Skip to main content
SpringerLink
Log in

Diagnostische Strategien bei Verdacht auf periprothetische Infektion einer Kniegelenktotalendoprothese

Literaturübersicht und aktuelle Empfehlungen

Diagnostic strategies in cases of suspected periprosthetic infection of the knee

A review of the literature and current recommendations

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

Zusammenfassung

Die sichere Bestimmung der periprothetischen Infektion des Kniegelenks ist eine diagnostische Herausforderung. Die vorliegende Arbeit gibt eine Literaturübersicht zu den verfügbaren diagnostischen Verfahren.

Bei Infektionen nach Knietotalendoprothese (Knie-TEP) zeigen die Blutkörperchensenkung und das C-reaktive Protein (CRP) eine relativ hohe Sensitivität bei geringer Spezifität und werden deshalb vornehmlich zum Infektausschluss eingesetzt. Die Leukozytenszintigraphie zeigte sehr unterschiedliche Wertigkeiten, ein Einsatz als Standarddiagnostikum kann nach den vorliegenden Daten nicht empfohlen werden.

Für die Antigranulozytenszintigraphie und die FDG-PET als neuere Verfahren konnte in den durchgeführten kleineren Studien eine gute Genauigkeit mit hoher Sensitivität gezeigt werden. Eine Validierung in größeren Studien ist notwendig. Unbestritten ist die hohe Spezifität der mikrobiologischen Untersuchung präoperativer Punktate, jedoch verbleiben durchschnittlich 20% falsch-negative Befunde. Eine Punktion wird jedoch aufgrund der Möglichkeit der präoperativen Keimdifferenzierung empfohlen.

Eine gute Genauigkeit zeigte auch die intraoperative Gefrierschnittuntersuchung. Als Standards werden die intraoperative Kultur und Histologie eingesetzt, die echte Wertigkeit ist jedoch aufgrund fehlender Goldstandards schwer zu beurteilen.

Große Studien zu den diagnostischen Verfahren und validierte Kriterien zur definitiven Diagnosestellung sind zur Optimierung des diagnostischen Algorithmus notwendig.

Abstract

Reliable confirmation of periprosthetic infection after total knee arthroplasty is a diagnostic challenge. The present work reviews published data evaluating the available diagnostic tools.

Erythrocyte sedimentation rate and C-reactive protein serum levels are relatively sensitive methods with rather low specificity towards periprosthetic infection and are mainly applied to exclude infection. Studies evaluating scintigraphic methods – especially white cell scans – provide inconsistent data with varying accuracy. Consequently, white cell scans cannot be recommended as standard methods.

Immunoscintigraphy with antigranulocyte antibodies and FDG-PET scans demonstrated promising results with particularly high sensitivities, but have to be validated in larger studies. Microbiological evaluation of joint aspirates proved high specificity for periprosthetic infection. However, an average of 20% of infected cases remained undetected. Nevertheless, aspiration is widely recommended for preoperative isolation of the infecting organism. Intraoperative frozen sections demonstrated excellent specificity with good sensitivity. The real accuracy of intraoperative culture and permanent histology cannot be determined due to the missing golden standard; however, a combination of both methods is recommended to define the final diagnosis.

Large studies validating both methods and criteria for the final diagnosis of periprosthetic infection are necessary to optimize the diagnostic algorithm.

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

Literatur

  1. Abdul-Karim FW, McGinnis MG, Kraay M et al. (1998) Frozen section biopsy assessment for the presence of polymorphonuclear leukocytes in patients undergoing revision of arthroplasties. Mod Pathol 11(5): 427–431

    PubMed  Google Scholar 

  2. Athanasou NA, Pandey R, de Steiger R et al. (1995) Diagnosis of infection by frozen section during revision arthroplasty. J Bone Joint Surg Br 77(1): 28–33

    PubMed  Google Scholar 

  3. Atkins BL, Athanasou N, Deeks JJ et al. (1998) Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. The OSIRIS Collaborative Study Group. J Clin Microbiol 36(10): 2932–2939

