Pomen prepoznavanja zgodnje manifestacije indolentne oblike okužbe sklepnih endoprotez v ortopediji

Brumat, Peter (author), Trebše, Rihard (mentor)

Namen: Z usmerjeno analizo perioperativnih parametrov zgodnjega pooperativnega obdobja po vstavitvi sklepne endoproteze postaviti utemeljen sum, ali gre za okužbo umetnega sklepa, preden preide v kronično fazo, ko manj invazivne metode zdravljenja niso več uspešne. Proučiti klinične, laboratorijske in radiološke napovednike za indolentno in fulminantno obliko okužbe vstavljene sklepne endoproteze (angl. prosthetic joint infection - PJI) v prvih pooperativnih dneh po primarni totalni artroplastiki kolka/kolena (angl. Total hip/knee arthroplasty – THA/TKA). Metode: Proučili smo interni register osteoartikularnih okužb Ortopedske bolnišnice Valdoltra med letoma 2011 in 2021. V observacijsko retrospektivno raziskavo s kontrolno skupino smo vključili kohorto 152 bolnikov, ki so se zdravili zaradi PJI (32 indolentnih PJI, 63 akutnih fulminantnih PJI in 57 kroničnih fulminantnih PJI), v isti ustanovi pa so jim opravili THA/TKA. Velikost kontrolne skupine smo vnaprej določili v razmerju najmanj 1 : 1 ali več glede na največjo preiskovano PJI podskupino in v razmerju najmanj 2 : 1 glede na najmanjšo preiskovano PJI-podskupino. Z neparametričnimi statističnimi testi smo primerjali povprečja numeričnih in kategoričnih demografskih in od kirurga odvisnih spremenljivk (starost, spol, ITM, malignom, diabetes, vnetna artropatija, kajenje, sklep, implantat, ASA, trajanje, znotrajsklepna aplikacija traneksamične kisline, kirurška drenaža). Vpliv laboratorijskih in kliničnih kazalnikov na tveganje za PJI v prvih pooperativnih dneh po primarnem THA/TKA je bil proučen z multivariatno analizo za vsako PJI-podskupino in zavajajoče spremenljivke. Vsak laboratorijski kazalnik smo sistematično analizirali v ločenem multivariatnem modelu za šest različnih odnosov (predoperativna vrednost, vrednost drugi pooperativni dan, vsota, razlika, kvocient in zmnožek predoperativne vrednosti ter vrednosti drugi pooperativni dan), skupaj z od kirurga odvisnimi spremenljivkami in s podaljšanim iztokom iz kirurške rane (PIKR) kot edinim napovednim kliničnim kazalnikom. Občutljivost in specifičnost za spremenljivko PIKR smo analizirali za vsako PJI-podskupino za prvih sedem pooperativnih dni in za spremenljivko zmnožek predoperativne vrednosti levkocitov in vrednosti levkocitov drugi pooperativni dan za pražne vrednosti 70, 80, 90, 100, 110, 120, 130 in 140. Preiskovane radiološke parametre smo po statistično neznačilni osnovni statistični analizi izključili iz nadaljnje analize. Rezultati: Za vsak dodaten dan podaljšanega iztoka iz kirurške rane po inicialni operaciji je PIKR povečal tveganje za PJI v skupini z akutno fulminantno PJI-obliko z razmerjem obetov (angl. Odds Ratio – OR) 39.4 (p = 0.000, 95 % IZ 1.171–1.661), v skupini z indolentno PJI z OR 26.0 (p = 0.045, 95 % IZ 1.005–1.579), vendar ne v skupini s kronično fulminantno PJI (OR 16.6, p = 0.142, 95 % IZ 0.950–1.432). Po sistematski analizi je zmnožek števila levkocitov pred operacijo in na drugi dan po operaciji > 100 povečal tveganje za PJI v skupini z akutno fulminantno PJI (OR 2.1, p = 0.025, 95 % IZ 1.003–1.039) ter v skupini s kronično fulminantno PJI (OR 2.0, p = 0.018, 95 % IZ 1.003–1.036). Podoben trend smo opazili tudi v skupini z indolentno PJI, vendar ni bil statistično značilen (OR 2.3, p = 0.061, 95 % IZ 0.999–1.048). Najbolj optimalno pražno napovedno vrednost tveganja za PJI smo beležili samo v akutni fulminantni PJI-podskupini, kjer je bil PIKR več kot tri dni po inicialni operaciji pomemben dejavnik tveganja za PJI z občutljivostjo 62,9 % in specifičnostjo 90,6 %, medtem ko je zmnožek števila levkocitov pred operacijo in na drugi dan po operaciji več kot 100 pokazal specifičnost 96,9 %. Osnovna analiza radioloških kazalnikov in vrednosti: glukoze, eritrocitov, hemoglobina, trombocitov in CRP niso imele statistične značilnosti pri napovedi zgodnjega tveganja za PJI. Sklepi: Dinamika laboratorijskih in kliničnih kazalnikov v prvih dneh po primarni THA/TKA lahko napove tveganje za indolentno in akutno fulminantno obliko PJI. Podaljšan iztok iz kirurške rane in dinamika levkocitov sta se izkazala kot najpomembnejša napovednika. Z analizo radioloških parametrov nismo uspeli dokazati statistične značilnosti pri napovedi zgodnjega tveganja za PJI.

