Periprothetische Gelenkinfektionen

Zusammenfassung

Periprothetische Infektionen stellen ein dauerhaftes Risiko für Endoprothesenträger dar und werden als schwerwiegende Komplikation nach Prothesenimplantation angesehen. Bei einer perioperativen Infektrate von ca. einem Prozent nach Primärimplantation und zunehmenden Fallzahlen ist die Inzidenz steigend. Die Diagnostik beruht neben der klinischen Symptomatik, die bei Patienten mit entzündlichen Synovialkrankheiten aufgrund immunsuppressiver Medikamente fehlen kann, auf der Serologie und der bildgebenden Diagnostik sowie vor allem auf der mikrobiologischen Punktatdiagnostik vor Beginn einer antibiotischen Therapie. Koagulasenegative Staphylokokken und Staphylococcus aureus sind in der überwiegenden Zahl für periprothetische Infektionen verantwortlich. Das Ziel der Behandlung periprothetischer Infektionen ist die vollständige bakterielle Eradikation mit Wiederherstellung einer schmerzfreien Gelenkfunktion. Dies kann nur durch eine konsequente operative Therapie mit antibiotischer Medikation gelingen. Inwieweit ein implantaterhaltender Eingriff mit Débridement, Spülung und Austausch der Polyethylenteile möglich oder ob ein kompletter ein- bzw. zweizeitiger Prothesenwechsel erforderlich ist, wird vom zeitlichen Auftreten der Infektion nach der Operation und dem Bakterientyp abhängig gemacht.

Summary

Periprosthetic joint infections remain a permanent risk factor and a severe complication after total joint arthroplasty. Although the incidence of one percent appears to be small, the total amount of joint revision arthroplasty is on the rise. The preoperative workup includes the clinical symptoms which can be absent in patients with rheumatoid arthritis or immunocompromised patients, as well as serology, imaging methods and especially joint aspiration before initial antibiotic drug therapy. The organisms most commonly isolated in cases of deep periprosthetic joint infection are predominantly coagulase-negative staphylococcus and staphylococcus aureus. The success in the treatment of periprosthetic joint infections with regaining a normal function depends on an extensive surgical debridement and effective antibiotic therapy. However, the art of surgical therapy including operative debridement and retention of the infected prosthesis, one- or two stage revision surgery as well as resection arthroplasty, depends on the time course and the medical condition of the patient.

Schlüsselwörter

Infektion - Endoprothese - Antibiotikum - periprothetische Infektion

Keywords

Infection - joint arthroplasty - antibiotics - periprosthetic joint infection

• Literatur

• 1 Kurtz SM, Ong KL, Lau E. et al. Prosthetic joint infection risk after total hip arthroplasty in the Medicare population. J Arthroplasty 2010; 24: 105-110.
• 2 Ong KL, Kurtz SM, Lau E. et al. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res 2009; 468: 52-56.
• 3 Poss R, Thornhill TS, Ewald FC. et al. Factors influencing the incidence and outcome of infection following total joint arthroplasty. Clin Orthop Relat Res 1984; 182: 117-126.
• 4 Schmalzried TP, Amstutz HC, Au MK, Dorey FJ. Etiology of deep sepsis in total hip arthroplasty. The significance of hematogenous and recurrent infections. Clin Orthop Relat Res 1992; 280: 200-207.
• 5 Frommelt L. Prinzipien der Antibiotikabehandlung bei periprothetischen Infektionen. Orthopäde 2004; 33: 822-826.
• 6 Galloway JB, Hyrich KL, Mercer LK. et al. Risk of septic arthritis in patients with rheumatoid arthritis and the effect of anti-TNF therapy: results from the British Society for Rheumatology Biologics Register. Ann Rheum Dis 2011; 70 (10) 1810-1814.
• 7 Barrack RL, Jennings RW, Wolfe MW. et al. The Coventry Award. The value of preoperative aspiration before total knee revision. Clin Orthop Relat Res 1997; 345: 8-16.
• 8 Morrison TA, Figgie M, Miller AO, Goodman SM. Periprosthetic joint infection in patients with inflammatory joint disease: a review of risk factors and current approaches to diagnosis and management. HSS J 2013; 9 (02) 183-194.
• 9 Lohmann CH, Fürst M, Niggemeyer O, Rüther W. The treatment of periprostetic infections. Z Rheumatol 2007; 66 (01) 28-33.
• 10 Chapman MW. Chapman’s operative orthopaedics. 3. Aufl.. Philadelphia: Lippincott; 2001: 1800
• 11 Pons M, Angles F, Sanchez C. et al. Infected total hip arthroplasty - the value of intraoperative histology. Int Orthop 1999; 23: 34-36.
• 12 Fuerst M, Fink B, Rüther W. The value of preoperative knee aspiration and arthroscopic biopsy in revision total knee arthroplasty. Z Orthop Ihre Grenzgeb 2005; 143 (01) 36-41.
• 13 Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty: a study of treatment of one hundred and six infections. J Bone Joint Surg Am 1996; 78: 512-523.
• 14 Toms AD, Davidson D, Masri BA, Duncan CP. The management of peri-prosthetic infection in total joint arthroplasty. J Bone Joint Surg Br 2006; 88: 149-152.
• 15 Fitzgerald Jr RH, Norlan DR, Ilstrup DM. et al. Deep wound sepsis following total hip arthroplasty. J Bone Joint Surg Am 1996; 78: 847-855.
• 16 Zimmerli W, Moser C. Pathogenesis and treatment concepts of orthopaedic biofilm infections. FEMS Immunol Med Microbiol 2012; 65 (02) 158-168.
• 17 Frommelt L. Principles of systemic antimicrobial therapy in foreign material associated infection in bone tissue, with special focus on periprosthetic infection. Injury 2006; 37 (Suppl. 02) S87-S94.
• 18 Riegels-Nielsen P, Frimodt-Moller N, Sorensen M, Jensen JS. Antibiotic treatment insufficient for established septic arthritis. Staphylococcus aureus experiments in rabbits. Acta Orthop Scand 1989; 60 (01) 113-115.
• 19 Zimmerli W, Tramputz A, Ochsner PE. Prosthetic joint infection. New Engl J Med 2004; 351: 1645-1654.
• 20 Trampuz A, Zimmerli W. Prosthetic joint infections: update in diagnosis and treatment. Swiss Med Wkly 2005; 135: 243-251.
• 21 Langlais F, Lambotte JC, Thomazeau H. Treatment of infected hip replacement. In: Lemaire R, Herom F, Scott J. eds. European Instructional Course Lecture. vol 6. London: The British Society of Bone and Joint Surgery; 2003: 158-167
• 22 Haddad FS, Muirhead-Allwood SK, Manktelow AR, Bacarese-Hamilton I. Two-stage uncemen- ted revision hip arthroplasty for infection. J Bone Joint Surg Br 2000; 82: 689-694.
• 23 Zimmerli W, Widmer AF, Blatter M. et al. Role of rifampicin for treatment of orthopedic implant- related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA 1998; 279: 1537-1541.
• 24 Saag K, Teng G, Patkar N. et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008; 59: 762-784.