Department of Orthopaedic Surgery, Duke University, Durham, North Carolina.
J Arthroplasty. 2024 Oct;39(10):2581-2590. doi: 10.1016/j.arth.2024.06.007. Epub 2024 Jun 8.
The purpose of this study was to evaluate the management and outcomes of aseptic revision total knee arthroplasty (arTKA) with unsuspected positive cultures (UPCs) compared to those with sterile cultures.
The institutional database at a single tertiary center was retrospectively reviewed for arTKA from January 2013 to October 2023. Patients who met Musculoskeletal Infection Society criteria for periprosthetic joint infection (PJI) based on available preoperative infectious workup, received antibiotic spacers, or did not have at least 1 year of follow-up were excluded. Patients were stratified based on intraoperative cultures into 4 cohorts: sterile cultures, 1 UPC, ≥ 2 UPCs with different organisms, and ≥ 2 UPCs with the same organism. Univariable analyses were used to compare these groups. Kaplan-Meier survivorship analysis assessed infection-free survival at 5 years, and Cox proportional hazards regressions were used to evaluate factors that influence infection-free survival. A total of 691 arTKAs at a mean follow-up of 4.2 years were included in the study. Of these, 49 (7.1%) had 1 UPC with a new organism, 10 (1.4%) had ≥2 UPCs of the same organism, and 2 (0.2%) had ≥2 UPCs with different organisms.
Postoperative antibiotics were prescribed to 114 (16.5%) patients-13 (26.5%) with 1 UPC, 6 (60.0%) with ≥2 UPCs of the same organism, and 0 (0.0%) of patients who had ≥2 UPCs of different organisms. There were no differences in infection-free survival at 5 years between patients who had sterile cultures and 1 UPC (96 versus 89%; P = .39) nor between sterile cultures and ≥2 UPCs of different organisms (96 versus 100%; P < .72). However, patients who had ≥2 UPCs of the same organism had significantly worse infection-free survival at 5 years compared to patients who had sterile cultures (58 versus 96%; P < .001). Cox proportional hazards regression suggested that when adjusting for covariates, an American Society of Anesthesiologists classification of ≥3 (hazard ratio [HR] = 3.1; P = .007), ≥2 UPCs of the same organism (HR = 11.0; P < .001), 1 UPC (HR = 4.2; P = .018), and arTKA with hinge constructs (HR = 4.1; P = .008) were associated with increased risk of rerevision for PJI.
Patients who had 1 UPC or ≥2 UPCs with different organisms had similar infection-free survival at 5 years as patients who had sterile cultures. However, patients who had ≥2 UPCs of the same organism had significantly worse infection-free survival at 5 years. Overall, 1 UPC or ≥2 UPCs of the same organism at the time of arTKA may suggest the patient is at higher risk of rerevision for PJI. More studies are needed to determine what interventions can be implemented to mitigate this risk.
本研究旨在评估与无菌培养（sterile cultures）相比，在关节镜翻修全膝关节置换术（arTKA）中发现不明原因阳性培养物（unsuspected positive cultures，UPCs）的患者的管理和结局。
我们对单中心的机构数据库进行了回顾性研究，纳入了 2013 年 1 月至 2023 年 10 月间进行的 arTKA。基于术前感染性检查、使用抗生素 spacer、或随访时间不足 1 年的患者被排除在外。根据术中培养结果，患者分为 4 组：无菌培养、1 个 UPC、≥2 个 UPC 且不同病原体、≥2 个 UPC 且相同病原体。采用单变量分析比较这些组。Kaplan-Meier 生存分析评估 5 年无感染生存率，Cox 比例风险回归用于评估影响无感染生存率的因素。研究共纳入了 691 例 arTKA，平均随访 4.2 年。其中，49 例（7.1%）有 1 个 UPC 且有新病原体，10 例（1.4%）有≥2 个 UPC 且病原体相同，2 例（0.2%）有≥2 个 UPC 且病原体不同。
114 例（16.5%）患者术后使用了抗生素，其中 13 例（26.5%）有 1 个 UPC，6 例（60.0%）有≥2 个相同病原体的 UPC，而 0 例（0.0%）有≥2 个不同病原体的 UPC。在 5 年无感染生存率方面，无菌培养组和有 1 个 UPC 组之间（96%与 89%；P=0.39）以及无菌培养组和≥2 个相同病原体的 UPC 组之间（96%与 100%；P<0.72）均无差异。然而，有≥2 个相同病原体的 UPC 组的 5 年无感染生存率明显低于无菌培养组（58%与 96%；P<0.001）。Cox 比例风险回归表明，在校正了混杂因素后，美国麻醉师协会（American Society of Anesthesiologists）分类≥3 分（风险比[HR] 3.1；P=0.007）、≥2 个相同病原体的 UPC（HR 11.0；P<0.001）、1 个 UPC（HR 4.2；P=0.018）和铰链结构的 arTKA（HR 4.1；P=0.008）与翻修关节镜下感染的风险增加相关。
有 1 个 UPC 或≥2 个不同病原体的 UPC 的患者与无菌培养组患者在 5 年无感染生存率方面相似。然而，有≥2 个相同病原体的 UPC 的患者在 5 年无感染生存率方面明显更差。总体而言，arTKA 时的 1 个 UPC 或≥2 个相同病原体的 UPC 可能提示患者翻修关节镜下感染的风险更高。需要进一步研究以确定可以实施哪些干预措施来降低这种风险。
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