Humphrey Tyler J, Marchwiany Daniel, Salimy Mehdi S, Nelson Sandra B, Bedair Hany S, Melnic Christopher M
Orthopaedic Surgery, Massachusetts General Hospital, Boston, USA.
Infectious Disease, Massachusetts General Hospital, Boston, USA.
Cureus. 2022 Apr 14;14(4):e24139. doi: 10.7759/cureus.24139. eCollection 2022 Apr.
Introduction Concurrent diagnosis of periprosthetic joint infection (PJI) of total hip arthroplasty (THA) or total knee arthroplasty (TKA) with infectious endocarditis is a devastating clinical scenario infrequently documented in the literature. To date, no studies have fully described the orthopedic and infectious outcomes of patients with these concurrent diagnoses. The purpose of this study was to conduct a case series of patients with these diagnoses and document the orthopedic and infectious outcomes so that surgeons may effectively counsel patients regarding the gravity of the condition and the expected course of treatment. Methods This study is a retrospective case series using patient data from five hospitals within an academic healthcare system in the northeastern United States. Cases of concurrent endocarditis and THA or TKA PJI with a minimum of one-year follow-up were identified from January 2000 to January 2021. Basic statistics such as means, standard deviations, and percentages were used to identify trends within our series. Kaplan-Meier survivorship curves with log-rank tests were performed to determine if there were any differences in two-year mortality and joint survival (defined as needing explant) between patients who had cardiac surgery prior to surgical management for their PJI and those who had surgical management for PJI prior to cardiac surgery. Results A total of 18 joints in 16 patients with endocarditis and concurrent TKA or THA PJI were identified. All PJIs were managed surgically, with 14/18 (77.77%) of joint infections initially being managed by debridement, antibiotics, and implant retention (DAIR) and 4/18 (22.22%) of joint infections initially being managed by explant. Within the first six months of PJI diagnosis, 25% (4/16) of patients died of complications related to their infection, and one additional patient died of bacteremia just over a year after the initial PJI diagnosis. Of the 18 PJIs, 72.23% (13/18) had treatment failure, defined as any outcome equal to or worse than requiring chronic suppressive antibiotics for the infection. Due to low statistical power, we were not able to identify any differences in two-year mortality from PJI diagnosis (p=0.311) or joint survival (in terms of requiring explant) (p=0.420) depending on whether cardiac surgery or DAIR was performed first. Conclusions Concurrent infectious endocarditis and prosthetic joint infection is associated with high morbidity and mortality. Patients with these concurrent infections should be counseled that not only the associated mortality rate is high, but also the surgical treatment of their PJI has a high rate of treatment failure, including an explant following an initial DAIR, an explant with retained spacer, or a requirement of lifelong antibiotic suppression.
引言 全髋关节置换术（THA）或全膝关节置换术（TKA）的假体周围关节感染（PJI）与感染性心内膜炎的同时诊断是一种灾难性的临床情况，文献中鲜有记载。迄今为止，尚无研究全面描述这些同时诊断患者的骨科和感染结局。本研究的目的是对这些诊断的患者进行病例系列研究，并记录骨科和感染结局，以便外科医生能够有效地向患者咨询病情的严重性和预期的治疗过程。方法 本研究是一项回顾性病例系列研究，使用了美国东北部一个学术医疗系统内五家医院的患者数据。从2000年1月至2021年1月，确定了同时患有心内膜炎和THA或TKA PJI且至少随访一年的病例。使用均值、标准差和百分比等基本统计数据来确定我们系列中的趋势。进行了带有对数秩检验的Kaplan-Meier生存曲线分析，以确定在PJI手术治疗前进行心脏手术的患者与在心脏手术前进行PJI手术治疗的患者之间，两年死亡率和关节生存率（定义为需要取出假体）是否存在差异。结果 共确定了16例患有心内膜炎并同时患有TKA或THA PJI的患者的18个关节。所有PJI均通过手术治疗，其中14/18（77.77%）的关节感染最初采用清创、抗生素和保留植入物（DAIR）治疗，4/18（22.22%）的关节感染最初采用取出假体治疗。在PJI诊断后的前六个月内，25%（4/16）的患者死于与感染相关的并发症，另有一名患者在最初PJI诊断一年多后死于菌血症。在18例PJI中，72.23%（13/18）出现治疗失败，定义为任何等于或比因感染需要长期使用抑制性抗生素更差的结局。由于统计效力较低，我们无法确定根据是先进行心脏手术还是先进行DAIR，PJI诊断后两年死亡率（p = 0.311）或关节生存率（就需要取出假体而言）（p = 0.420）是否存在差异。结论 同时存在感染性心内膜炎和假体关节感染与高发病率和高死亡率相关。对于这些同时感染的患者，应告知他们不仅相关死亡率高，而且他们PJI的手术治疗失败率也高，包括最初采用DAIR后取出假体、保留间隔物取出假体或需要终身使用抗生素抑制。
