Diagnostischer Algorithmus der schmerzhaften Knietotalendoprothese

Zusammenfassung

Die Implantation von Knietotalendoprothesen (KTEP) gehört zu den häufigsten Operationen in der Orthopädie und Unfallchirurgie. Der klinische Erfolg dieser Operationen kann anhand der Standzeiten der Endoprothesen, der Funktionsverbesserung, aber natürlich auch über die Zufriedenheit der Patienten und deren Schmerzen gemessen werden. Trotz des klinischen Erfolgs der Knietotalendoprothetik mit 10-Jahres-Überlebensraten von bis zu 95 % sind etwa 20 % der Patienten mit ihren Prothesen aus verschiedenen Gründen unzufrieden. Eindeutige Ursachen für ein Implantatversagen sind meist mithilfe der klinischen Diagnostik und einer Standardröntgenuntersuchung zu identifizieren, wogegen die unklare schmerzhafte Knietotalendoprothese nach wie vor eine Herausforderung für den Chirurgen darstellt. Hier ist zwischen extra- und intraartikulären Schmerzen zu differenzieren, wobei Letztere eine biologische oder eine mechanische Ursache haben können. Um zwischen mechanisch und nicht mechanisch bedingten Schmerzen zu unterscheiden, sind der Beginn der Schmerzen nach der Operation und das Auftreten bei Bewegung oder in Ruhe wegweisend. Grundsätzlich gilt ein schmerzhaftes Kniegelenk bis zum Beweis des Gegenteils verdächtig für einen periprothetischen Infekt. Es ist wichtig zu betonen, dass schmerzhafte Knietotalendoprothesen, bei denen keine Ursache identifiziert werden kann, nicht einer Revisionsoperation zugeführt werden sollten. Methode: In dieser Übersichtsarbeit wird ein diagnostischer Algorithmus beschrieben, der eine detaillierte Analyse von schmerzhaften Knietotalendoprothesen erlaubt. Die Analyse beinhaltet eine genaue Anamnese mit einer ausführlichen Schmerzanamnese, eine sorgfältige klinische Untersuchung des betroffenen Knies und der angrenzenden Gelenke wie der Wirbelsäule, der Hüfte und der Sprunggelenke, eine Labor- und radiologische Analyse sowie weiterführende invasive Untersuchungsmethoden wie Gelenkspunktionen und Biopsien. Schlussfolgerung: Diese Übersichtsarbeit bietet dem Leser mithilfe eines diagnostischen Algorithmus eine wichtige Unterstützung zur Abklärung der Ursache von schmerzhaften Knietotalendoprothesen.

Abstract

Total knee arthroplasty (TKA) is one of the most common procedures in orthopedic surgery and clinical success can be characterized by the revision rate and improvement of function, as well as the patientsʼ satisfaction and pain. Despite the clinical success of primary TKA with 10-year survival rates as high as 95 %, about 20 % of the patients after TKA are not completely satisfied with their outcomes for several reasons. Obvious causes of failure might be identified with clinical examinations and standard radiographs only, whereas the unexplained painful TKA still remains a challenge for the surgeon. Failure can be classified into extra- and intraarticular disorders, the latter being divided into biological and mechanical origins. The onset of the pain after the operation and the differentiation between pain in motion and at rest are helpful to distinguish between mechanical and non-mechanical problems. An infection should be the first diagnosis to be ruled out in a painful TKA. It is generally accepted that a clear understanding of the failure mechanism in each case is required prior to considering revision surgery. Method: In this review a practical diagnostic algorithm is described for failure analysis in more detail. The evaluation of a painful TKA includes a detailed history with an extended analysis of the type of pain, thorough clinical examination including spine, hip and ankle, radiographic and laboratory analysis, as well as invasive examinations like joint aspiration and biopsies. Conclusion: This diagnostic algorithm offers an important tool for a sufficient failure analysis in almost all patients with painful TKA.

Key words

Knietotalendoprothetik - Schmerzen - Implantatversagen - Diagnostik

Key words

total knee arthroplasty - pain - failure in knee arthroplasty - diagnostic algorithm

• Literatur

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