臨床整形外科51巻3号

2016年03月発行

Lecture

腫瘍型人工関節の手術部位感染

著者： 森井健司¹

所属機関： ¹杏林大学医学部整形外科

ページ範囲：P.275 - P.282

はじめに

　腫瘍型人工関節の手術部位感染(surgical site infection，以下SSI)は管理が困難であり，克服すべき合併症の1つであるが，骨軟部腫瘍治療の特性として，①機能よりも救命や確実な切除が優先されること，②手術部位が多様であること，③患者背景が多岐にわたることに加えて，④症例数が少ないことが研究を困難なものとしており，他領域の感染症研究と比べて，解析が遅れがちである．独立変数の多様性と症例の希少性ゆえランダム化比較試験の遂行は困難であり，本分野での知見はいまだ後方視的研究によるところが大きい．筆者は同領域におけるSSIの治療指針を確立することを目標として，多くの骨軟部腫瘍専門施設の先生方の支援のもと，骨軟部悪性腫瘍の周術期感染症の実態を調査しデータ集積を行ってきたが，多くの未解決の問題が残されているのが現状である．本論文では骨軟部肉腫研究会(Japanese Musculoskeletal Oncology Group；JMOG)において得られた研究成果と，同分野で報告されている最新の知見を踏まえて，腫瘍型人工関節SSIの発生頻度・発生時期・危険因子・初期症状および臨床検査データ・感染起因菌などの疫学的データ，腫瘍学的治療成績・患肢機能・患肢温存への影響，予防，治療法，今後の展望などを概説する．

参考文献

1　）Ahlmann ER, Menendez LR, Kermani C, et al:Survivorship and clinical outcome of modular endoprosthetic reconstruction for neoplastic disease of the lower limb. J Bone Joint Surg Br 88:790-795, 2006

2　）Aoyagi T, Morii T, Tajima T, et al:Analysis of the risk factors for febrile neutropenia in patients with bone and soft tissue sarcoma. Anticancer Res 35:2375-2383, 2015

3　）Chiang HY, Herwaldt LA, Blevins AE, et al:Effectiveness of local vancomycin powder to decrease surgical site infections:a meta-analysis. Spine J 14:397-407, 2014

4　）Dhanoa A, Ajit Singh V, Elbahri H:Deep Infections after endoprosthetic replacement operations in orthopedic oncology patients. Surg Infect (Larchmt) 16:323-332, 2015

5　）Enneking WF, Dunham W, Gebhardt MC, et al:A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res 286:241-246, 1993

6　）Funovics PT, Hipfl C, Hofstaetter JG, et al:Management of septic complications following modular endoprosthetic reconstruction of the proximal femur. Int Orthop 35:1437-1444, 2011

7　）Gosheger G, Hardes J, Ahrens H, et al:Silver-coated megaendoprostheses in a rabbit model--an analysis of the infection rate and toxicological side effects. Biomaterials 25:5547-5556, 2004

8　）Gosheger G, Gebert C, Ahrens H, et al:Endoprosthetic reconstruction in 250 patients with sarcoma. Clin Orthop Relat Res 450:164-171, 2006

9　）Grimer RJ, Carter SR, Tillman RM, et al:Endoprosthetic replacement of the proximal tibia. J Bone Joint Surg Br 81:488-494, 1999

10　）Hardes J, Gebert C, Schwappach A, et al:Characteristics and outcome of infections associated with tumor endoprostheses. Arch Orthop Trauma Surg 126:289-296, 2006

11　）Hayashi K, Tsuchiya H, Yamamoto N, et al:Functional outcome in patients with osteosarcoma around the knee joint treated by minimised surgery. Int Orthop 32:63-68, 2008

12　）Hettwer WH, Horstmann PF, Hovgaard TB, et al:Low infection rate after tumor hip arthroplasty for metastatic bone disease in a cohort treated with extended antibiotic prophylaxis. Adv Orthop 2015:428986, 2015

13　）Jeys LM, Grimer RJ, Carter SR, et al:Periprosthetic infection in patients treated for an orthopaedic oncological condition. J Bone Joint Surg Am 87:842-849, 2005

14　）Jeys LM, Grimer RJ, Carter SR, et al:Post operative infection and increased survival in osteosarcoma patients:are they associated? Ann Surg Oncol 14:2887-2895, 2007

15　）Jeys LM, Kulkarni A, Grimer RJ, et al:Endoprosthetic reconstruction for the treatment of musculoskeletal tumors of the appendicular skeleton and pelvis. J Bone Joint Surg Am 90:1265-1271, 2008

16　）Kanayama M, Hashimoto T, Shigenobu K, et al:Effective prevention of surgical site infection using a Centers for Disease Control and Prevention guideline-based antimicrobial prophylaxis in lumbar spine surgery. J Neurosurg Spine 6:327-329, 2007

