PJI with Sepsis, a Complex Emergency Situation with Prodromal Stage

Introduction: With a considerable morbidity, mortality and a high financial impact, PJI has been considered as one of the most serious complications after arthroplasty. Special awareness must be given to these patients due to a life threatening systemic PJI related complication, sepsis. A prompt detection and adequate medical management of this situation is crucial for avoiding unfavorable outcomes. Methods: Between January 2011 and December 2012, we retrospectively examined adult patients who met PJI-SIRS criteria. Medical history search for patients’ anamnesis, surgical times, laboratory-microbiological findings and success rates was performed. Results: Twenty patients were enrolled in this study with a mean age of 71.35 years. Men population was more commonly affected with 55% of the cases. The knee was mainly the affected joint with 52%. A severe systemic disease was present in 80% of the cases. A sickness sensation and pain were the most common prodromal symptoms found 4.9 days before the admission to the hospital. In 85.7% of the cases the etiological agent was identified, with Staphylococcus aureus as the most common. Two-stage surgery treatment was performed with a time interval between admission and the first operation of 5.45 h. The mean time during the first and second operation was of 23 minutes and 117 minutes respectively. A reduction on microbiological positive cultures was found after the first rapid operation (P = 0.0038). Serum CRP levels and fever disappearance were the first parameters which indicated a favorable disease evolution after the first operation (P = 0.0137) and (P = 0.0181) respectively. A successful management was possible in 90% of the cases. Conclusion: Sepsis in patients with PJI announces itself early through the leading symptoms of feeling sick and pain in the affected joint. This time interval should be used therapeutically and diagnostically to prevent the complication of a life-threatening sepsis at best.

Increased Detection of Polymicrobial Infections by Sonication and Significance of Prosthesis Design and Fixation Technique in Cases of Low-Grade PJI, a Retrospective Study

Introduction: Low-grade PJI remains a diagnostic dilemma in the medical community. It is mainly caused by low-virulent bacteria that cause chronic infection. This is mainly due to the formation of biofilms on the implant surface. This biofilm formation poses a diagnostic challenge that causes difficulties in the microbiological diagnosis of the infection by conventional culture methods. Sonication culture of implants has proven to be useful for biofilm forming bacteria. Therefore, we examined the evaluation of low-grade PJI using sonication culture methods and searched for influencing factors. The methods: Between October 2016 and November 2019 we retrospectively examined adult patients with suggestive clinical and laboratory findings of low-grade PJI. The patient's medical history, demographic information, prosthesis type, laboratory findings and length of hospital stay were collected. The results of the microbiological culture were divided into the results of the conventional preoperative and intraoperative culture method and the results of the sonication. In addition, laboratory chemical diagnostics of the joint punctures and CRP determination were performed. Additionally, the influence of prosthesis design and fixation technique, with and without cement, was investigated. The Results: Fifty-two patients with a mean age of 70.5 years were included in this study. The female population was more frequently affected. The most frequently affected joints were hip and knee. A higher percentage of pathogen detection was found at sonication with 60% of positive cultures, compared to 52% of intraoperative and 40% of preoperative conventional positive culture findings. The majority of patients were monomicrobial infections, with Staphylococcus epidermidis being the most frequently detected etiologic pathogen. The sonication culture was best able to detect a polymicrobial infection in 14% of cases compared to 6% of intraoperative and 4% of preoperative conventional cultures. Patients with a polymicrobial infection showed higher CRP values (P = 0.0172) and longer hospitalization (P = 0.0017) than monomicrobial infected patients. The results of the intraoperative conventional culture showed the highest congruence with the results of the sonication culture (concordance of 79%) compared to the preoperative culture. An infectious histopathological classification confirmed the microbiological ultrasound findings in 69% of cases with an infectious category. Cemented fixation showed a trend towards less positive microbiological findings, and total hip arthroplasty showed the highest detection of bacteria by sonication culture compared to bicondylar surface knee replacement (P = 0.0072). Conclusion: The sonication culture proved to be an important microbiological diagnostic tool, especially for the detection of polymicrobial infections in cases of low-grade PJI. This method has an established place in the diagnosis of low-grade PJI. The prosthesis design and the cemented fixation technique seem to have an influence on the detection of bacteria.

