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Periprothetische Infektion nach Hüftendoprothetik

Periprosthetic infection after hip arthroplasty

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Zusammenfassung

Hintergrund

Die periprothetische Infektion (PPI) ist sowohl bzgl. Diagnostik als auch Behandlung eine der komplexesten Komplikationen in der Endoprothetik. Die Inzidenz der PPI des Hüftgelenks liegt bei ca. 1 % bei primären Eingriffen und ca. 4 % bei Revisionseingriffen. Etwa zwei Drittel der PPI werden durch intraoperative Besiedlung verursacht, die restlichen Prothesen infizieren sich während einer hämatogenen Streuung.

Ziel der Arbeit

Es wird ein Überblick über die aktuelle evidenzbasierte Diagnostik und Behandlung der PPI des Hüftgelenks gegeben mit Etablierung eines klaren Algorithmus.

Methode

Es wurde eine selektive Literaturrecherche unter Einbeziehung eigener Arbeiten vorgenommen.

Ergebnisse

Bei schmerzhaften Prothesen oder Lockerungszeichen innerhalb der ersten Jahre nach Implantation muss aktiv eine PPI ausgeschlossen werden. Das C-reaktive Protein (CRP) kann insbesondere bei chronischen („low-grade“) PPI normal sein und darf deshalb nicht als Ausschlusskriterium gewertet werden. Die Standarddiagnostik umfasst eine präoperative Gelenkpunktion mit Kultur und Bestimmung der Leukozytenzahl sowie eine Kultur und histologische Untersuchung von periprothetischem Gewebe. Bildgebende Verfahren, wie die MRT oder die Szintigraphie, haben in der Diagnostik der PPI einen untergeordneten Stellenwert. Neue Methoden, wie die Sonikation von entfernten Implantaten, haben die Diagnostik revolutioniert; viele Fälle, welche bisher als aseptische Lockerungen interpretiert wurden, sind als PPI identifiziert.

Wesentliche Parameter für den Therapiealgorithmus sind die Reife des Biofilms, die Stabilität der Prothese, die Art des Erregers und der Zustand der Weichteile. Ein Prothesenerhalt kann nur bei unreifem Biofilm (akuten PPI) angestrebt werden. Bei chronischen („low-grade“) PPI ist die Sanierung der Infektion nur durch einen Wechsel der Prothese möglich. Hierbei werden die Patienten entweder einem ein- oder zweizeitigen Vorgehen mit kurzem (2 bis 4 Wochen) oder langem Intervall (> 6 Wochen) zugeordnet. Biofilmaktive Antibiotika spielen eine entscheidende Rolle für die Therapie und müssen gezielt eingesetzt werden.

Diskussion

Die erfolgreiche Diagnostik und Behandlung der PPI setzen die konsequente Durchführung eines klaren Algorithmus voraus. Die interdisziplinäre Zusammenarbeit mit der Infektiologie und Mikrobiologie stellt hierbei ein entscheidendes Kriterium dar.

Abstract

Background

Periprosthetic infections (PPI) represent one of the most complex complications in arthroplasty concerning both, diagnosis and therapy. The incidence of PPI of the hip is approximately 1 % after primary procedures and 4 % after revision surgery. About two thirds of PPIs occur via intraoperative contamination and the remaining PPIs are acquired by hematogenous seeding.

Aim

This article presents an overview of up to date evidence-based diagnostics and therapy of PPI of the hip with the establishment of a clear algorithm.

Methods

A selective literature search was carried out with the inclusion of own work.

Results

A PPI must be actively excluded in cases of a painful prosthesis or signs of loosening within the first years after implantation. Measurement of C-reactive protein (CRP) can be normal especially in cases of chronic (low grade) PPI and cannot be used as an exclusion criterion. The standard diagnostic procedure includes preoperative joint aspiration with culture and leukocyte counts as well as culture and histology of periprosthetic tissue. Imaging techniques, such as magnetic resonance imaging (MRI) and scintigraphy are of inferior significance. Newer methods, such as sonication of removed implants have revolutionized the diagnostics and several cases which had previously been considered aseptic loosening failures have now been reclassified as PPI.

Essential parameters for the treatment algorithm are maturity of the biofilm, stability of the prosthesis, the causative organism and the state of the soft tissue. Retention of the prosthesis can only be considered when the biofilm is still immature (acute PPI). In chronic (low grade) PPI eradication of the infection can only be achieved by exchanging the prosthesis. This has to be performed either as a one-stage procedure or as a two-stage exchange with a short (2–4 weeks) or a long (> 6 weeks) interval. Biofilm active antibiotics play an essential role in the treatment of PPI and have to be used as targeted therapy.

Discussion

Successful therapy and diagnostics of PPI require following an exact algorithm. The interdisciplinary cooperation between specialists for infectious diseases and microbiologists represents a decisive factor.

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Notes

  1. Ausnahme: Pseudopus bei Metall/Metall-Gleitpaarungen.

  2. Für einen positiven Befund muss hierbei ein niedrigvirulenter Keim (z. B. Staphylococcus epidermidis, Propionibacterium acnes) in mindestens zwei Proben detektiert werden. Im Falle eines hochvirulenten Erregers (z. B. Staphylococcus aureus) reicht die Detektion in einer Probe.

  3. Ausnahme: Vorhandensein von Erkrankungen aus dem rheumatologischen Formenkreis (z. B. Kristallopathie, Psoriasis, rheumatoide Arthritis).

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Einhaltung ethischer Richtlinien

Interessenkonflikt. T. Winkler, A. Trampuz, S. Hardt, V. Janz, C. Kleber, C. Perka geben an, dass kein Interessenkonflikt besteht. Alle Patienten wurden erst nach erfolgter Aufklärung und Einwilligung in die Studie eingeschlossen. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Abteilung für Septische Chirurgie und Protheseninfektion, Klinik für Orthopädie, Centrum für Muskuloskeletale Chirurgie, Charité-Universitätsmedizin Berlin, Augustenburgerplatz 1, 13353, Berlin, Deutschland

    T. Winkler, A. Trampuz, S. Hardt, V. Janz, C. Kleber & C. Perka

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  1. T. Winkler
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  2. A. Trampuz
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  3. S. Hardt
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  4. V. Janz
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  5. C. Kleber
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  6. C. Perka
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Correspondence to T. Winkler.

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Winkler, T., Trampuz, A., Hardt, S. et al. Periprothetische Infektion nach Hüftendoprothetik. Orthopäde 43, 70–78 (2014). https://doi.org/10.1007/s00132-013-2132-y

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