Discuz!NT|BBS|论坛

注册

 

医库账号可直接登录
发新话题 回复该主题

病例漫谈110:一例75岁骨性关节炎伴腘窝囊肿的男性患者关节镜手术后诱发的复杂脓毒性关节炎 [复制链接]

1#
SUMMARY
A 75-year-old man presented in shock secondary to septic arthritis of the knee. The patient, with a known history of knee osteoarthritis, was treated elsewhere for mechanical locking symptoms and effusion with arthroscopic debridement, and developed septic arthritis, which disseminated to the leg and foot after a tear in the capsule, and a ruptured pyogenic popliteal cyst. Open debridement of the knee joint, and drainage of the abscesses of the leg and foot, were performed. Antibiotic-loaded cement beads were left in the residual space. Debridement was repeated and cement beads removed after 4 days, and finally the infection was eradicated without any serious consequences for the patient. There is debate over arthroscopic intervention for osteoarthritic knees. The presence of a popliteal cyst, which is a rather common finding in the latter, could be related to a significant number of complications, such as septic arthritis.
摘要
一名75岁男性表现为继发性脓毒性膝关节炎。此患者有膝关节骨性关节炎病史,在其他医疗机构因症状和积液进行了机械固定治疗和关节镜下清理术,之后,诱发了脓毒性关节炎,囊肿撕裂后传播到了小腿和脚部,同时出现了脓毒性腘窝囊肿破裂。膝关节切开行清理术、左腿和脚部行脓肿引流术。残留空隙中填充抗生素骨水泥珠链。4天后,再次行清理术并除去骨水泥珠链,最终患者感染被根治,且没有任何严重后果。关节镜手术治疗膝关节骨性关节炎仍有争议。腘窝囊肿,是一种更为常见的病症,它的出现可能与许多并发症有关,如脓毒性关节炎。

BACKGROUND
Septic arthritis in adults is a potential life-threatening condition with a major risk to joint function. Mortality is reported to be as high as 8–15%, 1 which rises to 19% in the elderly. The incidence of septic arthritis in Western Europe is estimated between 4–10/100 000, but appears to increase in association with a rise of orthopaedic-related infections and ageing population, more aggressive surgical procedures and the increasing use of immunosuppressants. In the elderly, septic arthritis is most common in the knee in patients with concurrent medical conditions (24% diabetes mellitus) and is associated with a high complication rate (38% developing osteomyelitis, 18% osteoarthritis).
背景
脓毒性关节炎是一种潜在危及成人生命的疾病,是影响关节功能的主要风险之一。据报道,死亡率高达8-15%,老年人则上升至19%。脓毒性关节炎在西欧的发病率大约为4-10 / 100 000,但随着骨科相关感染和人口老龄化的加剧、外科手术更强力以及免疫抑制剂的使用增加,发病率呈现上升趋势。脓毒性膝关节炎在伴有并发性疾病(24%为糖尿病)的老年患者中最常见,并与高并发症率相关(38%为发展性骨关节炎,18%为骨性关节炎)。

CASE PRESENTATION
A 75-year-old man presented to the emergency department in shock (heart rate 130, systolic pressure 75 mm Hg) with a swollen, erythaematous knee and temperature of 39°C, persistent for the previous 7 days. Haematology revealed a white cell count (WCC) of 22 000 /mL, erythrocyte sedimentation rate (ESR) of 92 and C reactive protein levels of 220 mg/L. The patient was non-diabetic, non-rheumatological and had no history of immunosuppression. He had been treated elsewhere for mechanical locking due to osteoarthritis and effusion during the past 30 days. He had previously been subjected to three joint aspirations for the effusion. Subsequently, he had an arthroscopic debridement planned to treat the locking and effusion attributed to osteoarthritis and degenerative meniscal pathology. After this procedure, the patient became febrile with malaise and was subsequently subjected to another arthroscopic debridement 5 days later. This resulted in a temporary improvement and a short non-feverish 12 h period, but fever rebounded to >38.5°C levels. The patient was then transferred to our department for further treatment.
病例报告
一名75岁男性因休克被送到急诊室(心率130,收缩压75mm Hg),一侧膝出现肿胀和红斑,体温连续7天保持39°C。血液检查显示白细胞计数(WCC)为22 000 /mL,红细胞沉降率(ESR)为92和C反应蛋白水平为220 mg/L。患者没有糖尿病、风湿和免疫抑制史。过去30天,患者因骨性关节炎和积液,在其他医疗机构接受了机械固定治疗。此前,患者因关节积液接受了三次关节穿刺术。随后,患者接受了关节镜下清理术治疗因骨性关节炎和退行性半月板病变导致的固定和积液。术后,患者出现了发热和不适,5天后再次接受了关节镜下清理术。通过上述治疗过程,患者病情得到改善,12小时内没有再发热,但随后体温反跳并超过38.5°C。患者随后被转移到我们部门接受进一步治疗。

