Lortat-Jacob A, Desplaces N, Gaudias J, Dacquet V, Dupon M, Carsenti H, Dellamonica P
Service de Chirurgie Orthopédique et Traumatologique, Hôpital Ambroise-Paré, 9, avenue Charles-de-Gaulle, 92100 Boulogne.
Rev Chir Orthop Reparatrice Appar Mot. 2002 Feb;88(1):51-61.
Peroperative contamination is the most frequent cause of infection after arthroplasty. For other cases of infection subsequent to bacteremia or a neighboring focus, it would be more appropriate to use the term "secondary" infections rather than hematogeneous infections. Arguments favoring secondary infection include long symptom-free interval between prosthesis implantation and the infectious episode, a causal germ not generally responsible for peroperative infection, presence of a distant infectious focus, positive blood culture, and a positive bacteriological sample from the prosthesis level showing the same strain as grown from the distant focus or blood samples. Both acute and chronic infections are observed, leading to prosthesis dysfunction. History taking generally identifies a neglected acute but transient episode. Search for a bacteriological diagnosis must be completed before initiating an antibiotic regimen. If detected very early, washing with open synovectomy and resection of suspicious tissue should be attempted in order to maintain the implant if possible. Local antibiotics have proven efficacy. Beyond a certain delay, treatment for chronic infection usually requires removing the prosthesis, cleaning the bone interface, and new arthroplasty delayed or not. Search for the portal must be undertaken early in order to initiate appropriate local treatment. The causal event may be any invasive procedure, with or without material implantation. The risk-benefit ratio for antibiotic prophylaxis remains to be determined.
手术中污染是关节置换术后感染最常见的原因。对于菌血症或邻近病灶继发的其他感染病例，使用“继发性”感染一词比血源性感染更合适。支持继发性感染的依据包括假体植入与感染发作之间较长的无症状间隔、通常不是手术感染致病菌的病原体、远处感染病灶的存在、血培养阳性以及假体部位细菌学样本阳性且显示与远处病灶或血样中生长的菌株相同。急性和慢性感染均有发生，导致假体功能障碍。病史采集通常能发现被忽视的急性但短暂的发作。在开始抗生素治疗前必须完成细菌学诊断。如果在极早期检测到，应尝试进行开放性滑膜切除术冲洗并切除可疑组织，以便尽可能保留植入物。局部使用抗生素已证明有效。超过一定时间后，慢性感染的治疗通常需要取出假体、清理骨界面，并延迟或不延迟进行新的关节置换。必须尽早寻找感染途径以便开始适当的局部治疗。病因可能是任何侵入性操作，无论有无材料植入。抗生素预防的风险效益比仍有待确定。
