术前血液学相关指标预测抗菌药物骨水泥旷置术结果的临床价值

Role of blood markers in predicting the failure of prosthesis removal and antibiotic-loaded bone cement spacer implantation for treatment of periprosthetic joint infection

目的探讨术前血液学相关指标对预测抗菌药物骨水泥旷置术效果的价值。方法回顾性分析河南省人民医院骨科2016年6月至2020年10月收治的接受抗菌药物骨水泥旷置术治疗的70例假体周围感染患者的临床资料。其中男性28例,女性42例,年龄(65.5±11.9)岁(范围:37~88岁)。根据旷置术后感染是否被控制,将患者分为成功组和失败组,比较两组患者术前实验室检查结果,包括C反应蛋白(CRP)、红细胞沉降率(ESR)、ESR与CRP的比值(ESR/CRP)、白细胞计数(WBC)、血小板计数(PLT)、血红蛋白(HB)、淋巴细胞计数(TLC)、白蛋白、纤维蛋白原(FIB),CRP与白蛋白的比值(CAR)及预后营养指数(PNI)等。组间比较采用独立样本t检验或χ^(2)检验。绘制受试者工作特征(ROC)曲线,分析术前实验室检查指标预测旷置术治疗假体周围感染失败的曲线下面积(AUC)、最佳诊断阈值、灵敏度及特异度。结果患者随访时间均大于2年,旷置术成功者55例,失败者15例,旷置术整体失败率为21.4%。成功组患者术前的CRP(35.9±16.2)mg/L、PLT(280.0±104.0)×10^(9)/L、CAR 1.3±0.8,均低于失败组[CRP(71.7±47.3)mg/L,PLT(364.7±119.3)×10^(9)/L及CAR 2.5±2.0],差异均有统计学意义(P值均<0.05)。成功组患者术前的ESR/CRP为3.3±3.1、白蛋白为(35.3±5.2)g/L、PNI为43.6±6.2,均高于失败组[ESR/CRP 1.6±1.4、白蛋白(31.3±4.8)g/L及PNI 39.2±15.1],差异均有统计学意义(P值均<0.05)。通过ROC曲线分析发现,CRP预测旷置术失败的AUC、最佳阈值、灵敏度、特异度分别为0.776(95%CI:0.660~0.867)、35.4 mg/L、86.7%、67.3%;ESR/CRP的上述结果分别为0.725(95%CI:0.605~0.825)、1.0、60.0%、78.2%,CAR为0.772(95%CI:0.656~0.863)、1.1、86.7%、67.3%。结论假体周围感染患者术前CRP、ESR/CRP及CAR在预测旷置术失败时具有较高价值;CRP>35.4 mg/L、ESR/CRP≤1.0及CAR>1.1,可为预测抗菌药物骨水泥旷置术治疗失败提供参考。

Objective To investigate the value of inflammation,coagulation and nutrition markers in predicting the failure of prosthesis removal and antibiotic-loaded bone cement spacer implantation for treatment of periprosthetic joint infection(PJI).Methods A retrospective study was conducted on 70 patients who undertook prosthesis removal and antibiotic-loaded bone cement spacer implantation due to PJI from June 2016 to October 2020 in the Department of Orthopedics,Henan Provincial People′s Hospital.There were 28 males and 42 females,aged(65.5±11.9)years(range:37 to 88 years).Patients were divided into two groups as the successful group and the failed group depended on whether reinfection occurred after prosthesis removal and antibiotic-loaded bone cement spacer implantation at the last follow up.Patient demographics,laboratory values(C-reactive protein(CRP),erythrocyte sedimentation rate(ESR),ESR and CRP ratio(ESR/CRP),white blood cell count(WBC),platelet count(PLT),hemoglobin(HB),total lymphocyte count(TLC),albumin、fibrinogen(FIB),CRP and albumin ratio(CAR),prognostic nutritional index(PNI)),and reinfection rates were assessed.Comparison between groups was conducted by the independent sample t test orχ^(2)test.Receiver operating characteristic(ROC)curve was plotted,and the area under the curve(AUC),optimal diagnostic threshold,sensitivity,and specificity were analyzed to predict the failure of prosthesis removal and antibiotic-loaded bone cement spacer implantation.Results All patients were followed up for at least two years,and the follow-up time was(38.4±15.2)months(range:24 to 66 months).Fifteen patients suffered failure after prosthesis removal and antibiotic-loaded bone cement spacer implantation,while the other 55 patients succeeded.The overall failure rate of prosthesis removal and antibiotic-loaded bone cement spacer implantation in PJI treatment was 21.4%.Level of preoperative CRP((35.9±16.2)mg/L),PLT((280.0±104.0)×10^(9)/L)and CAR(1.3±0.8)in successful group were lower than CRP((71.7±47.3)mg/L),PLT((364.7±119.3)×10^(9)/L)and CAR(2.5±2.0)in failed group(all P<0.05).Whereas,level of preoperative ESR/CRP(3.3±3.1),Albumin((35.3±5.2)g/L)and PNI(43.6±6.2)in successful group were higher than ESR/CRP(1.6±1.4),Albumin((31.3±4.8)g/L)and PNI(39.2±15.1)in failed group(all P<0.05).AUC of ROC curve,optimal threshold value,sensitivity and specificity of CRP,ESR/CRP,PLT,Albumin,CAR and PNI for the predicting failure of prosthesis removal and antibiotic-loaded bone cement spacer implantation were 0.776(95%CI:0.660 to 0.867),35.4 mg/L,86.7%,67.3%;0.725(95%CI:0.605 to 0.825),1.0,60.0%,78.2%;0.713(95%CI:0.593 to 0.815),253,93.3%,47.3%;0.721(95%CI:0.601 to 0.822),35.7,93.3%,49.1%;0.772(95%CI:0.656 to 0.863),1.1,86.7%,67.3%;0.706(95%CI:0.585 to 0.809),45.7,100%,41.8%respectively.Conclusion In patients with PJI,CRP>35.4,ESR/CRP≤1.0 and CAR>1.1 could predict the failure of prosthesis removal and antibiotic-loaded bone cement spacer implantation.