肘关节假体周围感染诊治进展

肘关节假体周围感染(PJI)是全肘关节置换术后最严重的并发症之一。新型诊断技术如关节滑液聚合酶链反应(PCR)和蛋白分析、超声波法或涡旋法取样行微生物培养等对肘关节PJI有较好的敏感性和特异性,术中冰冻组织切片法是非常可靠的诊断手段。而脱氧葡萄糖-正电子发射断层扫描(FDG-PET)等影像学检查不推荐应用于肘关节PJI的诊断。肘关节PJI治疗主要为抗感染治疗和手术治疗,二期假体置换术是最佳术式,保留假体清创术适用于假体功能良好的急性非表皮葡萄球菌肘关节PJI,一期假体置换术在肘关节PJI治疗中效果不佳,骨重建可应用于肘关节PJI合并关节周围严重骨丢失。该文就肘关节PJI诊治进展作一综述。     

关节假体周围感染研究进展

关节假体周围感染(PJI)是人工关节置换术最严重的并发症之一,病态肥胖、双侧手术、二次手术、住院时间长和异体输血均为危险因素。关节假体超声波降解液培养的敏感度及特异度超过假体周围组织培养。聚合酶链反应技术对检测曾使用抗生素而培养困难的标本有较高成功率。脱氧葡萄糖正电子发射断层扫描技术正发展为新的PJI诊断技术。抗PJI治疗主要针对培养结果选择抗生素,一般采用利福平联合利奈唑胺、万古霉素和替考拉宁均有较好效果。目前的观点认为,一期彻底清创、非骨水泥型假体更换联合短期抗生素疗法是治疗PJI的较好方法 。     

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...     

多重病原感染合并髋臼严重骨缺损假体周围感染二期翻修术1例报道并文献复习

假体周围感染(periprosthetic joint infection,PJI)是关节置换术后的严重并发症之一,其发病率为1%~3%,严重影响患者的生活质量,并带来沉重的经济负担[1,2]。目前,治疗PJI的标准术式为人工关节二期翻修术,包括第一阶段取出人工假体,进行彻底清创、植入含抗生素骨水泥间隔器,并在术后使用敏感抗生素治疗;第二阶段待感染控制后,植入新的人工关节[3]。本文报道1例多重感染合并髋臼严重骨缺损患者的诊治过程,针对PJI的病原诊断和重建骨缺损等治疗难点进行探讨。     

人工关节置换术后感染的生物治疗方法及前景

人工关节假体术后感染是骨科临床治疗的难点、热点。目前假体周围感染(PJI)的治疗方法包括保守治疗和手术治疗,但总的治疗效果不理想。PJI生物治疗是指利用新型杀菌/抑菌剂、生物工程、组织工程等方法,通过破坏生物膜、靶向杀灭致病菌、被动免疫以及局部缓释杀菌剂等方式对PJI进行治疗的新方法。它的出现有望解决PJI治疗存在的一系列难题。本文就近年来PJI生物治疗的研究进展及应用前景进行综述。     

TKA术后慢性假体周围感染治疗策略的思考——应用决策分析法在一期和二期全膝翻修术中寻找最佳策略

正随着全膝关节置换术(total knee arthroplasty,TKA)手术量的逐年增加,术后假体周围感染(periprosthetic joint infection,PJI)受到越来越多的关注。尽管二期翻修手术被认为是治疗PJI的金标准,但术后仍有很高的再发率和死亡率。与之相比,一期翻修手术死亡率更低,患者术后生活质量更高。如何在两种术式之间做出选择,需要综合考虑感染控制效果、健康效用以及费用支出等情况。本研究目的     

