人工全髋关节翻修术治疗假体置换术后感染

目的:探讨全髋关节置换术后假体周围感染的治疗方法.方法:1998年1月～2002年6月共收治7例全髋关节置换术后感染患者.采用一期全髋关节翻修术3例,二期全髋关节翻修术4例,术后平均随访14个月.结果:患者髋关节评分平均提高37.6分(Harris评分),经随访无一例感染患者复发.结论:人工全髋关节置换术后感染患者经过彻底清创和使用有效抗生素治疗后,可一期或二期进行全髋关节翻修术,治疗假体周围感染,改善患肢关节功能.     

人工全髋关节翻修术治疗假体置换术后感染

目的:探讨全髋关节置换术后假体周围感染的治疗方法。方法:1998年1月～2002年6月共收治7例全髋关节置换术后感染患者。采用一期全髋关节翻修术3例,二期全髋关节翻修术4例,术后平均随访14个月。结果:患者髋关节评分平均提高37.6分(Harris评分),经随访无一例感染患者复发。结论:人工全髋关节置换术后感染患者经过彻底清创和使用有效抗生素治疗后,可一期或二期进行全髋关节翻修术,治疗假体周围感染,改善患肢关节功能。     

二期翻修术治疗髋关节假体周围感染

[目的]探讨采用临时间隔物并二期髋关节翻修手术治疗髋关节假体周围感染的有效性和治疗效果。[方法]回顾性分析2010年1月~2014年3月进行二期髋关节翻修手术治疗髋关节假体周围感染的29例患者资料。其中男18例,女11例,平均年龄(58.48±12.26)岁。采用一期取出假体、清创的抗生素间隔物置入,二期行关节翻修置换术。分析患者感染病原,通过比较术前术后Harris评分评估翻修术的效果。[结果]2例细菌培养为耐甲氧西林金黄色葡萄球菌(MRSA)的患者经数次清创后仍不能控制感染,另1例患者二期翻修因感染复发失败。其余26例患者二期手术后平均随访(29.12±9.26)个月(12~51个月),没有发生假体松动和感染复发,术前Harris评分平均为(48.11±19.42)分(18~91分),末次随访时平均为(84.27±14.11)分(58~100分),差异具有统计学意义(P0.05)。[结论]髋关节假体周围感染通过一期清创,间隔物置入及二期翻修手术可以有效控制感染并重建髋关节功能。而MRSA造成的髋关节假体周围感染是一期清创失败的原因之一。     

人工全髋关节翻修术治疗假体置换术后感染

目的：探讨全髋关节置换术后假体周围感染的治疗方法。方法：1998年1月～2002年6月共收治7例全髋关节置换术后感染患者。采用一期全髋关节翻修术3例，二期全髋关节翻修术4例，术后平均随访14个月。结果：患者髋关节评分平均提高37．6分(Harris评分)，经随访无一例感染患者复发。结论：人工全髋关节置换术后感染患者经过彻底清创和使用有效抗生素治疗后，可一期或二期进行全髋关节翻修术，治疗假体周围感染，改善患肢关节功能。     

保留假体清创治疗急性假体周围感染

[目的]探讨保留假体清创治疗急性假体周围感染(PJI)的临床效果与炎性指标的早期变化.[方法]2010年1月～2017年8月,对28例髋/膝关节置换术后急性PJI患者采用保留假体清创联合抗生素治疗,设为感染组.随机选取同期初次髋/膝关节置换患者40例为非感染组.比较两组患者围手术期、随访与实验室检验结果.[结果]两组患...     

