Mont M A, Waldman B J, Hungerford D S
Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21239, USA.
J Bone Joint Surg Am. 2000 Nov;82(11):1552-7. doi: 10.2106/00004623-200011000-00006.
Two-stage reimplantation has proven to be highly successful in the treatment of patients with infection at the site of a total knee arthroplasty. However, up to 20 percent of patients have a recurrence of infection following this treatment. The purpose of our study was to determine whether aspiration of the affected joint and culture of the specimen, performed before reimplantation and after discontinuation of antibiotic therapy, would help to identify patients who might have a recurrent infection.
We prospectively followed sixty-nine patients who were treated for a culture-proven deep infection at the site of a total knee arthroplasty. Group I consisted of thirty-five patients who were treated with removal of the prosthetic components and irrigation and debridement of the joint, followed by six weeks of antibiotic therapy and reimplantation of a prosthesis. Group II was composed of thirty-four patients who were treated with removal of the components and irrigation and debridement of the joint, six weeks of antibiotic therapy, and then repeat culture four weeks after the antibiotic course had ended. If the culture was negative, the patient was managed with a second-stage reimplantation of a prosthesis. If the culture was positive, the protocol was repeated, beginning with irrigation and debridement. The two groups were similar with regard to male-to-female ratio, age, preoperative Knee Society scores, time since primary surgery, types of infectious organisms, duration of symptoms, duration of follow-up, and number of previous revisions. All of the patients were evaluated clinically with use of the objective scoring system of the Knee Society and were followed with serial radiographs. Success was defined as no infection and a functional prosthesis, with a Knee Society score of at least 75 points at the last (thirty-six-month-minimum) follow-up evaluation.
Of the thirty-five patients in Group I, five (14 percent) had recurrence of infection. One of the patients was managed with a successful second-stage revision, three were managed with arthrodesis of the knee, and one continued with chronic antibiotic suppressive treatment. Of the thirty-four patients in Group II, three (9 percent) had a positive culture after the course of antibiotics. The protocol was repeated for all three, and they subsequently had a successful second revision. One other patient (3 percent) in Group II, who had a negative culture, had a recurrent infection and was eventually managed with arthrodesis of the knee.
Prerevision cultures, grown after discontinuation of antibiotic treatment and before reimplantation of the components, helped to identify the patients with infection at the site of a total knee arthroplasty in whom the infection might recur. The performance of aspiration and cultures resulted in a substantial improvement in the clinical outcome.
两阶段再植入已被证明在治疗全膝关节置换术部位感染的患者中非常成功。然而，高达20%的患者在这种治疗后会出现感染复发。我们研究的目的是确定在再植入前且抗生素治疗停止后对患侧关节进行穿刺抽吸并对标本进行培养，是否有助于识别可能发生感染复发的患者。
我们前瞻性地随访了69例经培养证实为全膝关节置换术部位深部感染的患者。第一组由35例患者组成，他们接受了假体部件移除、关节冲洗和清创，随后接受了六周的抗生素治疗并再次植入假体。第二组由34例患者组成，他们接受了部件移除、关节冲洗和清创、六周的抗生素治疗，然后在抗生素疗程结束后四周进行重复培养。如果培养结果为阴性，患者接受二期假体再植入治疗。如果培养结果为阳性，则从冲洗和清创开始重复该方案。两组在男女比例、年龄、术前膝关节协会评分、初次手术后的时间、感染微生物类型、症状持续时间、随访时间以及先前翻修次数方面相似。所有患者均使用膝关节协会的客观评分系统进行临床评估，并进行系列X线片随访。成功定义为无感染且假体功能良好，在最后一次（至少36个月）随访评估时膝关节协会评分至少为75分。
第一组的35例患者中，5例（14%）出现感染复发。其中1例患者成功进行了二期翻修，3例接受了膝关节融合术，1例继续接受慢性抗生素抑制治疗。第二组的34例患者中，3例（9%）在抗生素疗程后培养结果为阳性。对这3例患者均重复了该方案，随后他们成功进行了二次翻修。第二组中另1例（3%）培养结果为阴性的患者出现了感染复发，最终接受了膝关节融合术。
在停用抗生素治疗后且部件再植入前进行翻修前培养，有助于识别全膝关节置换术部位感染可能复发的患者。进行穿刺抽吸和培养显著改善了临床结局。