    PubMed  Google Scholar 

  4. Banit DM, Kaufer H, Hartford JM (2002) Intraoperative frozen section analysis in revision total joint arthroplasty. Clin Orthop Relat Res 401: 230–238

    Article  PubMed  Google Scholar 

  5. Barrack RL, Jennings RW, Wolfe MW, Bertot AJ (1997) The Coventry Award. The value of preoperative aspiration before total knee revision. Clin Orthop Relat Res 345: 8–16

    Article  PubMed  Google Scholar 

  6. Bengtson S (1993) Prosthetic osteomyelitis with special reference to the knee: risks, treatment and costs. Ann Med 25(6): 523–529

    PubMed  Google Scholar 

  7. Bengtson S, Knutson K (1991) The infected knee arthroplasty. A 6-year follow-up of 357 cases. Acta Orthop Scand 62(4): 301–311

    PubMed  Google Scholar 

  8. Clarke MT, Roberts CP, Lee PT et al. (2004) Polymerase chain reaction can detect bacterial DNA in aseptically loose total hip arthroplasties. Clin Orthop Relat Res 427: 132–137

    Article  PubMed  Google Scholar 

  9. Davis LP (1994) Nuclear imaging in the diagnosis of the infected total joint arthroplasty. Semin Arthroplasty 5(3): 147–152

    PubMed  Google Scholar 

  10. Deirmengian C, Lonner JH, Booth RE Jr (2005) The Mark Coventry Award: white blood cell gene expression: a new approach toward the study and diagnosis of infection. Clin Orthop Relat Res 440: 38–44

    Article  PubMed  Google Scholar 

  11. Della Valle CJ, Scher DM, Kim YH et al. (1999) The role of intraoperative Gram stain in revision total joint arthroplasty. J Arthroplasty 14(4): 500–504

    Article  PubMed  Google Scholar 

  12. Di Cesare PE, Chang E et al. (2005) Serum interleukin-6 as a marker of periprosthetic infection following total hip and knee arthroplasty. J Bone Joint Surg Am 87(9): 1921–1927

    Article  PubMed  Google Scholar 

  13. Duff GP, Lachiewicz PF, Kelley SS (1996) Aspiration of the knee joint before revision arthroplasty. Clin Orthop Relat Res 331: 132–139

    Article  PubMed  Google Scholar 

  14. Fehring TK, McAlister JA Jr (1994) Frozen histologic section as a guide to sepsis in revision joint arthroplasty. Clin Orthop Relat Res 304: 229–237

    PubMed  Google Scholar 

  15. Feldman DS, Lonner JH, Desai P, Zuckerman JD (1995) The role of intraoperative frozen sections in revision total joint arthroplasty. J Bone Joint Surg Am 77(12): 1807–1813

    PubMed  Google Scholar 

  16. Fuerst M, Fink B, Ruther W (2005) Die Wertigkeit von präoperativer Punktion und arthroskopischer Synopvialisprobenentnahme bei Knietotalendoprothesenwechsel. Z Orthop Ihre Grenzgeb 143(1): 36–41

    Article  PubMed  Google Scholar 

  17. Geipel U, Herrmann M (2004) Das infizierte Implantat. Teil 1: Bakteriologie. Orthopade 33(12): 1411–1426

    Article  PubMed  Google Scholar 

  18. Glithero PR, Grigoris P, Harding LK et al. (1993) White cell scans and infected joint replacements. Failure to detect chronic infection. J Bone Joint Surg Br 75(3): 371–374

    PubMed  Google Scholar 

  19. Gollwitzer H, Burgkart R, Diehl P et al. (2006) Therapie der Arthrofibrose nach Kniegelenkendoprothetik. Orthopade 35(2): 143–152

    Article  PubMed  Google Scholar 

  20. Gollwitzer H, Heizer V, Stahl A et al. (2005) Die F-18-FDG-PET als neues Verfahren zur präoperativen Diagnostik der Totalendoprotheseninfektion: Was ist der Nutzen für den orthopädischen Chirurgen? Eine prospektive Studie. 1. Gemeinsamer Kongress Orthopädie – Unfallchirurgie, Berlin, 2005

