Anagnostakos Konstantinos, Wilmes Philippe, Schmitt Eduard, Kelm Jens
Klinik fur Orthopadie und Orthopadische Chirurgie, Universitat des Saarlandes, Homburg/Saar, Germany.
Acta Orthop. 2009 Apr;80(2):193-7. doi: 10.3109/17453670902884700.
Late infections after total hip arthroplasty are still a problem. Treatment procedures include resection arthroplasty with implantation of antibiotic-loaded beads or implantation of an antibiotic-impreganted spacer. However, little is known about antibiotic elution from bone cement beyond the first 2-3 postoperative days in humans.
17 hip spacers (80 g PMMA, 1g gentamicin, and 4 g vancomycin) and 11 chains (40 g PMMA, 0.5 g gentamicin, and 2 g vancomycin) in 28 patients were studied. The release of both agents was measured in the drainage fluid on a daily basis. The drains were left in situ until less than 50 mL was produced per day. The elution of both antibiotics was determined by fluorescence polarization immunoassay. Systemic antibiotics were given postoperatively according to antibiogram. If possible, no gentamicin or vancomycin was given.
Peak mean concentrations from beads and spacers were reached for gentamicin (1,160 (12-371) microg/mL and 21 (0.7-39) microg/mL, respectively) and for vancomycin (80 (21-198) microg/mL and 37 (3.3-72) microg/mL) on day 1. The last concentrations to be determined were 3.7 microg/mL gentamicin and 23 microg/mL vancomycin in the beads group after 13 days, and 1.9 microg/mL gentamicin and 6.6 microg/mL vancomycin in the spacer group after 7 days. Between the fifth and seventh day, an intermittent increase in elution of vancomycin from both beads and spacers and of gentamicin from spacers was noticed. No renal or hepatic dysfunction was observed.
Beads showed higher elution characteristics in vivo than the spacers due to their larger surface area; however, a great amount of inter-subject variability was seen for both beads and spacers. The inferior elution properties of spacers emphasize the importance of additional systemic antibiotics for this treatment procedure during the postoperative period. Future studies should clarify whether the dose of antibiotics or length of antibiotic therapy may be reduced in the case of bead implantation, without jeopardizing the control of infection.
全髋关节置换术后的晚期感染仍是一个问题。治疗方法包括植入载抗生素骨珠的关节切除成形术或植入含抗生素的间隔物。然而，关于人类术后2 - 3天之后骨水泥中抗生素的洗脱情况，人们了解甚少。
对28例患者中的17个髋关节间隔物（80克聚甲基丙烯酸甲酯、1克庆大霉素和4克万古霉素）和11条链（40克聚甲基丙烯酸甲酯、0.5克庆大霉素和2克万古霉素）进行了研究。每天测量引流液中两种药物的释放量。引流管一直留置原位，直至每日引流量少于50毫升。两种抗生素的洗脱量通过荧光偏振免疫测定法测定。术后根据药敏试验给予全身抗生素治疗。如有可能，不给予庆大霉素或万古霉素。
第1天时，骨珠和间隔物中庆大霉素的平均峰值浓度分别为1160（12 - 371）微克/毫升和21（0.7 - 39）微克/毫升，万古霉素的平均峰值浓度分别为80（21 - 198）微克/毫升和37（3.3 - 72）微克/毫升。在骨珠组中，13天后最后测定的庆大霉素浓度为3.7微克/毫升，万古霉素浓度为23微克/毫升；在间隔物组中，7天后最后测定的庆大霉素浓度为1.9微克/毫升，万古霉素浓度为6.6微克/毫升。在第5天至第7天之间，观察到骨珠和间隔物中万古霉素的洗脱量以及间隔物中庆大霉素的洗脱量出现间歇性增加。未观察到肾或肝功能障碍。
由于骨珠的表面积较大，其在体内的洗脱特性高于间隔物；然而，骨珠和间隔物在个体间均存在很大差异。间隔物较差的洗脱特性强调了术后该治疗过程中额外使用全身抗生素的重要性。未来的研究应阐明，在植入骨珠的情况下，是否可以在不影响感染控制的前提下减少抗生素剂量或缩短抗生素治疗疗程。