有效足量抗生素配合清创手术治疗假体相关感染保留置入假体的疗效分析

目的探讨髋关节与膝关节置换术后假体感染(PJI)的全身和局部抗生素治疗从而保留置换假体的临床疗效。方法自2010-02—2014-09诊治18例髋关节与10例膝关节置换术后感染,处理前均出现感染症状。对于有窦道患者采用手术清创联合规范足量静脉滴注与口服抗生素治疗,对于单纯红肿渗液无窦道患者,进行静脉滴注联合口服抗生素治疗。结果 28例中2例治疗失败,1例双侧髋关节置换术后感染控制后出院失访,余25例均获得随访4个月~4年,平均38个月,均恢复良好,切口愈合,未再发生感染。髋关节感染患者术前Harris评分为(42.3±23.5)分,术后(78.4±12.0)分,手术前后比较差异有统计学意义(t=5.642,P0.001);膝关节感染患者术前HSS评分为(42.9±12.9)分,术后(68.8±25.7)分,差异有统计学意义(t=2.850,P=0.001)。患者的关节功能和生活质量都得到极大改善,抗生素抗感染治疗成功率和假体保存率92.9%。结论诊断明确的髋膝关节置换术后感染,根据患者创口情况选择性进行清创手术并规范联合应用抗生素治疗,可以达到无需取出置入假体控制感染的目的,获得满意的临床疗效。     

含抗生素关节型骨水泥间隔器治疗人工关节感染的问题分析

目的探讨采用含抗生素关节型骨水泥间隔器二期翻修治疗人工关节假体周围感染(periprosthetic joint infection,PJI)存在的问题及解决方法。方法回顾分析2001年1月-2013年1月采用含抗生素关节型骨水泥间隔器行二期翻修的27例PJI患者临床资料。男12例,女15例。年龄25~81岁,平均62.7岁。均为单侧关节置换,髋关节19例,膝关节8例。初次置换至确诊感染时间为3~252个月,平均25个月。使用间隔器联合全身抗生素治疗,至感染控制后行二期翻修手术,评价患者临床疗效及间隔器有效性和相关并发症。结果 1例患者一期术后2 d因大面积心肌梗死死亡。19例患者一期术后感染控制,顺利行二期翻修手术;其中3例发生髋关节间隔器断裂后卧床,卧床期间1例发生深静脉血栓形成并保守治愈。7例患者一期术后感染复发,再次手术取出间隔器后旷置并更换敏感抗生素,其中3例感染未能控制,放弃治疗,余4例感染控制后行翻修手术。23例行二期翻修手术的患者术后均获随访,随访时间1~5年,平均2.3年。翻修术后1年髋关节患者Harris评分及膝关节患者膝关节学会评分系统(KSS)均显著优于术前,比较差异有统计学意义(P0.05)。8例致病菌含革兰阴性菌或真菌患者,7例一期术后感染复发;12例致病菌仅为革兰阳性菌患者均无感染复发。3例最终治疗失败放弃治疗者,1例为革兰阳性菌和革兰阴性菌混合感染,2例为真菌感染。结论在PJI二期翻修术中使用含抗生素关节型骨水泥间隔器可获良好临床疗效。但需注意髋关节间隔器可能发生断裂并增加翻修手术风险;若致病菌为革兰阴性菌或真菌,间隔器可能增加感染复发风险。     

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...     

CSA-90 reduces periprosthetic joint infection in a novel rat model challenged with local and systemic Staphylococcus aureus

Infection of orthopedic implants is a growing clinical challenge to manage due to the proliferation of drug-resistant bacterial strains. In this study, we aimed to investigate whether the treatment of implants with ceragenin-90 (CSA-90), a synthetic compound based on endogenous antibacterial peptides, could prevent infection in a novel rat model of periprosthetic joint infection (PJI) challenged with either local or systemic Staphylococcus aureus. A novel preclinical model of PJI was created using press-fit porous titanium implants in the distal femur of male Wistar rats. Sterile implants were pre-treated with 500 μg CSA-90 in saline. S. aureus was applied either directly at the time of surgery or administered via tail vein injection immediately afterward. Animals were monitored daily for clinical and radiographic evidence of infection for a total of 6 weeks. Post-study microbiological, radiographic, and histological analysis were performed to determine the incidence of PJI and assess osseointegration. CSA-90 treated groups demonstrated a reduced rate of PJI as confirmed by deep tissue swab culture at the time of cull compared with untreated groups with both local (33% vs 100%; P = .009) and systemic (10% vs 90%; P < .0001) S. aureus inoculation. Median survival time also increased from 8 to 17 days and from 8 to 42 days, respectively. In conclusion, this study describes a novel preclinical model of local and hematogenous PJI using a porous metal implant. CSA-90 reduced the incidence of PJI in this model supporting its further development as an antimicrobial coating for orthopedic implants.     

