全膝关节置换术后感染的预防和治疗VIP免费

InfectionFollowingTotalKneeArthroplasty:PreventionandManagement全膝关节置换术后感染的预防和治疗KevinL.Garvin,MD,andBeauS.Konigsberg,MDAnInstructionalCourseLecture,AmericanAcademyofOrthopaedicSurgeonsPeriprostheticjointinfectionisoneofthemostformidablechallengesforarthroplastysurgeons.Physiciansandscientistshaveworkeddiligentlytolowertheincidenceofinfectionsaroundprostheticjoints,butthepercentageofpatientswhodevelopaninfectionafterprimarytotalkneereplacementremainsintherangeof0.4%to2%1-3.Medicaredataindicatethattherateofperiprostheticinfectionwithinthefirsttwoyearsafterkneearthroplastyis1.55%.Theinfectionrateinthefollowingtwototenyearsisanadditional0.46%4,5.关节假体周围感染是关节外科医师所面临的最严峻的挑战之一。尽管医生和科学家们一致努力降低关节假体周围感染的发病率，但初次全膝关节置换术后发生感染的患者的比例仍有0.4%-2%。医疗数据显示，关节假体周围感染在膝关节置换术后前2年的发生率为1.55%，而之后的2-10年的发生率增加0.46%。Whilethepercentageofprosthetickneesthatareassociatedwithinfectionislow,thenumberswillincreasewiththegrowingnumberoftotalkneereplacements.Kurtzetal.projectedthatthedemandforprimarykneearthroplastywillgrowby673%,from450,000in2005to3.48millionin20306.If2%ofthe3.48millionpatientsdevelopaninfectionwithinthefirstyearafterthekneearthroplasty,asmanyas69,000patientsmaybetreatedforperiprosthetickneeinfectioneachyear.Thisgroupdoesnotincludepatientswhodevelopaninfectionmorethanoneyearafterthesurgeryorafterarevisiontotalkneearthroplasty.Theburdenandcomplexityarealsoincreasingbecauseofthenumberofresistantpathogens.然而与膝关节假体相关的感染的发生率较低，感染的例数随着全膝关节置换的数量增加而增加。Kurtz等曾经预测需要行初次全膝关节置换的病例数将会从2005年的450，000例增加到2030年的348万例，增加673%。如果348万例患者有2%在膝关节置换术后第1年发生感染，每年大约会有69，000例患者会因膝关节假体周围感染而进行治疗。这些还不包括术后1年以后或者膝关节翻修术后发生感染的患者。因为耐药菌的产生，患者的负担和疾病的复杂性也相应增加了。Staphylococcusaureusaccountsforthemajorityofperiprostheticjointinfections.Infectionscausedbymethicillin-resistantStaphylococcusaureus(MRSA)areespeciallydifficulttotreat7-9.TheStaphylococcusinfectionsmaybeacquiredinthehospital,butsomepatientsareknowncarriersofStaphylococcusaureusandinfectthemselves10,11.Patientswhoarecarrierscanbescreenedanddecolonizationcanbecarriedoutpreoperatively,potentiallyloweringtheriskofperiprostheticjointinfection.金黄色葡萄球菌感染占关节假体周围感染的大多数。尤其是耐甲氧酸西林金黄色葡萄球菌（MRSA）感染更难治疗。葡萄球菌感染可能是医学获得性感染，但一些患者是金黄色葡萄球菌携带者，为自身感染。病原菌携带者可以进行筛选，并在术前进行治疗，可以降低关节假体周围感染的风险。Prevention预防Avarietyofinterventionscanreducetheincidenceofinfections.Priortosurgery,surgeonsshouldidentifyandaddresshostfactorsassociatedwithanincreasedrisk,carryoutdecolonizationwhenapatientisabacterialcarrier,anduseperioperativeantibiotics.Prophylacticantibioticsareeffectiveinpreventingsurgicalsiteinfections.Theprotocolshouldbetoadministertheantibioticsonehourbeforethesurgicalincisionismade.Rosenbergetal.reportedthat,inathree-monthintervalbeforetheinitiationofaprotocoltoensurecompliancewithantibioticdosing,onlytwenty-six(65%)offortypatientsreceivedprophylacticantibioticswithinonehourbeforetheincision12.Aftertheprotocolwasstarted,thecomplianceincreasedto180(97%)of186pati...