影响膝关节假体周围感染再置换术预后的相关因素

Predictors for outcome of exchange arthroplasty for periprosthetic joint infections after primary total kneearthroplasty

目的探讨膝关节置换术后假体周围感染的患者行一期或二期再置换术的临床疗效及影响预后的相关因素。方法回顾性分析上海交通大学附属第六人民医院和厦门大学附属东南医院2012年1月至2014年11月因膝关节置换术后假体感染接受一期或二期再置换术的患者39例。对患者进行关节穿刺液细菌培养及组织标本培养。所有患者随访时间至少1年，期间每4周复查C反应蛋白（CRP）、红细胞沉降率（ESR）、降钙素原（PCT）、血常规，同时观察病变关节的疼痛、功能、活动度及畸形情况。采用方差分析或两独立样本t检验；关节假体再置换术预后指标筛选采用单因素Logistic回归分析。结果39例患者接受了膝关节假体感染一期或二期再置换术，其中男20例（51．3％），女19例（48．7％），平均年龄（62．4±11．7）岁。39例患者中有18例培养出革兰阳性菌，6例培养出革兰阴性菌，2例培养出结核分枝杆菌，1例培养出光滑假丝酵母菌。39例患者中有10例患者出现再置换术后感染，再置换术成功组及失败组间初次行膝关节置换术至确诊假体感染的时间、手术时间、是否合并耐药菌感染、治疗前后ESR及治疗后CRP，差异均有统计学意义（t0P〈0．05）。多因素回归分析提示，初次行膝关节置换术至确诊假体感染的时间（OR=0．96，95％CI：0．92～1．00，P=0．025）及治疗前后ESR（OR=0．97，95％CI：0．95～1．00，P=0．045；OR=0．94，95％CI：0．91～0．98，P=0．002）为再置换术预后的独立相关因素。结论膝关节置换术后假体感染再置换术后失败率仍较高，初次行膝关节置换术至确诊假体感染的时间、治疗前后ESR可有效预测再置换术的临床预后。

Objective To evaluate the overall failure rate of one or two-stage exchange arthroplasty for infections in total knee arthroplasty （TKA） and the predictors affecting the outcome of exchange. Methods Thirty-nine cases received one or two-stage exchange arthroplasty for periprosthetic joint infections after primary TKA in Shanghai Sixth People＇s Hospital affiliated to Shanghai Jiao Tong University School of Medicine and Southeast Hospital affiliated to Xiamen University from January 2012 to November 2014 were reviewed. Periprosthetic tissue and articular fluid of all patients were analyzed by bacterial culture. All patients were followed up for more than one year. C-reactive protein （CRP）, erythroeyte sedimentation rate （ESR）, proealcitonin （PCT） and blood routine were tested every four weeks, and the evaluation on pain, total periprosthetic function, range of motion and deformation of arthroplasty were conducted. Differences between groups were analyzed using chi-square test or Student＇s t test when appropriate, k stepwise selection approach in logistic regression analysis was used to screen key predictors for outcome of one or two-stage exchange for infections in TKA. Results There were 39 patients who had undergone one or two-stage exchange for infections in TKA, including 20 males （51.3%） and 19 females （48.7%） with an average age of （62.4±11.7） years. Among the 39 patients,18 gram-positive strains were isolated from specimens, and 6 gram negative strains, 2 Mycobacterium tuberculosis and 1 candida albicans. Ten of 39 reimplantations developed reinfection. Between the success and failure groups, there were significant differences in the time from primary TKA to revision （P=0. 023）, operative time （P = 0. 029）, multidrug resistant organisms （P = 0. 045）, the preoperative and post operative ESR （P=0. 002 and P〈0. 001, respectively） and post-operative CRP （P=0. 018）. Muhivariable logistic regression analysis demonstrated that time from primary TKA to revision （OR= 0.96,95%CI： 0.92--1.00, P=0. 025）, preoperative ESR （OR 0. 97,95%CI： O. 95--1. 00, P=0.045） and post operative ESR （OR=0. 94,95%CI： O. 91--0. 98, P=0. 002） were independent indicators associated with the outcome of one or two-stage revision. Conclusions The failure rate after revision for infected TKA is relatively high. The time from primary TKA to revision, preoperative and post operative ESR could predict the outcome of one or two-stage revision effectively.