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LE INFEZIONI IN ORTOPEDIA
Silvio Borr
U.O.C. MALATTIE INFETTIVE
- VERCELLI -
Osteomieliti
post-traumatiche
Infezione
mezzi
osteosintesi
Pseudoartrosi
infette
ORTOPEDICO
Osteomieliti
ematogene
Spondilodisciti
Artriti
Piede
diabetico
Infezione di protesi
articolare
INFETTIVOLOGO
Mortalit 4.7%
Costo stimato : 257.000.000
Pseudoartrosi
focolaio frattura
Mobilizzazione
protesi
Stefan Landgraeber et al.,The pathology of orthopedic implant failure is mediated by innate immune system cytokines.
Mediators Inflamm. 2014: 185150.
INTRACELLULAR SURVIVAL
Evidence of an
intracellular reservoir
in osteocytes (A,B),
osteoblasts (C)
bone matrix ( D)
of a patient with
recurrent osteomyelitis
peso molecolare
legame proteico
lipofilia
caratteristiche acido / base
Landersdorfer C B. et al.:
Landersdorfer C B. et al.:
Frattura chiusa
(integrit delle parti molli)
dopo 9 mesi
Il trasporto viene terminato e il fissatore esterno rimosso.
2013
168.487 protesi impiantate
1 MILIONI DI ITALIANI SONO PORTATORI DI
PROTESI ARTICOLARI
Prima
In aumento
le revisioni
edizione: novembre
2015
2015 Il Pensiero Scientifico Editore
5853
0.8 - 1.9%
2.2 %*
0.3 - 1.7%
2.2 %*
* Tande A.J. Et al:Prosthetic Joint Infection Clin. Microbiol. Rev. 2014, 27(2):302.DOI:10.1128/CMR.00111-13.
Infezione di Endoprotesi
-in frattura femore-
6.9 %
*Merrer J. Et al Infect Control Hosp Epidemiol 2007;28:1169-74.
Fino 20%
Barberan J. Management of infections of osteoarticular prosthesis.
Clin Microbiol Infect 2006; 12 Suppl 3: 93101.
procedures.
J. S. Coste et al J Bone Joint Surg Br. 2004 Jan;86(1):65Peri-prosthetic Infections after Shoulder Hemiarthroplasty
9 -2008: 1,349 patients 1,431 primary hemi-arthroplasties 14
1976
infections 1%
J Shoulder Elbow Surg. Oct 2012; 21(10): 13041309.
Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective
1976 -2008 : 2,207 patients 2,588 primary TSAs
J Shoulder Elbow Surg. Nov 2012; 21(11): 15341541.
46 infections
1.7%
surgery
Eric T. Ricchetti et al.: JBJS Reviews, 2013 Nov;1
CLASSIFICAZIONE
* Le classificazioni sono necessarie per creare gruppi omogenei di pazienti
permettere di confrontare i risultati ottenuti/pubblicati
e definire linee guida di trattamento
Early
1st month
Delayed 2nd-6th months
Late
> 6th months
- Cellularit
- Colturale
- Biomarker
- Esterasi leucocitaria
- -defensina
LA STORIA D
EL
PAZIENTE
GB VES PCR
- PCT IL-6
Rx
+++ colturali
- Scintigrafia Tc Es.istologico
Leu N.C.
- ECO TC RM
LA CLINI
CA
Methods
We performed a prospective study of 133 patients in whom synovial fluid specimens were collected before
total knee arthroplasty revision between January 1998 and December 2003. Patients with underlying
inflammatory joint disease were excluded.
Results
Aseptic failure was diagnosed in 99 patients and prosthetic joint infection was diagnosed in 34 patients. The
synovial fluid leukocyte count was significantly higher in patients with prosthetic joint infection (median,
18.9 103/L; range, 0.3 to 178 103/L) than in those with aseptic failure (median, 0.3 103/L; range,
0.1 to 16 103/L; P <0.0001); the neutrophil percentage was also significantly higher in patients with
prosthetic joint infection (median [range], 92% [55% to 100%] vs. 7% [0% to 79%], P <0.0001). A leukocyte
count of >1.7 103/L had a sensitivity of 94% and a specificity of 88% for diagnosing prosthetic joint
infection; a differential of >65% neutrophils had a sensitivity of 97% and a specificity of 98%.
Staphylococcus aureus was the only pathogen associated with leukocyte counts >100 103/L.
Conclusion
A synovial fluid leukocyte differential of >65% neutrophils (or a leukocyte count of >1.7 103/L) is
a sensitive and specific test for the diagnosis of prosthetic knee infection in patients without
underlying inflammatory joint disease.
Bedair H. et al: Diagnosis of Early Postoperative TKA Infection Using Synovial Fluid Analysis
Clin Orthop Relat Res (2011) 469:3440
The Mark Coventry Award: diagnosis of early postoperative TKA infection using synovial fluid analysis.
Javad Parvizi et al.: J Bone Joint Surg Am, 2011 Dec 21;93(24):2242-2248.
Our test results confirm that the leukocyte esterase test can accurately detect PJI and that
it can be used as a part of the traditional PJI workup.
In the assessment of native joints, its high negative predictive value suggests that it is a
valuable tool in excluding native joint septic arthritis.
Parvizi J. et al. Clin Orthop Relat Res. Nov 2014; 472(11): 32543262. Published online Mar 4, 2014.
doi: 10.1007/s11999-014-3543-8
The Synovasure PJI Test is the first and only test specifically
designed and validated for the diagnosis of
Periprosthetic Joint Infection (PJI).
The Synovasure Test achieves 97% sensitivity and 96% specificity by measuring synovial
fluid alpha defensin (antimicrobial peptide released by neutrophils in response to pathogens )
Superior ease of use- rapid results visible within 10 minutes
Identificazione microbiologica
- Almeno 3 - meglio 5 o 6 -,campioni di tessuto o la stessa protesi
inviati per coltura(B-II).
- sospendere eventuale terapia antibiotica per almeno 2
settimane prima dei prelievi intraoperatori (A-II).
- Cellularit
- Colturale
LA STORIA D
EL
PAZIENTE
LA CLINI
CA
- Esterasi leucocitaria
- -defensina
GB VES PCR
- PCT IL-6
Rx
- Scintigrafia Tc
Leu N.C.
- ECO TC RM
IDENTIFICAZIONE
DEL PATOGENO
+++ colturali
Es.istologico
Prosthesis sonication
67,6 %
87,5%
p: 0,041
Tande A. J. Et al:Prosthetic Joint InfectionClin. Microbiol. Rev. April 2014vol. 27 no. 2 302-345
Reimplantation may be considered without an antibioticfree period, with additional antibiotic prophylaxis before
reimplantation.
Where multiple reimplantation cultures are positive in the absence of clinical indicators of
ongoing infection, a limited course of oral antibiotics may be appropriate.
Beion P. et al., Two-stage revision for prosthetic joint infection: predictors of outcome and the role of
reimplantation microbiology J Antimicrob Chemother. 2010 Mar; 65(3): 569575.
65
Tande A. J. Et al:Prosthetic Joint InfectionClin. Microbiol. Rev. April 2014vol. 27 no. 2 302-345
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