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Infektionsmanagement bei Megaimplantaten

Infection management of megaimplants

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Zusammenfassung

Nicht nur bei posttraumatischen Zuständen oder primären wie sekundären Knochentumoren steigen Bedarf und Implantationszahlen von Megaprothesen, vielmehr verlangen die immer größeren Defekte in der Revisionsendoprothetik den immer häufigeren Einsatz von Megaimplantaten. Grunderkrankung, Medikation, Alter und Eingriffe begünstigen das Infektionsrisiko, welches bei Megaprothesen in der Größenordnung von >10% anzusetzen ist. Nicht zuletzt tragen auch Größe, Oberfläche und Design der Implantate zur Infektgefährdung bei.

Jährlich behandeln wir >45 Patienten mit periprothetischen Infektionen von Mega- und großen Wechselimplantaten, leider sind multiresistente Keime auf dem Vormarsch – MRSA eher MRSE stellen dabei eine besondere Rezidivgefahr (19%) dar. Die Wechselstrategie bleibt vorzugsweise zwei- oder mehrstufig; die zwischenzeitliche Stabilisierung kann extern mit Fixateuren oder Orthesen bzw. intern mit Spacern (PMMA, Interimprothesen) erfolgen. Eine Prophylaxe des Infektrezidivs besteht in antiinfektiösen Oberflächenbeschichtungen (Silber), lokalen Antibiotikaträgern (Kollagen, PMMA) und v. a. in einer konsequenten Weichteildeckung (lokale Muskellappen) und in der radikalen Behandlung der Osteitis. Amputationen sind nicht sicher zu vermeiden, im Kniebereich liegt unsere Amputationsrate nach Infektionen von Megaimplantaten bei 5%.

Eingriffe bei Infektionen nach Megaendoprothesen werden zunehmen. Medizinische, pflegerische, logistische, technologische und finanzielle Belastungen für Patienten, Operateure, Kliniken und Versicherungen werden steigen!

Abstract

More and more megaprostheses are being implanted – not just injuries or primary and secondary bone tumors, but also the increase in extended bone defects in revision arthroplasty call for the more frequent use of megaimplants. Underlying disease, medication, age, and frequency of surgical procedures give rise to infections which occur in more than 10% of the patients receiving megaprostheses. Size, surface, and design of the implants themselves increase the infection rate.

Every year we treat more than 45 patients with periprosthetic infections of megaimplants and large revision prostheses, many of them infected with multi-resistant germs. MRSE and MRSA have been shown to increase the rate of relapses (19%). The treatment strategy continues to consist of multiple steps, and temporary stabilization is achieved either externally with external fixation devices or orthoses or internally with spacers (PMMA, interim implants). To avoid relapsing infections surgeons must rely on anti-infective surface coatings (silver), local drug carriers (collagen, PMMA), and especially soft tissue coverage with local muscle flaps and radical treatment of the bone infection. Amputations, however, cannot be avoided completely; 5% of our patients had to undergo amputations above the knee after infections of megaimplants.

Surgery will be required more frequently to treat infections of megaprostheses and increase the medical, nursing, logistic, technological, and financial burden on the patients, surgeons, clinics, and insurance companies.

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  1. Zentrum für Spezial- und Wechselendoprothetik, chirurgische Infektiologie, Überregionales Zentrum für Wechselendoprothetik Chemnitz-Leipzig-München-Rummelsberg, Zeisigwaldkliniken Bethanien, Zeisigwaldstraße 101, 09130, Chemnitz, Deutschland

    R. Ascherl

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Ascherl, R. Infektionsmanagement bei Megaimplantaten. Orthopäde 39, 980–993 (2010). https://doi.org/10.1007/s00132-009-1570-z

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