Fowler Mia J, Belay Elshaday S, Hughes Andrew J, Devine Daniel K, Chiu Yu-Fen, Carli Alberto V
Adult Reconstruction & Joint Replacement, Hospital for Special Surgery, New York, New York.
Adult Reconstruction & Joint Replacement, Hospital for Special Surgery, New York, New York; Stavros Niarchos Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, New York.
J Arthroplasty. 2025 May;40(5):1301-1307.e3. doi: 10.1016/j.arth.2024.10.127. Epub 2024 Nov 2.
In critically ill periprosthetic joint infection (PJI) patients, surgeons need to balance the need for aggressive, definitive treatment against the health state of a potentially unstable patient. A clear understanding of the association between treatment outcomes and assessment scores for sepsis would benefit clinical decision-making in these urgent cases. The current study evaluates the effect of critical illness on debridement, antibiotics, and implant retention (DAIR) outcomes, as defined by systemic inflammatory response syndrome (SIRS) and, for the first time, by contemporary markers quick sequential organ failure assessment (qSOFA) and Modified Early Warning Score (MEWS).
We retrospectively identified 253 patients who underwent DAIR for PJI at a single institution between 2017 and 2021. The SIRS, qSOFA, and MEWS scores were calculated based on variables on admission. A DAIR treatment failure, defined as reoperation or mortality, was measured at 90 days and two years. Univariate analysis was used to determine the association between elevated critical care scores and DAIR failure.
The DAIR treatment success was 59% at two years, with hip procedures and Charlson comorbidity index ≥ one independently associated with higher odds of DAIR failure. There were 43 patients (16%) who presented with SIRS; however, only four (2%) had positive qSOFA scores. Neither SIRS nor qSOFA was predictive of DAIR failure. Only for knees, elevated MEWS scores were predictive of 90-day DAIR failure (P = 0.019).
Over one in six patients undergoing DAIR for PJI presented with SIRS, while only one in 50 had a positive qSOFA. The SIRS and qSOFA scores were not predictive of DAIR failure. Elevated MEWS scores were associated with DAIR failure at 90 days postoperatively in knee PJIs only and should be confirmed in a larger cohort. Our results suggest that SIRS is not predictive of DAIR outcomes, possibly because it overestimates the proportion of critically ill patients.
在危重症人工关节周围感染（PJI）患者中，外科医生需要在积极、确定性治疗的需求与潜在不稳定患者的健康状况之间取得平衡。清楚了解脓毒症治疗结果与评估评分之间的关联将有助于这些紧急情况下的临床决策。本研究评估了危重症对清创、抗生素和植入物保留（DAIR）结果的影响，这些结果由全身炎症反应综合征（SIRS）定义，并且首次由当代标志物快速序贯器官衰竭评估（qSOFA）和改良早期预警评分（MEWS）定义。
我们回顾性确定了2017年至2021年期间在单一机构接受DAIR治疗PJI的253例患者。根据入院时的变量计算SIRS、qSOFA和MEWS评分。将再次手术或死亡定义为DAIR治疗失败，并在90天和两年时进行测量。采用单因素分析确定重症监护评分升高与DAIR失败之间的关联。
两年时DAIR治疗成功率为59%，髋关节手术和Charlson合并症指数≥1与DAIR失败几率较高独立相关。有43例患者（16%）出现SIRS；然而，只有4例（2%）qSOFA评分呈阳性。SIRS和qSOFA均不能预测DAIR失败。仅对于膝关节，MEWS评分升高可预测90天DAIR失败（P = 0.019）。
接受DAIR治疗PJI的患者中，超过六分之一出现SIRS，而每50例中只有1例qSOFA呈阳性。SIRS和qSOFA评分不能预测DAIR失败。MEWS评分升高仅与膝关节PJI术后90天的DAIR失败相关，应在更大队列中予以证实。我们的结果表明，SIRS不能预测DAIR结果，可能是因为它高估了危重症患者的比例。
