Skip to main content

Advertisement

SpringerLink
Log in

Periprothetische Früh- und Spätinfektionen

Neuste Entwicklungen, Strategien und Behandlungsalgorithmen

Periprosthetic joint infections

Latest developments, strategies and treatment algorithms

  • Leitthema
  • Published:
Der Orthopäde Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Periprothetische Infektionen sind aufgrund ihrer multidimensionalen Folgen eine schwerwiegende Komplikation in der Endoprothetik. Es bestehen Uneinigkeiten in der Literatur bezüglich der genauen Klassifikationszeiträume bei zeitgleich nicht immer klarer Bedeutung für das praktische Vorgehen.

Therapeutisches Vorgehen

Im therapeutischen Vorgehen spielen neben dem Debridement mit Antibiose und Implantaterhalt die Möglichkeiten des ein- oder zweizeitigen Wechsels eine bedeutende Rolle. Während der Implantaterhalt überwiegend bei akuten Infektionen und kurzer Symptomdauer infrage kommt, sind Prothesenwechsel bei längerer Symptomdauer indiziert. Für beide Verfahren des Prothesenwechsels existieren interinstitutionell und international abweichende Indikationskriterien unter Abwägung von Pros und Contras. Beide bergen spezifische Probleme, wie insbesondere die Dauer der Antibiose, Fragen der Prothesenverankerung und, im Falle eines zweizeitigen Vorgehens, die Konstruktion des Platzhalters.

Abstract

Background

Due to their multidimensional consequences, periprosthetic joint infections are a serious complication in arthroplasty. There are disagreements in the literature regarding their classification. At the same time, a consequence for the practical procedure cannot always be derived.

Therapeutic procedures

In addition to debridement with antibiotics and implant retention, there are options for a one or two-stage change in the therapeutic procedure. Although the preservation of implants is only possible in the case of acute infections with a short duration of symptoms, prosthesis changes are indicated with a longer symptom duration. For both procedures, there are interinstitutional deviating indication criteria, weighing pros and cons. Both have specific problems, such as, in particular, the duration of the antibiotics course, the question of anchoring the prosthesis and, in the case of a two-stage procedure, the shape of the spacer.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4

Abbreviations

BGB:

Bürgerliches Gesetzbuch

CRP :

C‑reaktives Protein

DAIR :

„Debridement, antibiotics and implant retention“

DTT :

„Difficult-to-treat“-Erreger

EPRD :

Endoprothesenregister Deutschland

MARS :

„Metal artefact reduction sequence“

MAVRIC :

„Multi-acquisition variable-resonance image combination“

MBO‑Ä :

Muster-Berufsordnung für die in Deutschland tätigen Ärztinnen und Ärzte

MIC :

Minimale Hemmkonzentration

MRSA :

Methicillin-resistenter Staphylococcus aureus

PMMA :

Polymethylmethacrylat

PPI :

Periprothetische Infektion

SEMAC :

„Slice encoding for metal artifact correction“

TEP :

Totalendoprothesen

Literatur

  1. Endoprothesenregister Deutschland (EPRD) (2019) Jahresbericht (2019) https://www.eprd.de/fileadmin/user_upload/eprd_broschuere_doppelseite_2019_WEB__2019-10-24T06_45_17.027_.pdf. Zugegriffen: 16. Juni 2020

  2. Dale H, Hallan G, Espehaug B, Havelin LI, Engesaeter LB (2009) Increasing risk of revision due to deep infection after hip arthroplasty. Acta Orthop 80:639–645

    PubMed  PubMed Central  Google Scholar 

  3. Kurtz SM, Ong KL, Lau E et al (2010) Prosthetic joint infection risk after TKA in the medicare population. Clin Orthop Relat Res 468:52–56

    PubMed  Google Scholar 

  4. Izakovicova P, Borens O, Trampuz A (2019) Periprosthetic joint infection: current concepts and outlook. Efort Open Rev 4:482–494

    PubMed  PubMed Central  Google Scholar 

  5. Zajonz D, Zieme A, Prietzel T et al (2016) Periprosthetic joint infections in modular endoprostheses of the lower extremities: a retrospective observational study in 101 patients. Patient Saf Surg 10:6. https://doi.org/10.1186/s13037-016-0095-8

    Article  PubMed  PubMed Central  Google Scholar 

  6. Gebert C, Wessling M, Götze C, Gosheger G, Hardes J (2010) The modular universal tumour and revision system (MUTARS®) in endoprosthetic revision surgery. Int Orthop 34(8):1261–1265. https://doi.org/10.1007/s00264-010-1007-7

