非愈合患者感染的术前诊断。

Preoperative diagnosis of infection in patients with nonunions.

机构信息

Department of Orthopaedic Surgery, Boston University Medical Center, 850 Harrison Avenue, Boston, MA 02118, USA.

出版信息

J Bone Joint Surg Am. 2013 Aug 7;95(15):1409-12. doi: 10.2106/JBJS.L.01034.

DOI:10.2106/JBJS.L.01034

PMID:23925746

Abstract

BACKGROUND

The surgical treatment of a fracture nonunion is complicated in the presence of infection. The purpose of the present study is to report on the utility of a standardized protocol to rule out infection in high-risk patients and to evaluate the efficacy of each component of the protocol.

METHODS

A single protocol of preoperative laboratory tests (white blood-cell count, C-reactive protein level, and erythrocyte sedimentation rate) and a combined white blood cell/sulfur colloid scan were performed for patients with a high risk of fracture nonunion. Infection was diagnosed on the basis of positive intraoperative cultures, evidence of gross infection at the time of the procedure, or evidence of gross infection during the immediate postoperative period. With use of infection as the end point, univariate analysis and multiple logistic regression analysis were used to compare tests. A risk stratification method was used to combine tests.

RESULTS

Ninety-three patients with ninety-five nonunions were evaluated. Thirty of the ninety-five nonunions were ultimately diagnosed as being infected. With use of a combination of elevated white blood-cell count, erythrocyte sedimentation rate, and C-reactive protein level and a positive scan, the predicted probabilities of infection associated with zero, one, two, and three positive tests were 18%, 24%, 50%, and 86%, respectively. With the elimination of the nuclear scan, the predicted probabilities for zero, one, two, and three risk factors were 20%, 19%, 56%, and 100%.

CONCLUSIONS

The erythrocyte sedimentation rate and the C-reactive protein level were both independently accurate predictors of infection. Use of a risk stratification method showed that the likelihood of infection increased with each additional positive test. A combined white blood cell/sulfur colloid scan was the least predictive method of revealing infection and is not cost effective, even as part of a stratification scheme.

LEVEL OF EVIDENCE

Diagnostic level III. See instructions for authors for a complete description of levels of evidence.

摘要

背景

在存在感染的情况下，骨折不愈合的手术治疗较为复杂。本研究旨在报告一种排除高危患者感染的标准化方案，并评估该方案各组成部分的疗效。

方法

对有骨折不愈合高危风险的患者，采用术前实验室检查（白细胞计数、C 反应蛋白水平和红细胞沉降率）和白细胞/硫胶体扫描联合的单一方案。根据术中培养阳性、手术时存在明显感染的证据或术后即刻存在明显感染的证据来诊断感染。以感染为终点，采用单变量分析和多变量逻辑回归分析比较检测结果。采用风险分层方法联合检测。

结果

共评估了 93 例 95 处不愈合。30 处不愈合最终被诊断为感染。采用白细胞计数、红细胞沉降率和 C 反应蛋白水平升高以及扫描阳性的联合方案，零、一、二和三个阳性检测结果与感染相关的预测概率分别为 18%、24%、50%和 86%。如果排除核扫描，零、一、二和三个危险因素的预测概率分别为 20%、19%、56%和 100%。