OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.
University of California, San Francisco, San Francisco, California.
J Bone Joint Surg Am. 2021 Jan 6;103(1):53-63. doi: 10.2106/JBJS.20.00240.
Extraction of implants because of periprosthetic infection (PJI) following complex revision total knee arthroplasty (rTKA) with extensive instrumentation is a daunting undertaking for surgeon and patient alike. The purpose of the present study was to evaluate whether infections following complex rTKA are better treated with 2-stage exchange or irrigation and debridement (I&D) with modular component exchange and antibiotic suppression in terms of infection control, reoperation, and function.
We reviewed rTKAs that had been performed for the treatment of PJI from 2005 to 2016. Extensive instrumentation was defined as the presence ≥1 of the following: metaphyseal cones/sleeves, distal femoral replacement, periprosthetic fracture instrumentation, or fully cemented stems measuring >75 mm. Cases were categorized according to the initial treatment (I&D with antibiotic suppression or initiation of 2-stage exchange).
Eighty-seven patients with PJI and extensive instrumentation were identified: 56 patients who were managed with I&D with suppression and 31 who were managed with the initiation of 2-stage exchange. The rate of success (defined as no reoperation for infection) was similar for the 2 groups (62.5% the I&D group compared with 67.7% for the 2-stage group; p = 0.62). The rate of mortality was also similar (39.3% for the I&D group compared with 38.7% for the 2-stage group; p = 0.96). Of the 31 patients in the 2-stage group, 18 (58.1%) underwent reimplantation with a revision replacement. Of those 18 patients, 13 were still infection-free at the time of the most recent follow-up; however, when the analysis was expanded to all 31 patients in the 2-stage group, only 13 (41.9%) both had a successful reimplantation and did not require additional surgery for infection. Nine (29.0%) of the 31 patients in the 2-stage group never underwent the second stage, and 4 (12.9%) of the 31 required arthrodesis at the second stage. In contrast, 35 (62.5%) of the 56 patients in the I&D group were successfully managed, without additional surgery for the treatment of infection. At the time of the latest follow-up (mean, 3.2 years; range, 2 to 13 years), more patients in the I&D group were ambulatory (76.8% in the I&D group compared with 54.8% in the 2-stage group; p = 0.05) and maintained a functional bending knee joint (85.7% in the I&D group compared with 45.2% in the 2-stage group; p < 0.001).
In the treatment of periprosthetic infection of rTKA with extensive instrumentation, I&D with chronic antibiotic suppression was as effective as 2-stage exchange in terms of preventing reoperation for infection and was more effective in terms of maintaining function. These data apply to rTKA with extensive periarticular instrumentation and should not be extrapolated to primary or simple revision implants.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
在进行复杂的全膝关节翻修术（rTKA）时，由于假体周围感染（PJI）而需要取出假体，这对于外科医生和患者来说都是一项艰巨的任务。本研究的目的是评估在控制感染、再次手术和功能方面，对于广泛使用器械的复杂 rTKA 后发生的感染，采用 2 期置换术还是灌洗清创术（I&D）联合模块化组件置换和抗生素抑制更为有效。
我们回顾了 2005 年至 2016 年治疗 PJI 的 rTKA。广泛使用器械的定义为存在以下任何一种情况≥1：骨水泥型髓内钉/套管、股骨远端置换、假体周围骨折器械或完全骨水泥固定的长度>75mm的柄。根据初始治疗（I&D 联合抗生素抑制或开始 2 期置换）对病例进行分类。
确定了 87 例 PJI 伴广泛器械使用的患者：56 例患者接受 I&D 联合抗生素抑制治疗，31 例患者接受 2 期置换术治疗。2 组的成功率（定义为无感染再次手术）相似（I&D 组为 62.5%，2 期组为 67.7%；p=0.62）。死亡率也相似（I&D 组为 39.3%，2 期组为 38.7%；p=0.96）。在 2 期组的 31 例患者中，18 例（58.1%）进行了翻修置换的再植入。在这 18 例患者中，在最近的随访时，13 例仍无感染；然而，当分析扩展到 2 期组的所有 31 例患者时，只有 13 例（41.9%）既成功再植入，又无需再次手术治疗感染。2 期组的 31 例患者中，有 9 例（29.0%）从未进行过第 2 期手术，有 4 例（12.9%）需要在第 2 期进行融合。相比之下，I&D 组的 56 例患者中有 35 例（62.5%）成功接受了治疗，无需再次手术治疗感染。在最近一次随访时（平均 3.2 年；范围 2 至 13 年），I&D 组有更多的患者能够行走（I&D 组为 76.8%，2 期组为 54.8%；p=0.05），且保持膝关节功能良好（I&D 组为 85.7%，2 期组为 45.2%；p<0.001）。
在广泛使用器械的 rTKA 假体周围感染的治疗中，I&D 联合慢性抗生素抑制与 2 期置换术在预防感染再次手术方面同样有效，且在保持功能方面更有效。这些数据适用于广泛使用关节周围器械的 rTKA，不应推广至初次或简单的翻修植入物。
证据水平：治疗性 III 级。有关证据水平的完整描述，请参见作者说明。
