髋关节感染二期翻修手术中应用骨水泥型假体占位器

假体周围感染(PJI)是全髋关节置换术后灾难性的并发症,目前二期翻修手术对于髋关节PJI仍是最为有效的治疗方法.传统的抗生素骨水泥关节型占位器的植入是二期翻修间隔期控制感染复发的关键,但既往研究中患者于间隔期髋关节功能及生活质量均处于较低水平.骨水泥型假体是较为新颖的二期翻修占位器设计,以PROSTALAC系统为代表的...     

Preoperative Prediction of Failure Following Two-Stage Revision for Knee Prosthetic Joint Infections

While two-stage revision is the gold standard for treatment of knee prosthetic joint infection (PJI), it is not without risk. The purpose of this study was to develop a tool to preoperatively predict the probability that a two-stage revision would fail to eradicate knee PJI. 3,809 surgical cases were retrospectively reviewed and data were collected from 314 charts. Overall, 105 (33.4%) cases failed to eradicate PJI using this procedure. Univariate analysis identified multiple variables independently associated with reinfection. Logistic regression was used to generate a model (bootstrap-corrected concordance index of 0.773) predicting failure of infection eradication. Preoperative knowledge of a high probability of failure may improve risk assessment, lead to more aggressive management, and allow for time to consider alternative therapies.     

Statin Exposure and Risk of Prosthetic Joint Infection After Total Knee or Hip Arthroplasty Among U.S. Veterans

BackgroundStatins have a variety of pleiotropic effects that could be beneficial for patients undertaking total knee or hip arthroplasty. In vitro and in vivo models suggest the beneficial effects of statins through bone formation and modulating proinflammatory cytokines triggered by implant debris. However, statins also exhibit antimicrobial action and may reduce the risk of revision surgery via reducing the risk of infection. We sought to explore the relationship between statin use and prosthetic joint infection (PJI) after total knee or hip arthroplasty.MethodsWe use a retrospective cohort of patients undergoing total knee or hip arthroplasty performed within the Department of Veterans Affairs. To minimize selection bias between the statin exposed and unexposed patients, we used 1:1 ratio propensity score matching. We fit adjusted Cox proportional hazards models to quantify the risk of PJI between the cohorts within 1 year, 3 years, and all follow-up time.ResultsWith a study period beginning from January 2000, a total of 60,241 patients were included. The unmatched Cox models reveal, over the entire follow-up time, a statistically significant lower risk of infection for the statin exposed patients (hazard ratio = 0.869; 95% confidence interval = [0.79-0.956]). The matched Cox model results reveal a statistically significant lower risk of PJI, only in the overall model, for the statin exposed cohort compared with the unexposed cohort (hazard ratio = 0.895, 95% confidence interval = [0.807-0.993]).ConclusionOur analysis finds some support for the beneficial effects of statins for preventing PJI among patients undergoing total knee or hip arthroplasty.     

Evaluation and Management of Periprosthetic Joint Infection–an International,Multicenter Study

Background

Controversies still exist regarding the optimal diagnostic and therapeutic strategies in patients with prosthetic joint infections (PJI).

Questions/Purposes

How effective are preoperative and intraoperative cultures in isolating organisms and how do these culture results compare to one another? What are the results of surgical treatment of PJI in the hip and knee in an international, tertiary referral center cohort?

Patients and Methods

One hundred sixteen patients (N = 59 hip PJI, N = 57 knee PJI) were recruited prospectively to registries at three international, tertiary referral centers between December 2008 to November 2011. Retrospective review of prospective registry data including demographics, microbiology results, and operative reports was performed.

Results

Preoperative synovial fluid aspiration yielded an organism in only 45.2% and 44.4% of cases, respectively, for knee and hip PJI. False-negative rates of preoperative aspiration relative to intraoperative culture were 56% and 46% in hip and knee PJI, respectively, with discordance rates of 25% and 21.4%, respectively. Rates of negative intraoperative cultures were 15% in hip PJI and 20.7% in knee PJI. Open debridement with prosthetic retention was the most common initial revision procedure performed (48.3% of hip PJI and 63.8% of knee PJI). This method of revision was successful in 41.3% of hip PJI and 59.4% of knee PJI. Initial failure rates for prosthetic revision was lower than debridement with prosthetic retention but remained substantial in both hip PJI (initial success of one-stage exchange 60% and two-stage exchange 70%) and knee PJI (initial success of one-stage exchange 80% and two-stage exchange 75%).