保留假体碘伏冲洗治疗人工关节置换术后急性假体周围感染

目的评估清创灌洗+碘伏浸泡,保留假体的手术策略治疗急性假体周围感染(PJI)的临床疗效。方法回顾性分析上海长海医院自2011年4月至2015年8月间收治的28例急性PJI的患者,纳入标准:初次人工关节置换术后,通过关节液培养或术中病理确诊为PJI,且发病时间小于4周,未发现窦道形成,排除标准:患者自诉对碘过敏。治疗方法采用在传统清创灌洗,保留假体的基础上,增加碘伏浸泡,时间不少于20 min,术中更换假体可动组件,术后给予足量足疗程抗生素治疗。采用SPSS 20.0软件的重复测量方差分析对手术前后的功能评分进行比较,包括Harris髋关节疼痛与功能评分、纽约特种外科医院(HSS)膝关节疼痛与功能评分和加州大学洛杉矶分校(UCLA)评分。结果平均随访时间(48±16)月,所有28例患者中有25例感染得到控制,在最近的随访中均停用抗生素。其中,12例全髋关节置换(THA)患者Harris评分平均为(94.2±2.3)分,13例全膝关节置换(TKA)患者HSS评分平均为(94.5±2.5)分。感染复发3例均出现在TKA组,后期行两期置换。清创术后与术前比较,Harris评分、HSS评分、和UCLA评分均显著改善(均为P0.05)。结论与同期单纯采用清创灌洗,保留假体治疗急性PJI的文献结果相比,在传统清创灌洗的基础上增加碘伏浸泡的方法,可能提高急性PJI的感染控制率,但仍需大样本量随访观察。     

保留假体清创术在膝关节假体周围感染中的应用

目的探讨保留假体清创结合抗生素骨水泥间质体填充及负压封闭引流技术辅助治疗膝关节置换术后假体周围感染的疗效。 方法选取2014年6月至2019年6月收治的12例膝关节置换术后假体周围感染的病历资料，男女各6例；平均年龄(60±9)岁。所有患者均行膝关节彻底清创，取出聚乙烯衬垫，使用万古霉素骨水泥间质体填充，负压封闭引流技术(VSD)，术后生理盐水持续冲洗1周为一周期，待感染控制后取出间质体更换同种型号衬垫并关闭术口。术后使用万古霉素稀释后关节腔注射，并复查白细胞、降钙素原、血沉、C-反应蛋白检测感染控制情况。采用独立样本t检验分析比较术前及术后3个月视觉模拟评分法(VAS)、美国特种外科医院膝关节评分(HSS)评估患者症状改善及功能恢复情况。 结果所有患者经过3～4周治疗，术口均甲级愈合，复查白细胞、降钙素原、血沉、C-反应蛋白等指标逐渐恢复正常。出院后患者均获得12～60个月随访，平均(30.1±17.8)个月。患者均无感染复发或新的感染，术后3月VAS评分及HSS评分[VAS评分(1.1±1.0)分；HSS评分(87.3±5.4)分]与治疗前相比[VAS评分(5.5±1.4)分；HSS评分(43.0±16.2)分]相比明显改善(t＝8.713，P <0.05; t＝8.970，P <0.05)。 结论保留假体清创结合抗生素骨水泥间质体填充及负压封闭引流技术在治疗膝关节置换术后假体周围感染中能够有效控制感染且保留良好的关节功能。     

初次髋关节置换术后早期感染的手术治疗体会

目的探讨初次人工髋关节置换术后假体周围早期感染的手术治疗经验及其效果。方法本组9例初次人工髋关节置换术后假体周围早期感染,关节穿刺做为主要诊疗手段。确定感染的患者尽快根据药敏结果抗生素治疗。抗生素治疗一周效果不佳者、局部脓肿和窦道形成者及穿刺抽出脓液者尽快手术。感染4周内者以抗生素＋清创＋闭式灌洗术式为主,超过4周者行一期翻修。1例清创失败者取出假体旷置后二期翻修。所有患者于术后1、3、6、12个月和以后每年复诊,随访时间2452个月,平均37个月。内容包括Harris髋关节功能评分、X线评估、血沉和CRP的复查。结果 9例患者均恢复良好,局部症状消失。体温、C反应蛋白、血沉及周围血象均恢复正常,关节功能得到恢复。末次随访时均未见感染复发,髋关节Harris评分由术前平均44.6分（2466分）提高到术后的平均85.3分（7194分）。结论初次人工髋关节置换术后假体周围早期感染国内外文献报告均较少,仅能得出较初步的经验。术前关节腔穿刺及术中菌培养对诊断及治疗极有帮助。在对患者的临床表现和各项检查结果进行综合评价的基础上,如有把握清创彻底,抗生素治疗得当,可考虑先行一期保留假体清创或取出假体翻修手术。     

