Kopp Sandra L, Berbari Elie F, Osmon Douglas R, Schroeder Darrell R, Hebl James R, Horlocker Terese T, Hanssen Arlen D
From the *Department of Anesthesiology, †Section of Orthopedic Infectious Diseases, Division of Infectious Diseases, ‡Health Science Research, and §Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota.
Anesth Analg. 2015 Nov;121(5):1215-21. doi: 10.1213/ANE.0000000000000956.
Surgical site infection (SSI) is one of the most challenging and costly complications associated with total joint arthroplasty. Our primary aim in this case-controlled trial was to compare the risk of SSI within a year of surgery for patients undergoing primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) and revision TKA or THA under general anesthesia versus neuraxial anesthesia. Our secondary aim was to determine which patient, anesthetic, and surgical variables influence the risk of SSI. We hypothesized that patients who undergo neuraxial anesthesia may have a lesser risk of SSI compared with those who had a general anesthetic.
We conducted a retrospective, case-control study of patients undergoing primary or revision TKA and THA between January 1, 1998, and December 31, 2008, who subsequently were diagnosed with an SSI. The cases were matched 1:2 with controls based on type of joint replacement (TKA versus THA), type of procedure (primary, bilateral, revision), sex, date of surgery (within 1 year), ASA physical status (I and II versus III, IV, and V), and operative time (<3 vs >3 hours).
During the 11-year period, 202 SSIs were identified. Of the infections identified, 115 (57%) occurred within the first 30 days and 87 (43%) occurred between 31 and 365 days. From both univariate and multivariable analyses, no significant association was found between the use of central neuraxial anesthesia and the postoperative infection (univariate odds ratio [OR] = 0.92; 95% confidence interval [CI], 0.63-1.34; P = 0.651; multivariable OR = 1.10; 95% CI, 0.72-1.69; P = 0.664). The use of peripheral nerve block also was not found to influence the risk of postoperative infection (univariate OR = 1.41; 95% CI, 0.84-2.37; P = 0.193; multivariable OR = 1.35; 95% CI, 0.75-2.44; P = 0.312). The factors that were found to be associated with postoperative infection in multivariable analysis included current smoking (OR = 5.10; 95% CI, 2.30-11.33) and higher body mass index (BMI) (OR = 2.68; 95% CI, 1.42-5.06 for BMI ≥ 35 kg/m compared with those with BMI < 25 kg/m).
Recent studies using large databases have concluded that the use of neuraxial compared with general anesthesia is associated with a decreased incidence of SSI in patients undergoing total joint arthroplasty. In this retrospective, case-controlled study, we found no difference in the incidence of SSI in patients undergoing total joint arthroplasty under general versus neuraxial anesthesia. We also concluded that the use of peripheral nerve blocks does not influence the incidence of SSI. Increasing BMI and current smoking were found to significantly increase the incidence of SSI in patients undergoing lower extremity total joint arthroplasty.
手术部位感染（SSI）是全关节置换术相关的最具挑战性且成本高昂的并发症之一。在这项病例对照试验中，我们的主要目的是比较接受初次全膝关节置换术（TKA）或全髋关节置换术（THA）以及初次或翻修TKA或THA的患者在全身麻醉与椎管内麻醉下术后1年内发生SSI的风险。我们的次要目的是确定哪些患者、麻醉和手术变量会影响SSI的风险。我们假设接受椎管内麻醉的患者发生SSI的风险可能低于接受全身麻醉的患者。
我们对1998年1月1日至2008年12月31日期间接受初次或翻修TKA和THA且随后被诊断为SSI的患者进行了一项回顾性病例对照研究。根据关节置换类型（TKA与THA）、手术类型（初次、双侧、翻修）、性别、手术日期（1年内）、美国麻醉医师协会（ASA）身体状况分级（I和II级与III、IV和V级）以及手术时间（<3小时与>3小时），将病例与对照按1:2匹配。
在这11年期间，共识别出202例SSI。在识别出的感染中，115例（57%）发生在术后前30天内，87例（43%）发生在31至365天之间。单因素和多因素分析均未发现使用椎管内麻醉与术后感染之间存在显著关联（单因素比值比[OR]=0.92；95%置信区间[CI]，0.63 - 1.34；P = 0.651；多因素OR = 1.10；95% CI，0.72 - 1.69；P = 0.664）。也未发现使用外周神经阻滞会影响术后感染风险（单因素OR = 1.41；95% CI，0.84 - 2.37；P = 0.193；多因素OR = 1.35；95% CI，0.75 - 2.44；P = 0.312）。多因素分析中发现与术后感染相关的因素包括当前吸烟（OR = 5.10；95% CI，2.30 - 11.33）和较高的体重指数（BMI）（与BMI < 25 kg/m²的患者相比，BMI≥35 kg/m²时OR = 2.68；95% CI，1.42 - 5.06）。
近期使用大型数据库的研究得出结论，与全身麻醉相比，椎管内麻醉用于全关节置换术患者可降低SSI的发生率。在这项回顾性病例对照研究中，我们发现接受全身麻醉与椎管内麻醉的全关节置换术患者的SSI发生率无差异。我们还得出结论，使用外周神经阻滞不影响SSI的发生率。发现BMI增加和当前吸烟会显著增加接受下肢全关节置换术患者的SSI发生率。