Conclusion

Diagnosis and treatment of PJI remains challenging with difficulty in isolating the offending organism and with high rates of prosthetic revision and initial treatment failures. Future advances in organism isolation and international standardization of treatment protocols may improve patient outcomes.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9366-4) contains supplementary material, which is available to authorized users.     

Ten-Year Results Following One-Stage Septic Hip Exchange in the Management of Periprosthetic Joint Infection

BackgroundAlthough 2-stage revision is still considered the gold standard for surgical management of periprosthetic joint infection (PJI), 1-stage revision has been reported to be as effective. Long-term reports for 1-stage revision in hip PJIs are lacking.MethodsWe reviewed our 10-11 years of results of 85 patients who underwent 1-stage exchange of the hip with an antibiotic-loaded bone cemented prosthesis due to PJI to determine the following: (1) What is the infection-free survival? (2) What is the overall survival? and (3) What are the long-term clinical outcomes? All 1-stage revision total hip arthroplasties (THAs) for infection between January 2006 and December 2007, with a minimum 10-year follow-up (range 10-11), were included in this retrospective cohort. Patients from another country or patients who were unable to participate were excluded. Eighty-five patients with a hip PJI were available at the last follow-up. Thirty-seven patients died during the 10-year study. Harris Hip Scores were recorded before the surgery and at last follow-up. Failures are reported as infection-related or aseptic.ResultsThe 10-year infection-free survival was 94% and the surgery-free survival was 75.9%. The Harris Hip Scores improved from 43 (range 3-91) to 75 (range 10-91) (P < .001). The main indication for re-revision after 1-stage exchange was instability (10/20 patients).ConclusionOne-stage exchange of the hip for PJI is a reliable treatment option with high rate of infection control and long-lasting favorable outcomes.     

髋关节置换术后假体周围感染的治疗

目的 探讨髋关节置换术后假体周围感染患者接受清创术、一期翻修术、二期翻修术及旷置术的临床效果.方法 1993年6月至2008年6月因髋关节置换术后假体周围感染接受手术治疗患者46例,男27例,女19例;年龄34～80岁,平均55.8岁.术前诊断感染的方法包括红细胞沉降率、C反应蛋白检查,放射性核素扫描,窦道分泌物及关节穿刺液培养.行保留假体的清创术7例,一期翻修术14例,二期翻修术21例,旷置术4例.术后观察伤口外观,随访时采用Harris评分对髋关节功能进行评估,行实验室检查确定感染控制情况.结果 46例假体周围感染患者中29例培养结果 阳性,表皮葡萄球菌占感染病原体的首位(37.9%),其次为金黄色葡萄球菌(24.2%).35例获得随访,随访时间12～179个月,平均61.6个月.末次随访时Harris评分2～99分,平均76.5分.清创术后假体周围感染的控制率为16.7%,一期翻修术为54.5%,二期翻修术为93.3%,旷置术为100%.二期翻修术后假体周围骨折发生率13.3%,术后脱位率13.3%.11例感染复发,复发时间为感染治疗术后2～127个月,平均39.5个月.其中10例再次接受手术治疗,包括清创术1例、二期翻修术8例、旷置术1例.结论 清创术与一期翻修术的选择应严格把握适应证.二期翻修术感染控制率高,但有发生假体周围骨折和脱位的风险.表皮葡萄球菌及金黄色葡萄球菌足关节感染的主要病原菌.     

髋关节置换术后假体周围感染的治疗

目的 探讨髋关节置换术后假体周围感染患者接受清创术、一期翻修术、二期翻修术及旷置术的临床效果.方法 1993年6月至2008年6月因髋关节置换术后假体周围感染接受手术治疗患者46例,男27例,女19例;年龄34～80岁,平均55.8岁.术前诊断感染的方法包括红细胞沉降率、C反应蛋白检查,放射性核素扫描,窦道分泌物及关节穿刺液培养.行保留假体的清创术7例,一期翻修术14例,二期翻修术21例,旷置术4例.术后观察伤口外观,随访时采用Harris评分对髋关节功能进行评估,行实验室检查确定感染控制情况.结果 46例假体周围感染患者中29例培养结果 阳性,表皮葡萄球菌占感染病原体的首位(37.9%),其次为金黄色葡萄球菌(24.2%).35例获得随访,随访时间12～179个月,平均61.6个月.末次随访时Harris评分2～99分,平均76.5分.清创术后假体周围感染的控制率为16.7%,一期翻修术为54.5%,二期翻修术为93.3%,旷置术为100%.二期翻修术后假体周围骨折发生率13.3%,术后脱位率13.3%.11例感染复发,复发时间为感染治疗术后2～127个月,平均39.5个月.其中10例再次接受手术治疗,包括清创术1例、二期翻修术8例、旷置术1例.结论 清创术与一期翻修术的选择应严格把握适应证.二期翻修术感染控制率高,但有发生假体周围骨折和脱位的风险.表皮葡萄球菌及金黄色葡萄球菌足关节感染的主要病原菌.     

