Skip to main content
SpringerLink
Log in

Septische Revisionsprothetik: Vorbereitung, Durchführung und Nachbehandlung

Septic revision arthroplasty: how to confirm diagnosis, plan surgery and manage follow-up treatment

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

Zusammenfassung

Hintergrund

Die septische Revisionsendoprothetik stellt in ihrer Diagnostik, Durchführung und Nachbehandlung eine interdisziplinäre Herausforderung dar.

Diagnose

Zur Sicherung der Diagnose muss das Abarbeiten eines standardisierten Algorithmus erfolgen: Anamnese, Klinik, Bildgebung, Blutentnahme und Gelenkpunktion sind die diagnostischen Grundpfeiler. Letztere sollte immer die Bestimmung der Leukozytenzahl, die Bestimmung der neutrophilen Granulozyten und eine mikrobiologische Untersuchung des Punktats umfassen. Abhängig von der Dauer der angegebenen Beschwerden unterscheidet man klinisch zwischen akuten (< 3 Wochen) und chronischen (> 3 Wochen) Infekten.

Therapie

Während akute Infektionen einen unreifen Biofilm aufweisen und in der Regel chirurgisch über ein Debridement und den Wechsel der mobilen Teile adressiert werden können, muss bei chronischen Infektionen nahezu immer ein kompletter Wechsel des Implantates erfolgen. Dies kann je nach Allgemeinzustand des Patienten, dem Erreger und den Resistenzen sowie der Wundverhältnisse ein- oder zweizeitig erfolgen. Der chirurgischen Revision schließt sich in jedem Fall eine resistenzgerechte Antibiose an, deren Therapiedauer durch unterschiedliche Faktoren bestimmt wird.

Abstract

Background

Septic revision arthroplasty represents an interdisciplinary challenge in terms of diagnosis as well as surgical and follow-up treatment.

Diagnosis

The implementation of a standardized diagnostic algorithm including anamnesis, clinic, imaging, blood sampling and joint aspiration is essential. Depending on the duration of the symptoms acute (< 3 weeks) and chronic (> 3 weeks) infections are distinguished.

Therapy

While acute infections show an immature biofilm and can usually be addressed surgically via debridement and changing the mobile parts, chronic infections almost always require a complete change of the implant. This can be done in one or two stages, depending on the general condition of the patient, the pathogen, its resistances as well as the wound conditions. The surgical revision is always followed by a resistance-based antibiotic treatment.

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

BSG:

Blutsenkungsgeschwindigkeit

CRP :

C‑reaktives Protein

DAIR :

„Surgical debridement, antibiotics and retention of the implant“

EBJIS :

European Bone and Joint Infection Society

HbA1c :

Hämoglobin A1c

KLIC :

„Chronic Kidney disease, Liver cirrhosis, Index surgery for fracture, Cemented prosthesis“, CRP > 115 mg/l

LE:

Leukozytenesterase

MSIS :

Musculoskeletal Infection Society

PCR :

Polymerase-Kettenreaktion

PPI :

Periprothetische Infektion

S‑PECAM :

S‑Platelet endothelial cell adhesion molecule

Literatur

  1. Bedair H (2019) CORR insights(R): what are the factors associated with re-revision after one-stage revision for periprosthetic joint infection of the hip? A case-control study. Clin Orthop Relat Res 477:2264–2266

    Article  Google Scholar 

  2. Blevins K, Aalirezaie A, Shohat N et al (2018) Malnutrition and the development of periprosthetic joint infection in patients undergoing primary elective total joint arthroplasty. J Arthroplasty 33:2971–2975

    Article  Google Scholar 

  3. Bori G, Navarro G, Morata L et al (2018) Preliminary results after changing from two-stage to one-stage revision arthroplasty protocol using cementless arthroplasty for chronic infected hip replacements. J Arthroplasty 33:527–532

    Article  Google Scholar 

  4. Duque AF, Post ZD, Lutz RW et al (2017) Is there still a role for irrigation and debridement with liner exchange in acute periprosthetic total knee infection? J Arthroplasty 32:1280–1284

    Article  Google Scholar 

  5. Edwards PK, Fehring TK, Hamilton WG et al (2014) Are cementless stems more durable than cemented stems in two-stage revisions of infected total knee arthroplasties? Clin Orthop Relat Res 472:206–211

