二期翻修治疗培养阴性膝关节假体周围感染

doi:10.3877/cma.j.issn.1674-134X.2021.06.005

目的

回顾性分析二期翻修治疗细菌培养结果为阴性的膝关节假体周围感染(PJI)的临床结果。

方法

检索2010年至2017年西京医院关节外科收治的人工膝关节置换术后PJI，排除急性感染、培养阳性和一期翻修的病例，纳入慢性感染且微生物培养结果为阴性的病例共27例，所有患者均采用二期翻修手术治疗，术中使用抗生素骨水泥，术后给予6周抗生素治疗(静脉输入3周+口服左氧氟沙星+利福平胶囊3周)的方案。感染持续时间、是否使用抗生素等因素与窦道形成的相关性采用logistic回归分析。

结果

纳入的27个病例中，感染治愈共26例(96.3%)，其中保留关节功能的24例(88.9%)，经关节融合治愈的患者2例，感染控制失败的1例(3.7%)。性别、年龄、是否使用抗生素、感染持续时间、C反应蛋白、血沉、白细胞计数、中性粒细胞百分比、D-二聚体等因素与窦道形成无显著相关性(均为P>0.05)。

结论

采用二期翻修+万古霉素/妥布霉素联合抗生素骨水泥，术后采用静滴头孢菌素的抗感染治疗，可以获得较好的治愈率并保留关节功能；但因缺乏对照且病例数较少，该方案的有效性尚需进一步论证。

关键词: 关节假体, 感染, 关节成形术，置换，膝, 再手术, 抗菌药, 骨水泥

Objective

To retrospectively evaluate the effect of two-stage revision on periprosthetic knee infections with negative cultured result.

Methods

Twenty-seven cases of microorganism culture negative periprosthetic joint infections(PJI) after total knee arthroplasty from January 2010 to December 2017 were collected for this study. The treatment included using antibiotic-loaded bone cement spacer, post-operative parenteral antibiotic for three weeks, following by oral levofloxacin and rifampicin for three weeks. The successful rate of treatment for periprosthetic knee infections were evaluated. Logistic regression was used to analyze the correlation between sinus tract formation and duration of infection, antibiotic usage, etc.

Results

A total of 27 cases of culture-negative PJI, of which 26 cases were cured, success rate of infection treatment was 96.3%, 24 cases(88.9%) preserved functional knees, two cases were cured by arthrodesis. Only one case failed to be eradicated infection, the failure rate was 3.7%. Gender, age, time of preoperative antibiotic infection control, C-reactive protein, erythrocyte sedimentation rate, white blood cell count, neutrophil percentage, D-dimer and other factors had no significant correlation with sinus tract formation(all P>0.05).

Conclusions

The culture-negative periprosthetic knee infections can be treated successfully by second-stage revision using antibiotic-loaded bone cement (vancomycin, tobramycin) implantation combined with intravenous cephalosporin infusions, the strategy may obtain a reasonable cure rate and preserve joint function. However, the effectiveness of this treatment strategy needs to be further demonstrated due to the lack of control group and short of cases.

Key words: Joint prosthesis, Infections, Arthroplasty, replacement, knee, Reoperation, Anti-bacterial agents, Bone cements

表1 窦道相关因素的logistic回归

窦道相关因素	参数估计	标准误	Waldχ²	P值	OR值	OR值的95%CI
性别	1.658	1.917	0.748	0.387	5.248	(0.123，224.609)
年龄(≤65岁/>65岁)	-2.422	2.389	1.028	0.311	0.089	(<0.001，9.586)
术前抗生素(是/否)	-12.941	220.788	0.003	0.953	0.000	(<0.001，>999.999)
旷置后感染控制期^*	0.197	0.464	0.180	0.671	1.218	(0.490，3.026)
C反应蛋白	0.052	0.059	0.757	0.384	1.053	(0.937，1.183)
红细胞沉降率	-0.123	0.146	0.709	0.400	0.884	(0.664，1.178)
白细胞计数	-0.143	0.403	0.126	0.723	0.867	(0.393，1.910)
中性粒细胞百分比	0.167	0.194	0.748	0.387	1.182	(0.809，1.728)
D-二聚体	-0.298	0.884	0.114	0.736	0.742	(0.131，4.192)

表1 窦道相关因素的logistic回归

窦道相关因素	参数估计	标准误	Waldχ²	P值	OR值	OR值的95%CI
性别	1.658	1.917	0.748	0.387	5.248	(0.123，224.609)
年龄(≤65岁/>65岁)	-2.422	2.389	1.028	0.311	0.089	(<0.001，9.586)
术前抗生素(是/否)	-12.941	220.788	0.003	0.953	0.000	(<0.001，>999.999)
旷置后感染控制期^*	0.197	0.464	0.180	0.671	1.218	(0.490，3.026)
C反应蛋白	0.052	0.059	0.757	0.384	1.053	(0.937，1.183)
红细胞沉降率	-0.123	0.146	0.709	0.400	0.884	(0.664，1.178)
白细胞计数	-0.143	0.403	0.126	0.723	0.867	(0.393，1.910)
中性粒细胞百分比	0.167	0.194	0.748	0.387	1.182	(0.809，1.728)
D-二聚体	-0.298	0.884	0.114	0.736	0.742	(0.131，4.192)

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Treatment of culture-negative periprosthetic joint infection after total knee arthroplasty

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Treatment of culture-negative periprosthetic joint infection after total knee arthroplasty