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中华老年骨科与康复电子杂志

中华老年骨科与康复电子杂志 ›› 2024, Vol. 10 ›› Issue (02) : 88 -95. doi: 10.3877/cma.j.issn.2096-0263.2024.02.004

术后感染

带间隔器生存可作为慢性PJI中无法耐受二期翻修病例的可选方案——一项单中心队列研究
林嘉敏1, 丁海琦1, 黄昌瑜1, 陈旸2, 黄颖3, 张文明1, 方心俞1,†()   
  1. 1. 350005　福州，福建医科大学附属第一医院关节外科
    2. 350212　福州，福建医科大学附属第一医院滨海院区国家区域医疗中心关节外科
    3. 350005　福州，福建省骨科研究所
  • 收稿日期:2023-08-05 出版日期:2024-04-05
  • 通信作者: 方心俞
  • 基金资助:
    科技创新联合资金项目(2019Y9136)

Survival with spacer can be used as an alternative for patients with chronic PJI who cannot tolerate two-stage revision---- A single center cohort study

Jiamin Lin1, Haiqi Ding1, Changyu Huang1, Yang Chen2, Ying Huang3, Wenming Zhang1, Xinyu Fang1,†()   

  1. 1. Department of Orthopaedic Surgery, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
    2. Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
    3. Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China.
  • Received:2023-08-05 Published:2024-04-05
  • Corresponding author: Xinyu Fang
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引用本文：

林嘉敏, 丁海琦, 黄昌瑜, 陈旸, 黄颖, 张文明, 方心俞. 带间隔器生存可作为慢性PJI中无法耐受二期翻修病例的可选方案——一项单中心队列研究[J]. 中华老年骨科与康复电子杂志, 2024, 10(02): 88-95.

Jiamin Lin, Haiqi Ding, Changyu Huang, Yang Chen, Ying Huang, Wenming Zhang, Xinyu Fang. Survival with spacer can be used as an alternative for patients with chronic PJI who cannot tolerate two-stage revision---- A single center cohort study[J]. Chinese Journal of Geriatric Orthopaedics and Rehabilitation(Electronic Edition), 2024, 10(02): 88-95.

目的

评估慢性人工关节感染（PJI）带间隔器生存病例与完成二期翻修方案病例的临床疗效差异。

方法

回顾性收集2014年至2022年因慢性人工关节感染在我中心接受治疗的患者资料，按最终治疗方案分为带间隔器生存病例（DJS）与完成二期翻修方案病例（TSR）的队列；DJS组中根据植入间隔器类型不同分为骨水泥型（CS）和假体型（PS）。记录患者的年龄、性别、体重指数、实验室检测结果、术前术后关节功能评分、疼痛视觉模拟评分，比较DJS组和TSR组患者的感染控制率、并发症发生率。

结果

共纳入98例诊断为慢性PJI的患者，年龄为（65.14±9.88）岁（32~88岁）；DJS组35例，TSR组63例，所有患者至少随访1年（平均52.68±26.07个月）。在感染控制率方面，DJS组有5例复发感染（14.28%），TSR组有6例复发感染（9.52%），感染控制率差异无统计学意义（P=0.474）。功能方面，TSR组术后关节功能评分高于DJS组，然而在随访中DJS组患者对患肢的功能满意度（65.71%）和TSR组（66.67%）并没有显著差异（P=0.924）。并发症方面，DJS组术后出现假体断裂2例，关节脱位4例，关节假体周围骨折2例，深静脉血栓形成2例；TSR组2例假体周围骨折，2例脱位和2例下肢深静脉血栓形成，DJS组并发症发生率高于TSR组（P=0.015）；而DJS组中PS病例的并发症低于CS病例（P=0.009），与TSR组无显著差异（P=0.388）。

结论

DJS组与TSR组的感染控制率相似、功能接近，当患者无法耐受或无意愿进行二期翻修时，带间隔器生存尤其是假体型间隔器可作为部分慢性PJI患者的最终治疗选择。

关键词: 人工关节感染, 带间隔器生存, 二期翻修, 感染控制率, 并发症发生率
Objective

To evaluate the clinical outcomes of patients with chronic Periprosthetic Joint Infection (PJI) who survived with spacer and those who underwent two-stage revision.

