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摘要：结核（TB，tuberculosis）是一种具有漫长历史的古老疾病，常见于肺。膝关节结核（tuberculosis of the knee）是仅次于脊柱结核和髋关节结核的肺外结核。膝关节结核因其迟发性和非特异性表现，具有显著的发病率。膝关节结核的第二和第三阶段，放射学特征是非常明显且具有诊断性的，几乎可以预测疾病的预后情况。未经治疗的患者逐渐出现膝关节结构破坏，且为不可逆的，必须进行早期干预，以免造成膝关节功能丧失。出现骨质破坏提示已达到晚期，故此类患者预后一般很差。早期可采取保守治疗，如药物治疗等，在疾病早期的患者中产生了良好的治疗效果。对保守治疗没有良好临床治疗效果的患者应在膝关节严重破坏之前早期行手术治疗，如关节镜下病灶清除、关节腔冲洗等。晚期的膝关节结核因膝关节功能的基本丧失，往往采取病灶清除关节融合术，牺牲了膝关节功能，严重影响患者生活体验。随着关节置换术的发展，面对晚期结核性膝关节感染，全膝关节置换术（TKA，total knee arthroplasty）成为保留关节功能的有效手术方式。
关键词：结核；膝关节；置换；治疗
本文引用格式：米尔阿地力·麦麦提依明,袁宏.全膝关节置换术治疗晚期膝关节结核治疗进展[J].世界最新医学信息文摘,2019,19(100):82-84.
Progress of total Knee Arthroplasty in the Treatment of Advanced Tuberculosis of the Knee
Mieradili·Maimaitiyiming,YUAN Hong*
（The Postgraduate School of Xinjiang Medical University,Urumqi Xinjiang）
ABSTRACT：Tuberculosis is an ancient disease with a long history,which is common in the lung.Tuberculosis of the knee(TB of the knee)is an extrapulmonary tuberculosis next to spinal tuberculosis and hip tuberculosis.Because of its delayed and nonspecific manifestations,tuberculosis of the knee joint has a significant incidence.In the second and third stage of tuberculosis of knee joint,the radiologic characteristics are very obvious and diagnostic,which can almost predict the prognosis of the disease.Without treatment,the structure of the knee joint is damaged gradually,and it is irreversible.Early intervention is necessary to avoid the loss of knee joint function.The occurrence of bone destruction indicates that it has reached a late stage,so the prognosis of such patients is generally poor.In the early stage,conservative treatment,such as drug treatment,has produced good therapeutic effect in patients with early disease.For the patients who have no good clinical effect of conservative treatment,the early operation should be performed before the serious destruction of the knee joint,such as arthroscopic focus removal,joint cavity flushing and so on.Because of the basic loss of knee joint function,focal debridement and arthrodesis are often adopted in the late stage of knee joint tuberculosis,which sacrifices the knee joint function and seriously affects the life experience of patients.With the development of joint replacement,total knee arthroplasty(TKA)has become an effective way to preserve joint function in the face of late tuberculosis knee infection.
KEY WORDS：Tuberculosis;Knee joint;Replacement;Treatment
1 介绍
