PERİPROSTETİK EKLEM ENFEKSİYONUNDA İKİ AŞAMALI KALÇA ARTOPLASTİSİ TEDAVİSİ
Engin Türkay Yılmaz
Alaca Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Çorum, Türkiye
Yılmaz ET. Periprostetik Eklem Enfeksiyonunda İki Aşamalı Kalça Artoplastisi Tedavisi. Karaaslan F. editör. Periprostetik Eklem Enfeksiyonunda Tanı ve Tedavi. 1. Baskı. Ankara: Türkiye Klinikleri; 2024. p.99-107.
ÖZET
Kronik dönemdeki periprostetik kalça enfeksiyonunun standart tedavisi iki aşamalı kalça revizyon artroplastidir. Doğru bir planlamanın ardından birinci aşamada implantın çıkarılması, debridman ve eklem boşluğunu dolduracak antibiyotikli spacer uygulaması yapılır. Özellikle femoral implantın çıkarılmasında yaşanabilecek zorluk sebebiyle genişletilmiş trokanterik osteotomi gerekebilmektedir. Debridman sırasında doku kültürü alınmalıdır. Debridman sonrasında pulsatif lavaj enfeksiyon kontrolünde önemlidir. El yapımı spacerlar cerrah tarafından ihtiyaca uygun bir şekilde şekillendirilir. Kalıplı spacerlar ise çimentonun önceden hazırlanmış bir kalıba dökülmesi ile yapılır. Fabrikasyon spacerların uygulanması kolaydır ve operasyonun süresini kısaltır. Statik spacer ile kalça eklemi benzeri bir yapı oluşturma planlanmazken mobil spacerlar ile alt ekstremitede ağırlık verme ve fonksiyonel mobilite sağlar. Çimentoya eklenecek antibiyotiklerin özellikleri eklem boşluğuna yeterli derecede salınımı sağlayacak uygunlukta olmalıdır. Çimentoda kullanılan antibiyotik miktarı profilaktik olarak kullanılan antibiyotik miktarından daha yüksek dozda olmalıdır ama antibiyotik miktarı arttıkça çimentonun mekanik özel- liklerini zayıfladığı unutulmamalıdır. Birinci aşama sonrasındaki ara dönemde intravenöz antibiyotik uygulaması yapılır. Uygulanacak antibiyotiğin etkene karşı etkili olması için antibiyotik sensitivitesine uygun antibiyotik rejimi planlanmalıdır. Antibiyotik tedavisi sonrasında antibiyotiksiz izlenen dönemde plazmadan sedimentasyon ve C-reaktif protein takibi yapılır. Fibrinojen, D-Dimer ve plazma interlökin-6 seviyesi de fikir verebilir. Bu süre- cin sonunda kalça aspirasyonundan bakteri kültürü, hücre sayımı, polimorfonükleer lökosit oranı, alfa-defensin ve lökosit esteraz testi ile enfeksiyonun eradikasyonu değerlendirilebilir. İkinci aşama öncesinde antibiyotik uygulanmayan bir tatil dönemi verilebilir enfeksiyon değerlendirilebilir. İkinci aşama cerrahisi öncesi yumuşak dokunun reimplantasyon için uygunluğu değerlendirilmelidir. İkinci aşamada enfeksiyon eradike edilememişse debridman ve spacer tekrarlanır. Enfeksiyon eradike edilebildiyse debridman ve lavajdan sonra standart revizyon cerrahisi prensipleri uygulanır.
Anahtar Kelimeler: Protez-ilişkili enfeksiyon; Debridman; Total kalça replasmanı; Antibiyotikler; Kemik çi- mentosu
Citation
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