C反应蛋白在类风湿性关节炎患者全膝关节置换术中的临床应用价值研究进展

Research Progress on the Clinical Application Value of C-Reactive Protein in Total Knee Arthroplasty for Patients with Rheumatoid Arthritis

摘要: 类风湿性关节炎(rheumatoid arthritis, RA)患者接受全膝关节置换术(total knee arthroplasty, TKA)后，假体周围感染(periprosthetic joint infection, PJI)的发生风险明显高于骨关节炎患者，其潜在机制涉及RA引发的全身免疫功能紊乱、长期抗风湿药物暴露以及关节内持续性炎症反应等多重因素的协同作用。C反应蛋白(C-reactive protein, CRP)作为TKA术后感染监测和PJI筛查的关键血清学指标，在临床实践中被广泛采用。然而，RA患者固有的疾病特征——包括基线CRP水平偏高、生物制剂干预及疾病活动度波动——可显著削弱CRP的常规诊断效能。本文从三个核心维度系统梳理了国内外最新研究进展：1) RA患者TKA术后PJI的流行病学特征及特异性危险因素；2) RA病理背景下CRP的术后动态演变规律及其对PJI的诊断价值与截断值优化；3) 以CRP为核心导向的围手术期感染防控策略。现有证据提示，RA患者TKA术后CRP诊断截断值宜在常规标准基础上适度上调，且连续动态监测CRP变化趋势较单一时点测定具有更高的临床参考价值。此外，CRP联合红细胞沉降率(ESR)、白细胞介素-6 (IL-6)、关节液钙卫蛋白等多标志物综合诊断体系，能够有效提升RA背景下PJI的鉴别准确率。术前以CRP水平为依据优化手术时机选择与免疫抑制药物桥接管理，构成降低RA患者TKA术后PJI风险的关键环节。未来研究应致力于建立适用于RA患者特征的专属PJI诊断阈值体系与风险预测模型，以进一步改善这一特殊人群的感染相关预后。此外，本综述还专门阐述了不同类别抗风湿药物——传统合成DMARDs、TNF-α抑制剂、IL-6受体抑制剂、利妥昔单抗及JAK抑制剂等——对CRP基线水平及感染后反应的差异化影响，并归纳了相应用药背景下CRP解读的具体注意事项；同时以对比表格形式系统总结了RA与骨关节炎患者TKA术后PJI在流行病学、致病菌谱及危险因素方面的差异，以及各血清与关节液生物标志物在RA患者PJI诊断中的性能参数与临床应用优缺点，以便为临床快速查阅与决策提供参考。

Abstract: Patients with rheumatoid arthritis (RA) undergoing total knee arthroplasty (TKA) face a significantly elevated risk of periprosthetic joint infection (PJI) compared with osteoarthritis patients. The underlying mechanisms involve the synergistic effects of RA-induced systemic immune dysregulation, prolonged exposure to antirheumatic medications, and persistent intra-articular inflammation. C-reactive protein (CRP), a key serological biomarker for postoperative infection monitoring and PJI screening after TKA, is widely used in clinical practice. However, the inherent disease characteristics of RA patients—including elevated baseline CRP levels, biologic agent interventions, and disease activity fluctuations—can substantially compromise the conventional diagnostic performance of CRP. This review systematically synthesizes recent domestic and international research advances from three core dimensions: 1) epidemiological features and RA-specific risk factors for PJI following TKA; 2) postoperative dynamic CRP evolution patterns in the RA context and their diagnostic value and threshold optimization for PJI; and 3) CRP-guided perioperative infection prevention and management strategies. Current evidence suggests that the CRP diagnostic threshold for RA patients after TKA should be moderately adjusted upward from conventional standards, and that continuous trend monitoring of CRP dynamics provides superior clinical utility compared with single-point measurements. Furthermore, a multi-biomarker diagnostic system combining CRP with erythrocyte sedimentation rate (ESR), interleukin-6 (IL-6), and synovial fluid calprotectin can effectively enhance PJI diagnostic accuracy in the RA setting. Preoperative optimization of surgical timing and immunosuppressive medication bridging guided by CRP levels constitute critical measures for reducing PJI risk in RA patients undergoing TKA. Future research should focus on establishing PJI-specific diagnostic thresholds and risk prediction models tailored to RA patient characteristics, thereby improving infection-related outcomes in this unique population. In addition, this review specifically elaborates on the differential effects of different classes of antirheumatic drugs (conventional synthetic DMARDs, TNF-α inhibitors, IL-6 receptor inhibitors, rituximab, and JAK inhibitors, among others) on baseline CRP levels and post-infection CRP responses, and summarizes drug-specific caveats for CRP interpretation. Comparative tables systematically summarize the differences between RA and osteoarthritis patients in the epidemiology, causative pathogen spectrum, and risk factors of PJI after TKA, as well as the performance parameters and clinical advantages and limitations of serum and synovial fluid biomarkers in diagnosing PJI in RA patients, providing a quick reference for clinical decision-making.