Ji B C, Aimaiti Abudusaimi, Wang F, Zheng J J, Cao L
Department of Orthopaedics,the First Affiliated Hospital of Xinjiang Medical University,Urumqi 830054,China.
Zhonghua Wai Ke Za Zhi. 2023 Feb 1;61(2):129-137. doi: 10.3760/cma.j.cn112139-20220821-00363.
To evaluate the short-term outcomes of non-contact low-frequency ultrasonic debridement in treating periprosthetic joint infections(PJI). The clinical data of patients with PJI who met the eligibility criteria and were treated with non-contact low-frequency ultrasonic debridement from August 2021 to January 2022 at the Department of Orthopaedics,the First Affiliated Hospital of Xinjiang Medical University were prospectively analyzed. PJI was defined according to the modified Musculoskeletal Infection Society criteria in 2016. After mechanical debridement,an 8-mm handheld non-contact low-frequency ultrasound probe was used for ultrasonic debridement in the whole surgical area at a frequency of (25±5)kHz and power of 90% for 5 minutes. Each ultrasound lasted 10 seconds with 3-second intervals. The probe was repeatedly sonicated among all soft tissue,bone interface and metal prosthesis surface(patients underwent debridement,antibiotics and implant retention (DAIR)) in the surgical area. The femoral canal of the hip joint,the distal femoral canal and the posterior capsule of the knee were fully sonicated with a special right-angle probe. Before and after ultrasonic debridement,20 ml of liquid was extracted from each operation area and injected into aerobic and anaerobic culture bottles,respectively,for pathogen culture. Harris hip score and Hospital for Special Surgery (HSS) score were used to evaluate clinical function. Treatment failure was defined as the recurrence of infection in the same joint. The patients were routinely followed up in the outpatient clinic at 1,3,and 6 months postoperatively and then annually with a deadline of August 2022. The paired -test,rank sum,Mann-Whitney or test was used to compare the observed data,and rates among multiple groups were compared using the Bonferroni approach. A total of 45 patients were included in the study,including 21 men and 24 women with age of (65.8±15.2)years(range: 20 to 80 years) and body mass index of (29.3±4.2)kg/m(range: 20.2 to 38.5 kg/m). Twenty-eight patients (18 hips and 10 knees) underwent one-stage revision,and 17 cases (5 hips and 12 knees) underwent DAIR. Three of the patients (6.7%) had recurrent infections during follow-up. There were no intraoperative complications related to ultrasonic debridement (neurovascular and muscle injury,poor wound healing and fat liquefaction). Seventeen patients who received DAIR were followed for a median((IQR)) of 9(3) months,and two relapsed 3 weeks and 3 months post-operation,respectively. In addition,28 patients who underwent one-stage revision were followed for a median of 9(2) months,and one of the patients (3.6%,1/28) had a recurrence 6 months post-operation. The culture-positive rate of preoperative aspiration was 47.6% (20/42). The data of intraoperative soft tissue culture was 86.7% (39/45). The culture-positive rate of wound liquid before ultrasonic debridement was 46.7% (21/45). And the culture-positive rate after ultrasonic debridement was (75.6% (34/45)). After sonication,the culture-positive rate of explanted prostheses was 88.9% (40/45). There was a significant difference in culture-positive rates among all five cultures (=35.483,<0.01). Further pairwise comparison showed that the culture-positive rate of wound liquid after ultrasonic debridement was higher than that before ultrasonic debridement (=7.901,=0.005) but was not significantly different from the positive rates of other cultures (all >0.05). The median number of colonies 24 hours after ultrasonic debridement(2 240 (1 310) CFU/ml,range: 310 to 3 140 CFU/ml) was significantly higher than that before debridement(450 (550) CFU/ml,range: 10 to 910 CFU/ml) (=43, =0.017). The post-operative Harris ((78.6±4.2)points,range:70.5 to 85.3 points) and HSS scores((76.4±4.8)points,range: 68.5 to 84.3 points) were significantly higher than the preoperative scores((46.0±9.8)points,range: 27.5 to 64.3 points;and (45.5±10.3)points,range: 27.6 to 63.1 points) (=-14.6,=-12.7;both <0.01). Non-contact low-frequency ultrasonic debridement can increase the culture-positive rate and lead to a favorable short-term outcome. In addition,no complications are associated with using this new technique to treat PJI.
评估非接触式低频超声清创术治疗人工关节周围感染（PJI）的短期疗效。对2021年8月至2022年1月在新疆医科大学第一附属医院骨科符合入选标准并接受非接触式低频超声清创术治疗的PJI患者的临床资料进行前瞻性分析。PJI根据2016年改良的肌肉骨骼感染学会标准进行定义。在机械清创后，使用一个8毫米的手持式非接触式低频超声探头，以（25±5）kHz的频率、90%的功率在整个手术区域进行超声清创5分钟。每次超声持续10秒，间隔3秒。探头在手术区域的所有软组织、骨界面和金属假体表面（患者接受清创、抗生素和植入物保留（DAIR））反复进行超声处理。使用特殊的直角探头对髋关节的股骨髓腔、股骨远端髓腔和膝关节的后囊进行充分的超声处理。在超声清创前后，从每个手术区域抽取20毫升液体，分别注入需氧和厌氧培养瓶中进行病原体培养。采用Harris髋关节评分和特种外科医院（HSS）评分评估临床功能。治疗失败定义为同一关节感染复发。患者在术后1、3和6个月在门诊进行常规随访，然后每年随访一次，截止日期为2022年8月。采用配对t检验、秩和检验、Mann-Whitney U检验或卡方检验比较观察数据，多组间的率采用Bonferroni法进行比较。本研究共纳入45例患者，其中男性21例，女性24例，年龄为（65.8±15.2）岁（范围：20至80岁），体重指数为（29.3±4.2）kg/m²（范围：20.2至38.5 kg/m²）。28例患者（18髋和10膝）接受一期翻修，17例（5髋和12膝）接受DAIR。3例患者（6.7%）在随访期间出现感染复发。未发生与超声清创相关的术中并发症（神经血管和肌肉损伤、伤口愈合不良和脂肪液化）。17例接受DAIR的患者中位（（IQR））随访9（3）个月，2例分别在术后3周和3个月复发。此外，28例接受一期翻修的患者中位随访9（2）个月，其中1例患者（3.6%，1/28）在术后6个月复发。术前抽吸的培养阳性率为47.6%（20/42）。术中软组织培养数据为86.7%（39/45）。超声清创前伤口液体的培养阳性率为46.7%（21/45）。超声清创后的培养阳性率为75.6%（34/45）。超声处理后，取出假体的培养阳性率为88.9%（40/45）。所有五种培养的培养阳性率之间存在显著差异（χ²=35.483，P<0.01）。进一步的两两比较显示，超声清创后伤口液体的培养阳性率高于清创前（χ²=7.901，P=0.005），但与其他培养的阳性率无显著差异（均P>0.05）。超声清创后24小时的菌落中位数（2240（1310）CFU/ml，范围：310至3140 CFU/ml）显著高于清创前（450（550）CFU/ml，范围：10至910 CFU/ml）（t=43，P=0.017）。术后Harris评分（（78.6±4.2）分，范围：70.5至85.3分）和HSS评分（（76.4±4.8）分）显著高于术前评分（（46.0±9.8）分，范围：27.5至64.3分；和（45.5±10.3）分，范围：27.6至63.1分）（t=-14.6，t=-12.7；均P<0.01）。非接触式低频超声清创术可提高培养阳性率并带来良好的短期疗效。此外，使用这种新技术治疗PJI无并发症发生。