Debridement,antibiotics and implant retention in management of infected total knee arthroplasty: A systematic review

Total knee arthroplasty is a life changing operation. Although a rare complication, periprosthetic joint infection (PJI) can be a devastating event for patient and can be a challenging experience for the treating department. Management of the PJI is generally operative combined with extensive antibiotic therapy. The primary aim of treatment is to restore a functioning joint, either with debridement and retaining the well-fixed implants or with revision of part or all of the components. Whilst two stage revision arthroplasty has been considered as optimal treatment for PJI by many surgeons, Debridement, Antibiotics and Implant Retention (DAIR) could be considered as an alternative option in a selected group of patients.In this study, we review the recent literature to explore the efficacy and outcome of DAIR in PJI. We included all recent studies, which have used DAIR in PJI around total knee arthroplasty and assess for factors that would be either positive or negative towards the outcome. We particularly wanted to review role of timing of surgery and infecting organisms in outcomes of the treatment. We have also tried to identify whether patients have better functional outcome following DAIR in comparison to revision surgeries.     

RANK-ligand and osteoprotegerin as biomarkers in the differentiation between periprosthetic joint infection and aseptic prosthesis loosening

AIM To assess serum levels of RANK-ligand(RANKL) and osteoprotegerin(OPG) as biomarkers for periprosthetic joint infection(PJI) and compare their accuracy with standard tests.METHODS One hundred and twenty patients presenting with a painful total knee or hip arthroplasty with indication for surgical revision were included in this prospective clinical trial. Based on standard diagnostics(joint aspirate, microbiological, and histological samples) and Musculoskeletal Infection Society consensus classification,patients were categorized into PJI, aseptic loosening,and control groups. Implant loosening was assessed radiographically and intraoperatively. Preoperative serum samples were collected and analyzed for RANKL, OPG, calcium, phosphate, alkaline phosphatase(AP), and the bone-specific subform of AP(b AP). Statistical analysis was carried out, testing for significant differences between the three groups and between stable and loose implants. RESULTS All three groups were identical in regards to age, gender, and joint distribution. No statistically significant differences in the serum concentration of RANKL(P = 0.16) and OPG(P = 0.45) were found between aseptic loosening and PJI, with a trend towards lower RANKL concentrations and higher OPG concentrations in the PJI group. The RANKL/OPG ratio was significant for the comparison between PJI and non-PJI(P = 0.005). A ratio 60 ruled out PJI in all cases(specificity: 100%, 95%CI: 89, 11% to 100.0%) but only 30% of non-PJI patients crossed this threshold. The positive predictive value remained poor at any cut-off. In the differentiation between stable and loose implants, none of the parameters measured(calcium, phosphate, AP, and b AP) showed a significant difference, and only AP and b AP measurements showed a tendency towards higher values in the loosened group(with P = 0.09 for AP and P = 0.19 for b AP). CONCLUSION Lower RANKL and higher OPG concentrations could be detected in PJI, without statistical significance.     

Ceramic Coating in Cemented Primary Total Knee Arthroplasty is Not Associated With Decreased Risk of Revision due to Early Prosthetic Joint Infection

BackgroundProsthetic joint infection (PJI) is one of the most frequent and devastating causes of short-term revision total knee arthroplasty (TKA). In vitro evidence suggests ceramic surfaces demonstrate resistance to biofilm, but the clinical effect of bearing surface modifications on the risk of PJI remains unclear. This premier registry-based study examines the influence of ceramic bearing surface coatings on the outcome in cemented primary TKA.MethodsIn total, 117,660 cemented primary TKAs in patients with primary osteoarthritis recorded in the German arthroplasty registry since 2012 were followed up for a maximum of 3 years. The primary endpoint was risk of revision for PJI on ceramic coated and uncoated cobalt-chromium-molybdenum femoral components. Propensity score matching for age, gender, obesity, diabetes mellitus, depression and Elixhauser comorbidity index, and substratification on common design twins with and without coating was performed.ResultsIn total, 4637 TKAs (85.1% female) with a ceramic-coated femoral component were identified, 42 had been revised for PJI and 122 for other reasons at 3 years. No survival advantage due to the risk of revision for PJI could be determined for ceramic-coated components. Revision for all other reasons demonstrated a significant higher rate for TKAs with ceramic-coated components. However, the results of this were confounded by a strong prevalence (20.7% vs 0.3%) of metal sensitivity in the ceramic-coated group.ConclusionNo evidence of reduced risk for PJI due to ceramic-coated implants in cemented primary TKA was found. Further analysis for revision reasons other than PJI is required.     

