Implantatversagen aufgrund von Infekt/Low-grade Infekt – Ursachen und Behandlungskonzepte

Zusammenfassung

Implantatversagen im Sinne von Implantatlockerungen sind eine regelmäßige Komplikation spinaler Instrumentierungen. Die Ursachen von Implantatlockerungen sind oft aseptisch. Allerdings zeigen eine Reihe jüngerer Studien, dass Infektionen, insbesondere „low-grade“ Infektionen für einen relevanten Anteil der Implantatlockerungen ursächlich sind. Diese Infekt-bedingten Implantatlockerungen bedürfen einer angepassten Strategie im Hinblick auf Diagnostik und Therapie. Zur sicheren Diagnostik Infekt-bedingter Lockerungen sind Sonikate der Implantate notwendig. Die Implantatentfernung oder ein -tausch bei Lockerung sollte von einer angepassten Antibiotikatherapie begleitet sein.

Abstract

Loosening/failure of spinal implants is a regular complication of spinal instrumentation. Reasons for implant loosening are often aseptic. However, recent data reveal that infections as a source of spinal implant failure have been underestimated and are a common reason for screw loosening. Especially delayed low-grade infections are a typical cause and require special diagnostic procedures to identify the underlying infection. The diagnostic workup includes a sonication of removed implants to unmask microorganisms protected in biofilms. Unreplaced removal of contaminated implants or an implant exchange and an adjusted antibiotic therapy are necessary in the treatment of these low-grade infections.

Schlüsselwörter

Implantat-assoziierte Infektionen - Implantatlockerungen - Implantatversagen - Low-grade Infektionen - Pedikelschrauben - Pseudarthrose

Keywords

Implant-associated infections - implant loosening - implant failure - low-grade infections, pedicle screws - pseudarthrosis

