Prinzipien der Antibiotikabehandlung bei periprothetischen Infektionen

Periprosthetic infection is nowadays a rare complication in artificial joint replacement. The infection of joint prostheses is a foreign body associated infection at the site of bone tissue which is difficult to treat with antimicrobial agents. Apart from cases with early, non-established infections, the surgical removal of the foreign material and radical débridement of bone and soft tissue is necessary. The surgical revision is performed preferentially using a one or two stage exchange of the prosthesis. In some cases, only the removal of the prosthesis is necessary. In these cases, a pseudoarthroplasty or an arthrodesis without definitely implanted foreign material is performed. Amputation is carried out if all other forms of revision have failed. All of these surgical procedures are accomplished by antimicrobial therapy, whether systemically administered and/or topically by drug delivery systems. Controlled studies for the comparison of one and two stage exchange procedures are not currently available. For the therapy of periprosthetic infection, an infectious disease specialist who is experienced in this area is needed in addition to an experienced surgical team. Thus, the therapy of these infections should be performed exclusively in centres of competence.     

Komplikationsmanagement bei Infektionen und Dekubitus

This contribution provides an overview of the lectures addressing management of complications associated with infections and decubitus, which was the second main topic of the 33rd Conference on Trauma Medicine held in Baden-Baden on 17 and 18 October 2009. On the whole the session pointed out an important and cost-intensive issue in therapy for which there are now approaches available that should be implemented in the future.     

Komplikationsmanagement bei Infektionen und Dekubitus

Trauma und Berufskrankheit - Im vorliegenden Beitrag wird ein Überblick der Vorträge des 2. Hauptthemas der 33. Unfallmedizinischen Tagung in Baden-Baden am 17. und 18.10.2009,...     

Antibiotika- und Pilztherapie bei intraabdominellen Infektionen

Antimicrobial chemotherapy is a cornerstone in the treatment of intra-abdominal infections (IAI). The initiation of initial antibiotic therapy must immediately follow the diagnosis of IAI. Selection of the antimicrobial agent is based on the expected pathogenic bacterial spectrum as a calculated empirical therapy. It is impossible to give general recommendations concerning the selection of a certain class of antimicrobial chemotherapeutics, since all available clinical trials were designed to prove noninferiority to the comparator product. Nevertheless several societies developed guidelines and recommendations based on the multitude of clinical trials investigating antimicrobial chemotherapeutics. The antibiotic therapy of postoperative peritonitis has to be implemented according to the patient's risk profile (antibiotic pretreatment, multiresistant pathogens, hospital epidemiology). The development of invasive peritoneal mycoses is rare. The therapy should be guided by the results of the microbiological work-up of the intraperitoneal cultures.     

Knietotalendoprothesenwechsel bei periprothetischen Frakturen

Periprosthetic fractures associated with total knee arthroplasty may occur intraoperatively or postoperatively. Therapy depends on the stability of the fracture, the location of the fracture and bone quality. The parameter that determines the surgical treatment is the stability of the implant. In contrast to periprosthetic fractures associated with total hip arthroplasty the implant is stable in the majority of cases, so internal fixation is the therapy of choice. If the fracture is associated with an unstable implant, then a revision with a stemmed component and bridging of the fracture must be performed. In cases with deficient bone stock, tumor prostheses may be necessary. In this paper the indication, technique and results are described.     

Antibiotikaresistenz und deren Bedeutung bei urogenitalen Infektionen

Urinary tract infections (UTI) are among the most frequent bacterial infections and therefore make a significant contribution to the widespread use and extensive misuse of antibacterial drugs. The amount of antibiotics used directly correlates with the emergence of antibiotic resistance. The World Health Organization (WHO) has recently issued a fact sheet highlighting the worldwide increase in antibiotic resistance. The spectrum of urological diseases affected by antibiotic resistance ranges from benign uncomplicated cystitis to severe life-threatening urosepsis and from urethritis to multidrug resistant tuberculosis. The European Section of Infections in Urology (ESIU) performs an annual surveillance study to evaluate antibiotic resistance in urology which revealed excessively high resistance rates, similar to other surveillance studies. In the light of these developments the World Alliance against Antibiotic Resistance (WAAAR) has advocated a 10-point action plan to combat the rapid rise of worldwide antibiotic resistance.     

Erfahrungen mit winkelstabilen Plattensystemen bei periprothetischen Frakturen

In our opinion implants with multidirectional blocked screws are the ideal treatment for periprosthetic fractures even in the elderly and critically ill patient. The operation is not time-consuming and the blood loss is relatively low. In osteoporotic bone those fixateur intern systems with multidirectional screws give a high stability so that we rapidly achieve joint motion. With the possibility of fixing screws in various angles and the possibility of contouring the plate to the bone we even achieve a rigid fixation in the presence of a voluminous prostheses.     

