【正文】 y virus (HIV)11 have increased infection rates with joint replacement. Although these risk factors cannot be eliminated, the risks can be minimized. For example, patients with inflammatory arthritis should have a preoperative consultation with their rheumatologist about reducing or discontinuing immunosuppressive medications perioperatively. Patients with sicklecell disease should be screened for skin ulcerations or potential sources of osteomyelitis, which can cause seeding of the site of a prosthetic joint. Diabetic patients should have their hemoglobin A1C levels checked and normalized (to %, which reflects longterm glucose control) prior to surgery。 consultation with an endocrinologist may be necessary. Patients with renal failure certainly should have their renal function optimized prior to surgery, and patients with HIV should be placed on regimens that achieve an undetectable viral load, if possible, prior to joint replacement. Malnutrition is associated with an increased risk of infection。 therefore, preoperative optimization, with the assistance of a nutritionist if necessary, is beneficial12.其他的一些可能增加感染風險的因素通常都是可以控制的，因此，對于骨科的擇期手術而言，術前通常可以使相關的因素達到最優(yōu)化的狀態(tài)。例如，患者合并有炎癥性的關節(jié)炎【7】，鐮狀細胞性貧血癥【8】，糖尿病【9】，腎功能衰竭【10】和人免疫缺陷癥病毒（HIV）感染【11】會增加關節(jié)置換的感染率，雖然這些風險因素無法消除，但相關的風險則可以降至最低。比如，患者炎癥性關節(jié)炎的患者，可以在術前請風濕科醫(yī)生進行診治，在圍手術期盡量減少或停用免疫抑制類藥物。如患者合并有鐮狀細胞性貧血癥，則應仔細篩查皮膚潰瘍或骨髓炎的潛在病源，否則容易導致播散至關節(jié)假體處引起感染。糖尿病患者應檢查其血紅蛋白A1C水平，在術前調(diào)至正常（%，可反映長期的血糖控制情況），必要時請內(nèi)分泌科醫(yī)生會診。腎功能衰竭的患者當然也應在術前將腎功能調(diào)整至最佳水平，而感染HIV的患者，在關節(jié)置換之前，如果可能的話應通過藥物治療使其病毒載量達到檢測不到的程度。營養(yǎng)不良也會增加感染的風險，因此，必要時在營養(yǎng)師的幫助下，在術前進行優(yōu)化也是很有好處的【12】。 Smoking and obesity increase the risk of infection with spine surgery13. Although these factors are often difficult to modify, patients should be counseled that a benefit of smoking cessation and weight reduction is a decreased risk of infection with spine surgery. Patients considering or planning surgical weightloss treatments, such as gastric bypass surgery, probably should be advised to pursue these procedures first to reduce the risk of infection at the sites of hardware or prostheses as a benefit from weight loss. Working with patients and the appropriate consultants to optimize these factors prior to surgery may improve patient outes by lowering the risk of infection with highrisk jointreplacement and spine procedures. 吸煙和肥胖會增加脊柱手術感染的風險【13】。雖然這些因素通常難以控制，但仍然應該告知患者，戒煙以及減輕體重對于降低脊柱手術感染的風險具有重要意義。如果患者正在考慮或計劃通過手術來減輕體重，如胃旁路手術，那么應該建議患者先做減肥手術，因為這樣對于置入內(nèi)固定物或假體的部位可以減少感染的風險。與患者充分溝通，提出合理化的建議，在手術前盡量優(yōu)化這些因素，對這些關節(jié)置換和脊柱手術的高風險人群而言，可以改善臨床結(jié)果，降低感染的風險。