Kwandura ni kimwe mu bibazo bikomeye nyuma yo gusimburanya ibihimbano, ntibizana gusa kubagwa inshuro nyinshi kubarwayi, ahubwo binatwara ibikoresho byinshi byubuvuzi. Mu myaka 10 ishize, igipimo cyanduye nyuma yo gusimburanya ibihimba cyaragabanutse ku buryo bugaragara, ariko umuvuduko w’ubwiyongere bw’abarwayi barimo gusimburanya ibihimbano byarenze kure cyane igipimo cy’igabanuka ry’ubwandu, bityo ikibazo cyo kwandura nyuma yo kubagwa ntigikwiye kwirengagizwa.
I. Impamvu zitera uburwayi
Indwara zanduye nyuma yo guhinduranya zigomba gufatwa nkindwara zanduye ibitaro hamwe n’ibinyabuzima bitera imiti. Ibikunze kugaragara cyane ni staphylococcus, bingana na 70% kugeza 80%, garama-mbi ya bacili, anaerobes na streptococci itari A A nayo irasanzwe.
II Indwara
Indwara zigabanyijemo ibyiciro bibiri: kimwe ni kwandura hakiri kare ikindi ni kwandura bitinze cyangwa byitwa kwandura-gutangira. Indwara hakiri kare ziterwa no kwinjiza bagiteri mu ngingo mu gihe cyo kubagwa kandi ni epidermidis ya Staphylococcus. Indwara zitinze ziterwa no kwandura amaraso kandi akenshi ni Staphylococcus aureus. Ingingo zabazwe zirashobora kwandura. Kurugero, hari igipimo cyubwandu bwa 10% mugihe cyo kwisubiramo nyuma yo gusimburanya ibihimbano, kandi ubwandu nabwo buri hejuru kubantu basimbuye hamwe na rubagimpande ya rubagimpande.
Indwara nyinshi zibaho mugihe cyamezi make nyuma yo kubagwa, iyambere irashobora kugaragara mubyumweru bibiri byambere nyuma yo kubagwa, ariko kandi nko mumyaka mike mbere yuko hagaragara ibimenyetso byambere byerekana kubyimba bikabije kubyimba bikabije, kubabara no kugira umuriro, ibimenyetso byumuriro bigomba gutandukanywa nibindi bibazo, nk'umusonga nyuma yo kubagwa, kwandura inkari nibindi.
Mugihe cyo kwandura hakiri kare, ubushyuhe bwumubiri ntibukira gusa, ahubwo buzamuka nyuma yiminsi itatu nyuma yo kubagwa. Kubabara hamwe ntabwo bigabanuka gusa, ahubwo bigenda byiyongera buhoro buhoro, kandi hariho ububabare butuje kuruhuka. Hariho gusohora bidasanzwe cyangwa gusohora biturutse kumutwe. Ibi bigomba gusuzumwa neza, kandi umuriro ntukwiye guterwa byoroshye kwandura nyuma yo kubagwa mubindi bice byumubiri nkibihaha cyangwa inzira yinkari. Ni ngombwa kandi kutirengagiza gusa gusohora nkibisanzwe nkibisanzwe bisanzwe nko gusohora amavuta. Ni ngombwa kandi kumenya niba ubwandu buri mu ngingo zidasanzwe cyangwa hafi ya protezi.
Ku barwayi bafite indwara zateye imbere, benshi muri bo bakaba baravuye mu bitaro, kubyimba ingingo, kubabara, no kugira umuriro ntibishobora kuba bikomeye. Kimwe cya kabiri cy'abarwayi barashobora kugira umuriro. Epidermidis ya Staphylococcus irashobora gutera indwara itababaza hamwe na selile yera yera yiyongera ku barwayi 10% gusa. Kwiyongera kw'amaraso birasanzwe ariko nanone ntibisobanutse. Ububabare rimwe na rimwe busuzumwa nabi nko kurekura prostate, icya nyuma kikaba ububabare bujyanye no kugenda bigomba koroherezwa nuburuhukiro, nububabare butwika butaruhuka kuruhuka. Icyakora, hasabwe ko impamvu nyamukuru itera prothèse irekura ari ugutinda kwandura indwara zidakira.