TREATMENT
On admission to the emergency department, the patient was assessed and fluid resuscitation initiated for shock. The clinical diagnosis of septic shock secondary to major knee sepsis was performed. The decision for open arthrotomy and debridement was taken due to the general status of the patient (septic shock), the failure of previous arthroscopic debridements and the report of Gachter class Ⅲ lesions. It was considered necessary to resect all necrotic tissue. There was also a suspicion of a calf abscess starting directly below the affected knee joint and a possible foot abscess. An MRI, obtained before the two arthroscopic procedures prior to treatment in our department, was assessed. It was consistent with an effused arthritic knee, but there was a clear picture of a large popliteal cyst, which was also affected (figure 1).
治疗
急诊入院后,立即评估了患者病情,因休克进行了液体复苏,对继发于膝关节脓毒症的脓毒性休克进行临床诊断。根据患者的总体状况(脓毒性休克)、前期关节镜下清理术的失败和Gachter 评分报告为Ⅲ级病变,决定施行开放性关节切开术和清理术。切除坏死组织是必要的。怀疑受感染的膝关节下方小腿存在脓肿,脚部可能也有脓肿。患者被送至我们部门之前,前两次关节镜手术治疗前拍摄了MRI,我们对MRI结果进行了评估。MRI结果符合膝关节炎受累症状,但图像清晰可见一块较大的腘窝囊肿,这同样受到影响(图1)。  

Figure 1 A large popliteal cyst appeared in the MRI among the other findings.

图1 除其他结果外MRI检查结果显示一块较大的腘窝囊肿。


The knee joint was purulent and washed out thoroughly with 12 L of Ringer’s lactate serum. Synovectomy was performed due to the clinically apparent synovial infection. Fibrinous deposits and necrotic tissue were excised. A large tear was seen in the medial gutter of the knee (3×3 cm) located posterior-medially. The cartilage was inspected and its condition was classified as class IV according to the Gachter classification (figure 2). A suction drain was used. The calf also seemed to be affected, as it appeared to be tumescent and warm. Incision on the medial side of the calf was performed, which revealed an abscess containing one and a half litres of pus. This extended medially and posteriorly to the gastrocnemius muscle. The abscess extended further distally to the ankle joint and medially to the Achilles tendon. The incision was extended to 25 cm and an additional incision was made on the medial aspect of the foot (figure 3). Muscular fascias and Achilles tendon sheath were clinically unaffected. The abscess in the foot was in continuity with the calf abscess and extended for about 8 cm in the sole. An additional incision on the anterolateral aspect of the calf was performed and unveiled another abscess. The abscesses, which were all in continuity, were drained and washed out. Beads of PMMA (polymethylmethacrylate cement with gentamycin with additional vancomycin and imipenem) were placed in the calf and the foot. The residual wounds were covered with the bead-pouch technique (figure 4).
膝关节为化脓性表现,12L乳酸林格氏血清进行彻底清洗。滑膜感染临床表现明显,需行滑膜切除术。切除纤维蛋白沉积及坏死组织。膝关节后内侧的内侧沟槽可见较大撕裂(3×3cm)。检查软骨,同时根据Gachter分级,将其定为Ⅳ级(图2)。施行负压引流。小腿同时受累,呈现肿胀和发热。切开小腿内侧,显现一个含1.5L脓液的脓肿。并向腓肠肌中间和后方扩展。脓肿进一步向远端扩展至踝关节和跟腱内侧。扩大切口至25cm,并在脚内侧另开一处切口(图3)。 肌筋膜和跟腱鞘临床表现为未受累。脚部与小腿脓肿相连,并延伸至脚底约8cm。小腿前外侧另开一处切口,发现了另一脓肿。对这些连续的脓肿进行了排脓和冲洗。小腿和脚部放上PMMA微珠(庆大霉素、万古霉素和亚胺培南组成的聚甲基丙烯酸甲酯骨水泥)。其余伤口通过珠袋技术填充(图4)。  

Figure 2 The knee was filled with pus. The cartilage was inspected and classified as type or class Ⅳ according to the Gachter classification.

图2 膝部充满脓液。检查软骨,同时根据Gachter分级,将其定为Ⅳ级。


Figure 3 The incision was extended to 25 cm in the tibia and an additional incision at the medial aspect of the foot was also needed.

图3 胫骨处切口扩大至25cm,并在脚内侧另开一处切口。


Figure 4 Antibiotic loaded cement beads in the residual calf space.