Time to Revision After Periprosthetic Joint Infection in Total Ankle Arthroplasty: A Systematic Review

While not a common complication after total ankle arthroplasty (TAA), periprosthetic joint infection (PJI) presents a significant risk of implant failure. The primary aim of this systematic review was to evaluate time to revision after PJI in patients who had undergone TAA. An extensive search strategy via electronic databases initially captured 11,608 citations that were evaluated for relevance. Ultimately, 12 unique articles studying 3040 implants met inclusion criteria. The time to revision surgery due to PJI was recorded for each study and a weighted average obtained. The prevalence of PJI was 1.12% (n = 34). We found that the average time to revision due to PJI was 30.7 months, or approximately 2.6 years after the index TAA procedure. By literature definitions, the majority of cases (91.2%, n = 31) were beyond the “acute” PJI phase. The population was divided into 2 groups for further analysis of chronic infections. PJIs before the median were classified as “early” and those after as “late” chronic. The majority of cases (61.8%) were late chronic with an average time to revision of 44.3 months. A smaller number were early chronic (29.4%) with revision within 10.8 months. After summarizing the rates of infection and times to revision reported in the literature, we suggest modifying the current PJI classification to include early chronic and late chronic subgroups so that the total ankle surgeon is better prepared to prudently diagnose and treat PJIs.     

Implant retention after acute and hematogenous periprosthetic hip and knee infections: Whom,when and how?

Periprosthetic joint infections(PJI) of the hip and the knee are grossly classified as early post-operative, acute hematogenous and late chronic infections. Whereas two-stage exchange arthroplasty is the standard of care in North America for treating chronic infections, irrigation and debridement(I and D) with retention of implants has been used in an attempt to treat the other two types of PJIs. The rationale of this approach is that a PJI may be eradicated without the need of explanting the prostheses, as long as it has not transitioned into a chronic state. With the present paper, we review current evidence regarding the role of I and D with implant retention for treating PJIs of the hip and the knee. While a very wide range of success rates is reported in different studies, a short period of time between initiation of symptoms and intervention seems to play a prominent role with regards to a successful outcome. Moreover, pathogens of higher virulence and resistance to antibiotics are associated with a poorer result. Specific comorbidities have been also correlated with a less favorable outcome. Finally, one should proceed with serial I and Ds only under the condition that a predefined,aggressive protocol is applied. In conclusion,when treating a PJI of the hip or the knee, all the above factors should be considered in order to decide whether the patient is likely to benefit from this approach.     

Accuracy of the International Consensus Scoring System for diagnosis of periprosthetic joint infection in revision shoulder arthroplasty