    Article  Google Scholar 

  6. Fink B, Rechtenbach A, Büchner H et al (2011) Articulating spacers used in two-stage revision of infected hip and knee prostheses abrade with time. Clin Orthop Relat Res 469(4):1095–1102. https://doi.org/10.1007/s11999-010-1479-1

    Article  PubMed  Google Scholar 

  7. Fuchs M, Trampuz A, Kirschbaum S et al (2021) Soluble Pecam‑1 as a biomarker in periprosthetic joint infection. J Clin Med 10(4):612

    Article  CAS  Google Scholar 

  8. Hansen E, Tetreault M, Zmistowski B et al (2013) Outcome of one-stage cementless exchange for acute postoperative periprosthetic hip infection. Clin Orthop Relat Res 471:3214–3222

    Article  Google Scholar 

  9. Iza K, Foruria X, Moreta J et al (2019) DAIR (debridement, antibiotics and implant retention) less effective in hematogenous total knee arthroplasty infections. J Orthop Surg Res 14:278

    Article  Google Scholar 

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

    Article  Google Scholar 

  11. Karbysheva S, Yermak K, Grigoricheva L et al (2020) Synovial fluid d‑lactate—a novel pathogen-specific biomarker for the diagnosis of periprosthetic joint infection. J Arthroplasty 35:2223–2229.e2

    Article  Google Scholar 

  12. Kildow BJ, Della-Valle CJ, Springer BD (2020) Single vs 2‑stage revision for the treatment of periprosthetic joint infection. J Arthroplasty 35:S24–S30

    Article  Google Scholar 

  13. Kühn K (2014) PMMA cements. Springer, Heidelberg

    Google Scholar 

  14. Kunutsor SK, Whitehouse MR, Blom AW et al (2016) Patient-related risk factors for periprosthetic joint infection after total joint arthroplasty: a systematic review and meta-analysis. PLoS ONE 11:e150866

    Article  CAS  Google Scholar 

  15. Lasocki S (2015) The true obesity paradox: obese and malnourished? Crit Care Med 43:240–241

    Article  Google Scholar 

  16. Lee YS, Koo KH, Kim HJ et al (2017) Synovial fluid biomarkers for the diagnosis of periprosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am 99:2077–2084

    Article  Google Scholar 

  17. Leonard HA, Liddle AD, Burke O et al (2014) Single- or two-stage revision for infected total hip arthroplasty? A systematic review of the literature. Clin Orthop Relat Res 472:1036–1042

    Article  Google Scholar 

  18. Lowik CAM, Jutte PC, Tornero E et al (2018) Predicting failure in early acute prosthetic joint infection treated with debridement, antibiotics, and implant retention: external validation of the KLIC score. J Arthroplasty 33:2582–2587

    Article  Google Scholar 

  19. Lowik CaM CAM, Parvizi J, Jutte PC et al (2020) Debridement, antibiotics, and implant retention is a viable treatment option for early periprosthetic joint infection presenting more than 4 weeks after index arthroplasty. Clin Infect Dis 71:630–636

    Article  Google Scholar 

  20. Maale GE, Eager JJ, Srinivasaraghavan A et al (2020) The evolution from the two stage to the one stage procedure for biofilm based periprosthetic joint infections (PJI). Biofilm 2:100033

    Article  Google Scholar 

  21. Mcnally M, Sousa R, Wouthuyzen-Bakker M et al (2021) Infographic: the EBJIS definition of periprosthetic joint infection. Bone Joint J 103-B:16–17

    Article  CAS  Google Scholar 

  22. Morgenstern C, Cabric S, Perka C et al (2018) Synovial fluid multiplex PCR is superior to culture for detection of low-virulent pathogens causing periprosthetic joint infection. Diagn Microbiol Infect Dis 90:115–119

    Article  CAS  Google Scholar 

  23. Muller M, Trampuz A, Winkler T et al (2018) The economic challenge of centralised treatment of patients with periprosthetic infections. Z Orthop Unfall. https://doi.org/10.1055/s-0044-100732

