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Histopathologische Diagnose der periprothetischen Gelenkinfektion nach Hüftgelenkersatz

Verwendung eines standardisierten Klassifikationssystems der periprothetischen Interface-Membranen

Histopathological diagnosis of periprosthetic joint infection following total hip arthroplasty

Use of a standardized classification system of the periprosthetic interface membrane

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Zusammenfassung

Hintergrund

Die Unterscheidung zwischen aseptischer und septischer Hüftendoprothesenlockerung ist für therapeutisches Vorgehen und Erfolgsaussicht von grundlegender Bedeutung und erweist sich häufig als diagnostische Herausforderung. Ein wesentlicher Diagnoseparameter ist die histopathologische Klassifikation periprothetischer Lockerungsmembranen. Anhand charakteristischer Gewebestrukturen können Rückschlüsse über Lockerungsursachen gestellt werden. Ziel dieser Arbeit ist es, mit Hilfe der Konsensusklassifikation den Stellenwert der histopathologischen Gewebeuntersuchung in der Identifizierung von Hüftendoprotheseninfektionen zu untersuchen und nach Möglichkeit als ein Standardverfahren zu etablieren.

Methoden

Es wurden 106 Patienten mit hochgradigem präoperativen Verdacht einer Hüftendoprotheseninfektion einer Revisionsoperation unterzogen. Die Verdachtsdiagnose wurde anhand von anamnestischen, klinischen und radiologischen Auffälligkeiten sowie nach Laboruntersuchungen und Hüftpunktion erhoben. Eine definitive Diagnose ist nach Hinzuziehung eines intraoperativen Keimnachweises und einer histopathologischen Evaluierung entsprechend der Klassifikation der periprothetischen Membranen gestellt worden. Sensitivität, Spezifität und Genauigkeit wurden anschließend für jeden Untersuchungsparameter berechnet.

Ergebnisse

Bei 92 der 106 Patienten lag nachweislich eine Hüftendoprotheseninfektion vor, wobei in 86 (93,5%) Fällen die Histopathologie korrelierte (69-mal Typ II, 17-mal Typ III). Bei den 14 nichtinfizierten Fällen korrelierte der histopathologische Befund in 13 Fällen (93%; 10-mal Typ I, 3-mal Typ IV). Die Sensitivität lag bei 0,94, die Spezifität bei 0,93 und die Genauigkeit bei 0,93. Mikrobiologischer Keimnachweis und das C-reaktive Protein erwiesen sich ebenfalls als valide Parameter. Klinische radiologische Auffälligkeiten als auch die Hüftpunktion waren weniger sensitiv. Häufigste Erreger waren KNS (n=27) und Staphylococcus aureus (n=21).

Schlussfolgerung

Die histopathologische Begutachtung erweist sich als ein hervorragender Parameter in der Diagnose der periprothetischen Gelenkinfektion und sollte aufgrund hoher Genauigkeit standardmäßig bei jeder Revisionsoperation hinzugezogen werden. Bei allen Gewebeeinsendungen sollte zur Frage einer infektiös bedingten Entzündung Stellung genommen werden und eine Zuordnung der periprothetischen Membran entsprechend der Konsensusklassifikation erfolgen.

Abstract

Background

The distinction between aseptic and septic loosening of a total hip arthroplasty is a diagnostic challenge. Therapy and clinical success depend on the correct diagnosis. Histopathological evaluation of the periprosthetic interface membrane is one possible diagnostic parameter; detailed analysis of tissue characteristics may reflect the cause of failure. This study evaluated the diagnostic value of a published histopathological consensus classification for the periprosthetic interface membrane in the identification of periprosthetic joint infection (PJI).

Methods

Between 2004 and 2008, a prospective analysis was performed in 106 patients who had revisions because of assumed PJI. Based on clinical presentation, radiography, and haematological screening, infection was assumed, and a joint aspiration was performed. Based on these findings, a two-stage revision was performed, with intraoperative samples for culture and histological evaluation obtained. Final diagnosis of infection was based on the interpretation of the clinical presentation and the preoperative and intraoperative findings. The basis for histopathological evaluation was the consensus classification for the periprosthetic interface membrane. Sensitivity, specificity, and accuracy were calculated for each parameter.

Results

In 92 patients, a positive diagnosis of PJI could be made. Histopathology yielded the highest accuracy (0.93) in identification of PJI, identifying 86 of 92 infections (69 type II, 17 type III). In 13 of the 14 noninfected hips, histopathology correlated in 13 (93%) cases (10 type I, three type IV). The accuracies of microbiological culture, C-reactive protein, and aspiration were 0.82, 0.86, and 0.54, respectively.

Conclusion

In the diagnosis of PJI, histopathological evaluation of the periprosthetic interface membrane proved very effective. To analyse the cause of prosthesis loosening, tissue samples of the periprosthetic interface membrane should be evaluated on the basis of the consensus classification in all revision surgeries.

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Authors and Affiliations

  1. Centrum für Muskuloskeletale Chirurgie, Klinik für Orthopädie, Klinik für Unfall- und Wiederherstellungschirurgie, Charité-Universitätsmedizin Berlin, Chariteplatz 1, 10117, Berlin, Deutschland

    M. Müller, O. Hasart, P. Strube, C. Perka & S. Tohtz

  2. Institut für Pathologie, Charité-Universitätsmedizin Berlin, Berlin, Deutschland

    L. Morawietz

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  1. M. Müller
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Correspondence to M. Müller.

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Müller, M., Morawietz, L., Hasart, O. et al. Histopathologische Diagnose der periprothetischen Gelenkinfektion nach Hüftgelenkersatz. Orthopäde 38, 1087–1096 (2009). https://doi.org/10.1007/s00132-009-1471-1

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