保留假体清创治疗人工膝关节置换术后感染的作用

[目的]探讨保留假体清创在治疗人工膝关节置换术后感染中的可行性、适应证、成功和失败的相关因素以及注意事项.[方法]回顾分析本院自1990～2004年收治的人工膝关节置换术后感染病例,发现9例病人在治疗开始时曾尝试采用清创灌注冲洗的方法保留假体,对这9例病人进行总结,并对可能影响清创是否成功的因素进行统计学分析.[结果]本组9例病人中4例保留了假体,平均随访18个月（10～25个月）,感染均无复发.由于病例数较少,本研究针对可能影响清创成功的因素未能得出有意义的统计学结果,但从结果看：急性感染清创容易成功,而慢性感染则很难获得成功;表皮葡萄球菌成功率较高,金黄色葡萄球菌均失败;表面膝置换成功率较高,而铰链膝置换则难以获得成功;出现症状后应该抓紧时间进行清创,延误的时间越长,成功的可能性越低.[结论]保留假体清创在人工膝关节置换术后感染的治疗中有一定的应用价值,对于术后急性感染病人和术后晚期急性血源性感染病人应尝试进行保留假体清创治疗,但必须严格掌握手术时机及适应证才能获得成功.     

髋膝人工关节置换术后感染保留假体的清创治疗

目的 探讨人工髋、膝关节置换术后感染保留假体清创治疗的指征及注意事项.方法 回顾性分析自2004～2009年收治的7例髋、膝关节置换术后感染(髋3例,膝4例),经术前诊断、评估,行清创加术后抗生素抗感染的保留假体治疗,分析成功、失败原因.结果 7例中5例保留了假体,随访5～72个月,平均24.8个月,感染均无复发.2例...     

Explantation,Followed by Serial Debridement Without Antibiotic Spacers and Subsequent Revision With Cementless Components,Is Associated With High Remission Rates and Low Mortality in Periprosthetic Hip Joint Infections

BackgroundIn difficult-to-treat cases, it is necessary to add debridement steps in prosthesis-free interval of 2-stage exchange. We aimed to analyze the functional and clinical outcome of patients treated with a multistage exchange of total hip arthroplasty without the use of spacers, rather only cementless implants.MethodsBetween 2009 and 2018, 84 patients (mean age: 67.3 [39-90] years) suffering chronic late-onset periprosthetic joint infection (PJI) were treated using a multistage prosthesis exchange without spacers. The mean follow-up was 70 ± 45.3 [14-210] months. The treatment included prosthesis exchange and at least 1 additional revision step before a reimplantation, owing to ongoing acute infection in the prosthesis-free interval. High-efficiency antimicrobial therapy was administered in between, which was discontinued after cementless revision implantation.ResultsThe mean number of revisions between explantation and implantation was 2.6 (1-9). The most common microorganism was Staphylococcus epidermidis (53.6%) followed by Staphylococcus aureus (16.7%) and Cutibacterium acnes (11.9%). The bacterial load was more than one bacterium per patient in 38% of cases. All patients could be treated using a cementless implant. PJI remission was achieved in 92% of cases. Overall, 9 prostheses (11%) were replaced because of an ongoing PJI or fracture. The mean modified Harrison Hip Score was 63.4 (22-88) points. No patient died.ConclusionMultistage total hip arthroplasty exchange showed high remission rates and low mortality in difficult-to-treat cases. Spacer-free and multistage treatment had no negative effect on the success rate or functional outcome, consistent with the results of published 2-stage exchange studies. Implantation of an uncemented press-fit prosthesis was possible in all patients with no elevated periprosthetic fracture rate.     

A Second Surgical Debridement for Acute Periprosthetic Joint Infections Should Not Be Discarded

BackgroundIn acute periprosthetic joint infections (PJIs), a second surgical debridement (debridement, antibiotics, and implant retention [DAIR]) is generally not recommended after a failed first one. We identified the failure rate of a second DAIR and aimed to identify patients in whom an additional debridement might still be beneficial.MethodsPatients with acute PJI of the hip or knee and treated with DAIR between 2006 and 2016 were retrospectively evaluated. A second DAIR was routinely performed provided that the soft tissue was intact. Failure of a second DAIR was described as (1) the need for additional surgical intervention to achieve infection control, (2) the need for antibiotic suppressive therapy due to persistent clinical and/or biochemical signs of infection, or (3) PJI related death.ResultsFrom the 455 cases treated with DAIR, 144 cases underwent a second debridement (34.6%). Thirty-seven cases failed (37/144, 25.7%). The implant needed to be removed in 23 cases (23/144, 16%). Positive cultures during the second DAIR (odds ratio 3.16, 95% confidence interval 1.29-7.74) and chronic renal insufficiency (odds ratio 13.6, 95% confidence interval 2.03-91.33) were independent predictors for failure in the multivariate analysis. No difference in failure was observed between persistent infection with the same microorganism and reinfection with a new microorganism (failure rate 31.6% vs 34.6%, P = .83).ConclusionA second DAIR had a low failure rate in our cohort of patients and the implant could be retained in the majority of them. Therefore, a second DAIR should not be discarded in acute PJIs.     

