Feldman D S, Lonner J H, Desai P, Zuckerman J D
Department of Orthopaedic Surgery, Hospital for Joint Diseases, New York, N.Y. 10003, USA.
J Bone Joint Surg Am. 1995 Dec;77(12):1807-13. doi: 10.2106/00004623-199512000-00003.
We performed a retrospective analysis of thirty-three consecutive total hip and knee (twenty-three hip and ten knee) revision arthroplasties during which intraoperative frozen sections were analyzed. Data for the study were collected by means of a review of the charts, radiographic analysis, and evaluation of both frozen and permanent histological sections. The frozen sections, of periprosthetic tissue at the bone-cement interface or the pseudocapsule, were considered positive for active infection if there were more than five polymorphonuclear leukocytes per high-power field in at least five distinct microscopic fields. All patients were available for follow-up, at an average of thirty-six months (range, seventeen to seventy-nine months) after the initial revision operation. The frozen sections from ten patients were positive for infection, and those from twenty-three patients were negative. Comparison of the results of the analyses of the frozen sections (both positive and negative) with those of the analyses of the permanent histological sections of similar tissue showed a correlation of 100 per cent (sensitivity, 1.00; specificity, 1.00; and accuracy, 1.00). Nine patients had positive intraoperative cultures, and all of them had positive frozen sections (sensitivity, 1.00). Of the twenty-four patients who had negative intraoperative cultures, twenty-three had negative frozen sections (specificity, 0.96). Of the nine patients who had positive intraoperative cultures, only two were found to have infection on intraoperative gram-staining. The surgeon's operative assessment regarding the presence of infection, compared with the final pathological diagnosis, demonstrated a sensitivity of 0.70, a specificity of 0.87, and an accuracy of 0.82. All ten patients who had positive frozen sections were managed with excision arthroplasty; six of them subsequently had reimplantation, and the excision was the definitive procedure in the remaining four. One patient who had had a delayed reimplantation had a secondary skin slough and eventually was managed with an arthrodesis of the knee. In the group that had negative frozen sections, eighteen patients had a primary exchange revision arthroplasty and five had a delayed reimplantation. At the time of follow-up, one patient who had had a delayed reimplantation had radiographic loosening of the femoral component and was asymptomatic. One patient who had had a primary exchange arthroplasty was managed with a second revision because of aseptic loosening. There was no clinical recurrence of infection in any patient. The data indicate that analysis of frozen sections of periprosthetic tissue is a reliable predictor of the presence of active infection during revision joint arthroplasty. We recommend its use to differentiate aseptic from septic loosening.
我们对连续33例全髋关节和膝关节（23例髋关节和10例膝关节）翻修关节成形术进行了回顾性分析，术中对冰冻切片进行了分析。研究数据通过查阅病历、影像学分析以及对冰冻和永久组织学切片的评估来收集。如果在至少五个不同的显微镜视野中，每高倍视野的假体周围组织（在骨水泥界面或假包膜处）的冰冻切片中多形核白细胞超过五个，则认为存在活动性感染。所有患者均获得随访，初次翻修手术后平均随访36个月（范围为17至79个月）。10例患者的冰冻切片感染阳性，23例患者的冰冻切片感染阴性。将冰冻切片（阳性和阴性）分析结果与相似组织的永久组织学切片分析结果进行比较，显示相关性为100%（敏感性为1.00；特异性为1.00；准确性为1.00）。9例患者术中培养阳性，且所有患者的冰冻切片均为阳性（敏感性为1.00）。24例术中培养阴性的患者中，23例冰冻切片为阴性（特异性为0.96）。9例术中培养阳性的患者中，只有2例在术中革兰氏染色时发现有感染。与最终病理诊断相比，外科医生对感染存在情况的手术评估显示敏感性为0.70，特异性为0.87，准确性为0.82。所有冰冻切片阳性的10例患者均接受了关节切除成形术；其中6例随后进行了再植入，其余4例则以切除作为最终手术方式。1例延迟再植入的患者出现继发性皮肤溃疡，最终接受了膝关节融合术。在冰冻切片阴性的组中，18例患者进行了初次翻修关节置换术，5例进行了延迟再植入。在随访时，1例延迟再植入的患者出现股骨假体影像学松动，但无症状。1例初次翻修关节置换术的患者因无菌性松动接受了二次翻修。所有患者均无感染临床复发。数据表明，假体周围组织冰冻切片分析是翻修关节成形术中活动性感染存在的可靠预测指标。我们建议使用该方法来区分无菌性松动和感染性松动。
