限制性假体对全膝关节置换术后假体周围感染二期翻修效果的影响

The impact of constrained prostheses on the outcomes of two-stage revision for periprosthetic joint infection after total knee arthroplasty

目的比较采用高或低限制性假体对初次全膝关节置换术后假体周围关节感染(periprosthetic joint infection,PJI)二期翻修术后膝关节功能及感染控制效果的影响。方法回顾性分析2019年2月至2022年2月于上海交通大学附属第六人民医院接受全膝关节翻修术的患者40例,按照初次全膝关节置换假体的种类分为低限制性假体组和高限制性假体组。低限制性假体组28例(28膝),男12例、女16例,年龄69.0(63.0,74.0)岁,体质指数为(25.18±0.55)kg/m^(2);高限制性假体组12例(12膝),男5例、女7例,年龄66.5(65.0,71.5)岁,体质指数为(23.94±0.51)kg/m^(2)。均采用二期翻修术治疗,低限制性假体组1例使用旋转铰链膝RHK、27例使用髁限制性假体LCCK;高限制性假体组3例使用旋转铰链膝RHK、1例使用髁限制性假体PFC Sigma MBT、8例使用髁限制性假体LCCK。比较两组患者手术前后的关节活动度(range of motion,ROM)、美国膝关节协会评分(Knee Society score,KSS)以及术后感染控制率等。结果所有患者均获得随访,低限制性假体组随访时间为(22.79±8.02)个月,高限制性假体组为(23.92±7.04)个月,差异无统计学意义(t=0.426,P=0.680)。末次随访时低限制性假体组的KSS评分和ROM分别为(77.96±9.74)分和93.48°±7.45°,均高于术前的(38.93±8.01)分和68.89°±9.44°(P<0.05);高限制性假体组分别为(67.83±8.31)分和80.08°±5.89°,均高于术前的(34.25±6.31)分和66.50°±10.48°(P<0.05);两组患者KSS评分和ROM术前差异无统计学意义(P>0.05),末次随访时低限制性假体组均高于高限制性假体组(P<0.05)。细菌培养结果显示感染的主要细菌为凝固酶阴性葡萄球菌和金黄色葡萄球菌,总体感染控制率为80%(32/40),其中低限制性假体组的感染控制率为89%(25/28),高限制性假体组为58%(7/12),差异无统计学意义(χ^(2)=3.283,P=0.070)。结论二期翻修能有效控制全膝关节术后假体周围感染,且使用高限制性假体的初次全膝关节置换术后PJI二期翻修术后的膝关节功能较使用低限制性假体效果更差。

Objective To assess the clinical efficacy and infection control outcomes of two-stage revision in managing periprosthetic joint infection(PJI)following primary total knee arthroplasty(TKA)utilizing either a low or high constrained prosthesis.Methods A retrospective analysis was performed on 40 patients who underwent revision TKA in the Sixth People's Hospital Affiliated to Shanghai Jiao Tong University from February 2019 to February 2022.According to the type of prosthesis selected in primary TKA,they were divided into low constrained prosthesis group and high constrained prosthesis group.There were 28 patients(28 knees)in the low constrained group,including 12 males and 16 females,aged 69.0(63.0,74.0)years,with a body mass index of 25.18±0.55 kg/m2.And there were 12 patients(12 knees)in the high-constrained group,including 5 males and 7 females,aged 66.5(65.0,71.5)years,with a body mass index of 23.94±0.51 kg/m2.All patients underwent two-stage revision surgery,with RHK used in 1 case and LCCK in 27 cases in the low-constrained prosthesis group.In the high-constrained prosthesis group,3 patients were treated with RHK,1 patient with PFC Sigma MBT,and 8 patients with LCCK.The preoperative and postoperative range of motion(ROM),Knee Society score(KSS),and postoperative infection control rate were compared between the two groups.Results All patients were followed up.The follow-up time was 22.79±8.02 months in the low-constrained prosthesis group and 23.92±7.04 months in the high-constrained prosthesis group,with no significant difference between the two groups(t=0.426,P=0.680).At the last follow-up,the KSS and ROM in the low-constrained prosthesis group were 77.96±9.74 and 93.48°±7.45°,respectively,significantly higher than 38.93±8.01 and 68.89°±9.44°before the operation(P<0.05).The KSS score and ROM in the high-constrained prosthesis group were 67.83±8.31 and 80.08°±5.89°at the last follow-up,which were also significantly higher than those before operation(34.25±6.31 and 66.50°±10.48°,P<0.05).There was no significant difference in KSS and ROM between the two groups before operation(P>0.05),but the KSS score and ROM in the low-constrained prosthesis group were significantly higher than those in the high-constrained prosthesis group at the last follow-up(P<0.05).Bacterial culture results revealed that the primary infectious agents were coagulase-negative Staphylococcus and Staphylococcus aureus,with an overall infection control rate of 80%(32/40).The infection control rate was 89%(25/28)in the low-constrained prosthesis group and 58%(7/12)in the high-constrained prosthesis group,but the difference between the two groups was not statistically significant(χ2=3.283,P=0.070).Conclusion Two-stage revision effectively controls PJI,and the clinical outcomes of two-stage revision for PJI after primary TKA with a high-constrained prosthesis are inferior to those with a low-constrained prosthesis.Further exploration is needed to enhance efficacy.