图4 小腿残留空隙填充抗生素骨水泥珠链。


Postoperatively, the patient’s clinical condition improved significantly and temperature remained under 37°C. Four days later, the patient was taken back to the operating room, and underwent further debridement and lavage with 10 L of saline, but not inside the knee. The bead-pouch technique was necessary only for the wound in the medial calf. The wounds in the anterolateral calf and the foot were lavaged and sutured. Gastrocnemius muscle fascias were still unaffected. The patient had a further procedure 10 days after admission, in which the PMMA beads from the calf site were removed and the surgical site was closed. The patient was discharged 3 weeks after admission. On discharge, inflammation markers were: WCC 10 400, ESR44 and CRP 11 mg/L.
术后,患者临床症状明显改善,体温保持低于37°C。四天后,患者被送至手术室,进一步以10 L生理盐水进行清理和灌洗,但处理部位不在膝关节内。小腿内侧伤口行珠袋技术是有必要的。 清洗并缝合小腿前外侧和脚部的伤口。腓肠肌筋膜仍不受影响。入院10天后,患者进一步接受了治疗。移除小腿部的PMMA微珠,并缝合手术部位。患者住院三周。出院时,炎症标志物:WCC为10 400,ESR为44,CRP 为11 mg/L。

Between the last two surgical interventions, microbial cultures from the infected tissues grew Streptococcus viridans as the only pathogenic microorganism. Intravenous antibiotic administration was not altered by the antibiogram, as S.viridans was sensitive to imipenem-amikacin, which had been started empirically before cultures were available.
最后两次手术之间,取受感染的组织物样本进行微生物培养,培养出的草绿色链球菌是唯一致病微生物。静脉注射抗生素不受抗菌谱影响,如草绿色链球菌对亚胺培南-阿米卡星敏感,这在进行培养之前已有效。

OUTCOME AND FOLLOW-UP
One month later, the patient was non-feverish, there was no surgical site infection and the knee was functional (with the symptoms and signs of pre-existing osteoarthritis). At final follow-up 16 months after the last surgical procedure, the patient recorded an Oxford Knee functional score of 35, as is usual in mild to moderate osteoarthritis. The patient has returned to daily activities and does not use walking aids.
疗效和随访
一个月后,患者不再发热,手术部位没有感染,膝关节功能恢复(仍存在既有的骨性关节炎症状和体征)。最后一次手术治疗后16个月的随访中,患者的牛津膝关节功能评分为35,有轻到中度的骨性关节炎。患者已恢复日常活动,不需借助辅助行走器。

DISCUSSION
The aforementioned patient was treated with two arthroscopic procedures 5 and 1 day (respectively) before admission to our department. The most likely scenario is the iatrogenic rupture of a popliteal cyst and the medial aspect of the synovium during the arthroscopic procedures performed before transfer. The abscess extended to the calf and foot through the space between superficial and deep posterior tibial compartments. There are two distinct leakage pathways from the knee to the calf. One is a posteromedial route by rupture of an infected popliteal cyst. Another is a posterolateral route through the popliteus tendon. Arthroscopic debridement for knee osteoarthritis is a subject of major debate in orthopaedic surgery. Complication rates in older patients seem to be low, but they are sometimes fatal. Based in a search of the literature, there are only a few similar reports published of such a complicated septic arthritis of the knee. According to Izumi et al, two non-rheumatoid patients were reported with knee septic arthritis and a calf abscess, in which a ruptured popliteal cyst and a pathological popliteus hiatus were identified as the cause of the calf abscess. Only one of the cases had an arthroscopic procedure before developing the calf abscess. In the present case, three additional abscesses in the calf, anterolateral to the tibia and foot pad, were recognised and treated. In the three most recent case reports published in the UK on knee septic arthritis, 2/3 patients already had knee arthritis.
讨论
上述患者在送至我们部门之前5天和1天(分别)接受了两次关节镜手术。最可能的情况是在转入我院之前的关节镜手术中腘窝囊肿和滑膜内侧出现了医源性破裂。脓肿通过后侧胫骨间隔浅部和深部的空隙扩散到小腿和脚部。从膝关节到小腿有两种不同的渗漏途径。 一种是受感染的腘窝囊肿破裂后的内侧路径。另一种是通过腘肌腱的后外侧路径。关节镜下清理术治疗膝关节骨性关节炎是骨科手术中一个主要争论点。老年患者中并发症发生率低,但有时却是致命的。通过文献检索,发现有关膝部复杂脓毒性关节炎的类似报告仅有少数。根据 Izumi等人的报道,两名非类风湿患者出现了脓毒性膝关节炎和小腿脓肿。其中,腘窝囊肿和病理性腘肌裂孔为小腿脓肿的病因。仅一例病例在小腿脓肿病发之前接受了关节镜手术。本文病例中,小腿、胫骨前外侧和脚底这三处均发现脓肿,均确诊并进行了治疗。最新的三份在英国发表的有关膝关节脓毒性关节炎病例报告中,2/3的患者存在膝关节炎。

