What Are the Risk Factors and Management Options for Infection After Reconstruction With Massive Bone Allografts?
What Are the Risk Factors and Management Options for Infection After Reconstruction With Massive Bone Allografts?
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DOI：
10.1007/s11999-015-4353-3
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发表时间：
2016-03-01
影响因子：
4.2
通讯作者：
Farfalli, German L.
中科院分区：
文献类型：
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作者：
Aponte-Tinao, Luis A.;Ayerza, Miguel A.;Farfalli, German L.
大块同种异体骨移植已被用于骨肿瘤切除术的保肢，作为内假体的替代方案，尽管它们具有不同的结局和风险。使用大块同种异体骨移植物被认为与感染的高风险相关，并且对于这种并发症的管理和最终结果没有普遍共识。由于感染是保肢手术的严重并发症，有时会导致肢体丧失，因此认识感染的危险因素和治疗结果是很重要的。本研究的目的是：（1）分析一组接受大块同种异体骨移植的患者的感染频率;（2）分析风险因素，如年龄、性别、受影响的骨、重建类型、使用的手术室、初次或翻修手术、术后抗生素使用时间和化疗的使用;以及（3）确定治疗感染的同种异体骨移植物将导致成功重建的可能性。我们回顾性分析了1985年至2011年期间接受大块同种异体骨移植治疗良性或恶性骨肿瘤或作为先前保肢手术的翻修的患者的记录。在此期间，673名患者接受了大块同种异体骨重建，其中包括272例骨关节重建、246例椎间重建和155例同种异体骨-假体复合重建。通过图表回顾，我们确定了感染同种异体移植物治疗后感染和再手术的频率。最短随访时间为2年，除非患者在此之前死亡（平均106个月，范围6-360个月），无患者失访。使用多变量logistic回归分析所选变量，以确定感染的危险因素。我们分析了无感染生存率作为终点，在随访期间，60例患者（9%）发生了同种异体移植物的细菌感染，5年无感染生存率为92%（95%置信区间[CI]，90%-94%），10年为91%（95% CI，89%-93%）。我们发现胫骨移植物（p < 0.001;比值比[OR]，3.17; 95% CI，1.80-5.60），男性患者（p < 0.029; OR，1.92; 95% CI，1.08-3.49），在传统手术室进行的手术（p < 0.002; OR，3.15; 95% CI，1.58-6.62）和术后抗生素使用时间较长（p < 0.041; OR，2.25; 95% CI，1.02-4.88）是与感染风险较高相关的患者因素。在11名患者（18%，60例感染中的11例）中，通过抗生素和外科清创术控制了感染;然而，在49名患者（82%，60例感染中的49例）中，该方法失败，因此取出同种异体移植物并植入含抗生素的临时骨水泥垫片以控制感染。41名患者随后取出了垫片，并在感染控制后进行了重建，其中24名患者使用了另一种同种异体骨，17名患者使用了内假体。4名患者因感染接受截肢，4名患者在置入融合器后死于疾病。我们分析了41例二次重建的患者，14例因新感染而失败（34%，41例二次重建中有14例），其中12例用同种异体骨重建（29%），2例用内假体重建（5%）。感染可以通过切除同种异体骨、抗生素、临时骨水泥垫片和抗生素以及重复重建来治疗;但是，如果使用第二种同种异体骨，这种方法不太可能成功。感染很难治疗，需要更多的研究，但我们建议使用内假体重建来挽救感染的同种异体移植物。III级，治疗性研究。
Massive bone allografts have been used for limb salvage of bone tumor resections as an alternative to endoprosthesis, although they have different outcomes and risks. The use of massive bone allografts has been thought to be associated with a high risk for infection, and there is no general consensus on the management of this complication and final outcome. Because infection is such a devastating complication of limb salvage, at times leading to loss of a limb, recognizing the risk factors for infection and the results of treatment is important.The purposes of this study were (1) to analyze the frequency of infection in a group of patients treated with massive bone allografts; (2) to analyze risk factors such as age, sex, affected bone, type of reconstruction, operative room used, primary or revision procedure, length of postoperative antibiotic administration, and use of chemotherapy; and (3) to determine the likelihood that treatment of an infected allograft will result in a successful reconstruction.We retrospectively analyzed the records of patients treated with massive bone allografts for a benign or malignant bone tumor or as a revision for a previous limb salvage procedure between 1985 and 2011. During this period, 673 patients were reconstructed with massive bone allografts in long bones, which included 272 osteoarticular, 246 intercalary, and 155 allograft-prosthetic composite reconstructions. Using a chart review, we ascertained the frequency of infection and reoperations after the treatment of infected allografts. Minimum followup was 2 years unless death occurred earlier (mean, 106 months; range, 6-360 months), and no patient was lost to followup. The selected variables were analyzed using multivariate logistic regression to identify risk factors for infection. We analyzed survivorship free of infection as the endpoint.During followup, 60 patients (9%) had a bacterial infection of the allograft with a survivorship free from infection of 92% at 5 years (95% confidence interval [CI], 90%-94%) and 91% at 10 years (95% CI, 89%-93%). We found that tibia allografts (p < 0.001; odds ratio [OR], 3.17; 95% CI, 1.80-5.60), male patients (p < 0.029; OR, 1.92; 95% CI, 1.08-3.49), procedures performed in a conventional operating room (p < 0.002; OR, 3.15; 95% CI, 1.58-6.62), and the use of longer periods of postoperative antibiotics (p < 0.041; OR, 2.25; 95% CI, 1.02-4.88) were patient factors associated with a greater risk of infection. In 11 patients (18%, 11 of 60 infections) the infection was controlled with antibiotics and surgical d,bridement; however, in 49 patients (82%, 49 of 60 infections), this approach failed, so the allograft was removed and a temporary cement spacer with antibiotic was implanted to control the infection. Forty-one patients subsequently had the spacer removed and were reconstructed after infection control with another bone allograft in 24 and an endoprostheses in 17. Four patients underwent an amputation for infection and four died of disease with the spacer in place. When we analyzed the 41 patients with a second reconstruction, 14 failed with a new infection (34%, 14 of 41 secondary reconstructed) of whom 12 had been reconstructed with bone allograft (29%) and two had endoprostheses (5%).Management of infections of massive bone allografts with antibiotics and surgical d,bridement usually resulted in failure. Infections could be treated with resection of the allograft, antibiotics, a temporary cement spacer with antibiotics, and a repeat reconstruction; however, this approach is unlikely to be successful if a second bone allograft is used. Infections are difficult to treat, and more studies are needed, but we propose that it might be preferable to use endoprosthesis reconstruction for salvage of an infected allograft.Level III, therapeutic study.