应用抗生素骨水泥间隔体二期翻修治疗人工全膝关节置换术后迟发感染

目的探讨应用抗生素骨水泥间隔体二期翻修治疗人工全膝关节置换术后迟发感染的临床疗效。方法 2007年1月-2009年12月,收治23例(23膝)人工全膝关节置换术后迟发感染患者。男15例,女8例;年龄43～75岁,平均65.2岁。置换术后至出现感染时间为13～52个月,平均17.3个月;发生感染至入院翻修时间为15 d～7个月,平均2.1个月。一期清创、取出假体,植入含庆大霉素抗生素骨水泥间隔体;8～10周感染控制后二期植入假体。分别采用美国特种外科医院(HSS)评分及膝关节学会评分系统(KSS)评价翻修前后患膝功能,并统计总体感染控制率。结果术后患者切口均Ⅰ期愈合。2例二期翻修术后发生再感染,余21例感染控制,总体感染控制率91.3%。患者均获随访,随访时间2～5年,平均3.6年。HSS评分由术前(60.6±9.8)分提高至末次随访时(82.3±7.4)分,KSS评分由术前(110.7±9.6)分提高至末次随访时(134.0±10.5)分,手术前后比较差异均有统计学意义(P<0.01)。X线片复查示假体位置良好,无松动、断裂、假体周围透亮影等异常表现。结论应用抗生素骨水泥间隔体二期翻修能有效控制人工全膝关节置换术后迟发感染,并能较好恢复患膝功能。     

Two-stage operative strategy without local antibiotic treatment for infected hip arthroplasty: clinical and radiological outcome

Introduction Two-stage revision hip surgery with insertion of local antibiotic carriers is the therapy of choice for infected hip arthroplasty. The disadvantages are the incalculable pharmacokinetics of the antibiotic, with the danger of resistance and sensitisation. In a retrospective study, the effectiveness of a two-stage revision strategy done without local antibiotics was to be investigated. Patients and methods Thirty-one patients (32 hips) after two-stage revision hip surgery for infection without local antibiotics were monitored clinically and radiologically, with a follow-up of 41.3 months. Results Nine re-debridements in combination with a systemic antibiosis had to be conducted for eradication of the infections after explantation. Reconstruction of the majority of the hips was possible without the use of revision implants and without using large structured allografts. The re-infection rate was 6.3%, the patients achieved a Harris hip score of 75.4 (range 36.1–97.0) points at the latest follow-up, and the average difference in leg length was −0.7 (range −4.5 to + 2.5) cm. Conclusion Two-stage revision of the hip can be conducted without local antibiotic application, to achieve a comparatively efficient cure of the infection and function. This investigation underlines the significance of radical surgical debridement. The optional use of more effective antibiotic carriers may reduce the number of re-debridements in the future.     

一种新型间隔器技术在膝关节置换术后感染二期翻修中的应用

目的探讨一种新型间隔器制作方法在全膝关节置换术（TKA）后假体周围感染治疗方面的可行性和有效性。方法本研究纳入2009年7月至2012年1月间收入院的6例TKA术后慢性深部感染患者,采用二期翻修手术治疗第一阶段彻底清创后使用消毒后的股骨假体、新内衬和抗生素骨水泥作为关节间隔器,确认感染控制后行第二阶段膝关节翻修手术。术后观察感染控制情况和关节功能恢复情况。结果共5例患者按计划接受新型间隔器的二期翻修术。平均随访时间（24．4±10．5）个月（8—37个月）;术前、间隔器安置后、二期翻修后平均HSS评分分别为（40±5．3）分（32-46分）,（47±2．6）分（43～50分）,（65．4±2．3）分（62～68分）。术前、间隔器安置后、二期翻修后平均关节活动度分别为（75°±3．5°）（70°-80°）,（94°±4．2°）（90°～100°）,（106。±4．20）（100°-110°）。总体感染消除率为83．3％。结论消毒后假体和抗生素骨水泥组成的间隔器在治疗TKA术后假体周围感染上有优良的临床前景。     

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.     

