保留假体的清创术治疗初次关节置换术后早期假体周围感染

Outcomes of debridement and implant retention in treating periprosthetic joint infection after primary total joint arthroplasty

目的探讨保留假体的清创术治疗关节置换术后早期假体周围感染的疗效。方法回顾性分析2011年1月至2015年10月采用保留假体的清创术治疗的初次关节置换术后3个月内假体周围感染患者49例,男29例,女20例;年龄62.38±14.56岁(范围26~82岁)。膝关节假体周围感染27例,髋关节假体周围感染22例。术前23例患者出现窦道。手术失败定义为:因感染复发再次接受手术;窦道迁延不愈、持续渗出,受累关节严重疼痛;因感染导致患者死亡;术后需持续应用抗生素。结果微生物培养阴性18例(36.7%),培养阳性31例(63.3%)。其中甲氧西林敏感金黄色葡萄球菌培养阳性率28.6%(14/49)、耐甲氧西林金黄色葡萄球菌培养阳性率4%(2/49)、耐甲氧西林表皮葡萄球菌培养阳性率2%(1/49)、真菌及混合感染培养阳性率2%(1/49)。术后随访(68.34±14.02)个月(范围39~94个月)。末次随访时,膝关节假体周围感染患者膝关节协会评分(Knee Society Score,KSS)膝评分由术前的(38.37±12.39)分提高至(82.26±10.50)分(t=-17.09,P<0.001),KSS功能评分由术前的(42.19±10.14)分提高至(75.22±11.60)分(t=-12.53,P<0.001);髋关节假体周围感染患者Harris髋关节评分由术前(47.41±8.39)分提高至(86.41±6.07)分(t=-23.38,P<0.001)。6例手术失败,失败率12%(6/49),原因为感染复发再次接受外科手术,失败时间距手术时间(5.75±3.00)个月(范围1.5~10个月)。结论对初次髋、膝关节置换术后3个月内的假体周围感染,采用保留假体的清创术可取得较好的早中期疗效,但有一定的手术失败率。

Objective To present clinical effects of debridement, antibiotics, irrigation and retention of implant (DAIR) with integrated antibiotics application in treating periprosthetic joint infection (PJI) occurred within 3 months after primary surgery. Methods We retrospectively analyzed patients who received DAIR between January 2011 and October 2015. A total of 49 patients with a mean age of 62.38±14.56 years (range, 26-82 years) were included in this study, including 29 males and 20 females. There are 27 knees and 22 hips. Twenty-three patients has sinus tract. Failure was defined as subsequent surgical intervention for infection after the index procedure;persistent fistula, drainage, or excessive joint pain at the last follow-up;death related to the PJI;chronic suppression with antibiotics. Results There were 18 (36.7%) culture negative cases and 31 (63.3%) culture positive cases, including 28.6%(14/49) methicillin-sensitive staphylococcus aureus, 4%(2/49) methicillin-resistant staphylococcus aureus, 2%(1/49) methicillin-resistant staphylococcus epidermidis, 2%(1/49) mixed infection with fungus and so on. Within the 68.34±14.02 months (range, 39-94 months) follow-up duration, the Knee Society Score (KSS) score was improved from 38.37±12.39 points (range, 18-62 points) pre-operatively to 82.26±10.50 points (range, 49-96 points) post-operatively (t=-17.09, P<0.001). KSS function score was improved from 42.19±10.14 points (range, 26-67 points) pre-operatively to 75.22±11.60 points (range, 41-90 points) post-operatively (t=-12.53, P<0.001). Harris hip score was improved from 47.41±8.39 points (range, 32-58 points) pre-operatively to 86.41±6.07 points (range, 71-96 points) post-operatively (t=-23.38, P<0.001). There were 6 patients receiving subsequent surgical intervention as failure. The mean duration from the index surgery to failure was 5.75±3.00 months (range, 1.5-10 months). Conclusion The present protocol of DAIR for dealing with early-stage PJI, which is less than 3 months after primary TKA or THA, is fairly effective.