Method of treating purulent arthritis

FIELD: medicine.

SUBSTANCE: invention relates to traumatology and orthopaedics and can be applied for the treatment of purulent arthritis. Arthrotomy is carried out. Necrotised tissues, injured elements of the joint are ablated. Primarily a spacer from bone cement with an antibiotic is installed. The wound is sutured layer-by-layer. Drainage is carried out in portions, with the periodical closure of draining tubes in such a way, that drainage is realised for 5-10 min each hour on the first 2-3 days after operation. The spacer is replaced for the joint endoprosthesis after cupping the infectious process.

EFFECT: method makes it possible to reduce a risk of endoprophesies septic instability.

 

One of the most severe pathologies of the joints is the development of purulent infection. Typically, these complications leads to destruction of the articular elements and further debilitation of the patient.

Known variants of conservative treatment of purulent arthritis, consisting in drug systemic therapy. An analogue of the claimed method is surgery on the joint, including arthrotomy, removal of pus and nonviable tissue with subsequent drainage. Remove diseased articular bone elements and adapt them relative to each other (Cancer A.V., Linnik S. A., Savintsev A. M., p. P. Romashov, etc. Osteomyelitis of the pelvis, osteoarthritis of the hip joint and orthopedic consequences. Surgical treatment. - St. Petersburg. 2007 - P. 372). In the future, after the acute process if possible produce joint arthroplasty.

The disadvantages of this method are the restriction of the functional capability of the patient during the treatment of the infectious process, the development of the cicatricial process in the joint, which further complicates the installation of the prosthesis.

The invention consists in the combination of essential features ensures the achievement of the desired technical result, as the save functionality in p�affected joint and prevention of the shortening of the limb.

Essential features of the invention lie in the fact that in the process of arthrotomy remove the necrotic tissue and the affected elements of the joint, install the spacer (temporary prosthesis) from the bone cement with antibiotic primarily with the calculation of the individual characteristics of lesions of the bony elements of the joint, the sensitivity of microflora to antibiotics and proper tension para-articular muscles, the compensation shortening of the limb, then the wound is sutured in layers, and drainage produce fractional to full evacuation is detachable, and after the relief of infection produce replacement spacer for implant arthroplasty.

Advantages of this method are:

- Initial installation of the spacer allows to provide in the joint cavity high concentration of antibiotic to suppress microflora. Selection of an antibiotic produced by a preliminary sensitivity analysis of the microflora, and the size of the spacer on individual parameters of the defect of the bony elements of the joint of the patient.

- When installing the spacer takes into account the tension of the para-articular muscles and the full restoration of limb length, which distinguishes the claimed solution to the prototype, which provides a deliberate shortening of the limb.

- Installation of spacer joint makes it possible to retain �functional capabilities of the patient during the period of relief of infectious process.

- Fractional drainage of the wound, i.e. periodic overlap of drain pipe, allows to maintain a high concentration of antibiotic in the joint cavity on the background of staged removal of hematoma and accumulating detachable.

- Install the support joint endoprosthesis after the relief of infection reduces the risk of septic instability in the future.

The proposed method is as follows.

Produce arthrotomy. From the cavity of the opened joint remove purulent contents and devitalized tissue. Articular ends of the bone excised with area of necrosis. The wound is thoroughly cleaned mechanically and washed with antiseptic solutions. During the process to determine the required size of the spacer, and the type of antibiotic, included in its composition, to determine the operation according to microbiological research and sensitivity of pathogenic organisms. To improve the efficiency of action of antibiotics and their concentrations the spacer is fixed with bone cement, which are added to the process operations are also selected antibiotic. The spacer is fixed in position by the tension surrounding the joint muscles taking into account the length compensation of the affected limb. After orientation of the elements of the joint (reduction of the spacer) the wound is sutured tightly, bringing in the presence of a drainage� from the joint cavity through the additional skin incision. Postoperative drainage of the produced fractional, periodically blocking the drain tube. Since the concentration of the antibiotic, leaving bone cement is maximum in the first 48-72 h, the fractional drainage is sufficient to produce in the first 2-3 days after surgery. This period is enough for a full evacuation detachable - hematoma of the joint.

In the future, the patient activates, allowed to walk using crutches. Recommended active movement in the joint and partial weight bearing. After the relief of the infectious process (assessment according to laboratory, clinical, microbiological examination punctate joint fluid, etc.) replace the spacer on the standard support endoprosthesis.

The method is illustrated in the radiographs in Fig.1, where 1 a spacer, 2 - standard hip replacement.

Variant of the proposed method is shown by the example of the treatment of septic arthritis of the hip joint (coxitis).

Patient B., 43 years old, contacted the clinic with complaints of pain in the hip joints, which appeared for the first time in 2007. She was treated conservatively with temporary minor positive effect. From 10 February 2010 notes increased pain in the left hip joint, in connection with than one hundred�about impossible to give a support on his left leg. After further examination (CT - picture of destruction of the head of the left femur and the acetabular roof) diagnosed purulent (arthritis) Cox on the left.

09.04.2010 years surgery performed: audit, dental left hip joint, resection of the femoral head with the installation of factory articulating Speiser firm "TECRES" with an antibiotic (gentamicin), established active-flushing system. During surgery: the femoral head is lysed to 50% of its volume, flattened, its surface is hilly, covered osoznanno cloth dirty grey colour. The joint cavity completely filled with granulation tissue of different density and color (grey-dirty, purple, yellow), the latter when removing diffuse bleeding. Produced by osteotomy of the femoral neck at the level of 25 mm above the small trochanter. The head is removed. Acetabulum in all its extent, devoid of cartilage, bone tissue sharply osteoporotic, blood, in the roof area showed a cyst up to 1.5 cm3that removed. Installed drainage system. Layered sutures in the wound. After the operation was carried out fractional wound drainage (5-10 minutes every hour). Drains removed on day 4.

After healing, the patient was discharged to outpatient treatment. Postoperative recurrence of purulent process was not observed. After the dash�military survey 04.03.2011 surgery performed: arthrotomy, the removal of spacer, knee replacement of the left hip joint cementless endoprosthesis "Varioloc" company "AAR" Germany. Head Speiser dislocated into the wound. Found motoblaze growth of bone around the proximal part of Speiser, after excision which removed Epicor. Produced additional filing of the femoral neck at a distance of 15 mm above the small trochanter. Installed components cementless endoprosthesis according to preoperative planning (Fig.1). The postoperative course was uneventful, the patient was discharged to outpatient treatment.

Method of treatment of purulent arthritis, including arthrotomy, removal of necrotic tissue and the affected elements of the joint, initial installation of the spacer from the bone cement with antibiotic, the calculation of the individual characteristics of lesions of the bony elements of the joint, the sensitivity of microflora to antibiotics with the full tension of the para-articular muscles and compensate for the shortening of the limb, layer-by-layer suturing of the wound, drainage, replacement of the spacer for implant arthroplasty after relief of the infectious process, characterized in that the drainage produce fractional, periodically blocking the drainage tube, so that the drainage was carried out for 5-10 minutes every hour for the first 2-3 days after about�erachi.



 

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