RU2317022C1 - Method for treating purulent arthritis developed after total endoprosthetics of knee joint - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: the present innovation refers to reendoprosthetics in case of purulent arthritis of knee joint. On removing the elements of endoprosthesis and thorough debridement one should implant an articulating spacer that consists of the endoprosthesis' sterilized femoral component and a tibial component designed intrasurgically out of bony cement at addition of about 4-6 g gentamycinum and about 1-2 g vancomicin/cement mass. Both components should be applied at using bony cement that contains the same antibiotics and in the concentration being similar to that applied while preparing a tibial component. The innovation keeps articular function before reendoprosthetics.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to the field of medicine, namely to orthopedics and traumatology.

The most effective way of treating the infectious inflammation that developed after the primary knee arthroplasty is a two-stage surgical treatment, in which re-arthroplasty is performed as the second stage, against the background of massive antibiotic therapy both after removal and after repeated implantation of the arthroplasty. The installation of a cement spacer or “temporary” prosthesis made of bone cement containing a high concentration of antibiotic helps to achieve the maximum necessary concentration of antibiotics in the periarticular tissues for sanitation of the purulent process and along with this good functional results, facilitate the re-implantation of components of the endoprosthesis.

There is a method of installing a methyl methacrylate spacer block, made by the surgeon during an operation from bone cement containing gentamicin, corresponding in shape to the cavity formed after removal of the primary endoprosthesis components and placed into it after the polymerization is complete or during the solidification of methyl methacrylate, performing light traction in the foot along the axis of the limb (Hanssen A., 1997).

However, this method has a significant drawback: it cannot provide long-lasting function of the operated joint, since it limits the amplitude of movements, only minimal axial load on the limb is possible when walking, the contours of the supporting sawdust of the femur and tibia deform over time, losing the ability to support.

A known system of temporary joint prosthetics for a two-stage method of treating purulent complications PROSTALAC (prosthesis of antibiotic-loaded acrylic cement) is an endoprosthesis made intraoperatively using special casting molds, consisting of metal femoral hemispheres-sleds and plastic tibial inserts embedded in a high concentration of cement containing high concentration antibiotics. It allows you to maintain the support ability of the limb and movement in the joint (Hofmann A. et al., 1995).

However, the use of the PROSTALAC system is very expensive, since a large number of different sizes of femoral metal hemispheres and tibial plastic inserts, special casting molds are required, which limits it for wide clinical practice.

The technical result of the invention is the relief of purulent arthritis, the possibility of early axial load on the limb, a satisfactory range of motion in the joint, the optimal volume of the joint cavity is maintained, maximum saturation of periarticular soft tissues with drugs is ensured for a long time, and significant material costs are not required.

The result of the invention is achieved by removing the implant and performing a thorough debridement, using an articulating spacer consisting of a sterile standard femoral component and intraoperatively made of bone cement tibial component saturated with 4-6 g of gentamicin and 1-2 g of vancomycin per 40 g of cement mass, established using bone cement containing the above antibiotics in the same concentration.

The method is as follows.

In the presence of fistulous passages after processing the surgical field, a solution of diamond green is injected into them under pressure. From the median access with a length of 20-25 cm with excision of the postoperative scar, the extensor apparatus of the knee joint is isolated. Further, anterior-internal or anterior-external arthrotomy is performed to expose and remove the components of the endoprosthesis. With insufficient visibility, access is expanded due to osteotomy of the tibial tuberosity or intersection of the quadriceps tendon by Coonse-Adams or “quadriceps snip” by Insall. The femoral component is removed first using osteotomes, a Jigley saw, pads and sliding hammers. After this, wide access to the tibial component is formed and the possibility of its proximal displacement appears. The tibial component is also removed using osteotomes, an oscillatory saw, and pads. Removing both components, they are extremely careful about bone tissue, all sections are made along the contact line of the prosthesis-cement, and not the cement-bone. Next, they begin to debride the joint: remove cement, necrotic fragments of bone and soft tissues, the synovial membrane stained with a solution of diamond greens. The debridement is accompanied by a thorough multiple washing of the joint cavity with antiseptic solutions under pressure or with a pulsating stream.

The next step in the operation is to install a spacer that simulates an endoprosthesis instead of a remote one.

The configuration and geometric dimensions of the implanted femoral component should correspond to those of the removed component, especially in the sagittal plane, and in no case be smaller, which may require additional bone resection to fix it.