  21. Gollwitzer H, Langer R, Diehl P, Mittelmeier W (2004) Chronic osteomyelitis due to Mycobacterium chelonae diagnosed by polymerase chain reaction homology matching. A case report. J Bone Joint Surg Am 86(6): 1296–1301

    PubMed  Google Scholar 

  22. Hanssen AD, Rand JA (1999) Evaluation and treatment of infection at the site of a total hip or knee arthroplasty. Instr Course Lect 48: 111–122

    PubMed  Google Scholar 

  23. Henderson JJ, Bamford DJ, Noble J, Brown JD (1996) The value of skeletal scintigraphy in predicting the need for revision surgery in total knee replacement. Orthopedics 19(4): 295–299

    PubMed  Google Scholar 

  24. Johnson JA, Christie MJ, Sandler MP et al. (1988) Detection of occult infection following total joint arthroplasty using sequential technetium-99m HDP bone scintigraphy and indium-111 WBC imaging. J Nucl Med 29(8): 1347–1353

    PubMed  Google Scholar 

  25. Joseph TN, Mujtaba M, Chen AL et al. (2001) Efficacy of combined technetium-99m sulfur colloid/indium-111 leukocyte scans to detect infected total hip and knee arthroplasties. J Arthroplasty 16(6): 753–758

    Article  PubMed  Google Scholar 

  26. Kisielinski K, Cremerius U, Reinartz P, Niethard FU (2003) Fluordeoxyglucose positron emission tomography detection of inflammatory reactions due to polyethylene wear in total hip arthroplasty. J Arthroplasty 18(4): 528–532

    Article  PubMed  Google Scholar 

  27. Klett R, Kordelle J, Stahl U et al. (2003) Immunoscintigraphy of septic loosening of knee endoprosthesis: a retrospective evaluation of the antigranulocyte antibody BW 250/183. Eur J Nucl Med Mol Imaging 30(11): 1463–1466

    Article  PubMed  Google Scholar 

  28. Kordelle J, Hossain H, Stahl U et al. (2004) Wert der 16 s rDNA Polymerase-Ketten-Reaktion (PCR) zur intraoperativen Infektdetektion bei Endoprothesenrevisionseingriffen. Z Orthop Ihre Grenzgeb 142(5): 571–576

    Article  PubMed  Google Scholar 

  29. Kordelle J, Klett R, Stahl U et al. (2004) Infektdiagnostik nach Knie-TEP-Implantation. Z Orthop Ihre Grenzgeb 142(3): 337–343

    Article  PubMed  Google Scholar 

  30. Larikka MJ, Ahonen AK, Junila JA et al. (2001) Improved method for detecting knee replacement infections based on extended combined 99mTc-white blood cell/bone imaging. Nucl Med Commun 22(10): 1145–1150

    Article  PubMed  Google Scholar 

  31. Levitsky KA, Hozack WJ, Balderston RA et al. (1991) Evaluation of the painful prosthetic joint. Relative value of bone scan, sedimentation rate, and joint aspiration. J Arthroplasty 6(3): 237–244

    PubMed  Google Scholar 

  32. Lonner JH, Desai P, Dicesare PE et al. (1996) The reliability of analysis of intraoperative frozen sections for identifying active infection during revision hip or knee arthroplasty. J Bone Joint Surg Am 78(10): 1553–1558

    PubMed  Google Scholar 

  33. Love C, Pugliese PV, Afriyie MO et al. (2000) Utility of F-18 FDG Imaging for diagnosing the infected joint replacement. Clin Positron Imag 3(4): 159

    Article  Google Scholar 

  34. Magnuson JE, Brown ML, Hauser MF et al. (1988) In-111-labeled leukocyte scintigraphy in suspected orthopedic prosthesis infection: comparison with other imaging modalities. Radiology 168(1): 235–239

