J Arthroplasty:膝关节置换使用倒刺缝线会增加伤口感染率

2014-06-30 小小老虎 丁香园

关节置换手术是目前治疗晚期关节炎的常用方法,其手术技术日趋成熟。但是,一旦出现伤口感染这一外科手术常见并发症则会明显增加医患双方负担、影响治疗效果,最近的一些研究发现膝关节置换术后伤口感染的发生率仍在小于1%和10%之间。 有效关闭伤口的方法要满足以下三个原则:避免感染、促进愈合,并使伤口美观。不锈钢金属皮肤缝合金属钉、编织丝线等多种材料被用于手术后缝合以避免伤口出现愈合不良以及疤痕增生

关节置换手术是目前治疗晚期关节炎的常用方法,其手术技术日趋成熟。但是,一旦出现伤口感染这一外科手术常见并发症则会明显增加医患双方负担、影响治疗效果,最近的一些研究发现膝关节置换术后伤口感染的发生率仍在小于1%和10%之间。

有效关闭伤口的方法要满足以下三个原则:避免感染、促进愈合,并使伤口美观。不锈钢金属皮肤缝合金属钉、编织丝线等多种材料被用于手术后缝合以避免伤口出现愈合不良以及疤痕增生。在膝关节置换手术过程中,必须缝合关闭深筋膜封闭关节腔,因此表皮/真皮的缝合方法会决定手术切口的张力、形状以及外观效果。目前常用的缝合方式为使用可吸收的编织合成线皮下缝合,然后用皮肤金属钉关闭表皮。

带刺缝线伤口缝合线由乙交酯、对二氧环乙酮和三亚甲基碳酸酯共聚而成。是由一条具有单向倒钩的可吸收缝合线、一端的外科手术缝合针以及另一端的环形线圈组成。线体上的倒钩与环形线圈设计允许整个装置在不需打结的情况下完成伤口的组织对合处理。

外科医师可藉此快速稳固地闭合皮肤创口,毋需打结或改变标准的闭合技术。与对合强度等同的传统缝合相比,Covidien公司的V-Loc带刺缝线装置闭合创口的速度最高可快50%。V-Loc带刺缝线详细介绍及手术操作视频详见:http://surgical.covidien.com/products/wound-closure/barbed-sutures#

虽然使用倒刺缝线不产生疤痕、节省手术时间,可以缩短住院时间,在疝气修补和妇科手术中也取得了良好的效果,但是在关节置换手术中使用倒刺缝线的有效性和安全性尚未得到证实。美国纽约哥伦比亚大学医学中心Campbell教授进行了一项回顾性对照研究,发现和常规皮肤金属缝合钉相比,使用带刺缝线关闭伤口的膝关节置换患者发生伤口感染的情况更严重,其研究结果发表在2014年5月的 The Journal of Arthroplasty杂志上。

回顾性研究2007年11月至2011年10的关节置换患者,按照年龄大于18岁、全膝关节置换、单间室膝关节置换等条件设定纳入标准,排除膝关节翻修手术、既往存在膝关节手术史和慢性痴呆的患者。手术均为接受过关节重建专科医师培训并且临床经验超过10年的医师进行。

在屈膝45°时缝合关闭伤口,首先使用Maxon聚葡糖酸酯缝线缝合关闭深筋膜和关节腔。“皮肤金属缝合钉”组患者,使用2.0薇乔线(编织聚羟基乙酸)线间断缝合皮肤,然后使用皮肤缝合钉关闭表皮。“倒刺缝线”组患者先使用2.0V-Loc倒刺缝线缝合皮下,然后使用3.0V-Loc倒刺缝线闭合伤口。未统计缝合关闭伤口的时间。




由于伤口愈合时间通常需要超过12个月,因此在术后4至6周、3个月、1年时对患者进行随访。浅表感染、深部感染、伤口裂开、缝线处脓肿这四种情况被认为是严重伤口并发症,上述感染均需使用抗生素。次要伤口并发症则为:自限性痂皮坏死,大于2°的伤口渗出,关节纤维化,以及疤痕增生。

最终使用“皮肤金属缝合钉”关闭伤口者247例,其中全膝关节置换80.1%,单间室膝关节置换19.9%;“倒刺缝线”169例,全膝关节置换和单间室膝关节置换分别为81.2%和18.8%。手术时两组平均年龄分别为67.6岁和65.3岁。两组患者的合并疾病及Charlson合并症评分没有显著差异。

“皮肤金属缝合钉”组年龄明显大于“倒刺缝线”组,发生伤口感染等术后并发症的可能性本应该更高。但是作者统计发现结果并非如此,“皮肤金属缝合钉”组247例中有18例出现伤口裂开或感染,“倒刺缝线”组169例中有33例出现至少一种以上严重伤口并发症,“倒刺缝线”组切口并发症发生率以及浅表伤口感染、深部感染发生率均明显高于“皮肤金属缝合钉”组。

“倒刺缝线”组有两例深部感染患者(共8例深部感染)进行了关节翻修手术,而“皮肤金属缝合钉”组深部感染的2例患者却无需进行关节翻修。

在次要伤口并发症方面,两组患者的伤口积液和关节纤维化的发生率相似,“倒刺缝线”组患者的表皮坏死发生率要明显高于“皮肤金属缝合钉”组患者,但是后者出现伤口疤痕增生的情况要显著高于前者。

因此作者认为:虽然倒刺缝线在其他部位手术中和皮肤金属缝合钉一样安全有效,但是此次回顾性研究却发现在膝关节置换手术中使用倒刺缝线出现伤口感染的并发症发生率较高,并不安全,在关节置换手术关闭切口时应避免使用倒刺缝线。

原始出处:

Campbell AL1, Patrick DA Jr1, Liabaud B1, Geller JA2.Superficial wound closure complications with barbed sutures following knee arthroplasty.J Arthroplasty. 2014 May;29(5):966-9. doi: 10.1016/j.arth.2013.09.045. Epub 2013 Oct 1.

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