Knee Research Australia, Benowa, Queensland, Australia.
Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.
J Bone Joint Surg Am. 2018 Dec 5;100(23):2033-2040. doi: 10.2106/JBJS.17.01639.
Periprosthetic infection following total knee replacement remains alarmingly frequent, is devastating for patients, and is an increasingly substantial public health burden. While both the prosthetic design elements and type of polyethylene used in total knee replacement can independently affect survivorship of the prosthesis, their influence on the risk of revision for infection is unknown. Therefore, we examined the effects of total knee prosthetic design and type of polyethylene bearing on the long-term revision risk for nonacute infection following total knee replacement by comparing 4 different cohorts: patients who had minimally stabilized total knee prostheses with crosslinked polyethylene (XLPE) bearing surfaces, minimally stabilized total knee prostheses with noncrosslinked polyethylene (NXLPE), posterior stabilized total knee prostheses with XLPE, and posterior stabilized total knee prostheses with NXLPE.
National registry data on revision procedures for surgeon-reported infection following primary total knee replacement for osteoarthritis from September 1999 through December 2015 were obtained for 4 patient cohorts. The cohorts were defined by the total knee prosthetic design and polyethylene type used. Revisions at ≤6 months were censored to reduce confounding bias. Hazard ratios (HRs) were adjusted for age, sex, and antibiotic cement usage.
A total of 336,997 primary total knee prostheses were included, 1,651 (0.49%) of which underwent revision for periprosthetic infection. Compared with minimally stabilized total knee prostheses that had XLPE bearing surfaces, the revision risk for infection, adjusted for age, sex, and antibiotic cement usage, was 25% higher for minimally stabilized total knee prostheses with NXLPE bearing surfaces (HR = 1.25 [95% confidence interval (CI), 1.07 to 1.45]; p = 0.003), 89% higher for posterior stabilized total knee prostheses with XLPE (HR = 1.89 [95% CI, 1.52 to 2.35]; p < 0.001), and 102% higher for posterior stabilized total knee prostheses with NXLPE (HR = 2.02 [95% CI, 1.72 to 2.37]; p < 0.001). Posterior stabilized total knee prostheses with NXLPE had a 61% higher risk of infection compared with minimally stabilized total knee prostheses with NXLPE (HR = 1.61 [95% CI, 1.43 to 1.83]; p < 0.001). The revision risk for infection for posterior stabilized total knee prostheses with NXLPE was the same as that for posterior stabilized total knee prostheses with XLPE (HR = 1.08 [95% CI, 0.88 to 1.32]; p = 0.481).
Minimally stabilized total knee prostheses with NXLPE bearing surfaces and posterior stabilized total knee prostheses, irrespective of bearing type, had a greater long-term revision risk for periprosthetic infection when compared with the revision risk for minimally stabilized total knee prostheses with XLPE bearing surfaces.
Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
全膝关节置换术后的假体周围感染仍然令人震惊地频繁发生，对患者造成毁灭性影响，并且日益成为严重的公共卫生负担。虽然全膝关节置换术中使用的假体设计元素和类型的聚乙烯都可以独立影响假体的存活率，但它们对感染翻修风险的影响尚不清楚。因此，我们通过比较 4 个不同队列，研究了全膝关节假体设计和聚乙烯类型对全膝关节置换术后非急性感染的长期翻修风险的影响：使用交联聚乙烯（XLPE）的最小稳定型全膝关节假体、使用非交联聚乙烯（NXLPE）的最小稳定型全膝关节假体、使用 XLPE 的后稳定型全膝关节假体和使用 NXLPE 的后稳定型全膝关节假体。
从 1999 年 9 月至 2015 年 12 月，获得了全国登记处关于因骨关节炎初次全膝关节置换术后因感染而进行翻修手术的数据。这些队列是根据使用的全膝关节假体设计和聚乙烯类型来定义的。将 ≤6 个月的翻修术进行了删失，以减少混杂偏倚。风险比（HR）经年龄、性别和抗生素骨水泥使用情况进行了调整。
共纳入 336997 例初次全膝关节置换术，其中 1651 例（0.49%）因假体周围感染而行翻修术。与使用 XLPE 作为衬垫的最小稳定型全膝关节假体相比，在调整了年龄、性别和抗生素骨水泥使用情况后，使用 NXLPE 作为衬垫的最小稳定型全膝关节假体的感染翻修风险增加了 25%（HR=1.25[95%置信区间（CI），1.07 至 1.45]；p=0.003），使用 XLPE 作为衬垫的后稳定型全膝关节假体的感染翻修风险增加了 89%（HR=1.89[95%CI，1.52 至 2.35]；p<0.001），使用 NXLPE 作为衬垫的后稳定型全膝关节假体的感染翻修风险增加了 102%（HR=2.02[95%CI，1.72 至 2.37]；p<0.001）。使用 NXLPE 的后稳定型全膝关节假体与使用 NXLPE 的最小稳定型全膝关节假体相比，感染的翻修风险增加了 61%（HR=1.61[95%CI，1.43 至 1.83]；p<0.001）。使用 NXLPE 的后稳定型全膝关节假体与使用 XLPE 的后稳定型全膝关节假体的感染翻修风险相同（HR=1.08[95%CI，0.88 至 1.32]；p=0.481）。
与使用 XLPE 衬垫的最小稳定型全膝关节假体相比，使用 NXLPE 衬垫的最小稳定型全膝关节假体和后稳定型全膝关节假体无论衬垫类型如何，其假体周围感染的长期翻修风险都更高。
治疗性 III 级。有关证据水平的完整描述，请参见作者说明。