To determine the required dimensions in the manufacture of the tibial component, the following methods are used. The removed tibial component is applied by the articular surface to a rectangular transparent plastic and outlined on the outer perimeter with a sterile marker, obtaining an image of the outer contour. The height of the tibial component is determined by measuring the flexion and extensor gaps available in sets of surgical instruments for implantation of endoprostheses of any system. The height of the flexion and extensor spaces must be measured after the impact of the femoral component on the distal femur (otherwise, the height of the tibial component will be excessive). If the values of the flexion and extensor gaps turn out to be different, choose a smaller one, since in the conditions of a rehabilitation operation, taking into account the subsequent installation of the revision endoprosthesis, it is not advisable to perform additional bone filings or release soft tissues.

For the manufacture of the tibial component of the endoprosthesis, a certain amount of cement is required. A standard package of bone cement contains 1 g of gentamicin per 40 g of powder, in the case of a purulent process, the concentration of antibiotics can be increased to the maximum allowable: when mixing the cement components, 4 g of gentamicin and 1-2 g of vancomycin are added to the resulting mass based on 40 g of cement mass. The choice of antibiotic is due to its resistance to high temperatures arising from the polymerization of cement, and the sensitivity of microflora. Exceeding the concentration of antibiotic based on standard packaging of bone cement (40 g) is undesirable, as this significantly reduces the strength characteristics of methyl methacrylate after polymerization.

When the cement reaches the sculpting phase, the surgeon on the plastic sheet gives it the previously defined necessary shape, controlling the thickness in accordance with the previously selected gap meter. The thickness of the tibial component may be 1-2 mm less, given that it will be installed on the cement mantle.

Next, a test assembly of the endoprosthesis is performed, stability of the joint, the amplitude of movements in it are evaluated. Performing additional bone resection at this stage is already extremely undesirable, they allow limited release of soft tissues, according to indications, modeling of the tibial component is possible.

For the final implantation of the components, cement is kneaded, adding antibiotics to it at the concentration indicated above. The femoral component is implanted first, in contrast to primary endoprosthetics, strikes on the patch (impact) should not be strong, there is no need for deep penetration of cement into the cancellous bone of the condyles. The plateau of the tibia is covered with cement in excess, the manufactured tibial component is introduced into the prepared bed in the position of flexion of the lower leg and maximum distraction of the joint, excess cement is removed from the back, the lower leg is extensible with moderate traction. Excess cement is removed and 1-2 minutes before the completion of its polymerization, pressure is applied along the extremity axis to the foot for the solid implantation of both components. After the polymerization is completed, the stability of the fixation of the components is checked, the amplitude of movements in the joint is checked, if necessary, excess fragments of extruded cement are removed with an osteotome.

Remove the tourniquet. Perform thorough hemostasis. The joint is abundantly washed with antiseptic solutions, drained. The wound is sutured in layers.

The decision to immobilize the joint is made individually, depending on the size of the bone defect and the condition of the soft tissues.

From the day after the operation, the patient begins to walk with additional support on crutches and a metered load on the operated limb. From 2-3 days begins physical therapy, electrical stimulation of the thigh muscles.

Clinical example. Patient B., 62 years old, was on treatment with a diagnosis of stage III gonarthrosis on the right. Pain in the right knee joint was disturbed for about 5 years, 2 years ago a meniscectomy was performed that did not bring a positive result, conservative treatment is ineffective (Fig. 1).

The patient underwent total knee replacement with an unrelated F / S III Sulzer endoprosthesis using bone cement (Fig. 2). The postoperative course without features, after two weeks the patient was discharged for outpatient treatment.

Ten months later, pain and swelling developed in the area of the prosthetic joint, a fever appeared. The patient was hospitalized, a joint puncture was performed with a microbiological examination of the punctate. Based on the data of clinical, laboratory and microbiological examination, the diagnosis of late purulent gonitis of the endoprosthetic knee joint caused by Staphylococcus aureus was established (Fig. 3).

The audit operation has been completed. The ankle joint was opened from the anterior-medial access, about 150 ml of yellow turbid fluid was released, the latter was taken for microbiological examination. The infiltrated synovial membrane is excised. Both components of the endoprosthesis remained stably fixed. Using a Jigley saw and osteotomes, the femoral component is removed. To remove the tibial component, it turned out to be necessary to perform an osteotomy of the tibial tuberosity, since the leg length of the tibial component was 80 mm and it was not possible to dislocate the tibia anteriorly. Using osteotomes removed the tibial component. A thorough rehabilitation of the joint was performed, during which the remains of cement, necrotic bone, and synovial membrane were removed.