1例PJI术后抗生素性粒细胞减少症的抗菌药物选择的病例分析

目的通过参与1例人工关节术后感染使用万古霉素治疗后,引起粒细胞减少的的药物治疗实践,为临床合理用药提供参考。方法笔者通过回顾性分析1例人工关节术后感染使用万古霉素治疗后,引起粒细胞减少的抗菌药物选择病例,药师经过查阅相关文献及指南,并结合患者病情,药师针对该患者抗感染方案给予了个体化治疗建议。结论通过该病例,对于万古霉素治疗PJI出现血象异常,应综合考虑,确定是否为万古霉素相关,再决定治疗方案。

人工关节假体周围感染诊疗的研究进展

随着人口老龄化，行髋、膝关节置换术的患者逐年增加（预计到2030年，美国行髋、膝关节置换术者将分别达到570000例和3480000例［1］），髋、膝关节置换术后关节假体周围感染（prosthetic joint in-fection，PJI）的发生率也随之增加。因此，如何提高PJI 的诊疗水平已成为关节外科领域的研究热点。本文就近年来 PJI 的诊疗研究综述如下。

PCR-电喷雾电离质谱技术诊断人工关节感染

人工关节感染（prosthetic joint infection,PJI）是关节置换术后严重的并发症,在初次人工关节置换术后的发生率为1%~2%,在人工关节翻修术后的发生率为1%~10%[1]。虽然PJI的总体发生率不高,但随着人工关节置换术数量的增加,PJI的病例也将逐渐增多。PJI的诊断困难、治疗方法复杂、疗效不确切,部分患者可发生关节功能的永久丧失,给社会和家庭带来巨大负担。

全髋关节置换术后假体周围关节感染研究进展

全髋关节置换术后假体周围关节感染研究进展李金松王明喜邵光湘全髋关节置换术（简称ＴＨＡ）后假体周围关节感染（ｐｅｒｉｐｒｏｓｔｈｅｔｉｃＪｏｉｎｔＩｎｆｅｃｔｉｏｎｓ，简称ＰＪＩ）的发病率已由７０年代的９％下降至０．２７％〔１〕。这主要应归功于围手术...

二代测序技术在人工关节感染病原学诊断中的应用

目的研究应用宏基因组二代测序技术(metagenomic next-generation sequencing,mNGS)在人工关节感染(periprosthetic joint infection,PJI)病原学诊断中的价值,为临床选择诊断技术提供经验。方法收集2017年1月-2019年12月复旦大学附属中山医院收治的疑似PJI患者的临床资料。通过对术中关节液和假体周围组织进行常规病原培养和mNGS检测,结合临床表现及治疗效果确认致病病原体。结果根据美国骨骼肌肉感染协会(Musculoskeletal Infection Society,MSIS)诊断标准,13例患者诊断为PJI,mNGS检出阳性率为84.62%,高于培养阳性率(76.92%),主要检出病原体为金黄色葡萄球菌、屎肠球菌、白假丝酵母菌、人型支原体等。mNGS检测时间为48 h,较培养法用时少。结论mNGS可快速检测PJI,从病原学角度为临床早期诊断PJI提供依据,是传统培养方法的重要补充,尤其在诊断培养阴性PJI方面具有优势。

髋膝关节假体周围感染诊疗的研究进展

人工关节感染(PJI)是一种毁灭性并发症,对患者自身健康及社会经济造成极大损害。基于该病的认识进展主要集中于诊断与治疗方面,以改善PJI病人预后。PJI诊断标准及治疗方案的选择是目前关于PJI的临床研究热点领域。早期诊断及治疗对于改善病人的预后具有重要的意义。早期诊断对临床起到一定的指导作用,进而有助于医师选择适宜的外科治疗方法和抗感染方案。本文对关节假体周围感染诊治方法作一综述,以期对临床提供指导建议。临床上,关节置换手术在缓解疼痛,改善关节功能和提高生活质量等方面都表现出了良好的中远期效果。人工关节感染(PJI)是关节置换术的灾难性并发症,常引起关节周围的疼痛、酸胀、红肿、皮温增高及全身炎性反应等症状,最终导致假体感染性松动,使患者住院时间延长、丧失关节功能,甚至截肢,危及生命。因此,PJI是公认的骨科严重并发症[1]。最新研究发现,全髋关节置换术后PJI的概率是0.3%-1.7%,全膝关节置换术后发生PJI的概率为0.8%-1.9%;另外再感染发病率为15%左右[2-3]。因住院时间过长,使得治疗费用大大增加,另外反复多次手术,术后功能恢复慢等问题导致严重并发症(如深静脉血栓,坠积性肺炎,消化与泌尿系统的感染以及心理问题),PJI无论在经济上还是健康上均带来了严峻挑战[4]。到目前为止,临床上对于PJI尚缺乏特异性诊断的有效方法,PJI的诊断和治疗难度较大,在现今世界范围仍是焦点问题。

