计划外二次清创、抗生素使用及植入物保留对膝关节置换术长期疗效的影响：失败和再感染风险升高
Impact of unplanned second debridement, antibiotics and implant retention on long-term outcomes in knee exchange arthroplasty: Elevated risk of failure and reinfection.
作者信息
Lin Yu-Chih, Chen Wei-Cheng, Peng Shih-Hui, Chang Chih-Hsiang, Lee Sheng-Hsun, Lin Sheng-Hsuan
机构信息
Department of Orthopaedic Surgery Chang Gung Memorial Hospital (CGMH) Kweishan Taoyuan Taiwan.
Bone and Joint Research Center Chang Gung Memorial Hospital (CGMH) Kweishan Taoyuan Taiwan.
出版信息
J Exp Orthop. 2024 Apr 30;11(3):e12024. doi: 10.1002/jeo2.12024. eCollection 2024 Jul.
PURPOSE
This study investigates the outcomes of two-stage exchange arthroplasty (EA) for periprosthetic joint infection (PJI) following initial or unplanned repeat debridement antibiotics, and implant retention (DAIR).
METHODS
We retrospectively reviewed cases of knee arthroplasty infection treated with two-stage EA after DAIR, spanning from January 1994 to December 2010. A total of 138 patients were included, comprising 112 with initial DAIR and 26 with an unplanned second DAIR. Data on demographics, comorbidities, infection characteristics and causative organisms were analyzed. The primary outcome was implant failure or reinfection, observed over a minimum follow-up of 10 years.
RESULTS
The overall success rate for two-stage EA was 87% (119/138 patients). Factors identified for treatment failure included reinfection with the same pathogen for unplanned second DAIR (hazard ratio [HR] = 3.41; 95% confidence interval [CI] = 1.35-4.38; = 0.004), higher reinfection rates in patients undergoing EA after an unplanned second DAIR, especially with a prior history of PJI within 2 years (HR = 4.23; 95% CI = 2.39-5.31; = 0.002), pre-first DAIR C-reactive protein (CRP) levels over 100 mg/dL (HR = 2.52; 95% CI = 1.98-3.42; = 0.003) and recurrence with the same pathogen (HR = 2.35; 95% CI = 1.32-4.24; = 0.007). Additional factors such as male gender (HR = 3.92; 95% CI = 1.21-5.25; = 0.007) and osteoporosis (T score < -2.5; HR = 3.27; 95% CI = 1.23-5.28; = 0.005) were identified as risk factors for implant failure in all EA cases.
CONCLUSIONS
This study identifies key risk factors for worse knee EA outcomes following DAIR, including a pre-first DAIR CRP level over 100 mg/L, same pathogen recurrence, and PJI history within 2 years. It shows implant failure rates remain constant across EA cases, regardless of DAIR sequence, particularly with risk factors like male gender and severe osteoporosis (T score < -2.5). These results underscore the need for careful evaluation before an unplanned second DAIR, given its significant impact on EA success.
LEVEL OF EVIDENCE
Level III.
目的
本研究调查了在初次或非计划再次清创、抗生素治疗及植入物保留（DAIR）后，两阶段关节置换术（EA）治疗假体周围关节感染（PJI）的效果。
方法
我们回顾性分析了1994年1月至2010年12月期间接受DAIR后行两阶段EA治疗的膝关节置换感染病例。共纳入138例患者，其中112例为初次DAIR，26例为非计划再次DAIR。分析了人口统计学、合并症、感染特征及病原体的数据。主要结局为植入物失败或再次感染，随访至少10年。
结果
两阶段EA的总体成功率为87%（119/138例患者）。确定的治疗失败因素包括非计划再次DAIR时同一病原体再次感染（风险比[HR]=3.41；95%置信区间[CI]=1.35 - 4.38；P=0.004），非计划再次DAIR后行EA的患者再次感染率较高，尤其是既往2年内有PJI病史者（HR=4.23；95%CI=2.39 - 5.31；P=0.002），首次DAIR前C反应蛋白（CRP）水平超过100mg/dL（HR=2.52；95%CI=1.98 - 3.42；P=0.003）以及同一病原体复发（HR=2.35；95%CI=1.32 - 4.24；P=0.007）。其他因素如男性（HR=3.92；95%CI=1.21 - 5.25；P=0.007）和骨质疏松（T值＜-2.5；HR=3.27；95%CI=1.23 - 5.28；P=0.005）被确定为所有EA病例植入物失败的危险因素。
结论
本研究确定了DAIR后膝关节EA效果较差关键危险因素，包括首次DAIR前CRP水平超过100mg/L、同一病原体复发以及2年内有PJI病史。结果显示，无论DAIR顺序如何，EA病例的植入物失败率保持不变，尤其是存在男性和严重骨质疏松（T值＜-2.5）等危险因素时。这些结果强调了在非计划再次DAIR前进行仔细评估的必要性，因为其对EA的成功有重大影响。
证据级别
三级。
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