Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany.
Orthopaedic and Trauma Surgery Centre, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany.
Technol Health Care. 2020;28(6):721-731. doi: 10.3233/THC-192095.
To date only scanty data exist regarding the effect of failed debridement, antibiotics, irrigation and retention of the prostheses (DAIR) and negative pressure wound therapy (NPWT) on the outcome of a subsequent exchange arthroplasty.
The objective of this study was to determine the success rate of a two- or multi-stage procedure after initial failed DAIR/NPWT in patients with an acute periprosthetic joint infection (PJI) and to evaluate the influence of possible risk factors for treatment failure.
Nineteen consecutive patients with a persisting PJI and ongoing NPWT after treatment of an acute PJI with DAIR of the hip or knee joint from October 2010 to June 2017 were included. All patients were treated according to a structured treatment algorithm after referral to our hospital. The endpoint was a successful reimplantation with absence of signs of infection two years after replantation ("replantation group") or treatment failure ("treatment failure group") in terms of a permanent girdlestone arthroplasty, fistula, amputation or death. A risk factor analysis was performed between the two groups.
Explantation was performed in 15 cases, amputation in one case, and DAIR/establishment of a fistula in three cases. The treatment success rate after reimplantation in terms of "definitively free of infection" two years after surgery according to Laffer was 36.85% (seven out of 19 patients). Statistical analysis revealed the number of surgeries until wound consolidation (p= 0.007), number of detected bacterial strains (p= 0.041), a polymicrobial PJI (p= 0.041) and detection of a difficult-to-treat organism (p= 0.005) as factors associated with treatment failure. After failed DAIR/NPWT we could detect a significant higher number of different bacterial strains (p= 0.001).
The treatment success rate after failed DAIR and NPWT with 36% is low and associated with a high treatment failure rate (permanent girdlestone arthroplasty, fistula or amputation, death). Thus, the definition of risk factors is crucial. We found that the number of revisions until wound consolidation, a polymicrobial PJI and detection of a difficult-to-treat organisms were risk factors for treatment failure. Furthermore, after failed DAIR/NPWT we could detect a significant higher number of different bacterial strains, with a possible adverse effect on a consecutive exchange.
迄今为止，关于初次清创术、抗生素、灌洗和保留假体（DAIR）以及负压伤口治疗（NPWT）失败对随后的关节置换术结果的影响，仅有少量数据。
本研究旨在确定髋关节或膝关节急性假体周围关节感染（PJI）初次 DAIR/NPWT 治疗失败后，行两期或多期手术的成功率，并评估可能的治疗失败危险因素的影响。
2010 年 10 月至 2017 年 6 月，19 例髋关节或膝关节急性 PJI 患者行 DAIR 治疗后，持续 PJI 且持续 NPWT ，纳入本研究。所有患者均按我院制定的治疗方案进行治疗。研究终点为 2 年后无感染迹象的再次成功植入（“再植入组”）或永久性关节切除术、瘘管、截肢或死亡（“治疗失败组”）。对两组之间的危险因素进行了分析。
15 例患者行假体取出术，1 例患者行截肢术，3 例患者行 DAIR/建立瘘管术。术后 2 年，根据 Laffer 标准，“明确无感染”的再植入治疗成功率为 36.85%（19 例患者中有 7 例）。统计学分析显示，伤口愈合前的手术次数（p=0.007）、检出的细菌数量（p=0.041）、混合感染性 PJI（p=0.041）和检出难处理的病原体（p=0.005）是与治疗失败相关的因素。初次 DAIR/NPWT 治疗失败后，我们可检测到明显更多的不同细菌菌株（p=0.001）。
初次 DAIR 和 NPWT 治疗失败后，治疗成功率为 36%，治疗失败率高（永久性关节切除术、瘘管或截肢、死亡）。因此，危险因素的定义至关重要。我们发现，伤口愈合前的手术次数、混合感染性 PJI 和检出难处理的病原体是治疗失败的危险因素。此外，初次 DAIR/NPWT 治疗失败后，我们可检测到明显更多的不同细菌菌株，这可能对随后的关节置换术产生不利影响。
