，P＞0.05)。

1.2 資料收集 采用回顧性方法收集兩組患者的年齡、BMI值、手術(shù)時(shí)間、血清白蛋白水平、基礎(chǔ)疾病并發(fā)率、其他感染病灶存在率、引流管留置時(shí)間及髖膝部位創(chuàng)傷史率并進(jìn)行比較。

1.3 統(tǒng)計(jì)學(xué)方法 應(yīng)用SAS5.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)分析，計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(±s)表示，組間比較采用t檢驗(yàn)，計(jì)數(shù)資料比較采用χ2檢驗(yàn)，采用多因素Logistic回歸分析法分析各項(xiàng)指標(biāo)與感染的關(guān)系，以P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 兩組患者的年齡、BMI值、手術(shù)時(shí)間、血清白蛋白水平及引流管留置時(shí)間比較 觀察組患者的年齡、BMI值及手術(shù)時(shí)間均高于對照組，血清白蛋白水平低于對照組，差異均有統(tǒng)計(jì)學(xué)意義(P＜0.05)，見表1。

表1 兩組患者的年齡、BMI值、手術(shù)時(shí)間、血清白蛋白水平及引流管留置時(shí)間比較(±s)

表1 兩組患者的年齡、BMI值、手術(shù)時(shí)間、血清白蛋白水平及引流管留置時(shí)間比較(±s)

組別對照組(n=31)觀察組(n=31) t值P值年齡(歲) 72.60±4.81 78.42±5.21 6.243＜0.05 BMI(kg/m2) 22.87±2.14 25.16±2.32 5.972＜0.05手術(shù)時(shí)間(h) 1.98±0.22 2.56±0.30 6.459＜0.05血清白蛋白水平(g/L) 37.67±4.25 31.82±3.85 6.213＜0.05引流管留置時(shí)間(h) 24.08±2.53 31.64±2.76 5.880＜0.05

2.2 兩組患者的基礎(chǔ)疾病并發(fā)率、其他感染病灶存在率及髖膝部位創(chuàng)傷史率比較 觀察組患者的基礎(chǔ)疾病并發(fā)率、其他感染病灶存在率及髖膝部位創(chuàng)傷史率均高于對照組，差異均有統(tǒng)計(jì)學(xué)意義(P＜0.05)，見表2。

表2 兩組患者的基礎(chǔ)疾病并發(fā)率、其他感染病灶存在率及髖膝部位創(chuàng)傷史率比較[例（%）]

2.3 各項(xiàng)指標(biāo)與術(shù)后假體周圍感染的關(guān)系 經(jīng)多因素Logistic回歸分析結(jié)果顯示，年齡、BMI值、手術(shù)時(shí)間、血清白蛋白水平、并發(fā)基礎(chǔ)疾病、存在其他感染病灶、引流管留置時(shí)間及髖膝部位創(chuàng)傷史均與術(shù)后假體周圍感染發(fā)生率有密切的關(guān)系，見表3。

表3 觀察指標(biāo)與術(shù)后假體周圍感染的關(guān)系

3 討論

髖膝關(guān)節(jié)置換術(shù)是臨床中用于髖膝關(guān)節(jié)治療的常用術(shù)式，臨床中對于此類手術(shù)的相關(guān)研究較多見，對于影響患者最終治療效果的因素的研究也極為常見[4-5]。其中各類圍術(shù)期并發(fā)癥是嚴(yán)重影響患者最終治療效果的重要因素。而假體周圍感染作為其中極為重要且危害極大甚至可導(dǎo)致患者置換術(shù)失敗的一類并發(fā)癥[6-7]，臨床對其控制及治療的重視程度極高。再者，有研究認(rèn)為假體周圍感染不僅僅可導(dǎo)致局部炎性狀態(tài)的發(fā)生，對于下肢的微循環(huán)及其他方面狀態(tài)也有較大的不良影響，因此進(jìn)一步提升了對假體周圍感染防控的必要性。臨床中關(guān)于假體周圍感染的研究雖不少見，但是關(guān)于其發(fā)生的相關(guān)影響因素研究卻仍相對不足，而高齡患者作為此類手術(shù)患者中較為突出且要求較高的一類人群，對其進(jìn)行術(shù)后假體周圍感染相關(guān)影響因素的進(jìn)一步研究價(jià)值相對更高[8-9]。

本文中我們就高齡髖膝關(guān)節(jié)置換術(shù)后假體周圍感染發(fā)生的相關(guān)因素進(jìn)行探究，結(jié)果顯示，此類手術(shù)患者術(shù)后假體周圍感染者較未發(fā)生感染者存在明顯差異，表現(xiàn)為年齡、BMI值、手術(shù)時(shí)間、基礎(chǔ)疾病并發(fā)率、其他感染病灶存在率、引流管留置時(shí)間及髖膝部位創(chuàng)傷史率相對更高，血清白蛋白水平相對更低等方面，且經(jīng)Logistic回歸分析顯示，上述指標(biāo)均與感染的發(fā)生有密切的關(guān)系，分析原因，我們認(rèn)為高齡患者本身免疫狀態(tài)相對較差，其易于發(fā)生感染，加之BMI值較高者承重力較高，微循環(huán)相對較差等使其假體受到的不良影響更小[10]，因此更易于發(fā)生感染，再者，手術(shù)時(shí)間較長者大大延長了病原菌接觸時(shí)間，因此更易于發(fā)生感染，白蛋白較低者營養(yǎng)狀態(tài)較差[11]，存在其他感染病灶及引流管留置時(shí)間較長者接觸病原菌概率提高，髖膝部位創(chuàng)傷史者其康復(fù)速度相對較慢，效果可能相對更差，也更易于發(fā)生感染[12]。

綜上所述，筆者認(rèn)為年齡、BMI值、手術(shù)時(shí)間、血清白蛋白水平、基礎(chǔ)疾病并發(fā)率、其他感染病灶存在率、引流管留置時(shí)間及髖膝部位創(chuàng)傷史率均是高齡髖膝關(guān)節(jié)置換術(shù)后假體周圍感染發(fā)生的相關(guān)因素，應(yīng)給予充分的重視及干預(yù)。

[1]Weber-Spickschen TS,Alfke D,Agneskirchner JD.The use of a modular system to convert an anatomical total shoulder arthroplasty to a reverse shoulder arthroplasty:clinical and radiological results[J]. Bone Joint J,2015,97(12):1662-1667.

