Pharmacy Department, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, HA7 4LP, UK.
Bone Infection Unit, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, HA7 4LP, UK.
J Orthop Surg Res. 2023 Jan 30;18(1):75. doi: 10.1186/s13018-022-03446-1.
Infection is a devastating complication of endoprosthetic replacement (EPR) in orthopaedic oncology. Surgical treatments include debridement and/or one- or two-stage exchange. This study aims to determine the infection-free survival after surgical treatment for first and recurrent EPR infections and identify the risk factors associated with infection recurrence.
This single-centre cohort study included all patients with primary bone sarcomas or metastatic bone disease treated for infected EPR between 2010 and 2020. Variables included soft tissue status using McPherson classification, tumour type, silver coating, chemotherapy, previous surgery and microorganisms identified. Data for all previous infections were collected. Survival analysis, with time to recurrent infection following surgical treatment, was calculated at 1, 2 and 4 years. Cox regression analysis was used to assess the influence of different variables on recurrent infection.
The cohort included 99 patients with a median age of 44 years (29-58 IQR) at the time of surgical treatment. The most common diagnoses were osteosarcoma and chondrosarcoma. One hundred and thirty-three surgical treatments for first or subsequent infections were performed. At 2 years of follow-up, overall success rates were as follows: two-stage exchange 55.3%, one-stage exchange 45.5%, DAIR with an exchange of modular components 44.6% and DAIR without exchange of modular components 24.7%. Fifty-one (52%) patients were infection-free at the most recent follow-up. Of the remaining 48 patients, 27 (27%) were on antibiotic suppression and 21 (21%) had undergone amputation. Significant risk factors for recurrent infection were the type of surgical treatment, with debridement alone as the highest risk (HR 4.75: 95%CI 2.43-9.30; P < 0.001); significantly compromised soft tissue status (HR 4.41: 95%CI 2.18-8.92; P = 0.001); and infections due to Enterococcus spp.. (HR 7.31: 95%CI 2.73-19.52); P = 0.01).
Two-stage exchange with complete removal of all components where feasible is associated with the lowest risk of recurrent infection. Poor soft tissues and enterococcal infections are associated with higher risks of recurrent infection. Treatment demands an appropriate multidisciplinary approach. Patients should be counselled appropriately about the risk of recurrent infection before embarking on complex treatment.
感染是骨科肿瘤学中人工假体置换术（EPR）的一种毁灭性并发症。手术治疗包括清创术和/或一期或二期置换术。本研究旨在确定初次和复发性 EPR 感染的无感染生存情况，并确定与感染复发相关的危险因素。
本单中心队列研究纳入了 2010 年至 2020 年间因感染 EPR 接受治疗的原发性骨肉瘤或转移性骨病患者。变量包括使用 McPherson 分类法评估的软组织状况、肿瘤类型、银涂层、化疗、先前的手术和鉴定出的微生物。收集了所有先前感染的数据。以术后再次感染为时间节点，计算 1、2、4 年时的无感染生存情况。使用 Cox 回归分析评估不同变量对感染复发的影响。
该队列纳入了 99 名在手术治疗时中位年龄为 44 岁（29-58 IQR）的患者。最常见的诊断是骨肉瘤和软骨肉瘤。133 例患者因初次或后续感染接受了手术治疗。在 2 年的随访中，以下是各种手术方法的总体成功率：二期置换术 55.3%、一期置换术 45.5%、带有模块组件置换的清创术（DAIR）44.6%、无模块组件置换的 DAIR 24.7%。51 名（52%）患者在最近的随访中无感染。在其余 48 名患者中，27 名（27%）接受了抗生素抑制治疗，21 名（21%）接受了截肢手术。感染复发的显著危险因素是手术治疗类型，单纯清创术的风险最高（HR 4.75：95%CI 2.43-9.30；P<0.001）；明显受损的软组织状态（HR 4.41：95%CI 2.18-8.92；P=0.001）；以及肠球菌属感染（HR 7.31：95%CI 2.73-19.52；P=0.01）。
在可行的情况下，二期置换术彻底清除所有假体与感染复发的风险最低相关。软组织差和肠球菌感染与感染复发的风险增加相关。治疗需要采取适当的多学科方法。在开始复杂治疗之前，应向患者提供适当的咨询，告知其感染复发的风险。