III. Gusuzuma
1. Ikizamini cya Haematologiya:
Ahanini ushizemo ibara ryamaraso yera wongeyeho ibyiciro, interleukin 6 (IL-6), C-reaction proteine (CRP) nigipimo cyimitsi ya erythrocyte (ESR). Ibyiza byo gusuzuma haematologiya biroroshye kandi byoroshye kubikora, kandi ibisubizo birashobora kuboneka vuba; ESR na CRP bifite umwihariko muto; IL-6 ifite agaciro gakomeye muguhitamo kwandura periprosthetic mugihe cyambere yo kubaga.
2.Ikizamini cyerekana amashusho:
Filime X-ray: ntabwo yoroheje cyangwa idasanzwe mugupima indwara.
X-ray ya firime yo kwanduza ivi
Arthrography: imikorere nyamukuru ihagarariye mugupima kwandura ni isohoka ryamazi ya synovial na abscess.
CT.
MRI: yunvikana cyane mugutahura hakiri kare amazi hamwe nibisebe, ntibikoreshwa cyane mugupima indwara zanduye.
Ultrasound: kwirundanya kw'amazi.
3.Ubuvuzi bwa kirimbuzi
Technetium-99 yogusuzuma amagufwa ifite sensibilité ya 33% kandi ifite umwihariko wa 86% mugupima indwara ya periprosthetic nyuma ya arthroplastique, na indium-111 yanditseho leukocyte scan ifite agaciro kanini mugupima indwara zanduye, zifite sensibilité ya 77% kandi yihariye 86%. Iyo scan ebyiri zikoreshwa hamwe mugusuzuma indwara zanduye nyuma ya arthroplastique, hashobora kugerwaho sensibilité yo hejuru, umwihariko nukuri. Iki kizamini kiracyari igipimo cya zahabu mubuvuzi bwa kirimbuzi kugirango hamenyekane indwara zanduye. Fluorodeoxyglucose-positron yoherejwe na tomografiya (FDG-PET). Itahura ingirabuzimafatizo hamwe no gufata glucose mu gice cyanduye.
4. Ubuhanga bwibinyabuzima bwa molekuline
PCR: ibyiyumvo byinshi, ibyiza byibinyoma
Ikoranabuhanga rya chip chip: icyiciro cyubushakashatsi.
5. Arthrocentezi:
Isuzuma rya cytologiya ryamazi, umuco wa bagiteri no gupima ibiyobyabwenge.
Ubu buryo buroroshye, bwihuse kandi bwuzuye
Mu kwandura ikibuno, guhuza amazi ya leucocyte kubara> 3000 / ml hamwe no kwiyongera kwa ESR na CRP nicyo gipimo cyiza cyo kubaho kwa periprosthetic.
6. Intooperative yihuta gukonjesha igice histopathology
Igice cyihuta cyakonjeshejwe igice cya periprosthetic tissue nuburyo bukoreshwa cyane muburyo bwo kwisuzumisha mugupima histopathologique. Ibipimo byo kwisuzumisha kwa Feldman, ni ukuvuga, birenze cyangwa bingana na neutrophile 5 kuri magnificaire (400x) byibuze imirima 5 itandukanye ya microscopique, akenshi ikoreshwa mubice byafunzwe. Byerekanwe ko sensitivite nuburyo bwihariye bwubu buryo buzarenga 80% na 90%. Ubu buryo ni igipimo cya zahabu yo gusuzuma indwara.
7. Umuco wa bagiteri winyama zindwara
Umuco wa bagiteri wa tissue periprosthetic ufite umwihariko wo gusuzuma indwara kandi wafashwe nkurwego rwa zahabu mugupima indwara zanduye, kandi irashobora no gukoreshwa mugupima ibiyobyabwenge.
IV. Gusuzuma bitandukanyes
Indwara zifata ububabare buterwa n'ububabare buterwa na epidermidis ya Staphylococcus ziragoye gutandukanya no kwangirika kwa prostate. Igomba kwemezwa na X-ray nibindi bizamini.