Clinical Outcome of Massive Endoprostheses Used for Managing Periprosthetic Joint Infections of the Hip and Knee

Background

Endoprosthetic replacement (EPR) is an option for management of massive bone loss resulting from infection around failed lower limb implants. The aim of this study is to determine the mid-term outcome of EPRs performed in the treatment of periprosthetic joint infection (PJI) and infected failed osteosyntheses around the hip and knee joint and identify factors that influence it.

The outcome of two-stage arthroplasty using a custom-made interval spacer to treat the infected hip

Sixty-one patients undergoing a two-stage revision of an infected hip using a prosthesis of antibiotic-loaded acrylic cement were followed for an average of 43 months. Twelve patients were excluded (3 died, 6 had no proven infection, and 2 no second stage). Only 1 patient was lost to follow-up evaluation from those included, for a retrieval rate of 98% for those still living. Of the remaining 48 patients, 3 had further sepsis: Two became reinfected with different organisms and 1 with the same organism, for an infection eradication rate of 94%. The other 45 had no clinical, laboratory, or radiographic evidence of infection. Thirty-seven patients (80%) had a Harris hip score greater than 80 or an improvement of at least 30 points.     

Synovial-Based Tests Outperform Serum Markers to Rule Out Infection in Total Knee Arthroplasty and Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

BackgroundTotal knee arthroplasty (TKA) provides successful results in most patients. Periprosthetic joint infection (PJI) accounts for up to 25% of failed TKAs needing revision. In clinical practice, consensus in diagnostic strategy for excluding or diagnosing PJI is still lacking. In this systematic review and meta-analysis, we aim to provide a simplified data-driven diagnostic strategy for aseptic knee and hip revision surgeons to rule out PJI in the outpatient clinic phase.MethodsA literature search in EMBASE, MEDLINE, PubMed, and Cochrane was conducted. Studies involving the diagnosis of PJI in patients with failed TKAs and total hip arthroplasties needing revision were identified. Only studies using the Musculoskeletal Infection Society criteria were included. Quality was assessed using MINORS criteria. Meta-analysis was performed for each diagnostic test identified in the included studies. Pooled estimates of diagnostic accuracy measures were calculated using a bivariate model and plotted in summary receiver–operator characteristic curves. Positive and negative predictive values were calculated in a hypothetical sample of patients with a given disease prevalence.ResultsTwenty-four studies met the inclusion criteria, describing a total of 2974 patients. Quality scores ranged from 13 to 19. Meta-analysis could be performed on 7 unique diagnostic tests. Highest pooled sensitivity and specificity were demonstrated for α-defensin with values of 86% and 96.6%, respectively. α-defensin and white blood cell count in synovial fluid demonstrate highest negative predictive value values.ConclusionsWe recommend, in a clinical setting with low–intermediate prevalence of PJI, performing arthrocentesis and joint fluid analysis using α-defensin and/or white blood cell count before revision TKA and revision total hip arthroplasty surgery to rule out PJI.     

Two-Stage Revision for Infected Total Knee Arthroplasty: Based on Autoclaving the Recycled Femoral Component and Intraoperative Molding Using Antibiotic-Impregnated Cement on the Tibial Side

Background

The purpose of this study was to determine the degree of infection control and postoperative function for new articulating metal-on-cement spacer.

Methods

A retrospective study of 19 patients (20 cases), who underwent a two-stage revision arthroplasty using mobile cement prosthesis, were followed for a minimum of 2 years. This series consisted of 16 women and 3 men, having an overall mean age of 71 years. During the first stage of revision, the femoral implant and all the adherent cement was removed, after which it was autoclaved before replacement. The tibial component was removed and a doughy state, antibiotic-impregnated cement was inserted on the tibial side. To achieve joint congruency, intraoperative molding was performed by flexing and extending the knee joint. Each patient was evaluated clinically and radiologically. The clinical assessments included range of motion, and the patients were scored as per the Hospital for Special Surgery (HSS) and Knee Society (KS) criteria.

Results

The mean range of knee joint motion was 70° prior to the first stage operation and 72° prior to the second stage revision arthroplasty; following revision arthroplasty, it was 113° at the final follow-up. The mean HSS score and KS knee and function scores were 86, 82, and 54, respectively, at the final follow-up. The success rate in terms of infection eradication was 95% (19/20 knees). No patient experienced soft tissue contracture requiring a quadriceps snip.

Conclusions

This novel technique provides excellent radiological and clinical outcomes. It offers a high surface area of antibiotic-impregnated cement, a good range of motion between first and second stage revision surgery for the treatment of chronic infection after total knee arthroplasty, and is of a reasonable cost.     