    Article  PubMed  PubMed Central  Google Scholar 

  7. Zimmerli W, Trampuz A, Ochsner PE (2004) Prosthetic-joint infections. N Engl J Med 351:1645–1654

    PubMed  CAS  Google Scholar 

  8. Kapadia BH, Berg RA, Daley JA et al (2016) Periprosthetic joint infection. Lancet 387:386–394

    PubMed  Google Scholar 

  9. Berend KR, Lombardi AV, Morris MJ et al (2013) Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality. Clin Orthop Relat Res 471:510–518

    PubMed  Google Scholar 

  10. Toulson C, Walcott-Sapp S, Hur J et al (2009) Treatment of infected total hip arthroplasty with a 2-stage reimplantation protocol: update on “our institution’s” experience from 1989 to 2003. J Arthroplast 24:1051–1060

    Google Scholar 

  11. Pellegrini A, Legnani C, Meani E (2019) A new perspective on current prosthetic joint infection classifications: introducing topography as a key factor affecting treatment strategy. Arch Orthop Trauma Surg 139:317–322

    PubMed  Google Scholar 

  12. Tsukayama DT, Estrada R, Gustilo RB (1996) Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am 78:512–523

    PubMed  CAS  Google Scholar 

  13. Zimmerli W (2006) Infection and musculoskeletal conditions: Prosthetic-joint-associated infections. Best Pract Res Clin Rheumatol 20(6):1045–1063

    PubMed  Google Scholar 

  14. Barrett L, Atkins B (2014) The clinical presentation of prosthetic joint infection. J Antimicrob Chemother 69(Suppl 1):i25–i27. https://doi.org/10.1093/jac/dku250

    Article  PubMed  CAS  Google Scholar 

  15. Rodríguez D, Pigrau C, Euba G et al (2010) Acute haematogenous prosthetic joint infection: prospective evaluation of medical and surgical management. Clin Microbiol Infect 16(12):1789–1795. https://doi.org/10.1111/j.1469-0691.2010.03157.x

    Article  PubMed  Google Scholar 

  16. Azzam KA, Seeley M, Ghanem E et al (2010) Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited. J Arthroplasty 25:1022–1027

    PubMed  Google Scholar 

  17. Romanò CL, Manzi G, Logoluso N, Romanò D (2012) Value of debridement and irrigation for the treatment of peri-prosthetic infections. a systematic review. Hip Int 22(Suppl 8):S19–S24

    PubMed  Google Scholar 

  18. Mühlhofer HML, Feihl S, Suren C et al (2020) Implant-associated joint infections. Orthopäde 49:277–286

    PubMed  Google Scholar 

  19. Boyle KK, Kapadia M, Landy DC et al (2020) Utilization of debridement, antibiotics, and implant retention for infection after total joint arthroplasty over a decade in the united states. J Arthroplasty. https://doi.org/10.1016/j.arthr.2020.03.029

    Article  Google Scholar 

  20. Trampuz A, Perka C, Borens O (2013) Prosthetic joint infection: new developments in diagnosis and treatment. Dtsch Med Wochenschr 138:1571–1573

    PubMed  CAS  Google Scholar 

  21. Ilahi OA, Al-Habbal GA, Bocell JR, Tullos HS, Huo MH (2005) Arthroscopic debridement of acute periprosthetic septic arthritis of the knee. Arthroscopy 21:303–306

    PubMed  Google Scholar 

  22. Liu CW, Kuo CL, Chuang SY et al (2013) Results of infected total knee arthroplasty treated with arthroscopic debridement and continuous antibiotic irrigation system. Indian J Orthop 47:93–97

    PubMed  PubMed Central  Google Scholar 

  23. Diaz-Ledezma C, Espinosa-Mendoza R, Gallo J et al (2019) General assembly, diagnosis, imaging: Proceedings of international consensus on orthopedic infections. J Arthroplast 34:215–223

    Google Scholar 

  24. Saeed K (2014) Diagnostics in prosthetic joint infections. J Antimicrob Chemother 69(1):11–19. https://doi.org/10.1093/jac/dku248

    Article  Google Scholar 

  25. Porrino J, Wang A, Moats A, Mulcahy H, Kani K (2020) Prosthetic joint infections: diagnosis, management, and complications of the two-stage replacement arthroplasty. Skelet Radiol 49:847–859

    Google Scholar 

  26. Lehner B, Witte D, Suda AJ, Weiss S (2009) Revision strategy for periprosthetic infection. Orthopäde 38:681–688

    PubMed  CAS  Google Scholar 

  27. Zhang CF, He L, Fang XY et al (2020) Debridement, antibiotics, and implant retention for acute periprosthetic joint infection. Orthop Surg. https://doi.org/10.1111/os.12641

