Granovsky Gluskin Division of Orthopaedics, Mount Sinai Hospital, Toronto, Ontario, Canada; School of Medicine, Queen's University, Kingston, Ontario, Canada.
Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
J Arthroplasty. 2024 Dec;39(12):3062-3069. doi: 10.1016/j.arth.2024.05.084. Epub 2024 Jun 1.
Periprosthetic infection (PJI) with concomitant extensor mechanism disruption (EMD) and soft-tissue defect-hereinafter termed the "Terrible Triad"-is a devastating complication following total knee arthroplasty. The purpose of this study was to define the surgical and clinical outcomes following management of a cohort of patients who have the Terrible Triad.
From 2000 to 2022, 127 patients underwent operative management for PJI alone, 25 for PJI with soft-tissue defects (defined as defects requiring flap reconstruction or being a factor contributing to the decision of performing above-knee amputation or arthrodesis), 14 for PJI with EMD, and 22 for the Terrible Triad. A composite outcome of infection status, range of motion, extensor lag, and ambulatory status at final follow-up was used to compare the proportion of patients in each group with a favorable overall knee outcome. Differences between groups were determined using one-way analyses of variance with post hoc Tukey's tests and Pearson's Chi-square tests or Fisher's exact tests with post hoc Bonferroni adjustments, where applicable. Odds ratios (OR) were calculated for comparison of the overall knee outcome between groups. A Kaplan-Meier survival analysis for patient mortality was performed.
The mean follow-up was 8.4 years and similar between groups (P = .064). Patients who had the Terrible Triad had a 45.5% incidence of above-knee amputation, or arthrodesis, and an 86.4% incidence of an unfavorable outcome. Compared to patients in the PJI group, patients in the PJI who had a soft-tissue defect (OR = 5.8, 95% CI [confidence interval] 2.2 to 15.7), PJI with EMD (OR = 3.7, 95%CI 1.0 to 12.9), and Terrible Triad groups (OR = 11.6, 95% CI 3.3 to 41.5) showed higher odds of an unfavorable knee outcome.
This study demonstrates that the total knee arthroplasty Terrible Triad is a dreaded diagnosis with poor outcomes. Clinicians and patients might consider early treatment with amputation or arthrodesis.
III.
假体周围感染（PJI）伴伸肌机制破坏（EMD）和软组织缺损-以下简称“可怕三联征”-是全膝关节置换术后一种毁灭性的并发症。本研究的目的是定义一组患有可怕三联征的患者在接受治疗后的手术和临床结果。
2000 年至 2022 年，127 例患者因单纯 PJI 接受手术治疗，25 例因 PJI 伴软组织缺损（定义为需要皮瓣重建或导致决定行膝上截肢或关节融合术的缺损）接受手术治疗，14 例因 PJI 伴 EMD 接受手术治疗，22 例因可怕三联征接受手术治疗。在最终随访时，使用感染状态、活动范围、伸肌滞后和步行状态的综合结果来比较每组中具有良好整体膝关节结局的患者比例。使用单向方差分析和事后 Tukey 检验以及 Pearson 卡方检验或 Fisher 精确检验（视情况而定）比较组间差异，适用时进行事后 Bonferroni 调整。计算优势比（OR）以比较各组的整体膝关节结局。对患者死亡率进行 Kaplan-Meier 生存分析。
平均随访时间为 8.4 年，各组间相似（P=0.064）。患有可怕三联征的患者有 45.5%的膝上截肢或关节融合率，86.4%的不良结局发生率。与 PJI 组患者相比，PJI 伴软组织缺损（OR=5.8，95%CI [置信区间] 2.2 至 15.7）、PJI 伴 EMD（OR=3.7，95%CI 1.0 至 12.9）和可怕三联征组（OR=11.6，95%CI 3.3 至 41.5）的患者发生不良膝关节结局的可能性更高。
本研究表明，全膝关节置换可怕三联征是一种预后不良的可怕诊断。临床医生和患者可能会考虑早期行截肢或关节融合术治疗。
III 级。
