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Diagnostik und Management des Endoprotheseninfekts am Schultergelenk

Diagnosis and management of the infected shoulder endoprosthesis

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Zusammenfassung

Periprothetische Infekte stellen eine seltene jedoch schwerwiegende Komplikation nach Schulterendoprothesenimplantation dar. Je nach zeitlichem Auftreten und klinischer Manifestation können sie in Früh-, verzögerte oder Spätinfekte sowie Low-grade- und High-grade-Infekte eingeteilt werden. Das Erregerspektrum umfasst neben Staphylococcus aureus, Streptokokken, Enterokokken und gramnegativen Stäbchen auch niedrig-virulente Keime der Hautflora wie z. B. koagulasenegative Staphylokokken (z. B. Staphylococcus epidermidis) und Anaerobier (z. B. Propionibacterium acnes). Die Diagnostik des Schulterendoprotheseninfekts beruht neben der klinischen Untersuchung und allgemeinen Bildgebung v. a. auf labortechnischen Untersuchungen. Ein wichtiger Faktor ist hierbei die Gewinnung von Gewebeproben zur mikrobiologischen Untersuchung. Unterstützende diagnostische Mittel sind die Bestimmung der systemischen Entzündungsparameter, die histologische Untersuchung von Gewebeproben sowie die Bestimmung der Leukozytenzahl im Gelenkpunktat. Bei Frühinfekten oder akut aufgetretenen Infekten kann ein endoprothesenerhaltendes Vorgehen mit radikalem Débridement und Inlaywechsel gewählt werden. Sind die Voraussetzungen für ein endoprothesenerhaltendes Vorgehen nicht erfüllt, so empfiehlt sich der zweizeitige Endoprothesenwechsel mit temporärer Spacerimplantation und begleitender antibiotischer Therapie. Bei Vorliegen eines Low-grade-Infekts durch einen niedrig-virulenten Erreger mit Suszeptibilität auf biofilmaktive Antibiotika kann unter der Voraussetzung einer guten Weichteilsituation ein einzeitiger Wechsel durchgeführt werden.

Abstract

Periprosthetic infections represent a rare but severe complication after shoulder arthroplasty. Depending on the timing of the occurrence and the clinical symptoms, classification into early, delayed, and late infections as well as low- and high-grade infections can be made. Common causes of infection are Staphylococcus aureus, streptococci, enterococci, and gram-negative rods. Additionally, skin flora bacteria can be encountered including coagulase-negative staphylococci (e. g., Staphylococcus epidermidis) and anaerobes (e. g. Propionibacterium acnes). Besides clinical and radiological examination, laboratory tests are the main aid in the diagnosis of shoulder arthroplasty infections. The most important factor is the harvesting of tissue samples for microbiological examination. Additionally, general inflammation markers, histological examinations of tissue samples, as well as the leukocyte count of aspirated joint fluid can contribute important information to find the right diagnosis. In the case of an early or newly developed acute infection, an attempt can be made to preserve the endoprosthesis while performing radical debridement and inlay change. If the criteria for preservation of the endoprosthesis are not met, a two-stage revision including removal of the endoprosthesis, temporary spacer implantation, and reimplantation along with antibiotic therapy is recommended. In the case of low-grade infection, known low-pathogenic bacteria with susceptibility to antibiotics, and good soft-tissue status, a single-stage revision can be performed.

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Correspondence to Markus Scheibel.

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P. Moroder, C. Gerhardt, N. Renz, A. Trampuz und M. Scheibel geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Moroder, P., Gerhardt, C., Renz, N. et al. Diagnostik und Management des Endoprotheseninfekts am Schultergelenk. Obere Extremität 11, 78–87 (2016). https://doi.org/10.1007/s11678-016-0361-5

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