Another important preoperative consideration is preoperative bathing. Preoperative bathing has been used to reduce the bacterial load of the skin prior to surgery because skin preparation immediately before surgery does not pletely sterilize the skin. In addition, direct contamination can occur at the time of surgery. A recent Cochrane review was performed to assess the information in the literature regarding preoperative bathing with antiseptics for the prevention of surgical site infection14. Chlorhexidine gluconate is the most monly used antiseptic for preoperative bathing. The Cochrane review revealed evidence that the bacterial load of resident skin flora is reduced by use of chlorhexidine gluconate preparations for preoperative bathing. Repeated, consecutive treatments reduce this load progressively over time. However, concerns about the development of resistant organisms and hypersensitivity remain. Therefore, the authors of the review concluded that there is no clear evidence that preoperative bathing with chlorhexidine gluconate is superior to preoperative bathing with other products, such as bar soap, for reducing the incidence of surgical site infection. 手術前另一個重要的注意事項便是術前洗澡。由于術前即刻的皮膚消毒并不能完全殺滅所有細菌，因而通常都通過術前洗澡以減少皮膚的細菌接種量。此外，如果術前不洗澡，手術時也可能發(fā)生直接的污染。最近的一項Cochrane綜述對術前應用消毒劑洗澡預防手術部位感染的相關信息進行了評價【14】。洗必泰葡萄糖酸鹽是術前洗澡時應用最多的消毒劑。Cochrane綜述的相關證據(jù)顯示術前洗澡時應用洗必泰葡萄糖酸鹽進行消毒可使體表常居菌的細菌接種量明顯減少。隨著時間的延長，反復、持續(xù)地洗浴可使該接種量進行性地下降。然而，這樣做也有產(chǎn)生耐藥菌及出現(xiàn)過敏反應的風險。因此，上文作者的結(jié)論認為，為了減少手術部位感染的發(fā)生率，在術前洗澡時，并沒有明確的證據(jù)證實應用洗必泰葡萄糖酸鹽優(yōu)于其他的產(chǎn)品，如肥皂等。Hair removal has been used traditionally to keep hair from contaminating the wound. More recently, hair removal has allowed surgeons to apply occlusive dressings to the skin perioperatively to keep skin flora from directly contaminating the wound. Three methods used for hair removal include traditional razors, clippers, and hairremoval creams or depilatories. Hairless surgical sites can make the surgery and application of dressings and protective draping easier, but the use of razors to shave the surgical site increases the risk of introducing primary infections through microscopic injuries to the skin. The Centers for Disease Control and Prevention (CDC) remend that hair removal be minimized and that, when it is necessary, electric clippers or depilatories be used rather than razors15. A Cochrane review of the literature on hair removal prior to surgery supported the CDC remendations and added that hair removal can be done on the day of the surgery16. 以往術前通常都要求去除毛發(fā)以避免污染創(chuàng)口，而最近則傾向于讓外科醫(yī)生在術前應用密閉的敷料覆蓋皮膚，從而防止皮膚菌群直接污染創(chuàng)口。傳統(tǒng)的去毛方式主要有三種：剃毛、剪毛和脫毛膏或脫毛藥物。手術部位去毛后通?？墒故中g操作更為方便，并使貼膜和防護膜的應用也更為簡便，但應用剃刀刮除手術部位的毛發(fā)會對皮膚產(chǎn)生微小的損傷，通過這些損傷局部原發(fā)感染的風險會明顯增加。疾病預防和控制中心（CDC）建議，應盡量避免去毛，如果實在必要，也應該應用電動剪毛刀或脫毛劑，而應避免應用剃毛刀【15】。有學者對術前去毛相關的文獻進行了Cochrane綜述，其結(jié)論與CDC所推薦的方案一致，此外，去毛應該手術當天進行【16】。Dental care is another preoperative issue to be discussed with highrisk orthopaedic patients. All patients, but particularly those at high risk for infection, should be encouraged to maintain good dental health before and after surgery. Bacteremia from a dental infection can cause acute hematogenous infection at the site of a total joint replacement. Evidence shows that the most critical period is the first two years after surgery17. The American Academy of Orthopaedic Surgeons (AAOS) in conjunction with the American Dental Association (ADA) developed guidelines for antibiotic prophylaxis for patients with a total joint replacement who require denta