BackgroundTotal shoulder arthroplasty (TSA) continues to undergo dramatic growth with expanding indications and improvements in implants and surgical techniques. A major complication following TSA is periprosthetic joint infection (PJI), which remains difficult to diagnose, often relying on clinical judgment. A contemporary definition of PJI was established at the 2018 International Consensus Meeting (ICM) on Musculoskeletal Infection. We sought to retrospectively examine the accuracy of this scoring system in previously performed revision TSA and hypothesized that the ICM scoring system would be reliable in determining the presence of TSA PJI.MethodsOur institutional database was reviewed to identify patients undergoing revision TSA before the advent of the ICM PJI scoring system. Clinical notes and operative reports were reviewed for data regarding the preoperative clinical examination, laboratory values, and intraoperative findings. The findings were assigned scores based on the definition of probable PJI by the ICM scoring system. Scores were compared to treatment plans of infected vs. noninfected patients. The diagnosis of PJI was made using a combination of clinical examination, laboratory values, and intraoperative findings. Sensitivity, specificity, positive and negative predictive values, and accuracy of the ICM scoring system were calculated compared to actual treatment decision, the gold standard.ResultsOf 81 revision arthroplasties, 52 were revision reverse TSA (rTSA), and 29 were revision anatomic TSA (aTSA). Seven rTSA patients were treated as infected (7/52, 13.5%), and the scoring system identified 4 of those as being probable infections (4/7, 57.1%). One additional rTSA patient scored as probable infection, underwent a revision for instability, and was found to have no infection. Three aTSA patients were treated as infected (3/29, 10.3%), with one of those identified as probable infection by the scoring system (1/3, 33.3%). Four patients in the rTSA group and no patients in the aTSA group met the criteria for definite infection. Using the threshold of probable infection to identify PJI, the sensitivity of the scoring system was 0.6, and specificity was 0.99. The positive predictive value was 0.86, and the negative predictive value was 0.95. With the same threshold, the ICM scoring system was 93.8% accurate.ConclusionsIdentifying PJI in TSA remains difficult in the absence of definite signs of joint sepsis. This study found the scoring system to be highly accurate, although with modest sensitivity, and a reliable tool for the diagnosis of PJI following TSA.Level of evidenceLevel IV; Retrospective Case Series with No Comparison Group Treatment Study     

人工关节置换术后假体周围感染的临床分类

假体周围感染(PJI)是关节外科领域临床处理上最为棘手的问题之一。PJI的发生可以出现在关节置换术后任何时期,并且有着复杂多样的临床表现。同时PJI的病情迁延难愈,严重时可以导致截肢甚至危及生命。在针对PJI的治疗中,合理的临床分类能够帮助医生迅速判断病情,搭建对病情综合性评估的框架,进而做出合理化治疗方案选择。目前国际上关于PJI的临床分类还没有足够清晰的划分。毫无疑问,明确的临床分期和分型会对PJI的治疗有重大的意义。本综述旨在总结文献中PJI的不同临床分类角度,常见的临床分类,探讨其合理性,并进一步归纳其与治疗的关系,为PJI的临床分类及治疗策略选择提供参考。     

Single,Recurrent, Synchronous,and Metachronous Periprosthetic Joint Infections in Patients With Multiple Hip and Knee Arthroplasties

BackgroundThe rate for periprosthetic joint infection (PJI) exceeds 1% for primary arthroplasties. Over 30% of patients who have a primary arthroplasty require an additional arthroplasty, and the impact of PJI on this population is understudied. Our objective was to assess the prevalence of recurrent, synchronous, and metachronous PJI in patients who had multiple arthroplasties and to identify risk factors for a subsequent PJI.MethodsWe identified 337 patients who had multiple arthroplasties and at least 1 PJI that presented between 2003 and 2021. The mean follow-up after revision arthroplasty was 3 years (range, 0 to 17.2). Patients who had multiple infected prostheses were categorized as synchronous (ie, presenting at the same time as the initial infection) or metachronous (ie, presenting at a different time as the initial infection). The PJI diagnosis was made using the MusculoSkeletal Infection Society (MSIS) criteria.ResultsThere were 39 (12%) patients who experienced recurrent PJI in the same joint, while 31 (9%) patients developed PJI in another joint. Positive blood cultures were more likely in the second joint PJI (48%) compared to recurrent PJI (23%) or a single PJI (15%, P < .001). Synchronous PJI represented 42% of the second joint PJI cases (n = 13), while metachronous PJI represented 58% (n = 18). Tobacco users had 75% higher odds of metachronous PJI (odds ratio 1.75, 95% confidence interval: 1.1-2.9, P = .041).ConclusionOver 20% of the patients with multiple arthroplasties and a single PJI will develop a subsequent PJI in another arthroplasty with 12% recurring in the initial arthroplasty and nearly 10% ocurring in another arthroplasty. Particular caution should be taken in patients who use tobacco, have bacteremia, or have Staphylococcus aureus isolation at time of their initial PJI. Optimizing the management of this high-risk patient population is necessary to reduce the additional burden of subsequent PJI.Level of EvidencePrognostic Level IV.