17　）Kawai A, Muschler GF, Lane JM, et al:Prosthetic knee replacement after resection of a malignant tumor of the distal part of the femur. Medium to long-term results. J Bone Joint Surg Am 80:636-647, 1998

18　）Kawai A, Lin PP, Boland PJ, et al:Relationship between magnitude of resection, complication, and prosthetic survival after prosthetic knee reconstructions for distal femoral tumors. J Surg Oncol 70:109-115, 1999

19　）Kusuzaki K, Murata H, Matsubara T, et al:Clinical trial of photodynamic therapy using acridine orange with/without low dose radiation as new limb salvage modality in musculoskeletal sarcomas. Anticancer Res 25:1225-1235, 2005

20　）Lee JA, Kim MS, Kim DH, et al:Postoperative infection and survival in osteosarcoma patients. Ann Surg Oncol 16:147-151, 2009

21　）Mangram AJ, Horan TC, Pearson ML, et al:Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 27:97-132, 1999

22　）Manoso MW, Boland PJ, Healey JH, et al:Limb salvage of infected knee reconstructions for cancer with staged revision and free tissue transfer. Ann Plast Surg 56:532-535, 2006

23　）Morii T, Yabe H, Morioka H, et al:Postoperative deep infection in tumor endoprosthesis reconstruction around the knee. J Orthop Sci 15:331-339, 2010

24　）Morii T, Morioka H, Ueda T, et al:Deep infection in tumor endoprosthesis around the knee:a multi-institutional study by the Japanese musculoskeletal oncology group. BMC Musculoskelet Disord 14:51, 2013

25　）Morii T, Morioka H, Ueda T, et al:Functional analysis of cases of tumor endoprostheses with deep infection around the knee:a multi institutional study by the Japanese Musculoskeletal Oncology Group (JMOG). J Orthop Sci 18:605-612, 2013

26　）Mraovic B, Suh D, Jacovides C, et al:Perioperative hyperglycemia and postoperative infection after lower limb arthroplasty. J Diabetes Sci Technol 5:412-418, 2011

27　）Myers GJ, Abudu AT, Carter SR, et al:Endoprosthetic replacement of the distal femur for bone tumours:long-term results. J Bone Joint Surg Br 89:521-526, 2007

28　）Myers GJ, Abudu AT, Carter SR, et al:The long-term results of endoprosthetic replacement of the proximal tibia for bone tumours. J Bone Joint Surg Br 89:1632-1637, 2007

29　）Nakamura T, Kusuzaki K, Matsubara T, et al:A new limb salvage surgery in cases of high-grade soft tissue sarcoma using photodynamic surgery, followed by photo- and radiodynamic therapy with acridine orange. J Surg Oncol 97:523-528, 2008

30　）Olsen MA, Nepple JJ, Riew KD, et al:Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am 90:62-69, 2008

31　）Orlic D, Smerdelj M, Kolundzic R, et al:Lower limb salvage surgery:modular endoprosthesis in bone tumour treatment. Int Orthop 30:458-464, 2006

32　）Osmon DR, Berbari EF, Berendt AR, et al:Executive summary:diagnosis and management of prosthetic joint infection:clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 56:1-10, 2013

33　）Parvizi J, Saleh KJ, Ragland PS, et al:Efficacy of antibiotic-impregnated cement in total hip replacement. Acta Orthop 79:335-341, 2008

34　）Pofahl WE, Goettler CE, Ramsey KM, et al:Active surveillance screening of MRSA and eradication of the carrier state decreases surgical-site infections caused by MRSA. J Am Coll Surg 208:981-986, 2009

35　）Racano A, Pazionis T, Farrokhyar F, et al:High infection rate outcomes in long-bone tumor surgery with endoprosthetic reconstruction in adults:a systematic review. Clin Orthop Relat Res 471:2017-2027, 2013

36　）Sim IW, Tse LF, Ek ET, et al:Salvaging the limb salvage:management of complications following endoprosthetic reconstruction for tumours around the knee. Eur J Surg Oncol 33:796-802, 2007

37　）Tsuchiya H, Shirai T, Nishida H, et al:Innovative antimicrobial coating of titanium implants with iodine. J Orthop Sci 17:595-604, 2012

38　）Wang ZX, Jiang CP, Cao Y, et al:Systematic review and meta-analysis of triclosan-coated sutures for the prevention of surgical-site infection. Br J Surg 100:465-473, 2013

39　）Zeegen EN, Aponte-Tinao LA, Hornicek FJ, et al:Survivorship analysis of 141 modular metallic endoprostheses at early followup. Clin Orthop Relat Res 420:239-50, 2004