V. Umuti
1. Ubuvuzi bworoshye bwa antibiotique
Tsakaysma na se, gawa yashyize mu majwi indwara ya arthroplastique yanduye mu bwoko bune, ubwoko bwa I simptomatique, umurwayi ari mu muco wo kubaga uduce twinshi dusanga dufite imikurire ya bagiteri, kandi byibuze ingero ebyiri zifite umuco hamwe na bagiteri imwe; ubwoko bwa II ni infection hakiri kare, ibaho ukwezi kumwe kubagwa; ubwoko bwa IIl ni indwara yatinze; n'ubwoko bwa IV ni infection ikaze ya haematogenous. Ihame ryo kuvura antibiyotike iroroshye, umubare uhagije nigihe. Kandi mbere yo gutangira gufatira hamwe hamwe n'umuco wa tissue intraoperative bifite akamaro kanini muguhitamo neza antibiyotike. Niba umuco wa bagiteri ari mwiza mubwoko bwa I, gukoresha byoroshye antibiyotike zibyumweru 6 bishobora kugera kubisubizo byiza.
2. Kugumana prothèse, debridement na drainage, kubaga kuvomera amazi
Ikibanza cyo gufata icyemezo cyo guhahamuka kigumana imiti ya prothèse ni uko prothèse ihamye kandi yanduye cyane. Ibinyabuzima byanduza birasobanutse, virusi ya bagiteri ni mike kandi antibiyotike yunvikana irahari, kandi liner cyangwa spacer birashobora gusimburwa mugihe cyo guta. Ibipimo byo gukira bya 6% gusa hamwe na antibiotike yonyine na 27% hamwe na antibiotike hiyongereyeho debridement no kubungabunga prothèse byavuzwe mubitabo.
Irakwiriye kwandura hakiri kare cyangwa kwandura haematogenous kwandura hamwe na prothèse nziza; nanone, biragaragara ko kwandura ari virusi nkeya ya virusi itera virusi itera mikorobe. Ubu buryo bugizwe no kuvanaho neza, kwanduza mikorobe no kumena amazi (igihe cyibyumweru 6), hamwe na mikorobe ya nyuma yimikorere ya mikorobe (kumara ibyumweru 6 kugeza kumezi 6). Ibibi: igipimo kinini cyo kunanirwa (kugeza 45%), igihe kirekire cyo kuvura.
3. Kubaga icyiciro kimwe cyo kubaga
Ifite ibyiza byo guhahamuka gake, kumara igihe gito mubitaro, kugiciro gito cyubuvuzi, inkovu nkeya no gukomera hamwe, bifasha kugarura imikorere ihuriweho nyuma yo kubagwa. Ubu buryo burakwiriye cyane cyane kuvura indwara zanduye hakiri kare na haematogenous infection.
Gusimbuza icyiciro kimwe, ni ukuvuga uburyo bwintambwe imwe, bugarukira gusa ku kwandura uburozi buke, kuvanaho neza, sima ya antibiotique, no kuboneka kwa antibiotike zoroshye. Ukurikije ibisubizo bya tissue intraoperative tissue yahagaritswe, niba hari munsi ya 5 leukocytes / umurima wo gukuza cyane. Itanga igitekerezo cyo kwandura uburozi buke. Nyuma yo kuvanaho neza hakozwe icyiciro kimwe cya arthroplastique kandi ntihigeze kubaho kwandura nyuma yibikorwa.
Nyuma yo gukuraho neza, prothèse ihita isimburwa bidakenewe inzira ifunguye. Ifite ibyiza byo guhahamuka bito, igihe gito cyo kuvura nigiciro gito, ariko igipimo cyongera kwandura nyuma yo kubagwa kiri hejuru, ni hafi 23% ~ 73% ukurikije imibare. Gusimbuza icyiciro cya prothèse icyiciro kimwe bikwiriye cyane cyane kubarwayi bageze mu zabukuru, nta guhuza kimwe muri ibi bikurikira: (1) amateka yo kubagwa inshuro nyinshi ku gihimba cyo gusimbuza; (2) gushinga inzira ya sinus; (3) kwandura gukabije (urugero: septique), ischemia hamwe n'inkovu z'imitsi ikikije; (4) gutesha agaciro ihahamuka hasigaye sima igice; (5) X-ray yerekana osteomyelitis; (6) inenge zamagufa zisaba guhuza amagufwa; (7) indwara zivanze cyangwa bagiteri zifite virusi nyinshi (urugero: Streptococcus D, bacteri za Gram-mbi); (8) gutakaza amagufwa bisaba guhuza amagufwa; (9) gutakaza amagufwa bisaba guhuza amagufwa; na (10) ibihangano byamagufwa bisaba guhuza amagufwa. Streptococcus D, Gram-mbi ya bagiteri, cyane cyane Pseudomonas, nibindi), cyangwa kwandura fungal, kwandura mycobacterial; (8) Umuco wa bagiteri ntusobanutse.