Publication History

Article published online:
17 May 2022

• Literatur

• 1 Bokov A, Bulkin A, Aleynik A. et al. Pedicle Screws Loosening in Patients With Degenerative Diseases of the Lumbar Spine: Potential Risk Factors and Relative Contribution. Global Spine J 2019; 9: 55-61 DOI: 10.1177/2192568218772302. (PMID: 30775209)
• 2 Burge R, Dawson-Hughes B, Solomon DH. et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 2007; 22: 465-475 DOI: 10.1359/jbmr.061113. (PMID: 17144789)
• 3 El Saman A, Meier S, Sander A. et al. Reduced loosening rate and loss of correction following posterior stabilization with or without PMMA augmentation of pedicle screws in vertebral fractures in the elderly. Eur J Trauma Emerg Surg 2013; 39: 455-460 DOI: 10.1007/s00068-013-0310-6. (PMID: 26815440)
• 4 Galbusera F, Volkheimer D, Reitmaier S. et al. Pedicle screw loosening: a clinically relevant complication?. Eur Spine J 2015; 24: 1005-1016 DOI: 10.1007/s00586-015-3768-6. (PMID: 25616349)
• 5 Okuyama K, Abe E, Suzuki T. et al. Influence of bone mineral density on pedicle screw fixation: a study of pedicle screw fixation augmenting posterior lumbar interbody fusion in elderly patients. Spine J 2001; 1: 402-407 DOI: 10.1016/s1529-9430(01)00078-x. (PMID: 14588296)
• 6 Pepke W, Wantia C, Almansour H. et al. Peak timing for complications after spine surgery. Orthopade 2020; 49: 39-58 DOI: 10.1007/s00132-019-03770-1. (PMID: 31346644)
• 7 Weiser L, Huber G, Sellenschloh K. et al. Insufficient stability of pedicle screws in osteoporotic vertebrae: biomechanical correlation of bone mineral density and pedicle screw fixation strength. Eur Spine J 2017; 26: 2891-2897 DOI: 10.1007/s00586-017-5091-x. (PMID: 28391382)
• 8 Botolin S, Merritt C, Erickson M. Aseptic loosening of pedicle screw as a result of metal wear debris in a pediatric patient. Spine (Phila Pa 1976) 2013; 38: E38-42 DOI: 10.1097/BRS.0b013e3182793e51. (PMID: 23089930)
• 9 Hallab NJ, Cunningham BW, Jacobs JJ. Spinal implant debris-induced osteolysis. Spine (Phila Pa 1976) 2003; 28: S125-138 DOI: 10.1097/00007632-200310151-00006. (PMID: 14560184)
• 10 Huiskes R, Weinans H, van Rietbergen B. The relationship between stress shielding and bone resorption around total hip stems and the effects of flexible materials. Clin Orthop Relat Res 1992; 274: 124-134
• 11 Schatzker J, Horne JG, Sumner-Smith G. The effect of movement on the holding power of screws in bone. Clin Orthop Relat Res 1975; 257-262 DOI: 10.1097/00003086-197509000-00032. (PMID: 1157420)
• 12 Villa T, La Barbera L, Galbusera F. Comparative analysis of international standards for the fatigue testing of posterior spinal fixation systems. Spine J 2014; 14: 695-704 DOI: 10.1016/j.spinee.2013.08.032. (PMID: 25453618)
• 13 Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med 2009; 361: 787-794 DOI: 10.1056/NEJMcp0905029. (PMID: 19692690)
• 14 Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004; 351: 1645-1654 DOI: 10.1056/NEJMra040181. (PMID: 15483283)
• 15 Trampuz A, Piper KE, Jacobson MJ. et al. Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med 2007; 357: 654-663 DOI: 10.1056/NEJMoa061588. (PMID: 17699815)
• 16 Gerometta A, Rodriguez Olaverri JC, Bitan F. Infections in spinal instrumentation. Int Orthop 2012; 36: 457-464 DOI: 10.1007/s00264-011-1426-0. (PMID: 22218913)
• 17 Kasliwal MK, Tan LA, Traynelis VC. Infection with spinal instrumentation: Review of pathogenesis, diagnosis, prevention, and management. Surg Neurol Int 2013; 4: S392-403 DOI: 10.4103/2152-7806.120783. (PMID: 24340238)
• 18 Lall RR, Wong AP, Lall RR. et al. Evidence-based management of deep wound infection after spinal instrumentation. J Clin Neurosci 2015; 22: 238-242 DOI: 10.1016/j.jocn.2014.07.010. (PMID: 25308619)
• 19 Parchi PD, Evangelisti G, Andreani L. et al. Postoperative Spine Infections. Orthop Rev (Pavia) 2015; 7: 5900 DOI: 10.4081/or.2015.5900. (PMID: 26605028)
• 20 Schimmel JJ, Horsting PP, de Kleuver M. et al. Risk factors for deep surgical site infections after spinal fusion. Eur Spine J 2010; 19: 1711-1719 DOI: 10.1007/s00586-010-1421-y. (PMID: 20445999)
• 21 Dubee V, Lenoir T, Leflon-Guibout V. et al. Three-month antibiotic therapy for early-onset postoperative spinal implant infections. Clin Infect Dis 2012; 55: 1481-1487 DOI: 10.1093/cid/cis769. (PMID: 22942207)
• 22 Kowalski TJ, Berbari EF, Huddleston PM. et al. The management and outcome of spinal implant infections: contemporary retrospective cohort study. Clin Infect Dis 2007; 44: 913-920 DOI: 10.1086/512194. (PMID: 17342641)
• 23 Margaryan D, Renz N, Bervar M. et al. Spinal implant-associated infections: a prospective multicentre cohort study. Int J Antimicrob Agents 2020; 56: 106116 DOI: 10.1016/j.ijantimicag.2020.106116. (PMID: 32726675)
• 24 Portillo ME, Corvec S, Borens O. et al. Propionibacterium acnes: an underestimated pathogen in implant-associated infections. Biomed Res Int 2013; DOI: 10.1155/2013/804391. (PMID: 24308006)
• 25 Burger J, Akgun D, Strube P. et al. Sonication of removed implants improves microbiological diagnosis of postoperative spinal infections. Eur Spine J 2019; 28: 768-774 DOI: 10.1007/s00586-019-05881-x. (PMID: 30656472)