• Language: Slovenian
• Keywords: Napovednik, Obprotezna okužba umetnega sklepa, Vstavitev totalne sklepne endoproteze, Totalna artroplastika kolka, Totalna artroplastika kolena
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2024
• PID: 20.500.12556/RUL-155420
• Publication date in RUL: 31.03.2024

Secondary language

• Language: English
• Title: The importance of recognizing the early manifestation of the low-grade prosthetic joint infection in orthopaedics

Abstract

Purpose: We analyzed perioperative parameters during the early postoperative period following total hip or knee arthroplasty (THA/TKA) to establish reasonable suspicion of prosthetic joint infection (PJI) before transitioning to a chronic phase where less invasive treatment methods are no longer effective. We investigated clinical, laboratory and radiological predictors for both low-grade and fulminant PJI in the first few postoperative days after primary THA/TKA. Methods: We examined the internal registry of osteoarticular infections at the Valdoltra Orthopaedic Hospital between 2011–2021. An observational retrospective study with a control group included a cohort of 152 patients treated for PJI (32 low-grade PJI, 63 acute fulminant PJI, and 57 chronic fulminant PJI), all of whom underwent THA/TKA at the same institution. The control group size was predetermined at a ratio of at least 1 : 1 or more, based on the largest investigated PJI subgroup, and at a ratio of at least 2:1 based on the smallest investigated PJI subgroup. Non-parametric statistical tests were used to compare means of numerical and categorical demographic as well as surgeon-dependent variables (age, gender, BMI, malignancy, diabetes, inflammatory arthropathy, smoking, joint, implant, ASA, duration, intraarticular TXA, surgical drainage). The impact of laboratory and clinical parameters on the PJI risk in the early postoperative days after primary THA/TKA was studied using multivariate analysis for each PJI subgroup, controlling for confounding variables. Each laboratory parameter was systematically analyzed in a separate multivariate model for six different relationships (preoperative value, second postoperative day value, sum, difference, quotient, and product of preoperative value and second postoperative day value) alongside surgeon-dependent variables and prolonged wound discharge (PWD) as the sole predictive clinical parameter. Sensitivity and specificity for the PWD were analysed for each PJI subgroup for the first seven postoperative days, as well as for the product of preoperative leukocyte count and second postoperative day leukocyte count value for threshold values 70, 80, 90, 100, 110, 120, 130 and 140. We excluded the investigated radiological parameters from further analysis after a statistically non-significant basic statistical analysis. Results: For each additional day of wound discharge, PWD increased the risk of PJI in the acute fulminant PJI subgroup with an odds ratio (OR) of 39.4 (p = 0.000, 95 % CI 1.171–1.661), and in the low-grade PJI subgroup with an OR of 26.0 (p = 0.045, 95 % CI 1.005–1.579), but not in the chronic fulminant PJI subgroup (OR 16.6, p = 0.142, 95 % CI 0.950–1.432). Following systematic analysis, the product of leukocyte count before surgery and on the second day after surgery >100 increased the risk of PJI in the acute fulminant PJI subgroup (OR 2.1, p = 0.025, 95 % CI 1.003–1.039) and in the chronic fulminant PJI subgroup (OR 2.0, p = 0.018, 95 % CI 1.003–1.036). A similar trend was observed in the low-grade PJI subgroup, but it was not statistically significant (OR 2.3, p = 0.061, 95 % CI 0.999–1.048). The most optimal predictive threshold value for PJI risk was observed solely in the acute fulminant PJI subgroup, where PWD exceeding three days after primary surgery was a significant risk factor for PJI with a sensitivity of 62.9% and specificity of 90.6%, while the product of preoperative leukocyte count and second postoperative day leukocyte count value exceeding 100 showed a specificity of 96.9 %. Basic statistical analysis of radiological parameters, glucose, erythrocytes, haemoglobin, platelets, and CRP values did not have statistically significant values in predicting early PJI risk. Conclusions: The dynamics of laboratory and clinical parameters in the initial days after primary THA/TKA can predict low-grade and acute fulminant PJI. Prolonged wound discharge and leukocyte dynamics proved to be the most important predictors. With the analysis of radiological parameters, we were unable to demonstrate statistical significance in predicting early risk for PJI.

• Keywords: Predictor, Prosthetic joint infection, Total joint replacement, Total hip arthroplasty, Total knee arthroplasty