Outcomes of Primary Total Joint Arthroplasty After Lung Transplantation

Lung transplantation is increasingly common with improving survival rates. Post-transplant patients can be expected to seek total hip (THA) and knee arthroplasty (TKA) to improve their quality of life. Outcomes of 20 primary total joint arthroplasties (15 THA, 5 TKA) in 14 patients with lung transplantation were reviewed. Clinical follow-up time averaged 27.5 and 42.8 months for THA and TKA respectively. Arthroplasty indications included osteonecrosis, osteoarthritis, and fracture. All patients subjectively reported good or excellent outcomes with a final average Harris Hip Score of 88.7, Knee Society objective and functional score of 92.0. There were 4 minor and 1 major acute perioperative complications. 1 late TKA infection was successfully treated with two-stage revision. The mortality rate was 28.5% (4/14 patients) at an average 20.6 months following but unrelated to arthroplasty. Overall, total joint arthroplasty can be safely performed and provide good functional outcomes in lung transplant recipients.     

人工关节置换术后感染的临床及预后分析

目的分析人工关节置换术后假体周围感染的病原学、临床特征,以及治疗方法对患者预后的影响。方法采用回顾性分析,查阅自2003年1月至2012年1月成渝某两家三甲医院收治行人工关节（髋、膝和肘关节）置换术后发生假体周围感染的病例,了解患者感染的微生物特征,患者的相关临床指标和预后,并利用医院电话随访平台了解出院患者的感染再发生情况。用多因素回归方法了解对患者预后有影响的的危险因素,Kaplan-Meier生存分析二期翻修对再发感染的影响。结果 10年中共获得资料完整病例72例,髋、膝、肘关节手术分别为26例、44例和2例。其中Ⅰ期置换56例,Ⅱ期置换16例。52.8%（38/72）患者出现了晚期感染。膝关节是感染最常见的部位。金黄色葡萄球菌（金葡菌）是最常见的感染病原菌（30.6%）,其次是凝固酶阴性葡萄球菌（19.4%）和鲍曼不动杆菌（8.7%）。对置换术后感染的治疗总痊愈率为41.7%,其中二期翻修的患者治愈率为（83.3%）,其它治疗方式的治愈率（36.7%）。两者相比,有统计学差异（P〈0.01）。多因素回归分析显示,二期翻修是对患者预后有统计学意义的有益因素,Kaplan-Meier生存分析也显示二期翻修发生感染复发几率显著低于非二期翻修组。结论金葡菌是引起人工关节置换术后感染最常见病原菌,二期翻修是治疗置换术后感染的适宜选择。     

Treatment and Outcome of Periprosthetic Joint Infection in Unicompartmental Knee Arthroplasty

BackgroundPeriprosthetic joint infection (PJI) after unicompartmental knee arthroplasty (UKA) is a devastating but poorly understood complication, with a paucity of published data regarding treatment and outcomes. This study analyzes the largest cohort of UKA PJIs to date comparing treatment outcome, septic and aseptic reoperation rates, and risk factors for treatment failure.MethodsTwenty-one UKAs in 21 patients treated for PJI, as defined by Musculoskeletal Infection Society criteria, were retrospectively reviewed. Minimum and mean follow-up was 1 and 3.5 years, respectively. Fourteen (67%) patients had acute postoperative PJIs. Surgical treatment included 16 debridement, antibiotics, and implant retentions (DAIRs) (76%), 4 two-stage revisions (19%), and 1 one-stage revision (5%). Twenty (95%) PJIs were culture positive with Staphylococcus species identified in 15 cases (71%).ResultsSurvivorship free from reoperation for infection at 1 year was 76% (95% confidence interval, 58%-93%). Overall survival from all-cause reoperation was 57% (95% confidence interval, 27%-87%) at 5 years. Two additional patients (10%) underwent aseptic revision total knee arthroplasty for lateral compartment degeneration 1 year after DAIR and tibial aseptic loosening 2.5 years after 2-stage revision. All patients who initially failed PJI UKA treatment presented with acute postoperative PJIs (5 of 14; 36%).ConclusionSurvivorship free from persistent PJI at 1 year is low at 76% but is consistent with similar reports of DAIRs for total knee arthroplasties. Furthermore, there is low survivorship free from all-cause reoperation of 71% and 57% at 2 and 5 years, respectively. Surgeons should be aware of these poorer outcomes and consider treating UKA PJI early and aggressively.