对于肿瘤切除后接受节段性股骨远端或胫骨近端置换的患者，针对假体周围关节感染 (PJI) 进行两期翻修可能会带来相当大的发病率、疼痛和并发症风险，因为该手术通常会导致长骨关节被切除。 ，固定良好的源于骨干。清创、抗生素和种植体保留 (DAIR) 等攻击性较小的手术方法可能会因为发病率较低而对患者和外科医生有吸引力，但与传统的两阶段翻修相比，根除感染的可能性并不大为肿瘤患者设立。此外，对于该人群，DAIR 与两期翻修术后截肢的相对风险尚未确定。(1) 在股骨远端或胫骨近端节段模块化患者的感染控制方面，DAIR 与两期翻修相比如何内假体？ (2) 与感染的两阶段翻修相比，DAIR 作为初始手术是否会增加截肢风险？从我们机构纵向维护的骨科肿瘤手术数据库中，我们确定了 69 名接受过临床诊断治疗的患者1993 年至 2015 年间，膝关节发生 PJI。我们排除了 32% (22) 不符合至少一项肌肉骨骼感染协会 (MSIS) PJI 主要标准的患者，3% (2) 立即接受 PJI 治疗的患者截肢，3% (2) 的患者随访时间< 24 个月，7% (5) 的患者没有股骨远端或胫骨近端原发性肿瘤。该研究由 38 名患者组成，其中 8 名患者接受了两阶段翻修，26 名患者接受了 DAIR，4 名患者接受了延长 DAIR（去除所有节段组件，但保留固定在骨中的茎和组件）以进行初始手术。要被认为没有感染，患者必须符合 MSIS 标准，包括自上次手术后至少 2 年内没有培养、引流或手术清创呈阳性。使用 Kaplan-Meier 生存曲线和对数秩检验来比较因素，分析与感染复发、清除、截肢和患者生存的时间依赖性风险相关的因素。使用卡方检验和 Fisher 精确检验评估人口统计学和治疗因素的关联。接受 DAIR 的患者 5 年持续无感染生存率为 16%（95% CI 2% 至 29%），而接受 DAIR 治疗的患者为 75%（95% CI）。对于接受两阶段翻修的患者来说，这一比例为 45% 至 100% (p = 0.006)。 DAIR 手术总手术次数的中位数（范围）为每名患者 3 次（1 至 10 次），两阶段翻修手术为 2 次（2 至 5 次）。百分之二十九（38 名患者中的 11 名）最终接受了截肢手术。 DAIR 的无截肢生存率为 69%（95% CI 51% 至 86%），而两阶段翻修的 5 年生存率为 88%（95% CI 65% 至 100%）（p = 0.34）。最初接受 DAIR 治疗的患者达到无感染状态（上次治疗后连续 > 2 年）和保留肢体的患者累计比例为 58%（95% CI 36% 至 80%），而最初接受 DAIR 治疗的患者为 87%（95% CI 65%）对于首先接受两阶段翻修治疗的患者而言，这一比例降低至 100%（p = 0.001）。两阶段翻修的感染控制效果优于 DAIR。当选择两阶段翻修作为初始治疗时，保留肢体最终清除感染的机会更大。然而，两阶段修正组的随访失败可能会使感染控制的真实比例低于我们的估计。我们的经验表明，根除感染的过程是一个复杂而困难的过程。大多数患者接受多次手术。近三分之一的患者最终接受了截肢，这对两组患者来说都是一个严重的风险。虽然根据我们的数据，我们不能强烈推荐其中一种方法优于另一种方法，但我们仍然会考虑对出现急性短期症状（< 3 周）、固定种植体周围没有侵蚀迹象和生物体的患者使用 DAIR除金黄色葡萄球菌外。我们提倡延长 DAIR 手术，去除所有节段或模块化组件，并且我们会提醒患者，很有可能需要进一步手术。可能需要严格遵守适应症的前瞻性试验来评估延长 DAIR 手术与两阶段修正的相对优点。III 级，治疗研究。版权所有 © 2024，骨与关节外科医生协会。

Two-stage revision for periprosthetic joint infection (PJI) in patients who have undergone segmental replacement of the distal femur or proximal tibia after tumor resection can be associated with considerable morbidity, pain, and risk of complications because the procedure often results in removal of long, well-fixed stems from the diaphysis. A less-aggressive surgical approach, such as debridement, antibiotics, and implant retention (DAIR), may be attractive to patients and surgeons because of less morbidity, but the likelihood of eradicating infection in comparison to the traditional two-stage revision is not well established for oncology patients. Furthermore, the relative risk of subsequent amputation for DAIR versus two-stage revision has not been defined for this population.(1) How does DAIR compare with two-stage revision in terms of infection control for patients with distal femoral or proximal tibial segmental modular endoprostheses? (2) Is DAIR as an initial procedure associated with an increased risk of amputation compared with two-stage revision for infection?From the longitudinally maintained orthopaedic oncology surgical database at our institution, we identified 69 patients who had been treated for a clinical diagnosis of PJI at the knee between 1993 and 2015. We excluded 32% (22) of patients who did not meet at least one of the major criteria of the Musculoskeletal Infection Society (MSIS) for PJI, 3% (2) of patients who underwent immediate amputation, 3% (2) of patients who had