    Article  PubMed  PubMed Central  Google Scholar 

  28. Lehner B, Weiss S, Moradi B, Witte D (2009) Anwendung der V.A.C.-Instill-Therapie bei periprothetischen Hüft- und Kniegelenksinfekten im Rahmen einer Multi-Center-Studie. ZfW 14:21–25

    Google Scholar 

  29. Iorio R, Yu S, Schwarzkopf R et al (2020) Vancomycin powder and dilute povidone-iodine lavage for infection prophylaxis in high-risk total joint arthroplasty. J Arthroplasty. https://doi.org/10.1016/j.arth.2020.02.060

    Article  PubMed  PubMed Central  Google Scholar 

  30. Lora-Tamayo J, Murillo O, Iribarren JA (2013) A large multicenter study of methicillin-susceptible and methicillin-resistant staphylococcus aureus prosthetic joint infections managed with implant retention. Clin Infect Dis 56:182–194

    PubMed  Google Scholar 

  31. Zaruta DA, Qiu B, Liu AY, Ricciardi BF (2018) Indications and guidelines for debridement and implant retention for periprosthetic hip and knee infection. Curr Rev Musculoskelet Med 11:347–356

    PubMed  PubMed Central  Google Scholar 

  32. Argenson JN, Arndt M, Babis G et al (2019) Hip and knee section, treatment, debridement and retention of implant: Proceedings of international consensus on orthopedic infections. J Arthroplast 34:399–419

    Google Scholar 

  33. Wouthuyzen-Bakker M, Löwik CAM, Ploegmakers JJW et al (2020) A second surgical debridement for acute periprosthetic joint infections should not be discarded. J Arthroplasty. https://doi.org/10.1016/j.arth.2020.02.043

    Article  PubMed  Google Scholar 

  34. O’Neill KR, Smith JG, Abtahi AM et al (2011) Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J 11:641–646

    PubMed  Google Scholar 

  35. Sweet FA, Roh M, Sliva C (2011) Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. Spine 36:2084–2088

    PubMed  Google Scholar 

  36. Kilgus S, Karczewski D, Passkönig C et al (2020) Failure analysis of infection persistence after septic revision surgery: a checklist algorithm for risk factors in knee and hip arthroplasty. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-020-03444-0

    Article  PubMed  Google Scholar 

  37. Horch RE, Braumann C, Dissemond J et al (2018) Use of negative pressure wound therapy with instillation and dwell time for wound treatment—results of an expert consensus conference. Zentralbl Chir 143(6):609–616. https://doi.org/10.1055/a-0713-0517

    Article  PubMed  Google Scholar 

  38. Buchholz HW, Elson RA, Engelbrecht E et al (1981) Management of deep infection of total hip replacement. J Bone Joint Surg Br 63(B3):342–353

    PubMed  Google Scholar 

  39. Kildow BJ, Della-Valle CJ, Springer BD (2020) Single vs 2‑stage revision for the treatment of periprosthetic joint infection. J Arthroplasty 35:24–30

    Google Scholar 

  40. George DA, Haddad FS (2017) One-stage exchange arthroplasty: a surgical technique update. J Arthroplasty 32:59–62

    Google Scholar 

  41. Osmon DR, Berbari EF, Berendt AR et al (2013) Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the infectious diseases society of America. Clin Infect Dis 56(1):1–10. https://doi.org/10.1093/cid/cis966

    Article  PubMed  Google Scholar 

  42. Gehrke T, Zahar A, Kendoff D (2013) One-stage exchange: it all began here. Bone Joint J 95-B(11 Suppl A):77–83. https://doi.org/10.1302/0301-620X.95B11.32646

    Article  PubMed  CAS  Google Scholar 

  43. Pangaud C, Ollivier M, Argenson JN (2019) Outcome of single-stage versus two-stage exchange for revision knee arthroplasty for chronic periprosthetic infection. Efort Open Rev 4:495–502

    PubMed  PubMed Central  Google Scholar 

  44. George DA, Logoluso N, Castellini G et al (2016) Does cemented or cementless single-stage exchange arthroplasty of chronic periprosthetic hip infections provide similar infection rates to a two-stage? A systematic review. BMC Infect Dis 16(1):553

    PubMed  PubMed Central  CAS  Google Scholar 

  45. Kunutsor SK, Whitehouse MR, Lenguerrand E et al (2016) Re-infection outcomes following one- and two-stage surgical revision of infected knee prosthesis: A systematic review and meta-analysis. PLOS ONE 11:e151537