Komplikationsmanagement bei Infektionen

Trauma und Berufskrankheit - In eine Unfallklinik wird eine eindeutige Negativselektion mehrfach voroperierter Patienten mit erheblichen funktionellen Defiziten überwiesen, mit zudem...     

Procalcitonin Ein neuer diagnostischer Parameter bei schweren Infektionen und Sepsis

Procalcitonin (PCT), a glycoprotein consisting of 116 amino acids, has been proposed as a new marker of severe infection. The site of production under this condition remains unknown. The serum PCT concentration is determined by an immunoluminometric assay of 40?µl serum or plasma requiring approximately two hours. Elevations of PCT are for instance associated with levels of lipopolysaccharide and the cytokines TNF-α and IL-6. Bacterial, parasitic or fungal infections developing septic complications in contrast to local infections, often show values ex- ceeding 2?ng/ml. The specificity of the parameter in this context increases with its concentrations. Therapeutic actions that confine the infection locally are reflected by a decrease of the PCT value. PCT may be elevated within the first days after extended surgery or polytrauma, in some malignancies, heatstroke and during treatment of some hematologic diseases without an existing sepsis or severe infection. Previous studies indicate certain benefits of PCT compared to traditional markers of inflammation or sepsis, where the ability to indicate a generalized infection is the primary advantage.     

Retrograde Marknagelung bei periprothetischen Frakturen des distalen Femurs

Objective

Intramedullary stabilization of periprosthetic distal femoral fractures by interlocking nailing. Closed reduction by retrograde nail can be combined with the use of transmedullary support screws (TMS principle of Stedtfeld).

Indications

Supracondylar fractures above stable knee arthroplasty (Rorabeck types I and II), femoral shaft fractures ipsilateral of stable hip and/or knee arthroplasty, contraindications for antegrade nailing

Contraindications

Closed box design of femoral implant, intercondylar distance of the femoral component smaller than nail diameter, more than 40° flexion deficit of the knee, inability to place two bicortical distal interlocking screws. Relative contraindication: insufficient overlap with proximal implants

Surgical technique

Supine position and knee flexion of approximately 45°. Fluoroscopy should be possible between the knee and hip. Longitudinal skin incision into the pre-existing scar over the patellar tendon which is then split. The nail entry point is located in the intercondylar groove at the deepest point of Blumensaat’s line, often predetermined by the femoral arthroplasty component. Reaming is rarely necessary. Transmedullary support screws may correct axial malalignment during nail insertion. Static interlocking in a direction from lateral to medial by the aiming device. Insertion of locking cap.

Postoperative management

Retrograde nailing normally allows full weight bearing. Range of motion does not need to be restricted.

Results

Out of 101 fractures treated between 2000 and 2013 with a Targon RF nail (Aesculap, Tuttlingen, Germany) 10 were periprosthetic, all were classified as Rorabeck type II and of these 6 fractures were metaphyseal and 4 were diaphyseal. In four cases proximal implants were present. The mean operative time for periprosthetic fracture fixation did not significantly differ from that for normal retrograde femoral nailing. There were no postoperative infections, fixation failures or delayed unions. There was one revision for secondary correction of maltorsion.     

Behandlung von Schultergelenkinfektionen und periprothetischen Schulterinfekten

Infections of the shoulder joint are rare but nevertheless carry a high risk of complications. Successful therapy is mostly operative and should be planned according to the causes, stage, and expansion of the infection and the expected spectrum of bacteria. Moreover, the patient's general condition and previous illnesses must be considered. Patients with rheumatoid arthritis and immunotherapy are especially at risk for complications and require special attention. Shoulder infections and periprosthetic infections can be treated with arthroscopy, with open debridement, or, in the case of periprosthetic infections, with one- or two-stage exchange procedures. In cases of noncontrollable infections, resection arthroplasty or arthrodesis can be performed as a last resort. Results and possible complications are described herein, including those based on our own results.     

Gentamicin-PMMA-Miniketten bei Infektionen der Hand

Hitherto a prolonged treatment and immobilization was necessary in case of bone and soft tissue infections of the hand. The result was frequently a poor function of the hand due to ankylosis. The infection period can be shortened by an early, carefully performed sequestrotomy with additional temporary implantation of gentamicin-PMMA minichains. The evaluation of 200 cases shows the good results of this therapy method.     