[2]McArthur BA,Abdel MP,Taunton MJ,et al.Seronegative infections in hip and knee arthroplasty:periprosthetic infections with normal erythrocyte sedimentation rate and C-reactive protein level[J].Bone Joint J,2015,97(7):939-944.

[3]Rudert M,Holzapfel BM,von Rottkay E,et al.Impaction bone grafting for the reconstruction of large bone defects in revision knee arthroplasty[J].Oper Orthop Traumatol,2015,27(1):35-46.

[4]李勇,魏憲會.全髖關(guān)節(jié)置換術(shù)假體周圍感染的危險(xiǎn)因素及治療措施的研究[J].中國實(shí)用醫(yī)刊,2014,41(15):76-77.

[5]Helito CP,Junqueira JJ,Gobbi RG,et al.Effect of postoperative use of nasal oxygen catheter supplementation in wound healing following total knee arthroplasty[J].Clinics(Sao Paulo),2014,69(11): 735-739.

[6]Sprowson AP,Jensen CD,Parsons N,et al.The effect of triclosan coated sutures on rate of surgical site infection after hip and knee replacement:a protocol for a double-blind randomised controlled trial[J].BMC Musculoskelet Disord,2014,14(15):237.

[7]李朔,郭常安,閻作勤.人工關(guān)節(jié)假體周圍感染診療的研究進(jìn)展[J].中國臨床醫(yī)學(xué),2014,21(5):613-616.

[8]Hamaji A,Hajjar L,Caiero M,et al.Volume replacement therapy during hip arthroplasty using hydroxyethyl starch(130/0.4)compared to lactated Ringer decreases allogeneic blood transfusion and postoperative infection[J].Braz JAnesthesiol,2013,63(1):27-35.

[9]Pajarinen J,Jamsen E,Konttinen YT,et al.Innate immune reactions in septic and aseptic osteolysis around hip implants[J].J Long Term Eff Med Implants,2014,24(4):283-296.

[10]Nakano S,Yoshioka S,Tezuka F,et al.New surgical treatment using a docking nail for postoperative periprosthetic femoral fracture after total hip arthroplasty[J].JArthroplasty,2013,28(2):326-330.

[11]Alfargieny R,Bodalal Z,Bendardaf R,et al.Nutritional status as a predictive marker for surgical site infection in total joint arthroplasty [J].Avicenna J Med,2015,5(4):117-122.

[12]Anthony VF,Brian SP,Irving MS.Capturing orthopaedic surgical site infection data and assessing dental recommendations with respect to total joint arthroplasty[J].The Journal of theAmericanAcademy of Orthopaedic Surgeons,2015,23(Supp1):S55-59.

Related factors of infection around the prosthesis of patients with advanced age after hip and knee arthroplasty.

ZANG Ze-lin,LI Peng-fei,CAO Hai-quan.Intensive Care Unit,Nanchong Central Hospital,Nanchong 637000,Sichuan, CHINA

ObjectiveTo analyze the related factors of infection around the prosthesis of patients with advanced age after hip and knee arthroplasty,in order to provide evidence for the control of postoperative infection of patients with advanced age.MethodsA total of 31 patients of advanced age with infection around the prosthesis after hip and knee arthroplasty,who admitted to Intensive Care Unit(ICU)of our hospital from January 2013 to October 2015,were selected as the observation group.At the same time,31 patients without infection were selected as the control group.Then the ages,body mass index(BMI)value,operation time,serum albumin level,basic disease rates,other infection sites rates,drainage tube indwelling time,trauma history rates of hip and knee of the two groups were compared, and the relationship between those indexes and infection were analyzed by the logistic regression analysis.ResultsThe age,BMI value,operation time,basic disease rates,other infection sites rates,drainage tube indwelling time,trauma history rates of hip and knee of the observation group were respectively(78.42±5.21)years,(25.16±2.32)kg/m2,(2.56± 0.30)h,58.06%,35.48%,(31.64±2.76)h and 32.26%,which were all higher than(72.60±4.81)years,(22.87±2.14)kg/m2, (1.98±0.22)h,32.26%,12.90%,(24.08±2.53)h and 12.90%of the control group;while the serum albumin level(31.82± 3.85)g/L of the observation group was lower than(37.67±4.25)g/L of the control group;all of the above differences were statistically significant(P＜0.05).Logistic regression analysis showed that those indexes all had close relationship with the postoperative infection around the prosthesis(P＜0.05).ConclusionThe age,BMI value,operation time,serum albumin level,basic disease rates,other infection sites rates,drainage tube indwelling time,trauma history rates of hip and knee are all the related factors of infection around the prosthesis of patients with advanced age after hip and knee arthroplasty,so the indexes should be paid enough attention,and timely intervention measures should be taken.

Advanced age;Hip and knee arthroplasty;Prosthesis;Infection;Related factors

R687.4

A

1003—6350（2017）02—0302—03

10.3969/j.issn.1003-6350.2017.02.044

2016-07-15)

臧澤林。E-mail：zweigxy@163.com