a follow-up time of < 24 months, and 7% (5) of patients who did not have a primary tumor of the distal femur or proximal tibia. The study consisted of 38 patients, of whom eight underwent two-stage revision, 26 underwent DAIR, and four underwent extended DAIR (removal of all segmental components but with retention of stems and components fixed in bone) for their initial surgical procedure. To be considered free of infection, patients had to meet MSIS standards, including no positive cultures, drainage, or surgical debridement for a minimum of 2 years from the last operation. Factors associated with time-dependent risk of infection relapse, clearance, amputation, and patient survival were analyzed using Kaplan-Meier survivorship curves and the log-rank test to compare factors. Association of demographic and treatment factors was assessed using chi-square and Fisher exact tests.Continuous infection-free survival at 5 years was 16% (95% CI 2% to 29%) for patients undergoing DAIR compared with 75% (95% CI 45% to 100%) for patients undergoing two-stage revision (p = 0.006). The median (range) number of total surgical procedures was 3 per patient (1 to 10) for DAIR and 2 (2 to 5) for two-stage revision. Twenty-nine percent (11 of 38) of patients eventually underwent amputation. Survival without amputation was 69% (95% CI 51% to 86%) for DAIR compared with 88% (95% CI 65% to 100%) for two-stage revision at 5 years (p = 0.34). The cumulative proportion of patients achieving infection-free status (> 2 years continuously after last treatment) and limb preservation was 58% (95% CI 36% to 80%) for patients initially treated with DAIR versus 87% (95% CI 65% to 100%) for patients first treated with two-stage revision (p = 0.001).Infection control was better with two-stage revision than DAIR. The chance of eventual clearance of infection with limb preservation was better when two-stage revision was chosen as the initial treatment. However, the loss to follow-up in the two-stage revision group would likely make the true proportion of infection control lower than our estimate. Our experience would suggest that the process of infection eradication is a complex and difficult one. Most patients undergo multiple operations. Nearly one-third of patients eventually underwent amputation, and this was a serious risk for both groups. While we cannot strongly recommend one approach over the other based on our data, we would still consider the use of DAIR in patients who present with acute short duration of symptoms (< 3 weeks), no radiographic signs of erosion around fixed implants, and organisms other than Staphylococcus aureus. We would advocate the extended DAIR procedure with removal of all segmental or modular components, and we would caution patients that there is a high likelihood of needing further surgery. A prospective trial with strict adherence to indications may be needed to evaluate the relative merits of an extended DAIR procedure versus a two-stage revision.Level III, therapeutic study.Copyright © 2024 by the Association of Bone and Joint Surgeons.