Fehring Keith A, Abdel Matthew P, Ollivier Matthieu, Mabry Tad M, Hanssen Arlen D
1Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.
J Bone Joint Surg Am. 2017 Jan 4;99(1):19-24. doi: 10.2106/JBJS.16.00075.
Two-stage exchange arthroplasty after a previous, failed 2-stage exchange procedure is fraught with difficulties, and there are no clear guidelines for treatment or prognosis given the heterogeneous group of patients in whom this procedure has been performed. The Musculoskeletal Infection Society (MSIS) staging system was developed in an attempt to stratify patients according to infection type, host status, and local soft-tissue status. The purpose of this study was to report the results of 2-stage exchange arthroplasty following a previous, failed 2-stage exchange protocol for periprosthetic knee infection as well as to identify risk factors for failure.
We retrospectively identified 45 patients who had undergone 2 or more 2-stage exchange arthroplasties for periprosthetic knee infection from 2000 to 2013. Patients were stratified according to the MSIS system, and risk factors for failure were analyzed. The minimum follow-up was 2 years (mean, 6 years; range, 24 to 132 months).
At the time of follow-up, twenty-two (49%) of the patients had undergone another revision due to infection and 28 (62%) had undergone another revision for any reason. The infection recurred in 6 (75%) of 8 substantially immunocompromised hosts (MSIS type C) and in 3 (30%) of 10 uncompromised hosts (type A) following the second 2-stage exchange arthroplasty (p = 0.06). The infection recurred in 4 (80%) of 5 patients with compromise of the extremity (MSIS type 3) and 3 (33%) of 9 patients with an uncompromised extremity (type 1) (p = 0.27). Both extremely compromised hosts with an extremely compromised extremity (type C3) had recurrence of the infection whereas 3 (30%) of the 10 uncompromised patients with no or less compromise of the extremity (type A1 or A2) did. Five patients in the failure group underwent a third 2-stage exchange arthroplasty following reinfection, and 3 of them were infection-free at the time of the latest follow-up.
Uncompromised hosts (MSIS type A) with an acceptable wound (MSIS type 1 or 2) had a 70% rate of success (7 of 10) after a repeat 2-stage exchange arthroplasty, whereas type-B2 hosts had a 50% success rate (10 of 20). The repeat 2-stage exchange procedure failed in both type-C3 hosts; thus, alternative salvage procedures should be considered for such patients.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
在先前的两阶段翻修手术失败后再次进行两阶段关节置换术充满困难，而且鉴于接受该手术的患者群体具有异质性，目前尚无明确的治疗或预后指南。肌肉骨骼感染协会（MSIS）分期系统的制定旨在根据感染类型、宿主状态和局部软组织状态对患者进行分层。本研究的目的是报告在先前用于治疗假体周围膝关节感染的两阶段翻修方案失败后再次进行两阶段关节置换术的结果，并确定失败的危险因素。
我们回顾性地确定了2000年至2013年期间因假体周围膝关节感染接受过2次或更多次两阶段关节置换术的45例患者。根据MSIS系统对患者进行分层，并分析失败的危险因素。最短随访时间为2年（平均6年；范围24至132个月）。
在随访时，22例（49%）患者因感染再次接受翻修，28例（62%）患者因任何原因再次接受翻修。在第二次两阶段关节置换术后，8例严重免疫功能低下宿主（MSIS C型）中有6例（75%）感染复发，10例免疫功能正常宿主（A型）中有3例（30%）感染复发（p = 0.06）。5例肢体有损伤的患者（MSIS 3型）中有4例（80%）感染复发，9例肢体无损伤的患者（1型）中有3例（33%）感染复发（p = 0.27）。两个肢体严重受损的严重免疫功能低下宿主（C3型）均出现感染复发，而10例肢体无损伤或损伤较小的免疫功能正常患者（A1或A2型）中有3例（30%）出现感染复发。失败组中的5例患者在再次感染后接受了第三次两阶段关节置换术，其中3例在最近一次随访时无感染。
伤口情况可接受（MSIS 1型或2型）的免疫功能正常宿主（MSIS A型）在重复两阶段关节置换术后成功率为70%（10例中的7例），而B2型宿主的成功率为50%（20例中的10例）。C3型宿主的重复两阶段翻修手术均失败；因此，对于此类患者应考虑其他挽救手术。
治疗性IV级。有关证据水平的完整描述，请参阅作者指南。