Due to visual assessment, the femoral component necessary in size was selected. After its temporary fixation during flexion and extension of the tibia, the size of the flexion and extensor joint spaces was determined by measuring instruments. To make the tibial component, 4 g of gentamicin and 1 g of vancomycin were added to the cement containing 1 g of gentamicin (based on 40 g of cement). When the cement has reached the sculpting phase, the previously defined contours were given to it on the plastic sheet, and the required thickness was measured using the adjacent gap meter.

Then we performed a test assembly of the endoprosthesis, evaluated the stability of the joint, the amplitude of movements in it. For the final implantation of the components, the bone cement ingredients were mixed by adding antibiotics in the amount indicated above. The femoral component was implanted first. The plateau of the tibia was covered with cement in excess, the manufactured tibial component was fixed in the position of flexion of the lower leg and maximum extension of the joint, excess cement was removed along the back surface, the lower leg was unbent with moderate traction in the foot. The excess cement was removed along the lateral and anterior surfaces, and 1-2 minutes before the end of its polymerization, compression was performed along the limb axis on the foot for the solid implantation of both components. After polymerization was completed, stability of component fixation was checked, the amplitude of movements in the joint, excess cement fragments were removed with an osteotome. The joint cavity was drained through contraception and the wound was sutured in layers (Fig. 4).

Walking with support on crutches and a dosed load of the operated limb was allowed from the second day, electromyostimulation and the development of movements in the joint began from the third day after the operation.

During the first week after surgery, cefazolin was administered intravenously 1 g three times a day and metragil 100 ml three times a day, three days.

After obtaining the results of an intraoperative microbiological study and determining the sensitivity of microflora to antibiotics, intravenous antibiotic therapy with cefperazone was carried out for 4 weeks 2 times a day. The wound healed by first intention, the sutures were removed on the 14th day. 5 weeks after the revision surgery and the end of the course of parenteral antibiotic therapy, the patient was discharged for outpatient treatment. At discharge, laboratory indicators of inflammation were slightly higher than normal, the patient was recommended oral administration of cefran 0.5 g 2 times a day for 10 days.

A week after the end of antibiotic therapy, the patient is re-hospitalized in the department. Clinical and laboratory studies showed no signs of inflammation. The puncture of the joint with the sowing of the growth punctate did not reveal microflora, confirming the sterility of the joint.

7 weeks after the rehabilitation of the joint and installation of the spacer, a revision operation was performed. The screws were removed from the anteromedial access with excision of the postoperative scar and the tibial tuberosity osteotomy was repeated. Without particular difficulty, the femoral and tibial components of the spacer were removed by osteotomes and pads. A thorough debridement of the joint with removal of bone cement and scar tissue was performed. Using an appropriate set of tools, sawdust of the distal end of the femur was made, a plateau of the tibia was prepared, and a modeling resection and denervation of the patella was performed. An LCS DePuy endoprosthesis with a rotary platform was implanted on bone cement with an antibiotic.

In the postoperative period, cefazolinum was administered intravenously for 10 days, 1 g 3 times a day, for three days, 100 ml metragil three times a day. The postoperative wound healed by primary intention. The patient was discharged for outpatient treatment on day 17.

During the follow-up examination 6 months after the endoprosthetics, the patient does not complain, the joint function is good (range of motion 180-80 °, the joint is stable, the strength of the thigh muscles is 4 points), laboratory parameters are normal, the x-ray location of the joint is correct, there are signs of osteolysis, loosening and there is no inflammation (figure 5).

Bibliography

1. Hanssen A. Management of the infected total knee arthroplasty / G. Engh, C. Rorabeck Revision total knee arthroplasty // Baltymore: Williams & Wilkins, 1997 - Chapter 20 - P.371-393.

2. Hofmann A., Kane K., Tkach T. et al. Treatment of infected total knee arthroplasty using an articulating spacer // Clin. Orthop. - 1995 - V.321 - P.45-54.

Claims (1)

A method of treating purulent arthritis that developed after total knee arthroplasty, characterized in that by removing the implant and performing a thorough debridement, an articulating spacer consisting of a sterile standard femoral component and intraoperatively made of bone cement tibial component saturated with 4-6 g of gentamicin and 1-2 g of vancomycin per 40 g of cement mass, established using bone cement containing the above antibiotics in the same concentration and.

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