4. Kubaga icyiciro cya kabiri cyo kubaga
Yatoneshejwe n'abaganga babaga mu myaka 20 ishize kubera ibimenyetso byinshi byerekana (ubwinshi bw'amagufwa ahagije, imitsi yoroheje ya periarticular yoroheje) hamwe n'umuvuduko mwinshi wo kurandura indwara.
Umwanya, abatwara antibiotike, antibiotike
Hatitawe ku buhanga bwa spacer bwakoreshejwe, gukosora sima hamwe na antibiotique birakenewe kugirango hongerwe imbaraga za antibiyotike mu ngingo no kongera umuvuduko wo kwandura indwara. Antibiyotike ikoreshwa cyane ni tobramycin, gentamicin na vancomycine.
Umuryango mpuzamahanga w'amagufwa wabonye uburyo bwiza bwo kuvura indwara zanduye nyuma ya artthroplastique. Ubu buryo bugizwe no kuvanaho neza, kuvanaho prothèse nu mubiri w’amahanga, gushyira icyogajuru gihuriweho, gukomeza gukoresha imiti igabanya ubukana bwa mikorobe byibura ibyumweru 6, hanyuma, nyuma yo kugenzura neza kwandura, kwimura prothèse.
Ibyiza:
Igihe gihagije cyo kumenya ubwoko bwa bagiteri hamwe na mikorobe yica mikorobe, ishobora gukoreshwa neza mbere yo kubagwa.
Ihuriro ryizindi sisitemu yibanze yanduye irashobora kuvurwa mugihe gikwiye.
Hariho uburyo bubiri bwo kuvanaho gukuraho tissue nekrotic nu mubiri w’amahanga neza, ibyo bikaba bigabanya cyane umuvuduko wo kwandura indwara zanduye nyuma yo kubagwa.
Ibibi:
Kongera gutera anesthesia no kubaga byongera ibyago.
Igihe kinini cyo kuvura nigiciro kinini cyo kwivuza.
Nyuma yo gukira nyuma yo gukira irakennye kandi itinda.
Arthroplasty: Bikwiranye n'indwara zidakira zidakira kuvurwa, cyangwa inenge nini y'amagufwa; imiterere yumurwayi igabanya kongera gufungura no kunanirwa kwiyubaka. Ububabare busigaye nyuma yo kubagwa, gukenera gukoresha igihe kirekire kugirango ufashe kugendagenda, kutagira aho bihurira, kugabanya ingingo, ingaruka zikorwa, urugero rwo gusaba ni ruto.
Arthroplasty: ubuvuzi gakondo bwo kwandura nyuma yo kubagwa, hamwe no guhagarara neza nyuma yo kubagwa no kugabanya ububabare. Ibibi birimo kugabanya ingingo, guhungabana no gutakaza kugenda.
Amputation: Nuburyo bwa nyuma bwo kuvura indwara zanduye nyuma yo kubagwa. Birakwiriye: (1) gutakaza amagufwa akomeye adasubirwaho, inenge zoroshye; . (3) ifite amateka yo kunanirwa inshuro nyinshi zo kubagwa gusubiramo abarwayi banduye.
