Skip to main content
SpringerLink
Log in

Periprothetischer Infekt des Hüftgelenks

Klinisches Vorgehen

Periprosthetic infections of the hip joint

Clinical approach

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

Zusammenfassung

Hintergrund

Die Behandlung von periprothetischen Infektionen (PPI) stellt die behandelnden Ärzte und unser Gesundheitssystem in den nächsten Jahren vor große Herausforderungen. Neue und moderne Behandlungskonzepte erlauben es, an spezialisierten Zentren eine differenzierte Therapie anzubieten.

Ziel der Arbeit

Die vorliegende Arbeit gibt eine detaillierte Übersicht über die Behandlung PPI im Bereich der Hüfte mit Schwerpunkt auf diagnostischem Vorgehen und Therapieentscheidung.

Methode

Vorgenommen wurde eine selektive Literaturrecherche zu modernen Behandlungskonzepten bei PPI von Hüftgelenktotalendoprothesen mit den Schwerpunkten klinische Diagnostik und operative sowie antimikrobielle Biofilmbehandlung. Des Weiteren wurden eigene Erfahrungen aus einem spezialisierten Zentrum für septische Orthopädie berücksichtigt.

Ergebnisse

Man unterscheidet periprothetische Hüftinfekte mit unreifem und reifem Biofilm. Abhängig hiervon stehen verschiedene Behandlungskonzepte zur Verfügung. Vor jeder Wechseloperation steht der Keimnachweis im Vordergrund. Die präoperative Gelenkpunktion zur mikrobiologischen, zytologischen und pathologischen Untersuchung stellt den Standard dar. In Einzelfällen kann für die genannte Diagnostik eine arthroskopische Biopsiegewinnung sinnvoll sein. Abhängig von der Ausprägung des Biofilms und des Resistenzspektrums des Erregers sind das prothesenerhaltende Vorgehen oder der Prothesenwechsel mit unterschiedlichen Intervallen mögliche Therapiekonzepte. Größtmöglicher Erfolg wird nur im Zusammenspiel von chirurgischem Vorgehen und Einsatz biofilmaktiver antimikrobieller Substanzen erzielt.

Diskussion

Die Behandlung von Hüftendoprotheseninfekten stellt eine große Herausforderung für den behandelnden Orthopäden und das interdisziplinäre Team einer septischen Abteilung dar. Diese Herausforderungen sind durch eine standardisierte, evidenzbasierte Vorgehensweise unter Berücksichtigung individueller patientenbezogener Einflussfaktoren zu meistern.

Abstract

Background

Increasing rates of periprosthetic joint infections (PJI) will present orthopedic surgeons and the health care system with challenges in the next few years. New concepts in diagnostic and surgical pathways allow specialized centers to offer differentiated therapy of PJI.

Aim

This article presents an overview of recent treatment concepts for PJI of the hip emphasizing diagnosis and the clinical approach.

Method

A selective literature search was performed focusing on evidence-based concepts including diagnostics, surgical treatment, and biofilm active antibiotics.

Results

PJI of the hip are classified as mature biofilm or immature biofilm infections. The most important step in the diagnostic procedure is to identify the pathogen and its antimicrobial susceptibility. Preoperative joint aspiration and leukocyte count, differentiation, and microbiological culture should be standard. Arthroscopic biopsy may be necessary to identify the pathogen. Depending on the biofilm maturity and the antimicrobial susceptibility, implant retention or two-stage revisions should be performed. Combination of surgical therapy and biofilm-active antibiotics are of utmost importance for successful treatment.

Discussion

PJI represents a significant challenge for the orthopedic surgeon. Evidence-based and standardized clinical pathways are necessary for accurate and rapid diagnosis as well as patient-specific treatment concepts.

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

Literatur

  1. Kurtz S (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89(4):780–785. doi:10.2106/JBJS.F.00222

    Article  PubMed  Google Scholar 

  2. Urquhart DM, Hanna FS, Brennan SL, et al (2010) Incidence and risk factors for deep surgical site infection after primary total hip arthroplasty: a systematic review. J Arthroplasty 25(8):1216–22.e1–3. doi:10.1016/j.arth.2009.08.011

    Article  PubMed  Google Scholar 

  3. Perka C, Haas N (2011) Periprosthetic infection. Chirurg 82(3):218–226. doi:10.1007/s00104-010-2014-3

    Article  CAS  PubMed  Google Scholar 

  4. Ong KL, Kurtz SM, Lau E, Bozic KJ, Berry DJ, Parvizi J (2009) Prosthetic joint infection risk after total hip arthroplasty in the medicare population. J Arthroplasty. 24(6 Suppl):105–109. doi:10.1016/j.arth.2009.04.027