Outcome of Debridement,Antibiotics, and Implant Retention With Modular Component Exchange in Acute Culture-Negative Periprosthetic Joint Infections

BackgroundModular component exchange and culture-directed antibiotic treatment is routinely employed for acute periprosthetic joint infection (PJI). However, as many as 7%-23% of PJIs have been reported to yield negative culture results. The efficacy of debridement, antibiotics, and implant retention (DAIR) with modular component exchange in the setting of acute culture negative PJI remains largely unknown. The aim of our study is to evaluate the outcomes of DAIR with modular component exchange in acute culture-positive and culture-negative PJI.MethodsA total of 149 consecutive patients with primary total joint replacements (90 total knee arthroplasties and 59 total hip arthroplasties) who underwent DAIR with modular component exchange for acute PJI with at least 3 years of follow-up were evaluated: (1) 46 culture-negative PJI patients and (2) 103 culture-positive PJI patients. Reinfection and aseptic revision rates along with complication rates were compared.ResultsThe reinfection rate for DAIR in acute culture-negative PJI was 13.0% compared to 19.4% in culture-positive PJI (P = .48). Mean survival time from reinfection between culture-negative (7.7 ± 0.4 years) and culture-positive (7.4 ± 0.3 years) PJI groups did not differ significantly (P = .40). Aseptic revision rates were 8.7% and 4.9% (P = .46), respectively, with loosening being the primary reason for implant failure in both cohorts.ConclusionsDespite lack of an identifying organism to guide postoperative antibiotic therapy, DAIR with modular component exchange for acute culture-negative PJI was associated with similar reinfection rates compared to acute culture-positive PJI, suggesting that culture negativity may not be a contraindication to DAIR in patients with acute PJI.     

Total Femur Antibiotic Spacers: Effective Salvage for Complex Periprosthetic Joint Infections

BackgroundA simultaneous periprosthetic joint infection (PJI) of an ipsilateral hip and knee arthroplasty is a challenging complication of lower extremity reconstructive surgery. We evaluated the use of total femur antibiotic-impregnated polymethylmethacrylate (PMMA) bone cement spacers in the staged treatment of such limb-threatening PJIs.MethodsThirteen patients were treated with a total femur antibiotic spacer. The mean age at the time of spacer placement was 65 years. Nine patients had polymicrobial PJIs. All spacers incorporated vancomycin (3.0 g/40 g PMMA) and gentamicin (3.6 g/40 g PMMA), while 8 also included amphotericin (150 mg/40 g PMMA). Eleven spacers were biarticular. Twelve spacers were implanted through one longitudinal incision, while 8 of 12 reimplantations occurred through 2 smaller, separate hip and knee incisions. Mean follow-up after reimplantation was 3 years.ResultsTwelve (92%) patients underwent reimplantation of a total femur prosthesis at a mean of 26 weeks. One patient died of medical complications 41 days after spacer placement. At latest follow-up, 3 patients had experienced PJI recurrence managed with irrigation and debridement. One required acetabular component revision for instability. All 12 reimplanted patients retained the total femur prosthesis with no amputations. Eleven (91%) were ambulatory, and 7 (58%) remained on suppressive antibiotics.ConclusionTotal femur antibiotic spacers are a viable, but technically demanding, limb-salvage option for complex PJIs involving the ipsilateral hip and knee. In the largest series to date, there were no amputations and 75% of reimplanted patients remained infection-free. Radical debridement, antimicrobial diversity, prolonged spacer retention, and limiting recurrent soft tissue violation are potential tenets of success.Level of EvidenceIV.     