    PubMed  PubMed Central  Google Scholar 

  46. Nagra NS, Hamilton TW, Ganatra S, Murray DW, Pandit H (2016) One-stage versus two-stage exchange arthroplasty for infected total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc 24:3106–3114

    PubMed  Google Scholar 

  47. Wolff M, Lausmann C, Gehrke T et al (2019) Results at 10–24 years after single-stage revision arthroplasty of infected total hip arthroplasty in patients under 45 years of age. Hip Int. https://doi.org/10.1177/1120700019888877

    Article  PubMed  Google Scholar 

  48. Lange J, Troelsen A, Solgaard S et al (2018) Cementless one-stage revision in chronic periprosthetic hip joint infection. ninety-one percent infection free survival in 56 patients at minimum 2‑year follow-up. J Arthroplast 33(4):1160–1165

    Google Scholar 

  49. Insall JN, Thompson FM, Brause BD (1983) Two-stage reimplantation for the salvage of infected total knee arthroplasty. J Bone Joint Surg Am 65:1087–1098

    PubMed  CAS  Google Scholar 

  50. Mühlhofer HML, Knebel C, Pohlig F et al (2018) Synovial aspiration and serological testing in two-stage revision arthroplasty for prosthetic joint infection: evaluation before reconstruction with a mean follow-up of twenty seven months. Int Orthop 42:265–271

    PubMed  Google Scholar 

  51. Aalirezaie A, Bauer TW, Fayaz H et al (2019) Hip and knee section, diagnosis, reimplantation: Proceedings of international consensus on orthopedic infections. J Arthroplast 34:369–379

    Google Scholar 

  52. Rava A, Bruzzone M, Cottino U, Enrietti E, Rossi R (2019) Hip spacers in two-stage revision for periprosthetic joint infection: a review of literature. Joints 7:56–63

    PubMed  PubMed Central  Google Scholar 

  53. Nahhas CR, Chalmers PN, Parvizi J (2020) A randomized trial of static and articulating spacers for the treatment of infection following total knee arthroplasty. J Bone Joint Surg Am. https://doi.org/10.2106/JBJS.19.00915

    Article  PubMed  Google Scholar 

  54. Bowman EC, Malkani AL (2020) Point/counterpoint: static vs. articulating spacers-static spacers for resection arthroplasty of the knee. J Arthroplasty 35:35–39

    Google Scholar 

  55. Gomez MM, Tan TL, Manrique J, Deirmengian GK, Parvizi J (2015) The fate of spacers in the treatment of periprosthetic joint infection. J Bone Joint Surg Am 97:1495–1502

    PubMed  Google Scholar 

  56. Voleti PB, Baldwin KD, Lee GC (2013) Use of static or articulating spacers for infection following total knee arthroplasty: a systematic literature review. J Bone Joint Surg Am 95:1594–1599

    PubMed  Google Scholar 

  57. Warth LC, Hadley CJ, Grossman EL (2020) Two-stage treatment for total knee arthroplasty infection utilizing an articulating prefabricated antibiotic spacer. J Arthroplasty 35:57–62

    Google Scholar 

  58. Anagnostakos K, Kelm J (2009) Enhancement of antibiotic elution from acrylic bone cement. J Biomed Mater Res B Appl Biomater 90(1):467–475. https://doi.org/10.1002/jbm.b.31281

    Article  PubMed  CAS  Google Scholar 

  59. Anagnostakos K, Meyer C (2017) Antibiotic elution from hip and knee acrylic bone cement spacers: a systematic review. Biomed Res Int 2017:4657874. https://doi.org/10.1155/2017/4657874

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  60. Wouthuyzen-Bakker M, Kheir MM, Moya I et al (2019) Failure after 2‑stage exchange arthroplasty for treatment of periprosthetic joint infection: the role of antibiotics in the cement spacer. Clin Infect Dis 68(12):2087–2093. https://doi.org/10.1093/cid/ciy851

    Article  PubMed  Google Scholar 

  61. Corró S, Vicente M, Rodríguez-Pardo D et al (2020) Vancomycin-gentamicin prefabricated spacers in 2‑stage revision arthroplasty for chronic hip and knee periprosthetic joint infection: Insights into reimplantation microbiology and outcomes. J Arthroplasty 35(1):247–254. https://doi.org/10.1016/j.arth.2019.07.043