Methods

The data of patients with chronic PJI treated in our center from 2014 to 2022 were retrospectively collected. According to the final treatment plan, the patients were divided into Destination Joint Spacers (DJS) and Two-Stage Revision (TSR). DJS group was divided into Cement spacer (CS) and Prosthetic spacer (PS) according to the different types of implanted spacer. The patient's age, gender, body mass index, laboratory test results, preoperative and postoperative joint function scores, and visual analogue scale (VAS) of pain were recorded. The infection control rate and complication rate were compared between the DJS group and the TSR group.

Results

A total of 98 patients with chronic PJI were enrolled, with an average age of 65.14±9.88 years (range, 32-88 years). There were 35 patients in the DJS group and 63 patients in the TSR group. All patients were followed up for at least 1 year (mean 52.68±26.07 months). In terms of infection control rate, there were 5 cases (14.28%) of recurrent infection in the DJS group and 6 cases (9.52%) in the TSR group. There was no significant difference in infection control rate between the two groups (P=0.474). In terms of function, the postoperative joint function score of the TSR group was higher than that of the DJS group. However, there was no significant difference in functional satisfaction of the affected limb between the patients in the DJS group (65.71%) and TSR group (66.67%) during follow-up (P=0.924). In terms of complications, there were 2 cases of prosthesis fracture, 4 cases of joint dislocation, 2 cases of periprosthetic joint fracture, and 2 cases of deep vein thrombosis in DJS group. There were 2 cases of periprosthetic fracture, 2 cases of dislocation and 2 cases of deep vein thrombosis in the TSR group. The incidence of complications in the DJS group was higher than that in the TSR group (P=0.015). In the DJS group, the PS group had a significantly lower incidence of complications than the CS group (P=0.009), and there was no significant difference between the PS group and the TSR group (P=0.388).

Conclusions

DJS group and TSR group have similar infection control rates and functional outcomes. When patients cannot tolerate or are unwilling to undergo two-stage revision, survival with spacer, especially prosthetic spacer, can be the final treatment option for some patients with chronic PJI.