病灶清除加髓腔持续负压封闭引流治疗胫骨慢性骨髓炎

目的：探讨病灶清除加髓腔持续负压封闭引流对胫骨慢性骨髓炎的治疗效果。方法：2006年3月至2009年5月,采用彻底病灶清除,骨皮质开槽并髓腔内持续负压封闭引流治疗胫骨慢性骨髓炎19例,二次手术闭合创面,其中男12例,女7例;年龄25-68岁,平均39岁,均为创伤后导致的胫骨慢性骨髓炎,迁延不愈。病程10个月～5年。临床症状：局部软组织红肿、压痛、流脓,有经久不愈窦道及恶臭脓液流出。X线片示：骨质硬化,密度增高,有死骨、死腔或形成包壳。细菌培养：绿脓杆菌3例,金黄色葡萄球菌13例,产气杆菌1例,溶血性链球茵2例。其中3例为耐甲氧西林的金黄色葡萄球菌。结果：经清创、负压封闭引流18～22d,创面肉芽新鲜,直接缝合创面17例,行皮瓣移位修复创面2例,创面愈合标准是创面干燥、清洁,无渗液。所有创面I期愈合,观察6—12个月窦道无复发,X线片示骨质生长良好,没有发生骨折。结论：病灶清除加髓腔持续负压封闭引流是治疗胫骨慢性骨髓炎的一种安全、有效的方法．     

Preoperative waiting time increased the risk of periprosthetic infection in patients with femoral neck fracture

Background and purpose Prosthetic joint infection (PJI) remains a devastating complication of arthroplasty. Today, most displaced femoral neck fractures in the elderly are treated with arthroplasty. We estimated the incidence of and risk factors for PJI in primary arthroplasty after femoral neck fracture.

Patients and methods Patients admitted for a femoral neck fracture in 2008 and 2009 were registered prospectively. We studied clinical, operative, and infection data in 184 consecutive patients.

Results 9% of the patients developed a PJI. Coagulase-negative staphylococci and Staphylococcus aureus were the most frequently isolated organisms. We found that preoperative waiting time was associated with PJI and also with urinary tract infection. The median preoperative waiting time was 37 (11–136) h in the infection group as opposed to 26 (4–133) h in the group with no infection (p = 0.04). The difference remained statistically significant after adjusted analysis. The success of treatment with debridement and retention of the prosthesis was limited, and 5 of the 17 patients with PJI ended up with a resection arthroplasty. The 1-year mortality rate was 21% in the patients with no infection, and it was 47% in the infection group (p = 0.03).

Interpretation We found a high incidence of PJI in this elderly population treated with arthroplasty after hip fracture, with possibly devastating outcome. The length of stay preoperatively increased the risk of developing PJI.     

人工髋关节置换术后感染的临床经验分析

目的 总结人工髋关节感染的诊断及治疗方法。方法回顾性分析1975年5月至2004年12月收治的人工髋关节置换术后感染患者43例44髋的临床资料,其中男25例26髋,女18例18髋;本院感染病例16例16髋,外院感染病例27例28髋,平均年龄为54岁（24～81岁）。平均随访时间3年3个月（5个月～16年）。治疗包括：I期翻修7例,其中2例失败后行切除成形术;Ⅱ期翻修15例16髋,切除成形13例;保留假体清创5例;抗生素治疗、髋关节融合和截肢各1例。43例患者中40例术前和术中培养阳性,共培养出59株细菌,其中表皮葡萄球菌19株,金黄色葡萄球菌10株。结果术后随访36例,感染均无复发。29例进行术后Harris评分,平均为78．5分（45～98分）。结论人工髋关节置换术后感染诊断治疗均很困难,细菌毒力高、耐药率高,治疗时应予以重视,治疗方法选择应根据具体情况而定,以Ⅱ期翻修较为理想。     

Development of a Preoperative Risk Calculator for Reinfection Following Revision Surgery for Periprosthetic Joint Infection