因膝关节假体周围感染接受膝上截肢术患者术后主客观满意度分析

[目的]评估因膝关节假体周围感染行膝上截肢术患者术后主观满意度与客观功能的关系。[方法]回顾性分析13例因膝关节假体周围感染行膝上截肢术患者,女性7例,男性6例,中位数为69(45~73)岁。所有患者自初次膝关节置换术至截肢手术前因假体周围感染接受手术次数平均为2.9次(范围1~6)。13例患者按接受截肢手术时年龄被分为非老年组(<65岁)和老年组(≥65岁)。采用SF-12评分和Barthel指数评定量表评价患者术后功能及日常生活能力。通过调查问卷评价患者术后满意度。[结果]4例患者于截肢术后6个月内死亡,9名存活患者平均随访时间中位数为4.2(1.9~8.2)年,其中3例患者术后因残肢感染再次入院接受手术治疗。非老年组患者术后均可佩戴假肢步行,老年组患者中仅1例患者术后可佩戴假肢行走。非老年组患者截肢术后功能评分明显优于老年组病例(P<0.05),而老年组病例较年轻患者显示了更高的术后满意度。[结论]年轻的膝关节假体周围感染患者在接受膝上截肢术后功能水平及日常生活能力较高,然而由于对术后功能的较高期望和需求,使年轻患者对截肢手术的满意度低于老年患者;同时,尽管由于欠佳的全身状况导致老年患者截肢手术后功能水平较差,但因截肢手术减轻患者沉重的经济、心理负担以及老年人群对于功能相对偏低的期望值和需求,使老年患者对截肢手术后的生活状态感到相对满意。

感染和凝血相关指标在诊断慢性关节假体周围感染中的价值

目的探讨血液学感染和凝血指标C反应蛋白(CRP)、红细胞沉降率(ESR)、纤维蛋白原(FBG)、D-二聚体(D-dimer)和血小板(PLT)在诊断慢性关节假体周围感染(PJI)中的价值。方法收集2018年10月至2021年1月郑州大学附属郑州中心医院收治并完成初次关节置换术的149例患者资料。根据术后出现慢性PJI情况分为慢性PJI组(47例)和无感染对照组(102例)。比较两组术后CRP、ESR、FBG、D-dimer、PLT和PLT/平均血小板体积(MPV)的复查结果,采用ROC法分析CRP、ESR、FBG、D-dimer、PLT和PLT/MPV对慢性PJI的诊断效力。结果在关节置换术后,慢性PJI组CRP、ESR、FBG、D-dimer、PLT和PLT/MPV的水平显著高于无感染对照组(P<0.05)。ROC分析结果显示,CRP、ESR、D-dimer,FBG、PLT/MPV均具有诊断慢性PJI的价值(P<0.05)。进一步分析显示,CRP、ESR、FBG和D-dimer在诊断慢性PJI方面比较差异无统计学意义(P>0.05);CRP、ESR、FBG和D-dimer的诊断效能显著高于PLT和PLT/MPV(P<0.05)。但是,CRP、ESR、FBG和PLT/MPV诊断慢性PJI的截断值均在正常值范围内,而只有D-dimer的截断值高于正常值范围。结论FBG、D-dimer、CRP和ESR诊断慢性PJI的效能相当,且以D-dimer指标更具临床指导意义。