    PubMed  Google Scholar 

  35. Mariani BD, Martin DS, Levine MJ et al. (1996) The Coventry Award. Polymerase chain reaction detection of bacterial infection in total knee arthroplasty. Clin Orthop Relat Res 331: 11–22

    Article  PubMed  Google Scholar 

  36. Martinot M, Sordet C, Soubrier M et al. (2005) Diagnostic value of serum and synovial procalcitonin in acute arthritis: a prospective study of 42 patients. Clin Exp Rheumatol 23(3): 303–310

    PubMed  Google Scholar 

  37. Mason JB, Fehring TK, Odum SM et al. (2003) The value of white blood cell counts before revision total knee arthroplasty. J Arthroplasty 18(8): 1038–1043

    Article  PubMed  Google Scholar 

  38. Merkel KD, Brown ML, Dewanjee MK, Fitzgerald RH Jr (1985) Comparison of indium-labeled-leukocyte imaging with sequential technetium-gallium scanning in the diagnosis of low-grade musculoskeletal sepsis. A prospective study. J Bone Joint Surg Am 67(3): 465–476

    PubMed  Google Scholar 

  39. Mirra JM, Amstutz HC, Matos M, Gold R (1976) The pathology of the joint tissues and its clinical relevance in prosthesis failure. Clin Orthop Relat Res 117: 221–240

    PubMed  Google Scholar 

  40. Mirra JM, Marder RA, Amstutz HC (1982) The pathology of failed total joint arthroplasty. Clin Orthop Relat Res 170: 175–183

    PubMed  Google Scholar 

  41. Morrey BF, Westholm F, Schoifet S et al. (1989) Long-term results of various treatment options for infected total knee arthroplasty. Clin Orthop Relat Res 248: 120–128

    PubMed  Google Scholar 

  42. Niskanen RO, Korkala O, Pammo H (1996) Serum C-reactive protein levels after total hip and knee arthroplasty. J Bone Joint Surg Br 78(3): 431–433

    PubMed  Google Scholar 

  43. Pace TB, Jeray KJ, Latham JT Jr (1997) Synovial tissue examination by frozen section as an indicator of infection in hip and knee arthroplasty in community hospitals. J Arthroplasty 12(1): 64–69

    Article  PubMed  Google Scholar 

  44. Palestro CJ, Swyer AJ, Kim CK, Goldsmith SJ (1991) Infected knee prosthesis: diagnosis with In-111 leukocyte, Tc-99m sulfur colloid, and Tc-99m MDP imaging. Radiology 179(3): 645–648

    PubMed  Google Scholar 

  45. Panousis K, Grigoris P, Butcher I et al. (2005) Poor predictive value of broad-range PCR for the detection of arthroplasty infection in 92 cases. Acta Orthop 76(3): 341–346

    PubMed  Google Scholar 

  46. Peersman G, Laskin R, Davis J, Peterson M (2001) Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res 392: 15–23

    Article  PubMed  Google Scholar 

  47. Pelosi E, Baiocco C, Pennone M et al. (2004) 99mTc-HMPAO-leukocyte scintigraphy in patients with symptomatic total hip or knee arthroplasty: improved diagnostic accuracy by means of semiquantitative evaluation. J Nucl Med 45(3): 438–444

    PubMed  Google Scholar 

  48. Pring DJ, Henderson RG, Keshavarzian A et al. (1986) Indium-granulocyte scanning in the painful prosthetic joint. AJR Am J Roentgenol 147(1): 167–172

    PubMed  Google Scholar 

  49. Rand JA, Brown ML (1990) The value of indium 111 leukocyte scanning in the evaluation of painful or infected total knee arthroplasties. Clin Orthop Relat Res 259: 179–182

    PubMed  Google Scholar 

  50. Reing CM, Richin PF, Kenmore PI (1979) Differential bone-scanning in the evaluation of a painful total joint replacement. J Bone Joint Surg Am 61(6): 933–936