BackgroundA recent systematic review demonstrated that reinfection rates following eradication of hip and knee periprosthetic joint infection (PJI) may be as high as 29%. This study aimed to develop a preoperative risk calculator for assessing patient’s individual risk associated with reinfection following treatment of PJI in total joint arthroplasty (TJA).MethodsA total of 1081 consecutive patients who underwent revision TJA for PJI were evaluated. In total, 293 patients were diagnosed with TJA reinfection. A total of 56 risk factors, including patient characteristics and surgical variables, were evaluated with multivariate regression analysis. Analysis of the area under the receiver operating characteristics curve was performed to evaluate the strength of the predictive model.ResultsOf the 56 risk factors studied, 19 were found to have a significant effect as risk factor for TJA reinfection. The strongest predictors for TJA reinfection included previous PJI treatment techniques such as irrigation and debridement, the number of previous surgical interventions, medical comorbidities such as obesity, drug abuse, depression and smoking, as well as microbiology including the presence of Enterococcus species. The combined area under the receiver operating characteristics curve of the risk calculator for periprosthetic hip and knee joint reinfection was 0.75.ConclusionsThe study findings demonstrate that surgical factors, including previous PJI surgical treatment techniques as well as the number of previous surgeries, alongside microbiology including the presence of Enterococcus species have the strongest effect on the risk for periprosthetic THA and TKA joint reinfection, suggesting the limited applicability of the existing risk calculators for the development of PJI following primary TJA in predicting the risk of periprosthetic joint reinfection.     

Irrigation and Debridement With Implant Retention: Does Chronicity of Symptoms Matter?

BackgroundPeriprosthetic joint infection (PJI) remains a rare, yet devastating complication of total joint arthroplasty (TJA). Chronic infection is generally considered a contraindication to debridement, antibiotics, and implant retention (DAIR); however, outcomes stratified by chronicity have not been well documented.MethodsA retrospective review of all DAIR cases performed at a single institution from 2008 to 2015 was performed. Chronicity of PJI was categorized as acute postoperative, chronic, or acute hematogenous. Failure after DAIR, defined as re-revision for infection recurrence with the same organism, was evaluated between the 3 chronicity groups at 90 days as well as at a minimum 2-year follow-up.ResultsOverall, 248 patients undergoing DAIR for total hip arthroplasty or total knee arthroplasty PJI were included. Categorization of PJI was acute (acute postoperative) in 59 cases (24%), chronic in 54 (22%), and acute hematogenous in 135 (54%). DAIR survivorship was 47% (range 0.3-10 years). Overall, there were 118 (47.6%) treatment failures after DAIR with a minimum of 2-year follow-up. There was no difference in failure rate between total hip or total knee arthroplasty patients (P = .07). Patients infected with Staphylococcus conferred a higher risk of failure for all DAIR procedures regardless of chronicity category.ConclusionIdentification of microbial species prior to undertaking DAIR may be more clinically relevant than stratification according to chronicity category when considering treatment options.     

Dual Surgical Setup May Improve Infection Control Rate of Debridement and Implant Retention Procedures for Periprosthetic Infections of the Hip and Knee

BackgroundDebridement, antibiotics, and implant retention (DAIR) is an appealing treatment option for periprosthetic joint infection (PJI) due to its low cost and low morbidity. There are many nonmodifiable risk factors for DAIR failure that have previously been established. A dual DAIR setup constitutes establishing a new, sterile field after the initial debridement. The purpose of this study is to determine whether the modifiable surgical technique of a dual setup improves the infection control rate following PJI.MethodsA retrospective study was conducted from January 1, 2000 to December 31, 2017 to identify patients who underwent a DAIR procedure as initial surgical treatment for PJI of the hip or knee. Patients were divided between 2 groups, failed and successful DAIR procedures. Failure was defined as infection recurrence requiring surgical intervention. Demographic (age, gender, body mass index, smoking status, American Society of Anesthesiologists status), preoperative comorbidity (hypertension, cardiac disease, diabetes status, depression or anxiety diagnosis, pulmonary disease), operating surgeon, single vs dual setup, hospital, use of long-term antibiotics postoperatively (greater than 6 weeks of intravenous antibiotics), joint, and laterality data were compared between cohorts using multivariate regression analysis.ResultsTwo hundred sixty-three patients were identified who underwent DAIR as the exclusive and initial treatment for PJI. Single vs dual setup, knee vs hip joint, cardiac or vascular disease diagnosis, major depressive disorder or generalized anxiety disorder diagnosis, and staphylococcal infections were found to be independent predictive variables for DAIR failure.ConclusionIn our series, the dual setup DAIR was a modifiable surgical technique that significantly decreased the risk of infection recurrence compared to single setup DAIR.