血清D-二聚体在关节假体周围感染诊断中的意义

[目的]探讨血清D-二聚体在关节假体周围感染(prosthetic joint infection,PJI)诊断中的意义。[方法]回顾性分析本科2016年6月~2018年6月收治的80例患者,其中初次置换组33例,PJI分期翻修24例,无菌松动翻修术组23例。比较三组患者术前血清C-反应蛋白(CRP)、血沉(ESR)、D-二聚体等数据。[结果]三组患者一般资料比较差异无统计学意义(P>0.05)。PJI患者血清CRP、ESR水平显著高于初次关节置换及无菌性松动患者(P<0.05),PJI患者血清D-二聚体水平显著高于初次置换者(P<0.05),但与无菌性松动患者体内D-二聚体水平差异不具有统计学意义(P>0.05)。当以D-二聚体>0.85μg/L为PJI诊断标准时,血清CRP、ESR、D-二聚体诊断PJI的敏感性、特异性类似,差异无统计学意义(P>0.05)。当以D-二聚体>0.5μg/L为PJI诊断标准时,D-二聚体诊断PJI的敏感性与CRP及ESR类似(P>0.05),但特异性差于CRP及ESR,差异具有统计学意义(P<0.05)。[结论]与CRP、ESR相比,血清D-二聚体在PJI诊断中无明显优势。

全膝假体周围感染的清创抗生素假体保留治疗

[目的]探讨初次全膝置换术后假体周围感染(periprosthetic joint infection,PJI)的清创抗生素假体保留(debride-ment,antibiotics,and implant retention,DAIR)治疗的临床效果。[方法]回顾性分析2016年1月—2020年6月在本科采用DAIR治疗的33例初次全膝置换术后感染患者的临床资料,其中术后3个月内感染28例,术后4~6个月内感染5例。评价临床及检验结果。[结果]所有患者均顺利完成手术,手术时间平均(113.5±12.4)min,术中失血量平均(43.5±7.4)ml。随访(44.1±11.7)个月,28例手术成功,成功率84.8%;5例手术失败,其中初次置换术后3个月内感染2例,术后4~6个月内感染3例,失败率15.2%。与术前相比,末次随访时,患者疼痛VAS评分[(5.1±1.4),(1.4±0.9),P<0.001]显著降低,膝关节KSS功能评分[(43.0±9.9),(81.8±11.3),P<0.001]、KSS临床评分[(37.8±14.9),(84.0±7.0),P<0.001]均显著增加。检验方面,15例(45.5%)细菌培养结果阴性,18例(54.5%)细菌培养阳性。随时间推移,WBC、CRP、ESR均显著降低(P<0.05)。[结论]采用DAIR治疗PJI可取得较好的早期疗效。相比术后3个月内PJI,术后4~6个月内的PJI,失败率较高。

^(18)F-FDG符合线路显像联合滑液CRP检测诊断膝关节假体感染

[目的]探讨^(18)F-FDG符合线路显像联合滑液CRP检测在膝关节假体周围感染的诊断价值。[方法]回顾性分析87例高度疑诊为膝关节假体周围感染患者,术前行^(18)F-FDG显像符合线路显像(^(18)F-FDG显像)及滑液CRP检测,术中采集假体周围5个不同部位的滑液进行细菌培养,培养结果为阴性的延长培养时间至2周,以细菌培养最终检验结果作为诊断标准。分析比较联合检查、单纯^(18)F-FDG显像和单纯滑液CPR的诊断价值及意义。[结果]87例患者中,细菌培养阳性73例,确诊为假体感染(感染组);14例为阴性,排除假体感染(非感染组)。联合检查的敏感性为89.04%,特异性为92.86%,准确性为89.66%;单纯^(18)F-FDG显像的敏感性为87.67%,特异性为71.43%,准确性为85.06%;单纯滑液CPR的敏感性为90.41%,特异性为57.14%,准确性为82.76%。联合检查的特异性和准确性显著高于单纯^(18)F-FDG显像或单纯滑液CRP检测,差异具有统计学意义(P<0.05)。[结论]^(18)FFDG符合线路显像联合滑液CRP检测显著改进膝关节假体周围感染诊断的特异性和准确性,可为膝关节假体周围感染诊断提供依据。