VI. Kwirinda
1. Ibintu mbere yo gutangira:
Hindura neza umurwayi mbere yo gutangira kandi indwara zose zisanzwe zigomba gukira mbere yo gutangira. Indwara zandura cyane mu maraso ni iziva mu ruhu, mu nkari, no mu myanya y'ubuhumekero. Mu kibuno cyangwa mu ivi arthroplasti, uruhu rwo hepfo rugomba kuguma rutavunitse. Indwara ya bacteriuria idasanzwe, ikunze kugaragara ku barwayi bageze mu zabukuru, ntabwo ikeneye kuvurwa hakiri kare; ibimenyetso bimaze kugaragara bigomba kuvurwa bidatinze. Abarwayi barwaye toniillite, indwara zo mu myanya y'ubuhumekero yo hejuru, hamwe na tinea pedis bagomba kuvaho. Ibikorwa binini by amenyo nisoko ishobora kwanduza amaraso, kandi nubwo birinze, niba ari ngombwa kuvura amenyo, birasabwa ko ubwo buryo bwakorwa mbere ya artthroplastique. Abarwayi bafite ibibazo rusange muri rusange nka anemia, hypoproteinaemia, diyabete ihuriweho hamwe n'indwara zanduza inkari zidakira bagomba kuvurwa bikabije kandi hakiri kare kugirango indwara yibanze iteze imbere sisitemu.
2. Ubuyobozi bukorana:
(1) Ubuhanga nibikoresho bya aseptic byuzuye bigomba no gukoreshwa muburyo busanzwe bwo kuvura arthroplastique.
.
(3) Agace kibanziriza gutangira kugomba gutegurwa neza mugutegura uruhu.
. Kwambara uturindantoki tubiri birashobora kugabanya ibyago byo guhura n'intoki hagati yo kubaga n'umurwayi kandi birashobora gusabwa.
.
(6) Kunoza tekinike yo kubaga uyikoresha no kugabanya igihe cyo gukora (<2.5 h niba bishoboka). Kugabanya igihe cyo kubaga bishobora kugabanya igihe cyo guhura nikirere, nacyo gishobora kugabanya igihe cyo gukoresha amarushanwa. Irinde kubagwa nabi mugihe cyo kubagwa, igikomere gishobora kuhira inshuro nyinshi (imbunda yo kuhira imbunda ni nziza), kandi kwibiza iyode-vapor birashobora gufatwa kubice bikekwa ko byanduye.
3. Ibintu nyuma yo kubagwa:
. Kubwibyo, gukurikirana amaraso ya glucose nyuma yubuvuzi ni ngombwa.
(2) Umuvuduko ukabije w'amaraso wongera ibyago byo kurwara hematoma hamwe nibibazo biterwa nibikomere. Ubushakashatsi bwakozwe ku bushakashatsi bwerekanye ko gukoresha nyuma ya oporisiyo yo gukoresha heparine nkeya kugira ngo hirindwe imitsi iva mu mitsi byagize akamaro mu kugabanya amahirwe yo kwandura.
. Ibisubizo byibanze byerekana ko catheters intra-articular catheters ikoreshwa nkubuyobozi bwa nyuma yubuvuzi bwa analgesike nayo ishobora kwandura ibikomere.