世界卫生组织的《全球结核病报告》指出，2013年估计有900万新发结核病病例和150万肺结核死亡[1]，表明结核病仍然是一项重大的公共卫生挑战。肺外结核在脊柱的发病率较高，它按频率的递减顺序依次为膝关节、髋关节、踝关节、腕关节、骶髂关节[2-3]。由于缺乏特定的临床症状，膝关节结核通常在确诊时已导致相当大的骨质破坏[4-5]。早期的膝关节结核是可以在关节内也可以在关节外，滑膜型或关节内结核的症状、体征和影像学表现可与其他关节内疾病相似，如短暂性滑膜炎、类风湿性关节炎、骨关节炎和骨坏死6。晚期结核性关节炎是指患者临床表现为活动范围缩小，影像学表现为关节间隙明显变窄，关节面破坏，严重者伴关节半脱位或脱位[7]。晚期结核性关节炎必须通过手术治疗，包括关节融合术和全膝关节置换术（TKA）[8]。前者虽然能缓解疼痛和控制感染，但往往会导致肢体功能下降和严重影响患者生活质量[9]。TKA被认为是一种有效的治疗方法，但对于晚期结核性关节炎的手术时机、手术计划和围手术期治疗方案仍存在争议[10]。
2临床表现
膝关节结核患者可出现典型结核中毒症状，如午后低热、寒战、体重减轻等[11]。局部表现通常表现为膝关节肿胀和畸形，影响膝关节功能，走路时可能会出现疼痛。晚期病人出现膝关节严重挛缩，甚至骨性强直[12]。膝关节结构的改变可在膝关节x线片上得到体现。早期可能表现为膝关节周围软组织肿胀影，非负重区域的骨质疏松性改变。到晚期关节软骨及软骨下松质骨明显破坏，可形成局部脓肿，皮肤破溃及窦道形成[13]。
3病灶清除人工关节置换术
早期有学者认为活动性膝关节结核是关节置换术的禁忌症[14]，认为再次复发的风险较高。Eskola等人建议活动性膝关节结核应与TKA之间间隔30年以上[15]，有学者报告指出十年可能是最佳时间间隔[16]。Kim等人提出一年以上的静止期内行TKA有效降低复发率[17]，他们研究中复发的病例静止期只有三四个月时间。但仍有众多国内外学者从假体材料及感染机制进行了一系列的探索，发现羟基磷灰石和钛合金制作的关节假体表面粘附的结核杆菌远不如普通细菌数量，能一定程度上阻碍生物膜形成[18-19]，术前及术后合理应用抗结核药物，术中彻底清创也能防止结核杆菌粘附及繁殖，这为活动期关节结核行关节置换术提供了条件[20]。美国疾病控制中心要求临床医生在术前联合应用利福平、异烟肼、吡嗪酰胺，假如出现异烟肼耐药，则换成乙胺丁醇或链霉素，疗程需达到9个月以上[21]。Ozturkmen等人强调即使是活动性结核也不该成为TKA等的绝对禁忌症[22]。
手术时机的选择上尚有争议，目前认为如果术前2-4周抗结核药物治疗后体温控制在正常范围，膝关节局部红肿症状得到改善，红细胞沉降率和C-反应蛋白进行性下降趋势，无需降到完全正常，根据患者全身营养情况可一期行膝关节置换术[23]。若体温持续37.5℃以上，膝关节局部形成窦道流脓，严重骨质缺损患者可考虑行二期膝关节置换[24]。即使是静止期结核复发的风险总是不能消除的，通过单独的抗结核治疗，药物和手术的结合，必要时行关节假体翻修可达到最终治疗的目的[25-26]。
4术后复发及治疗
一些研究表明，一期人工关节置换成功的决定因素不是长时间的静止期，而是对感染组织的彻底清创，及术后规律使用抗结核药物[27]。有学者报道活动期结核无论是一期关节置换或二期关节置换，都有复发的风险，会导致关节假体松动，下沉等[28]。结核复发的处理方式仍有许多争议[29]。Kim等人报告[17]19名活动期结核膝关节置换患者中有3例复发，其中1名患者通过18个月的抗结核药物治疗获得成功；其余2位患者行病灶清除术，然后接受了连续18个月的抗结核药物治疗，解决了复发问题，没有进行任何关节假体翻修术。Johnson等人建议[30]移除关节假体以达到控制感染的目的，而McCullough建议[31]通过抗结核药物治疗及充分病灶清除可控制复发感染。Yoon等人强调[32-33]对结核杆菌感染组织的充分清除及术后至少1年的抗结核药物治疗对防止复发至关重要。若这些尝试都失败那么移除关节假体将是控制感染的唯一办法。Su等人报告[34]15例患者中5例复发，而这5人中有4人未接受术前抗结核药物治疗。在后续的治疗中其中1例接受了抗结核药物，余3例均接受病灶清除、抗结核药物治疗，疗程12-16月。最后一位接受长期皮质醇类药物治疗的类风湿性关节炎患者，由于抗结核治疗和外科清创未能控制感染的复发，接受了翻修手术。
5 结论
膝关节结核可导致关节破坏、严重残疾，而全膝关节置换术可有效治疗膝关节结核。根据目前的文献支持，对于因先前的结核感染而失去关节活动性的患者，在TKA治疗后预期会有良好的临床结果[35，36，37]。通过正确选择手术适应症，术前和术后抗结核药物的治疗，TKA可以大幅度缓解这部分病人的疼痛感，改善膝关节功能。多数作者主张术后抗结核抗生素治疗12-18个月[38，39，40]。当再次感染发生时，通常可以单独用抗结核药物治疗。因此，如果假体位置固定良好抗结核药物治疗应是第一道防线。Veloci等人的报告也证实了这一点[41]，该报告分析两例膝关节结核关节置换术后复发的患者，在未翻修关节假体的情况下应用抗结核药物获得了良好的治疗效果。
一期还是二期TKA？在Ozturkmen等人的研究中，所有12例患者均进行了二期TKA[13]。与此相反的是Kim等人的研究中22例患者中只有1例接受了二期TKA[17]。哈巴西等人报道10例患者均接受了一期TKA[25]。Zeng等人[9]在9例TKA中4例炎性指标升高的患者接受了二期TKA，其余炎性指标正常的患者接受了一期TKA。当进行二期手术时在组织活检的同时进行彻底的清创，并确认是否合并活动性感染，可以如Ozturkmen等人报道植入抗生素骨水泥，两个阶段手术之间的间隔应限制在6个月内，避免最终假体植入时膝关节僵硬[13]。
全膝关节置换术已被证明是治疗晚期膝关节结核的有效治疗手段，当然这是在严格把握手术适应症及制定严密的围术期计划的前提下进行。目前的证据支持术前和术后接受抗结核药物治疗，以降低复发的风险。结核仍然是全球性难题，发病率及耐药菌株的传播日益增加，这需要每位骨科医生都必须要更好地了解如何、何时、什么样的条件下对这些患者行TKA，以便取得良好手术治疗效果，降低复发风险，也需要进行更大的、更长期的研究来寻找答案。
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