    Article  PubMed  Google Scholar 

  5. Gollwitzer H, Dombrowski Y, Prodinger PM, et al (2013) Antimicrobial peptides and proinflammatory cytokines in periprosthetic joint infection. J Bone Joint Surg Am 95(7):644–651. doi:10.2106/JBJS.L.00205

    Article  PubMed  Google Scholar 

  6. Trampuz A, Piper KE, Hanssen AD, et al (2006) Sonication of explanted prosthetic components in bags for diagnosis of prosthetic joint infection is associated with risk of contamination. J Clin Microbiol 44(2):628–631. doi:10.1128/JCM.44.2.628-631.2006

    Article  PubMed Central  PubMed  Google Scholar 

  7. Lehil MS, Bozic KJ (2014) Trends in total hip arthroplasty implant utilization in the United States. J Arthroplasty 29(10):1915–1918. doi:10.1016/j.arth.2014.05.017

    Article  PubMed  Google Scholar 

  8. Vanhegan IS, Malik AK, Jayakumar P, Ul Islam S, Haddad FS (2012) A financial analysis of revision hip arthroplasty: the economic burden in relation to the national tariff. J Bone Joint Surg Br 94(5):619–623. doi:10.1302/0301-620X.94B5.27073

    Article  CAS  PubMed  Google Scholar 

  9. Lora-Tamayo J, Murillo O, Iribarren JA, et al (2012) A large multicenter study of methicillin-susceptible and methicillin-resistant staphylococcus aureus prosthetic joint infections managed with implant retention. Clin Infect Dis 56(2):182–194. doi:10.1093/cid/cis746

    Article  PubMed  Google Scholar 

  10. Zimmerli W, Trampuz A, Ochsner PE (2004) Prosthetic-joint infections. N Engl J Med 351(16):1645–1654

    Article  CAS  PubMed  Google Scholar 

  11. Cobo J, Miguel LGS, Euba G, et al (2010) Early prosthetic joint infection: outcomes with debridement and implant retention followed by antibiotic therapy. Clin Microbiol Infect 17(11):1632–1637. doi:10.1111/j.1469-0691.2010.03333.x

    Article  PubMed  Google Scholar 

  12. Gardner J, Gioe TJ, Tatman P (2010) Can this prosthesis be saved?: implant salvage attempts in infected primary TKA. Clin Orthop Relat Res 469(4):970–976. doi:10.1007/s11999-010-1417-2

    Article  PubMed Central  Google Scholar 

  13. Darouiche RO (2001) Device-associated infections: a macroproblem that starts with microadherence. Clin Infect Dis 33(9):1567–1572. doi:10.1086/323130

    Article  CAS  PubMed  Google Scholar 

  14. Trampuz A, Perka C, Borens O (2013) Gelenkprotheseninfektion: Neue Entwicklungen in der Diagnostik und Therapie. Dtsch med Wochenschr 138(31/32):1571–1573. doi:10.1055/s-0033-1343280

    Article  CAS  PubMed  Google Scholar 

  15. Breitenseher MJ, Mayerhöfer M, Gottsauner-Wolf F, Krestan C, Toma CD, Imhof H (2002) Bildgebung bei Hüftprothesen. Der Radiologe 42(6):474–479. doi:10.1007/s00117-002-0754-x

    Article  CAS  PubMed  Google Scholar 

  16. Moran E, Byren I, Atkins BL (2010) The diagnosis and management of prosthetic joint infections. J Antimicrob Chemother 65(Supplement 3):iii45–iii54. doi:10.1093/jac/dkq305

    Article  CAS  PubMed  Google Scholar 

  17. AAOS (2010) The diagnosis of periprosthetic joint infections of the hip and knee: guideline and evidence report. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, June 18. AAOS, Rosemont, S 1–294

  18. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG (2008) Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am 90(9):1869–1875. doi:10.2106/JBJS.G.01255

    Article  PubMed  Google Scholar 

  19. 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 

  20. Saleh KJ, Clark CR, Sharkey PF, Goldberg VM, R and JA, Brown GA (2003) Modes of failure and preoperative evaluation. J Bone Joint Surg Am 85-A(Suppl 1):S21–25

    PubMed  Google Scholar 

  21. Schäfer P, Fink B, Sandow D, Margull A, Berger I, Frommelt L (2008) Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis 47(11):1403–1409. doi:10.1086/592973

    Article  PubMed  Google Scholar 

  22. Fink B, Schäfer P, Frommelt L (2012) Logistic requirements and biopsy of periprosthetic infections. Orthopäde 41(1):15–19. doi:10.1007/s00132-011-1836-0

    Article  CAS  PubMed  Google Scholar 

  23. Krenn V, Morawietz L, Kienapfel H, et al (2013) Revised consensus classification. Z Rheumatol 72(4):383–392. doi:10.1007/s00393-012-1099-0