Key words: Periprosthetic joint infection, Destination joint spacers, Two-stage revision, Infection control rate, Complication rate
图1 患者纳入和排除流程图
表1 两组慢性人工关节感染患者的人口统计特征
组别 例数 年龄（岁，±s） 性别（例） 手术部位（例） BMI（kg/m2，±s） CCI（%，±s） 一期术前CRP（mg/L，±s）
男 女 髋关节 膝关节
DJS组 35 69.20±9.35 15 20 19 16 23.50±3.49 4.30±0.95 41.71±47.77
TSR组 63 62.89±10.90 23 40 28 35 25.46±4.77 3.20±1.23 37.20±38.10
统计值   t=2.881 χ2=0.382 χ2=0.873 t=-0.656 t=2.521 t=0.465
P值   0.005 0.536 0.350 0.514 0.061 0.643
组别 例数 一期术前ESR（mm/h，±s） 一期SF-WBC（×106/L，±s） 一期SF-PMN（%，±s） 一期术后CRP（mg/L，±s） 一期术后ESR（mm/h，±s）
DJS组 35 69.67±36.73 44251.74 ±72354.02 76.72±18.46 7.70±13.74 30.14±21.11
TSR组 63 75.90±33.65 54656.19 ±60923.54 85.01±11.56 10.36±19.56 31.74±22.51
统计值   t=-0.782 Z=1.654 Z=1.229 t=0.931 t=-0.576
P值   0.437 0.219 0.098 0.333 0.591
图2~3　患者，女，74岁，右膝PJI，使用膝关节假体型间隔器行膝关节翻修术　 图4~5　患者，女，81岁，左膝PJI，使用膝关节骨水泥型间隔器行膝关节翻修术　 图6~7　患者，男，73岁，右髋PJI，使用髋关节假体型间隔器行髋关节翻修术　 图8~9　患者，女，77岁，右髋PJI，使用髋关节骨水泥型间隔器行髋关节翻修术
表2 两组慢性人工关节感染患者的一期手术病原微生物信息
组别 例数 培养阴性 葡萄球菌属 MRSA 铜绿假单胞菌 脑膜败血伊丽莎白菌 大芬戈尔德菌 白色念珠菌 鹑鸡肠杆菌 阴沟肠杆菌 停乳链球菌
DJS组 35 8 11 1 1 1 2 1 0 2 2
TSR组 63 15 24 2 3 0 1 2 1 0 1
组别 例数 口腔链球菌 肺炎克雷伯菌 大肠埃希菌 近平滑念珠菌 产酸克雷伯菌 草绿色链球菌 鲍曼不动杆菌 枯草芽孢杆菌 奇异变形杆菌 皮氏罗尔斯顿菌 肠炎沙门菌
DJS组 35 0 2 1 1 0 0 0 0 0 1 1
TSR组 63 1 2 3 1 1 1 1 2 1 1 0
表3 两组慢性人工关节感染患者的疗效评价比较（±s）
组别 感染复发 术前VAS 术后VAS 术前HHS 术后HHS 术前KSS 术后KSS
DJS组（n=35） CS（n=10） 2 4.78±1.33 3.03±2.1 40.72±8.61 50.33±12.13 37.66±9.22 47.45±6.68
PS（n=25） 3 4.90±1.03 3.19±2.12 42.72±8.51 64.33±12.33 38.96±9.22 60.95±6.18
TSR组（n=63） 6 4.92±1.49 2.64±1.12 48.22±10.44 78.64±18.60 44.88±8.01 70.50±9.18
  DJS VS TSR χ2=0.512 t=0.309 t=0.655 t=0.643 t=2.152 t=1.006 t=2.960
  0.474 0.950 0.519 0.550 <0.05 0.120 <0.05
统计值 CS VS PS χ2=0.373 t=0.369 t=0.553 t=0.388 t=2.242 t=0.997 t=2.196
P值 0.541 0.886 0.668 0.845 <0.05 0.101 <0.05
  PS VS TSR χ2=0.120 t=0.243 t=0.789 t=0.791 t=1.116 t=0.955 t=0.929
  0.730 0.963 0.412 0.410 0.101 0.203 0.122
图10~13 膝关节Ⅱ型（骨水泥型）间隔器中出现的2例间隔器断裂。图10~11　患者，女，76岁，右膝PJI，使用膝关节骨水泥型间隔器行膝关节翻修术，术后1个月复查提示间隔器断裂　图12~13　患者，男，72岁，左膝PJI，使用膝关节骨水泥型间隔器行膝关节翻修术，术后2个月复查提示间隔器碎裂
表4 两组慢性人工关节感染患者的并发症发生数（例）
组别   间隔器断裂 脱位 关节周围骨折 深静脉血栓 合计
DJS组（n=35） CS（n=10） 2 4 0 0 6
PS（n=25） 0 0 2 2 4
TSR组（n=63）   0 2 2 2 6
  DJS VS TSR 0.055 0.102 0.543 0.543 0.015
  3.657 2.667 0.371 0.371 5.976
χ2值 CS VS PS 0.021 0.001 0.357 0.357 0.009
P值 5.303 11.290 0.848 0.848 6.776
  PS VS TSR / 0.367 0.327 0.327 0.388
  0.812 0.960 0.960 0.745
图14~15 术后感染复发及出现并发症的生存分析曲线对比；图14　完成二期翻修组（TSR）vs带间隔器生存组（DJS）；图15　完成二期翻修组（TSR）vs带间隔器生存组中的假体型间隔器组（PS）
表5 两组慢性人工关节感染患者的术后并发症单因素log-rank分析
影响因素 出现并发症 未出现并发症 P值 χ2值
性别        
男 5 33 0.499 0.456
女 11 49    
基础病        
无 5 30 0.684 0.166
有 11 52    
年龄        
≥65岁 11 40 0.144 2.139
<65岁 5 42    
间隔器类型        
骨水泥型 10 32 0.083 3.013
假体型 6 50    
BMI        
<25 3 23 0.441 0.594
≥25 13 59    
表6 两组慢性人工关节感染患者的多因素COX回归模型分析相对危险度
影响因素 回归系数B P值 相对危险度OR
年龄 -0.649 0.265 0.522
间隔器类别 0.746 0.160 2.108
基础病 0.132 0.816 1.141
BMI -0.055 0.936 0.946
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