• 26 Prinz V, Bayerl S, Renz N. et al. High frequency of low-virulent microorganisms detected by sonication of pedicle screws: a potential cause for implant failure. J Neurosurg Spine 2019; 31: 424-429 DOI: 10.3171/2019.1.SPINE181025. (PMID: 31137006)
• 27 Sampedro MF, Huddleston PM, Piper KE. et al. A biofilm approach to detect bacteria on removed spinal implants. Spine (Phila Pa 1976) 2010; 35: 1218-1224 DOI: 10.1097/BRS.0b013e3181c3b2f3. (PMID: 20445479)
• 28 Shiban E, Joerger AK, Janssen I. et al. Low-Grade Infection and Implant Failure Following Spinal Instrumentation: A Prospective Comparative Study. Neurosurgery 2020; 87: 964-970 DOI: 10.1093/neuros/nyaa133. (PMID: 32409827)
• 29 Fanous AA, Kolcun JPG, Brusko GD. et al. Surgical Site Infection as a Risk Factor for Long-Term Instrumentation Failure in Patients with Spinal Deformity: A Retrospective Cohort Study. World Neurosurg 2019; 132: e514-e519 DOI: 10.1016/j.wneu.2019.08.088. (PMID: 31449998)
• 30 Wang TY, Back AG, Hompe E. et al. Impact of surgical site infection and surgical debridement on lumbar arthrodesis: A single-institution analysis of incidence and risk factors. J Clin Neurosci 2017; 39: 164-169 DOI: 10.1016/j.jocn.2017.01.020. (PMID: 28202380)
• 31 Leitner L, Malaj I, Sadoghi P. et al. Pedicle screw loosening is correlated to chronic subclinical deep implant infection: a retrospective database analysis. Eur Spine J 2018; 27: 2529-2535 DOI: 10.1007/s00586-018-5592-2. (PMID: 29654369)
• 32 Pumberger M, Burger J, Strube P. et al. Unexpected positive cultures in presumed aseptic revision spine surgery using sonication. Bone Joint J 2019; 101-B: 621-624 DOI: 10.1302/0301-620X.101B5.BJJ-2018-1168.R1. (PMID: 31039032)
• 33 Garcia-Perez D, Lagares A, Castano-Leon AM. et al. Implant Microbial Colonization Detected by Sonication as a Cause for Spinal Device Failure: A Prospective Study. Spine (Phila Pa 1976) 2021; 46: 1485-1494 DOI: 10.1097/BRS.0000000000004063. (PMID: 34618709)
• 34 Agarwal A, Mooney M, Agarwal AG. et al. High Prevalence of Biofilms on Retrieved Implants from Aseptic Pseudarthrosis Cases. Spine Surg Relat Res 2021; 5: 104-108 DOI: 10.22603/ssrr.2020-0147. (PMID: 33842718)
• 35 Bratschitsch G, Puchwein P, Zollner-Schwetz I. et al. Spinal Surgery Site Infection Leading to Implant Loosening Is Influenced by the Number of Prior Operations. Global Spine J 2020; DOI: 10.1177/2192568220957268. (PMID: 32954814)
• 36 Gbejuade HO, Lovering AM, Webb JC. The role of microbial biofilms in prosthetic joint infections. Acta Orthop 2015; 86: 147-158 DOI: 10.3109/17453674.2014.966290. (PMID: 25238433)
• 37 Ha KY, Chung YG, Ryoo SJ. Adherence and biofilm formation of Staphylococcus epidermidis and Mycobacterium tuberculosis on various spinal implants. Spine (Phila Pa 1976) 2005; 30: 38-43 DOI: 10.1097/01.brs.0000147801.63304.8a. (PMID: 15626979)
• 38 Carlson BC, Hines JT, Robinson WA. et al. Implant Sonication versus Tissue Culture for the Diagnosis of Spinal Implant Infection. Spine (Phila Pa 1976) 2020; 45: E525-E532 DOI: 10.1097/BRS.0000000000003311. (PMID: 32282655)
• 39 Burger J, Palmowski Y, Strube P. et al. Low sensitivity of histopathological examination of peri-implant tissue samples in diagnosing postoperative spinal implant infection. Bone Joint J 2020; 102-B: 899-903 DOI: 10.1302/0301-620X.102B7.BJJ-2019-1725.R2. (PMID: 32600139)
• 40 Renz N, Cabric S, Morgenstern C. et al. Value of PCR in sonication fluid for the diagnosis of orthopedic hardware-associated infections: Has the molecular era arrived?. Injury 2018; 49: 806-811 DOI: 10.1016/j.injury.2018.02.018. (PMID: 29486892)
• 41 Ahmed R, Greenlee JD, Traynelis VC. Preservation of spinal instrumentation after development of postoperative bacterial infections in patients undergoing spinal arthrodesis. J Spinal Disord Tech 2012; 25: 299-302 DOI: 10.1097/BSD.0b013e31821fbf72. (PMID: 21617567)
• 42 Chen SH, Lee CH, Huang KC. et al. Postoperative wound infection after posterior spinal instrumentation: analysis of long-term treatment outcomes. Eur Spine J 2015; 24: 561-570 DOI: 10.1007/s00586-014-3636-9. (PMID: 25351841)
• 43 Lamberet A, Violas P, Buffet-Bataillon S. et al. Postoperative Spinal Implant Infections in Children: Risk Factors, Characteristics and Outcome. Pediatr Infect Dis J 2018; 37: 511-513 DOI: 10.1097/INF.0000000000001812. (PMID: 29088025)
• 44 Moyano CA, Tello CA, Piantoni L. et al. Infection Recurrence in Instrumented Spinal Fusion in Children. Global Spine J 2021; 11: 1040-1045 DOI: 10.1177/2192568220935818. (PMID: 32783471)
• 45 Hedequist D, Haugen A, Hresko T. et al. Failure of attempted implant retention in spinal deformity delayed surgical site infections. Spine (Phila Pa 1976) 2009; 34: 60-64 DOI: 10.1097/BRS.0b013e31818ed75e. (PMID: 19077923)
• 46 Lora-Tamayo J, Senneville E, Ribera A. et al. Group of Investigators for Streptococcal Prosthetic Joint I. The Not-So-Good Prognosis of Streptococcal Periprosthetic Joint Infection Managed by Implant Retention: The Results of a Large Multicenter Study. Clin Infect Dis 2017; 64: 1742-1752 DOI: 10.1093/cid/cix227. (PMID: 28369296)
• 47 Palmowski Y, Burger J, Kienzle A. et al. Antibiotic treatment of postoperative spinal implant infections. J Spine Surg 2020; 6: 785-792 DOI: 10.21037/jss-20-456. (PMID: 33447684)