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Berliner diagnostischer Algorithmus der schmerzhaften Knie-TEP

The Berlin diagnostic algorithm for painful knee TKA

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Zusammenfassung

Hintergrund

Nach knieendoprothetischer Versorgung sind ca. 20 % der Patienten mit dem postoperativen Ergebnis unzufrieden. Hauptursachen hierfür sind die periprothetische Infektion, die aseptische Lockerung, Instabilität, Malalignment und in selteneren Fällen die sekundäre Retropatellararthrose, periprothetische Frakturen, Streckapparatinsuffizienzen, Polyethylenabrieb und die Arthrofibrose. Die Identifikation der Schmerzursache ist dabei häufig schwierig, jedoch Voraussetzung für eine erfolgreiche Therapie.

Fragestellung

Ziel dieser Arbeit ist es, durch einen reproduzierbaren diagnostischen Algorithmus eine effiziente Analyse der schmerzhaften Knieendoprothese (Knie-TEP) zu erreichen.

Diskussion

Grundlegende Bausteine sind die Anamnese mit den Kernfragen nach Nacht- oder Ruheschmerz sowie dem zeitlichen Verlauf des Schmerzcharakters. Daran sollte sich die Basisdiagnostik mit klinischer, radiologischer und infektiologischer Untersuchung anschließen. Eindeutige Versagensursachen, wie eine Infektion oder aseptische Lockerung, lassen sich hierdurch in den überwiegenden Fällen diagnostizieren. Ist die Schmerzursache mit der Basisdiagnostik nicht eindeutig zuordenbar, ist die weiterführende infektiologische oder bildgebende Diagnostik notwendig. Bei unklaren Befundergebnissen sind seltenere Ursachen der Beschwerden wie extraartikuläre Schmerzursachen, Kausalgien oder die Arthrofibrose zu bedenken. Kann trotz dieser Maßnahmen keine eindeutige Ursache objektiviert werden, ist eine Revision nicht indiziert, sondern die Reevaluation im zeitlichen Verlauf.

Abstract

Background

Approximately 20 % of patients are unsatisfied with their postoperative results after total knee arthroplasty (TKA). Main causes for revision surgery are periprosthetic infection, aseptic loosing, instability and malalignment. In rare cases secondary progression of osteoarthritis of the patella, periprosthetic fractures, extensor mechanism insufficiency, polyethylene wear and arthrofibrosis can cause the necessity for a reintervention.  Identifying the reason for a painful knee arthroplasty can be very difficult, but is a prerequisite for a successful therapy.

Aim

The aim of this article is to provide an efficient analysis of the painful TKA by using a reproducible algorithm.

Discussion

Basic building blocks are the medical history with the core issues of pain character and the time curve of pain concerning surgery. This is followed by the basic diagnostics, including clinical, radiological, and infectiological investigations. Unique failures like periprosthetic infection or aseptic loosening can thereby be diagnosed in the majority of cases. If the cause of pain is not clearly attributable using the basic diagnostics tool, further infectiological investigation or diagnostic imaging are necessary. If the findings are inconsistent, uncommon causes of symptoms, such as extra-articular pathologies, causalgia or arthrofibrosis, have to be considered. In cases of ongoing unexplained pain, a revision is not indicated. These patients should be re-evaluated after a period of time.

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Authors and Affiliations

  1. Klinik für Orthopädie, Centrum für Muskuloskeletale Chirurgie, Charité – Universitätsmedizin Berlin, Chariteplatz 1, 10117, Berlin, Deutschland

    K. Thiele, J. Fussi, C. Perka & T. Pfitzner

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  1. K. Thiele
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  2. J. Fussi
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  3. C. Perka
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Correspondence to K. Thiele.

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Interessenkonflikt

K. Thiele, J. Fussi, C. Perka und T. Pfitzner geben an, dass kein Interessenkonflikt besteht.

Es liegt eine retrospektive Studie vor mit Vorlage eine Ethikvotums. Die Nachuntersuchungen sind jedoch alle im Rahmen der normalen Nachuntersuchungen erfolgt, so dass keine explizite Vorlage einer Patienteneinwilligung notwendig war bzw. gefordert war.

Alle beschriebenen Untersuchungen am Menschen wurden mit Zustimmung der zuständigen Ethik-Kommission, im Einklang mit nationalem Recht sowie gemäß der Deklaration von Helsinki von 1975 (in der aktuellen, überarbeiteten Fassung) durchgeführt. Von allen beteiligten Patienten liegt eine Einverständniserklärung vor.

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Thiele, K., Fussi, J., Perka, C. et al. Berliner diagnostischer Algorithmus der schmerzhaften Knie-TEP. Orthopäde 45, 38–46 (2016). https://doi.org/10.1007/s00132-015-3196-7

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