Early surgical management of septic arthritis of the knee is clearly related to a successful outcome. In elderly patients, poor outcome correlates with delayed treatment, multiple debridement procedures, more than one pathogen present and advanced macroscopic staging according to Gachter’s classification.
早期手术治疗脓毒性膝关节炎是治疗成功的关键。老年患者疗效较差的原因与治疗延迟、多次行清理术、存在多病原体以及Gachter评分级别较高有关。

Septic arthritis of the knee after arthroscopy is reported to be as rare as 0.4% in older patients (with men more often affected than women). However, taking into account that this is a very popular procedure worldwide, the total number of patients is certainly of concern (∼1100 septic knees in the series of Hame et al alone). Iatrogenic septic arthritis after arthroscopy must be considered, especially in patients in shock. Regarding the successful treatment of a septic knee, the pre-existence of a popliteal cyst, the duration of the operation, the number of procedures undertaken and the number of injections prior to the arthroscopic treatment, are considered factors affecting the outcome. Treatment of septic arthritis of the knee with arthroscopy is associated with better functional results than arthrotomy, but is advised only in Gachter’s I or II grading system. In advanced stages, open debridement is indicated, as in the presented case, with satisfactory outcome. Any dissemination of the infection must be treated aggressively in order to avoid irreversible damage to bony or soft tissues.
老年患者关节镜术后出现脓毒性膝关节炎较罕见,发生率仅为0.4%(男性受感染人数较女性多)。然而,考虑到关节镜手术在世界范围内是较普遍的手术治疗方法,患者总数是关键(仅Hame等人的系列报道中脓毒性膝关节就有1100例)。因此,应关注关节镜术后医源性脓毒性关节炎,尤其是休克患者。关于脓毒性膝关节炎的成功治疗,事先存在的腘窝囊肿、手术时间、疗程次数和关节镜手术治疗前的注射次数是影响疗效的重要因素。关节镜手术治疗脓毒性膝关节炎,恢复关节功能的效果比关节切开术更好,但仅在Gachter评分为Ⅰ或Ⅱ级时建议采用。晚期时,如文中的病例,行开放性清理术结果较令人满意。感染的任何一种传播形式都必须积极治疗,以避免骨骼或软组织的不可逆损害。

The dissemination of septic arthritis to the popliteal cyst during arthroscopy has been described by Corten et al, and has been related to the irrigation pump and the valve flow function of the cyst in flexion and extension of the joint. The same authors have proposed that immobilising the knee in extension may have contributed to the infected popliteal cyst as well. In our patient, this could be the opposite, with the popliteal cyst acting as an infection reservoir that apparently iatrogenically ruptured at some point, causing this nearly fatal complication. After the first arthroscopic procedure, septic arthritis developed, which could not be controlled arthroscopically. The second procedure following the iatrogenic rupture of the capsule and the presence of a ruptured popliteal cyst led to abscess formation and septic shock. The delay in transfer will have contributed to the patient’s poor clinical condition. The only fortunate factor being presence of a microorganism of low pathogenicity.
Corten等人曾报道脓毒性关节炎在关节镜手术中会传播至腘窝囊肿,这与关节屈伸时囊肿的灌入泵和阀的流量功能有关。他们同时提出膝关节保持伸展可能导致腘窝囊肿感染。我们治疗的患者与之相反,腘窝囊肿作为感染源出现明显破裂,导致几乎致命的并发症。首次关节镜手术后,病情未得到控制,脓毒性关节炎加剧。囊肿医源性破裂和腘窝囊肿破裂后,行第二次关节镜手术,导致了脓肿形成和脓毒性休克的出现。转移的延迟使患者临床状况欠佳。唯一值得幸运的是微生物呈现低致病性。

There have been 21 case reports of septic popliteal cysts, to our knowledge, with most of them being related to immunosuppressed patients. There are several other cases of ruptured cysts mimicking thrombophlebitis and fading away slowly after several weeks.
据我们所知,已有21例脓毒性腘窝囊肿的病例报告,患者中大多使用过免疫抑制剂。 还有几例病例出现了类似血栓性静脉炎的囊肿破裂,并在几周内缓慢消退。      

Septic arthritis of the knee is difficult to treat in the presence of a popliteal cyst. Popliteal cysts are common in arthritic knees. Subsequently, a correlation between negative outcomes after arthroscopic treatment in arthritic knees in the presence of a popliteal cyst could be investigated.
存在腘窝囊肿的脓毒性膝关节炎治疗难度较大。腘窝囊肿在膝关节炎中较常见。随后,可以对关节镜下治疗膝关节炎伴腘窝囊肿的失败病例进行调研,得到相关系数。

由MediCool医库软件 王露黔 编译

原文来自BMJ Case Rep

分享 转发
TOP
发新话题 回复该主题