    PubMed  Google Scholar 

  51. Scher DM, Pak K, Lonner JH et al. (2000) The predictive value of indium-111 leukocyte scans in the diagnosis of infected total hip, knee, or resection arthroplasties. J Arthroplasty 15(3): 295–300

    Article  PubMed  Google Scholar 

  52. Steinbrink K, Frommelt L (1995) Behandlung der periprothetischen Infektion der Hüfte durch einzeitige Austauschoperation. Orthopäde 24: 335–343

    Google Scholar 

  53. Teller RE, Christie MJ, Martin W et al. (2000) Sequential indium-labeled leukocyte and bone scans to diagnose prosthetic joint infection. Clin Orthop Relat Res 373: 241–247

    Article  PubMed  Google Scholar 

  54. Trampuz A, Hanssen AD, Osmon DR, et al. (2004) Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med 117(8): 556–562

    Article  PubMed  Google Scholar 

  55. 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(4): 512–523

    PubMed  Google Scholar 

  56. Tunney MM, Patrick S, Gorman SP, Nixon JR et al. (1998) Improved detection of infection in hip replacements. A currently underestimated problem. J Bone Joint Surg Br 80(4): 568–572

    Article  PubMed  Google Scholar 

  57. Van Acker F, Nuyts J, Maes A et al. (2001) FDG-PET, 99mtc-HMPAO white blood cell SPET and bone scintigraphy in the evaluation of painful total knee arthroplasties. Eur J Nucl Med 28(10): 1496–1504

    Article  PubMed  Google Scholar 

  58. Virolainen P, Lahteenmaki H, Hiltunen A et al. (2002) The reliability of diagnosis of infection during revision arthroplasties. Scand J Surg 91(2): 178–181

    PubMed  Google Scholar 

  59. von Rothenburg T, Schoellhammer M, Schaffstein J et al. (2004) Imaging of infected total arthroplasty with Tc-99m-labeled antigranulocyte antibody Fab’fragments. Clin Nucl Med 29(9): 548–551

    PubMed  Google Scholar 

  60. Wukich DK, Abreu SH, Callaghan JJ et al. (1987) Diagnosis of infection by preoperative scintigraphy with indium-labeled white blood cells. J Bone Joint Surg Am 69(9): 1353–1360

    PubMed  Google Scholar 

  61. Zhuang H, Duarte PS, Pourdehnad M et al. (2001) The promising role of 18F-FDG PET in detecting infected lower limb prosthesis implants. J Nucl Med: 4244–4248

    Google Scholar 

Download references

Interessenkonflikt

Es besteht kein Interessenkonflikt. Der korrespondierende Autor versichert, dass keine Verbindungen mit einer Firma, deren Produkt in dem Artikel genannt ist, oder einer Firma, die ein Konkurrenzprodukt vertreibt, bestehen. Die Präsentation des Themas ist unabhängig und die Darstellung der Inhalte produktneutral.

Author information

Authors and Affiliations

  1. Abteilung für Unfall- und Wiederherstellungschirurgie, Berufsgenossenschaftliche Unfallklinik, Prof.-Küntscher-Straße 8, 82418, Murnau/Staffelsee

    H. Gollwitzer

  2. Klinik für Orthopädie und Sportorthopädie, Technische Universität München

    P. Diehl

  3. Department Endoprothetik und Wirbelsäulenchirurgie, Klinik für Orthopädie und Unfallchirurgie, Mare-Klinikum, Kiel-Kronshagen

    L. Gerdesmeyer

  4. Orthopädische Klinik und Poliklinik, Universität Rostock

    W. Mittelmeier

Authors
  1. H. Gollwitzer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. P. Diehl
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. L. Gerdesmeyer
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. W. Mittelmeier
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to H. Gollwitzer.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Gollwitzer, H., Diehl, P., Gerdesmeyer, L. et al. Diagnostische Strategien bei Verdacht auf periprothetische Infektion einer Kniegelenktotalendoprothese. Orthopäde 35, 904–916 (2006). https://doi.org/10.1007/s00132-006-0977-z

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00132-006-0977-z

Schlüsselwörter

Keywords

Search

Navigation