Ergebnisse der mikrobiologischen und histopathologischen Revisionsdiagnostik bei unklarem Endoprothesenversagen

Die Endoprothetik ist eine der erfolgreichsten operativen Behandlungs-methoden der modernen Medizin und bietet Patienten mit fortgeschrittener Arthrose eine etablierte Therapiemöglichkeit. In Deutschland gehört der künst-liche Gelenkersatz im Bereich des Hüft- und Kniegelenkes zu den häufigsten durc...

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Bibliographic Details
Main Author: Riemann, Johannes
Contributors: Kienapfel, Heino (Prof. Dr.) (Thesis advisor)
Format: Dissertation
Published: Philipps-Universität Marburg 2016
Online Access:PDF Full Text
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Table of Contents: Total joint replacement is one of the most successful operative procedures in modern medicine and offer patients with advanced osteoarthritis an established therapeutic option. Throughout Germany the joint replacement of hip and knee is counted among the most frequent operations. The high number of joint replacements and increasing life expectancy also lead to an increasing number of revision surgery and therefore also growing costs in health care. Patients with an unclear implant failure are a diagnostic challenge for the orthopedic surgeons because of different treatment options depending on the cause of failure. Treatment failure has serious consequences for the patient and often leads to subsequent operations and a long time of suffering. The retrospective single center study took place in the Auguste-Viktoria-Klinikum Berlin (AVK) in the period of 2010 to 2014 and includes 205 patients with an unclear endoprosthesis failure. In order to finally clear up the cause of failure we acquired laboratory, histopathological and microbiological findings by performing an open or percutaneous surgery. The objective of this study was to statistically evaluate our diagnostic findings and compare them to recent publications. Furthermore we wanted to evaluate the algorithm of diagnosis before performing revision surgery and if necessary change or reform our algorithm. Because of the large number of patients general considerations and advises about diagnostics of implant failure should be made. The 205 patients had an average age of 68.9 and the majority were female (61.0 %). We performed 308 operations mainly in the area of the knee (53.7 %) and hip (43.3 %), less in the area of the shoulder joint (2.9 %). The most frequent proven periprosthetic membrane in the histopathological examination was type I (25.7 %) and type II (22.4 %). The microbiological examination could only detect an infection by a specific pathogen in 19.5 percent of cases. The main germs were coagulase-negative staphylococci (46.0 %), followed by streptococci (13.0 %) and staphylococcus aureus (12.0 %). In our study there was a periprosthetic joint infection (PJI) in 29.2 % of the cases. The highest sensitivity (88.9 %) and specificity (99.5 %) accomplishes the histopathological examination for detecting PJI. Percutaneous surgery yielded the same histopathological results as open surgery and should always be considered before performing open revision surgery. The microbiological examination accomplishes a lower sensitivity (54.4 %) and an almost equal specificity (95.0 %). Altogether the results of the histopathological and microbiological examination were in line with the published scientific literature. There was a statistically significant connection between the appearance of a PJI and the clinical findings of microbiology and histopathology (p <0.001). It was conspicuous, however, that there was a relative high rate of false-negative results obtained by microbiology (45.6 %). By using a ROC-curve we could calculate the AUC for our laboratory parameters. The AUC for the serum C-reactive protein (CRP) was 0.79 and for the serum white blood cell (WBC) count 0.57. Our study confirms that serum WBC count has only a minor role for detecting PJI. Optimal threshold for CRP was 13 mg/l (sensitivity 64.0 %, specificity 83.0 %). This result affirms other studies that propose a slightly higher threshold than 5 or 10 mg/l. The high clinical value of the histopathological examination at clarification of unclear endoprosthesis failure could be confirmed in our study. Microbiological examination achieved worse results than proposed in other studies. However, there was a lack of certain important procedures in our diagnostic algorithm, such as joint aspiration, the use of special aspiration tools (for example pediatric blood culture vials) or sonication. We already enhanced our diagnostic algorithm and because of this future studies should show a better detection of pathogens. Medical clarification of unclear endoprosthesis failure remains a great diagnostic challenge and there is a need for standardized procedures and if possible interdisciplinary teamwork.