    Article  PubMed  Google Scholar 

  62. Pivec R, Naziri Q, Issa K, Banerjee S, Mont MA (2014) Systematic review comparing static and articulating spacers used for revision of infected total knee arthroplasty. J Arthroplasty 29(3):553–557.e1. https://doi.org/10.1016/j.arth.2013.07.041

    Article  PubMed  Google Scholar 

  63. Gellert M, Hardt S, Köder K et al (2020) Biofilm-active antibiotic treatment improves the outcome of knee periprosthetic joint infection: Results from a 6-year prospective cohort study. Int J Antimicrob Agents. https://doi.org/10.1016/j.ijantimicag.2020.105904

    Article  PubMed  Google Scholar 

  64. Sendi P, Zimmerli W (2017) The use of rifampin in staphylococcal orthopaedic-device-related infections. Clin Microbiol Infect 23(6):349–350. https://doi.org/10.1016/j.cmi.2016.10.002

    Article  PubMed  CAS  Google Scholar 

  65. Chieffo G, Corsia S, Rougereau G et al (2020) Six-week antibiotic therapy after one-stage replacement arthroplasty for hip and knee periprosthetic joint infection. Med Mal Infect. https://doi.org/10.1016/j.medmal.2020.03.003

    Article  PubMed  Google Scholar 

  66. Zeller V, Lhotellier L, Marmor S et al (2014) One-stage exchange arthroplasty for chronic periprosthetic hip infection: results of a large prospective cohort study. J Bone Joint Surg Am 96(1):e1. https://doi.org/10.2106/JBJS.L.01451

    Article  PubMed  Google Scholar 

  67. Bernard L et al (2019) Durée de traitement des infections sur prothèses ostéo-articulaires (DATIPO): étude randomisée 6 versus 12 semaines. Med Mal Infect 49(4):12. https://doi.org/10.1016/j.medmal.2019.04.045

    Article  Google Scholar 

  68. Schwarze M, Gaidzik PW, Merle C, Schiltenwolf M (2019) Occurrence of typical complications in hip arthroplasty. Orthopäde 48:1045–1047

    PubMed  CAS  Google Scholar 

  69. Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the united states from 2005 to 2030. J Bone Joint Surg Am 89:780–785

    PubMed  Google Scholar 

  70. Schwartz AM, Farley KX, Guild GN, Bradbury TL Jr (2030) Projections and epidemiology of revision hip and knee arthroplasty in the united states to. J Arthroplasty. https://doi.org/10.1016/j.arth.2020.02.030

    Article  Google Scholar 

  71. Kurtz SM, Lau EC, Son MS et al (2018) Are we winning or losing the battle with periprosthetic joint infection: trends in periprosthetic joint infection and mortality risk for the medicare population. J Arthroplasty 33:3238–3245

    PubMed  Google Scholar 

  72. Xu C, Goswami K, Li WT et al (2020) Is treatment of periprosthetic joint infection improving over time? J Arthroplasty. https://doi.org/10.1016/j.arth.2020.01.080

    Article  PubMed  Google Scholar 

  73. Fowler TJ, Sayers A, Whitehouse MR (2019) Two-stage revision surgery for periprosthetic joint infection following total hip arthroplasty. Ann Transl Med 7(8):261

    Google Scholar 

  74. Petis SM, Abdel MP, Perry KI et al (2019) Long-term results of a 2-stage exchange protocol for periprosthetic joint infection following total hip arthroplasty in 164 hips. J Bone Joint Surg Am 101:74–84

    PubMed  Google Scholar 

  75. Boese CK, Lechler P, Frink M et al (2020) Cost analysis of inpatient versus outpatient intravenous antibiotic treatment for periprosthetic joint infections: a simulation. Orthopäde. https://doi.org/10.1007/s00132-020-03889-6

    Article  PubMed Central  Google Scholar 

  76. Otto-Lambertz C, Yagdiran A, Wallscheid F, Eysel P, Jung N (2017) Periprosthetic infection in joint replacement. Dtsch Arztebl Int 114(20):347–353. https://doi.org/10.3238/arztebl.2017.0347

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland

    B. Lehner, G.-W. Omlor & M. Schwarze

Authors
  1. B. Lehner
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. G.-W. Omlor
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. Schwarze
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to B. Lehner.

Ethics declarations

Interessenkonflikt

B. Lehner, G.-W. Omlor und M. Schwarze geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lehner, B., Omlor, GW. & Schwarze, M. Periprothetische Früh- und Spätinfektionen. Orthopäde 49, 648–659 (2020). https://doi.org/10.1007/s00132-020-03950-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00132-020-03950-4

Schlüsselwörter

Keywords

Search

Navigation