4. Indwara ya antibiyotike:
Kugeza ubu, ivuriro risanzwe rya dosiye ya antibiyotike ikoreshwa muburyo bwa sisitemu mbere na nyuma yo kubagwa bigabanya ibyago byo kwandura nyuma yo kubagwa. Cephalosporine ikoreshwa cyane mubuvuzi nka antibiotique yo guhitamo, kandi hariho isano U-ifata umurongo uhuza igihe cyo gukoresha antibiyotike nigipimo cy’indwara zandurira ahantu, hamwe n’ibyago byinshi byo kwandura haba mbere na nyuma yigihe ntarengwa cyo gukoresha antibiyotike. Ubushakashatsi bunini buherutse gukorwa bwagaragaje ko antibiyotike zikoreshwa mu minota 30 kugeza kuri 60 mbere yo guterwa zifite umubare muto w’ubwandu. Ibinyuranye na byo, ubundi bushakashatsi bukomeye bwakozwe kuri hip arthroplastique bwerekanye igipimo gito cyo kwandura antibiyotike zakozwe mu minota 30 ya mbere yo gutemwa. Kubwibyo rero igihe cyo kuyobora gifatwa nkiminota 30 mbere yo kubagwa, hamwe nibisubizo byiza mugihe cyo gutera anesteziya. Undi muti wa prophylactique wa antibiotique utangwa nyuma yo kubagwa. Mu Burayi no muri Amerika, ubusanzwe antibiyotike ikoreshwa kugeza ku munsi wa gatatu nyuma yo kubagwa, ariko mu Bushinwa, bivugwa ko ubusanzwe ikoreshwa mu gihe cy'ibyumweru 1 kugeza kuri 2. Icyakora, ubwumvikane rusange ni uko hagomba kwirindwa gukoresha igihe kirekire gukoresha antibiyotike nini nini cyane keretse habaye ibihe bidasanzwe, kandi niba ari ngombwa gukoresha antibiyotike igihe kirekire, ni byiza gukoresha imiti igabanya ubukana ifatanije na antibiyotike kugira ngo wirinde kwandura ibihumyo. Vancomycin yagaragaye ko ifite akamaro mu barwayi bafite ibyago byinshi bitwaje methicilline irwanya Staphylococcus aureus. Umubare munini wa antibiyotike ugomba gukoreshwa kubagwa igihe kirekire, harimo no kubaga byombi, cyane cyane iyo igice cya kabiri cya antibiotique ari gito.
5. Gukoresha antibiotike ufatanije na sima yamagufa:
Isima yatewe na sima nayo yakoreshejwe bwa mbere muri arthroplastique muri Noruveje, aho mu ikubitiro ubushakashatsi bw’imyandikire ya Arthroplasty yo muri Noruveje bwerekanye ko ikoreshwa ry’imiti ya antibiotique IV na sima (antibiyotike ya antibiotique) ryagabanije umuvuduko w’ubwandu bwimbitse kuruta uburyo bwonyine. Ubu bushakashatsi bwemejwe mu ruhererekane rw’ubushakashatsi bunini mu myaka 16 iri imbere. Ubushakashatsi bwakozwe muri Finilande hamwe n’ishyirahamwe ry’imyororokere muri Ositaraliya 2009 ryageze ku myanzuro isa n’uruhare rwa sima yatewe na antibiotique mu nshuro ya mbere no kuvugurura ivi. Byerekanwe kandi ko imiterere ya biomehanike ya sima yamagufa itagira ingaruka mugihe ifu ya antibiotique yongewemo mubipimo bitarenze g 2 kuri 40 g ya sima yamagufa. Ariko, antibiyotike zose ntizishobora kongerwaho sima ya sima. Antibiyotike ishobora kwongerwa kuri sima yamagufa igomba kuba ifite ibi bikurikira: umutekano, ituze ryumuriro, hypoallergenicity, gukemura neza kwamazi, imiti myinshi ya mikorobe, nibikoresho byifu. Kugeza ubu, vancomycine na gentamicin bikoreshwa cyane mubikorwa byubuvuzi. Byatekerezwaga ko antibiyotike yatewe muri sima byongera ibyago byo guterwa na allergique, kuvuka kwingingo zidashobora kwihanganira, no kurekura aseptike ya prostate, ariko kugeza ubu nta kimenyetso kibyemeza.
VII. Incamake
Gukora isuzuma ryihuse kandi ryukuri binyuze mumateka, kwisuzumisha kumubiri hamwe n'ibizamini bifasha ni ikintu gisabwa kugirango uvure neza indwara zanduye. Kurandura ubwandu no kugarura ububabare butagira ububabare, bukora neza ni ihame shingiro mukuvura indwara zanduye. Nubwo antibiyotike yo kuvura indwara yanduye yoroshye kandi ihendutse, kurandura kwandura indwara bisaba guhuza uburyo bwo kubaga. Urufunguzo rwo guhitamo ubuvuzi bwo kubaga ni ukureba ikibazo cyo gukuraho prothèse, aricyo kintu cyibanze cyo guhangana nindwara zifatika. Kugeza ubu, gukoresha antibiyotike, debridement na arthroplasty byahindutse uburyo bwuzuye bwo kwandura indwara zanduye. Ariko, iracyakeneye kunozwa no gutunganywa.
Igihe cyo kohereza: Gicurasi-06-2024