    Article  PubMed  Google Scholar 

  24. Omar M, Windhagen H, Krettek C et al (2021) Noninvasive diagnostic of periprosthetic joint infection by urinary peptide markers: a preliminary study. J Orthop Res 39:339–347

    Article  CAS  Google Scholar 

  25. 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

    Article  Google Scholar 

  26. Parvizi J, Gehrke T, Chen AF (2013) Proceedings of the international consensus on periprosthetic joint infection. Bone Joint J 95-B:1450–1452

    Article  CAS  Google Scholar 

  27. Parvizi J, Tan TL, Goswami K et al (2018) The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. J Arthroplasty 33:1309–1314.e2

    Article  Google Scholar 

  28. Parvizi J, Zmistowski B, Berbari EF et al (2011) New definition for periprosthetic joint infection: from the workgroup of the musculoskeletal infection society. Clin Orthop Relat Res 469:2992–2994

    Article  Google Scholar 

  29. Pohlig F, Muhlhofer HM, Lenze U et al (2017) Diagnostic accuracy of arthroscopic biopsy in periprosthetic infections of the hip. Eur J Med Res 22:6

    Article  CAS  Google Scholar 

  30. Razavi BM, Fazly Bazzaz BS (2019) A review and new insights to antimicrobial action of local anesthetics. Eur J Clin Microbiol Infect Dis 38:991–1002

    Article  CAS  Google Scholar 

  31. Razii N, Clutton JM, Kakar R et al (2021) Single-stage revision for the infected total knee arthroplasty : the Cardiff experience. Bone Jt Open 2:305–313

    Article  Google Scholar 

  32. Renz N, Perka C, Trampuz A (2016) Management of periprosthetic infections of the knee. Orthopäde 45:65–71

    Article  CAS  Google Scholar 

  33. Svensson K, Rolfson O, Naucler E et al (2020) Exchange of modular components improves success of debridement, antibiotics, and implant retention: an observational study of 575 patients with infection after primary total hip arthroplasty. JB JS Open Access 5(4):e20.00110. https://doi.org/10.2106/JBJS.OA.20.00110

    Article  PubMed  PubMed Central  Google Scholar 

  34. Toh RX, Yeo ZN, Liow MHL et al (2021) Debridement, antibiotics, and implant retention in periprosthetic joint infection: what predicts success or failure? J Arthroplasty 36(10):3562–3569. https://doi.org/10.1016/j.arth.2021.05.023

    Article  PubMed  Google Scholar 

  35. van den Kieboom J, Tirumala V, Box H et al (2021) One-stage revision is as effective as two-stage revision for chronic culture-negative periprosthetic joint infection after total hip and knee arthroplasty. Bone Joint J 103-B:515–521

    Article  Google Scholar 

  36. Winkler T, Trampuz A, Hardt S et al (2014) Periprosthetic infection after hip arthroplasty. Orthopade 43:70–78

    Article  CAS  Google Scholar 

  37. Wouthuyzen-Bakker M, Sebillotte M, Huotari K et al (2020) Lower success rate of debridement and implant retention in late acute versus early acute periprosthetic joint infection caused by staphylococcus spp. Results from a matched cohort study. Clin Orthop Relat Res 478:1348–1355

    Article  Google Scholar 

  38. Wouthuyzen-Bakker M, Shohat N, Parvizi J et al (2021) Risk scores and machine learning to identify patients with acute periprosthetic joints infections that will likely fail classical irrigation and debridement. Front Med (Lausanne) 8:550095

    Article  Google Scholar 

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

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Centrum für Muskuloskeletale Chirurgie, Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland

    Stephanie Kirschbaum &  Carsten Perka

Authors
  1. Stephanie Kirschbaum
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Carsten Perka
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Carsten Perka.

Ethics declarations

Interessenkonflikt

S. Kirschbaum und C. Perka 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.

Additional information

figure qr

QR-Code scannen & Beitrag online lesen

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kirschbaum, S., Perka, C. Septische Revisionsprothetik: Vorbereitung, Durchführung und Nachbehandlung. Orthopäde 50, 995–1003 (2021). https://doi.org/10.1007/s00132-021-04176-8

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00132-021-04176-8

Schlüsselwörter

Keywords

Search

Navigation