2017年 · 第55卷第03期

prosthetic joint infection (PJI) after total knee arthroplasty (TKA) is less common (1%-2%^[1,2,3]), but is a catastrophic complication for the patient and is one of the most common causes of post-TKA failure^[4]。 At present, secondary revision surgery is mostly used to treat chronic PJI after TKA. The infection clearance rate is 82% ~92%^[5,6]。 However, this procedure is time-consuming and expensive, and the knee joint function of patients is limited between two periods of surgery, and may increase the complication rate and mortality rate of patients^[7]。 In contrast, primary revision surgery has advantages over secondary revision surgery in terms of time consumption, cost and functional reconstruction of the knee. Therefore, we retrospectively studied the clinical data of 7 patients with primary revision surgery who were followed up for more than 6 years in our hospital, with the aim of knowing the infection clearance rate of primary revision surgery and the knee function score at medium and long-term follow-up, so as to provide clinical reference.

PatientMale, 31 years old, was admitted to hospital on December 18, 2015 due to "anorexia and abdominal distension for more than 2 months". Physical examination: No obvious positive signs. Liver function: ALT 187.9 U/L, AST 100.2 U/L, γ-glutamyltransferase 688.5 U/L, alkaline phosphatase 415 U/L, total bilirubin 28.1 μ mol/L, direct bilirubin 8.4 μ mol/L, indirect bilirubin 19.7 μ mol/L; Tumor markers: carcinoembryonic antigen 2.01 μ g/L, CA19-9 13.95 U/ml, alpha-fetoprotein 2.5 U/ml; Ultrasound examination: A hypoechoic light mass with a size of about 29 mm ×15 mm can be seen at the confluence of the left and right hepatic ducts, with unclear boundaries and dilated intrahepatic bile ducts; Enhanced CT examination: the intrahepatic bile duct, left and right hepatic ducts were mildly dilated, and a type of round slightly lower density shadow was seen in the hilar area, with clear boundaries and uniform density, and no enhancement was found in the enhanced scan (FIG. 1A)； Magnetic resonance cholangiopancreatography: A mass of T2WI slightly higher signal T1WI isosignal shadow was seen in the hilar of the liver, and the intrahepatic bile duct showed soft vine-like dilation (FIG. 1B)。 Preoperative diagnosis: hilar bile duct occupation.

PatientA 78-year-old male was admitted to the ICU of the Department of Hepatobiliary Surgery of our hospital on July 29, 2015 due to "persistent upper abdominal pain after eating for 24 h". Since the onset of the disease, it is accompanied by abdominal distension and fever, with a maximum body temperature of 39 ℃, and self-measured blood pressure 97/60 mmHg (1 mmHg =0.133 kPa). Previous history of hypertension, no history of underlying liver disease and intestinal disease. Physical examination: acute disease, abdominal swelling, abdominal muscle tension, upper abdominal tenderness, no rebound pain, negative mobile voicing, and disappearance of intestinal sounds. Abdominal X-ray showed small intestinal fluid and gas accumulation, and CT examination showed portal vein gas accumulation (Figure 1)。 Laboratory test: white blood cell count 33.23×10⁹/L, ALT 360 U/L, AST 181 U/L, total bilirubin 75.3 μ mol/L, urea nitrogen 12.57 mmol/L, creatinine 176 μ mol/L, conjugated procalcitonin (PCT)>100 μ g/L, lactic acid 6.4 mmol/L, combined with hypotension, the primary diagnosis was septic shock and multiple organ dysfunction syndrome. With conservative treatment such as anti-shock and organ function support, PCT and lactate levels gradually returned to normal, and organ function gradually improved (Table 1)。 However, abdominal distension persisted without relief, and no obvious embolism and stenosis were found by angiography, so the effect of conservative treatment was not good. Laparoscopic exploration showed intestinal adhesive contracture and intestinal lumen stenosis between 160 cm from Trigger's ligament and 100 cm from ileocecal region, without ischemic necrosis, so partial resection of small intestine and intestinal anastomosis were performed by laparotomy (Figure 2)。 The results of postoperative pathological examination: Chronic inflammation of small intestine with superficial necrosis, granulation tissue formation, fibrous tissue hyperplasia and foreign body granuloma formation, and reactive hyperplasia of peri-intestinal lymph nodes. Postoperative CT reexamination showed that portal vein gas disappeared (Figure 1), was cured and discharged 8 days after surgery. After discharge, the patient was followed up by telephone for 8 months. The patient lived normally, ate well, and had no abdominal pain and abdominal distension.