Interscalenus-Block bei Infektionen der Schulter

Ohne Zusammenfassung     

Zur Problematik des Prothesenwechsels bei Lockerungen und Infektionen des alloarthroplastischen Hüftgelenksersatzes

Zusammenfassung Die Lockerung und Infektion der Hüfttotalendoprothese ist eine folgenschwere Komplikation der Alloarthroplastik, die mehr und mehr an Bedeutung gewinnt. Im Rahmen einer vorläufigen Bilanz bei 1083 HTP werden die primären und sekundären Infektionen sowie die Lockerungen mit ihren daraus resultierenden Reoperationen dargestellt.Durch Routineabstriche bei der Operation im konventionellen Operationssaal läßt sich eine relativ hohe Kontamination mit verschiedenen Keimen nachweisen, die möglicherweise für Spätinfekte im Sinne einer Latenzinfektion verantwortlich gemacht werden können. Für Lockerungen ohne äußere Entzündungszeichen und ohne Keimnachweis bei der Austauschoperation unter Verwendung eines antibioticafreien Knochenzementes sind biomechanische Unzulänglichkeiten am ehesten als Ursache anzusehen, und eine prophylaktische Anwendung antibioticahaltigen Knochenzementes erscheint nicht gerechtfertigt.Die strenge Wahrung der Asepsis und eine Verbesserung derselben durch Nutzung einer sterilen Operationsbox ist auf Grund der festgestellten Keimverteilung sicherlich ein wesentlicher Schritt zur Senkung der Infektionsrate.Zur soliden Prothesenschaftverankerung ist eine Valgusposition derselben mit guter medialer Abstützung anzustreben. Bei Reoperationen sollte nach Möglichkeit eine Langschaftprothese Verwendung finden.

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Problems in exchange operations of the hip-joint-prosthesis after loosening and infection

Summary The loosening and the infection of the total hip-joint prothesis is a complication of great consequences for the alloarthroplasty which gains in importance more and more. In a preliminary balance with 1083 hip-joint prothesis, the primary and secondary infections are described, as well as the loosening followed by reoperations.Based on routine swabs during the operation in a conventional operation room, a relative high contamination with different germs can be found. This kind of contamination with different germs can be found. This kind of contamination could possibly be hold responsible for late or latent infections. The reason for loosening without an exterior sign of inflammation and without evidence for germs at the exchange operation when bone-cement free of antibiotics has been applied, are most easily biomechanic insufficiencies. Therefore, a prophylactic application of bone-cement containing antibiotics appears unjustified.The strong maintenance of asepsis and its improvement by using a sterile operation box is—based on an ascertained distributions of germs—certainly an important step towards lowering the infection rate.For a solid auchorage of the shaft prosthesis, one should aspire to a valgus position with a good medial point of suspension. As far as possible a long shaft prosthesis should be used by reoperations.

     

Gelenkempyeme und periprothetische Infektionen

A total of 31 patients with a proven methicillin and oxacillin-resistant Staphylococcus aureus (MRSA/ORSA) infection of a joint or joint replacement were treated, 29 by surgical methods and2 had to be treated conservatively due to severe accompanying illnesses. Depending on the stage of joint empyema, prior treatment, the extent of infection and level of joint damage, an open joint preserving operation or a primary joint resection was performed. A synovialectomy was performed for all surgery patients and an antibiotic carrier was implanted into the joint. In 28 out of 31 patients the infection was considered to be alleviated at the time of this retrospective study. Despite elaborate, complex and costly operative treatment only 2 joints and 2 hip replacements could be preserved. The clinical results are regarded as satisfactory with sometimes considerable limitations to mobility and quality of life. The results show that despite optimal treatment of joint empyema and infections of joint replacements with MRSA/ORSA, it is only rarely possible to preserve the joint. In most cases an arthrodesis or resection of the joint is necessary. In rare cases an amputation or exarticulation of the affected joint is required.     

Salvage-Prozeduren bei Knie-/kniegelenknahen Infektionen

Background

Advanced knee infections or chronic infections of knee endoprostheses are often accompanied by substantial local soft tissue involvement and require multidisciplinary treatment. After several replacements of endoprostheses, extensive bony substance defects are present in many cases which are regularly associated with a poor function or loss of the extensor mechanism.

Therapy

In order to maintain at least partial functional integrity radical débridement has to be performed as a salvage procedure, followed by complex soft tissue and ligament reconstruction and revision arthroplasty using special implants. Arthrodesis allows limb salvage while accepting a limited function of the joint. In rare cases amputation is required. These serious consequences and the permanent health damage lead not only to physical, psychological and socioeconomic problems for the patient but also to high expenditure for the accident insurance institutions and other healthcare funding organizations with the need for lifelong treatment.