Indelli Pier Francesco, Ghirardelli Stefano, Valpiana Pieralberto, Bini Lorenzo, Festini Michele, Iannotti Ferdinando
Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA 94063, USA.
Südtiroler Sanitätsbetrieb, 39042 Brixen, Italy.
Pathogens. 2023 Apr 16;12(4):605. doi: 10.3390/pathogens12040605.
Periprosthetic joint infections (PJI) represent a devastating consequence following total joint arthroplasty (TJA). In this study, the authors describe a modified surgical technique developed to enhance the classical irrigation and debridement procedure (DAIR) to improve the possibilities of retaining an acutely infected TJA.
This technique, debridement antibiotic pearls and retention of the implant (DAPRI), aims to remove the intra-articular biofilm allowing a higher and prolonged local antibiotic concentration by using calcium sulphate antibiotic-added beads in a setting of acute (<4 weeks from symptoms onset) PJI with pathogen identification. The combination of three different surgical techniques (tumor-like synovectomy, argon beam/acetic acid application and chlorhexidine gluconate brushing) aims to remove the bacterial biofilm from the implant without explanting the original hardware.
In total, 62 patients met the acute infection criteria (<4 weeks of symptoms); there were 57 males and five females. The patients' average age at the time of treatment was 71 years (62-77) and the average BMI was 37 kg/m. The micro-organism, always identified through synovial fluid analysis (culture, multiplex PCR or Next Generation Sequencing), was an aerobic Gram + in 76% ( 41%; 16%), Gram-in 10% ( 4%) and anaerobic Gram + in 4%. The DAPRI treatment was performed at an average of 3 days from symptoms onset (1-7 days). All patients underwent a 12-week course of post-operative antibiotic therapy (6 weeks I.V. and 6 weeks oral). All patients were available at the 2-year minimum FU (24-84 months). A total of 48 (77.5%) patients were infection-free at the final FU, while 14 patients underwent 2-stage revision for PJI recurrence. In total, four patients (6.4%) had a prolonged drainage from the wound after placement of the calcium sulphate beads.
This study suggests that the DAPRI technique could represent a valid alternative to the classic DAIR procedure. The current authors do not recommend this procedure outside of the main inclusive criteria (acute scenario micro-organism identification).
人工关节周围感染（PJI）是全关节置换术（TJA）后一个灾难性的后果。在本研究中，作者描述了一种改良的手术技术，该技术是在经典的冲洗清创术（DAIR）基础上发展而来，以提高保留急性感染的TJA的可能性。
该技术，即清创抗生素珠及保留植入物（DAPRI），旨在通过在急性（症状出现后<4周）PJI且已鉴定病原体的情况下使用添加抗生素的硫酸钙珠来去除关节内生物膜，从而实现更高且持久的局部抗生素浓度。三种不同手术技术（类肿瘤滑膜切除术、氩束/乙酸应用和葡萄糖酸洗必泰刷洗）的联合应用旨在在不取出原有假体的情况下从假体上去除细菌生物膜。
共有62例患者符合急性感染标准（症状出现<4周）；其中男性57例，女性5例。治疗时患者的平均年龄为71岁（62 - 77岁），平均体重指数为37kg/m²。通过滑液分析（培养、多重PCR或下一代测序）始终能鉴定出的微生物中，需氧革兰氏阳性菌占76%（41%；16%），革兰氏阴性菌占10%（4%），厌氧革兰氏阳性菌占4%。DAPRI治疗平均在症状出现后3天（1 - 7天）进行。所有患者均接受了为期12周的术后抗生素治疗（静脉注射6周，口服6周）。所有患者均在至少2年的随访期（24 - 84个月）内可进行随访。在最终随访时，共有48例（77.5%）患者无感染，而14例患者因PJI复发接受了二期翻修。共有4例患者（6.4%）在放置硫酸钙珠后伤口引流时间延长。
本研究表明，DAPRI技术可能是经典DAIR手术的一种有效替代方法。目前作者不建议在主要纳入标准（急性情况且微生物鉴定）之外应用此手术。
