Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany.
Knee Surg Sports Traumatol Arthrosc. 2020 Sep;28(9):2823-2834. doi: 10.1007/s00167-019-05627-8. Epub 2019 Jul 18.
Debridement, systemic antibiotics and implant retention (DAIR) is very successful for early periprosthetic joint infection (PJI), but can fail in late-onset cases. We selected patients with PJI who were unsuitable for two-stage exchange total knee arthroplasty (TKA) and compared the outcomes of DAIR with or without degradable calcium-based antibiotics.
All patients fulfilled the criteria for late-onset PJI of TKA, as defined by an International Consensus Meeting in 2013, but were unsuitable for multistage procedures and TKA exchange due to operative risk. Fifty-six patients (mean age: 70.6 years, SD ± 10.8), in two historical collectives, were treated using a single-stage algorithm consisting of DAIR without antibiotics (control group, n = 33, 2012-2014), or by DAIR following the implantation of degradable antibiotics as indicated by an antibiogram (intervention group, n = 23, 2014-2017). OSTEOSET (admixed vancomycin/tobramycin), and HERAFILL-gentamicin were used as carrier systems. The primary endpoint was re-infection or surgical intervention after DAIR.
There were no significant differences between the two groups in terms of mean age, Charlson comorbidity index or the rate of mixed infections. Overall, 65.2% of patients achieved remission in the intervention group compared with only 18.2% in the control group (p < 0.001); 50% of re-infections in the intervention group even occurred after 36 months. Kaplan-Meier analysis showed that, compared with controls, the intervention group experienced significantly longer 3-year infection-free survival.
DAIR shows poor efficacy in difficult-to-treat cases, as demonstrated in our control group, which had a re-infection rate of 81.8%. In contrast, a DAIR group receiving topical calcium-based antibiotics showed significantly higher 3-year infection-free survival. Therefore, the combination of DAIR and degradable antibiogram-based local antibiotics is a reasonable salvage procedure for this body of patients. This is important as the number of severely sick patients who are too old for appropriate PJI treatment is estimated to increase significantly due to demographic change.
清创术、全身抗生素和植入物保留（DAIR）对于早期人工关节感染（PJI）非常成功，但在晚期发病的情况下可能会失败。我们选择了不适合行二期翻修全膝关节置换术（TKA）的 PJI 患者，并比较了 DAIR 联合或不联合可降解钙基抗生素的疗效。
所有患者均符合 2013 年国际共识会议定义的 TKA 晚期 PJI 标准，但由于手术风险不适合行多阶段手术和 TKA 翻修。56 例（平均年龄：70.6±10.8 岁）患者分属于两个历史队列，采用单阶段方案治疗，包括无抗生素的 DAIR（对照组，n=33，2012-2014 年），或根据药敏试验结果植入可降解抗生素的 DAIR（干预组，n=23，2014-2017 年）。OSTEOSET（万古霉素/妥布霉素混合）和 HERAFILL-庆大霉素被用作载体系统。主要终点是 DAIR 后再感染或手术干预。
两组患者的平均年龄、Charlson 合并症指数或混合感染率无显著差异。总体而言，干预组 65.2%的患者获得缓解，而对照组仅为 18.2%（p<0.001）；干预组 50%的再感染甚至发生在 36 个月后。Kaplan-Meier 分析显示，与对照组相比，干预组 3 年无感染生存率显著延长。
在我们的对照组中，DAIR 在治疗困难的病例中疗效不佳，再感染率为 81.8%。相比之下，接受局部可降解抗生素治疗的 DAIR 组显示出更高的 3 年无感染生存率。因此，DAIR 联合可降解抗生素的使用是这类患者的一种合理的挽救治疗方案。这一点很重要，因为由于人口结构的变化，预计适合严重疾病的 PJI 治疗的老年患者数量将显著增加。
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