    Article  CAS  PubMed  Google Scholar 

  24. Trampuz A, Piper KE, Jacobson MJ, et al (2007) Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med 357(7):654–663. doi:10.1056/NEJMoa061588

    Article  CAS  PubMed  Google Scholar 

  25. Workgroup Convened by the Musculoskeletal Infection Society (2011) New definition for periprosthetic joint infection. J Arthroplasty 26(8):1136–1138. doi:10.1016/j.arth.2011.09.026

    Article  Google Scholar 

  26. Rao N, Crossett LS, Sinha RK, Le Frock JL (2003) Long-term suppression of infection in total joint arthroplasty. Clin Relat Res 414:55–60. doi:10.1097/01.blo.0000087321.60612.cf

    Article  Google Scholar 

  27. Parvizi J, Adeli B, Zmistowski B, Restrepo C, Greenwald AS (2012) Management of periprosthetic joint infection: The current knowledge. J Bone Joint Surg Am 94(14):e104. doi:10.2106/JBJS.K.01417

    Article  PubMed  Google Scholar 

  28. Senthi S, Munro JT, Pitto RP (2011) Infection in total hip replacement: meta-analysis. Int Orthop 35(2):253–260. doi:10.1007/s00264-010-1144-z

    Article  PubMed Central  PubMed  Google Scholar 

  29. Koo KH, Yang JW, Cho SH, et al (2001) Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty. J Arthroplasty 16(7):882–892. doi:10.1054/arth.2001.24444

    Article  CAS  PubMed  Google Scholar 

  30. Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hanseen A, Wilson WR, Infectious Diseases Society of America (2013) Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 56(1):e1–e25. doi:10.1093/cid/cis803

    Article  PubMed  Google Scholar 

  31. 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

    CAS  PubMed  Google Scholar 

  32. Aboltins CA, Page MA, Buising KL, et al (2007) Treatment of staphylococcal prosthetic joint infections with debridement, prosthesis retention and oral rifampicin and fusidic acid. Clin Microbiol Infect 13(6):586–591. doi:10.1111/j.1469-0691.2007.01691.x

    Article  CAS  PubMed  Google Scholar 

  33. Soriano A, Garcia S, Bori G, et al (2006) Treatment of acute post-surgical infection of joint arthroplasty. Clin Microbiol Infect 12(9):930–933. doi:10.1111/j.1469-0691.2006.01463.x

  34. Oliva A, Furustrand Tafin U, Maiolo EM, Jeddari S, Betrisey B, Trampuz A (2014) Activities of fosfomycin and rifampin on planktonic and adherent Enterococcus faecalis strains in an experimental foreign-body infection model. Antimicrob Agents Chemother 58(3):1284–1293. doi:10.1128/AAC.02583-12

    Article  PubMed Central  PubMed  Google Scholar 

  35. Mihailescu R, Furustrand Tafin U, Corvec S, et al (2014) High activity of fosfomycin and rifampin against methicillin-resistant Staphylococcus aureus (MRSA) biofilm in vitro and in experimental foreign-body infection model. Antimicrob Agents Chemother doi:10.1128/AAC.02420-12

  36. Falagas ME, Giannopoulou KP, Ntziora F, Papagelopoulos PJ (2007) Daptomycin for treatment of patients with bone and joint infections: a systematic review of the clinical evidence. Int J Antimicrob Agents 30(3):202–209. doi:10.1016/j.ijantimicag.2007.02.012

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland

    H. M. L. Mühlhofer,  H. Gollwitzer,  F. Lenze,  F. Pohlig,  R. von Eisenhart-Rothe &  J. Schauwecker

  2. Institut für Medizinische Mikrobiologie, Immunologie und Hygiene, Klinikum rechts der Isar, Technische Universität München, Trogerstraße 30, 81675, München, Deutschland

    S. Feihl

  3. ATOS Klinik München, Effnerstr. 32, 81925, München, Deutschland

    H. Gollwitzer

Authors
  1. H. M. L. Mühlhofer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. H. Gollwitzer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. F. Lenze
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. S. Feihl
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. F. Pohlig
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. R. von Eisenhart-Rothe
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. J. Schauwecker
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to H. M. L. Mühlhofer.

Ethics declarations

Interessenskonflikt

H.M.L. Mühlhofer, H. Gollwitzer, F. Lenze, S. Feihl, F. Pohlig, R. von Eisenhart-Rothe und J. Schauwecker geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag enthält keine Studien an Menschen oder Tieren.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mühlhofer, H., Gollwitzer, H., Lenze, F. et al. Periprothetischer Infekt des Hüftgelenks. Orthopäde 44, 357–365 (2015). https://doi.org/10.1007/s00132-015-3084-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00132-015-3084-1

Schlüsselwörter

Keywords

Search

Navigation