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Röhrl A, Klawonn F, Füchtmeier B, Wulbrand C, Gessner A, Zustin J, Ambrosch A. Results of a monocentric field study: value of histology compared to sonication method and conventional tissue culture in the diagnosis of periprosthetic joint infection (PJI). Infection 2024:10.1007/s15010-024-02278-x. [PMID: 38730201 DOI: 10.1007/s15010-024-02278-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/21/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND To confirm the diagnosis of periprosthetic joint infection (PJI), the Infectious Diseases Society of America (IDSA) and the International Consensus Meeting (ICM) have defined criteria that include histology as a minor criterion and the sonication method only as an additional criterion. The aim of this monocentric, retrospective study was to investigate the value of histology and whether sonication leads to a more accurate diagnosis. MATERIALS AND METHODS All revision surgeries for knee and hip arthroplasty between 2017 and 2020 were included. With regard to microbiological diagnostic, conventional culture of periprosthetic biopsies and sonication of explant material were performed. In addition, histology and non-specific inflammatory markers (CRP, leukocytes) were recorded. RESULTS A total of 78 patients with PJI and 62 aseptic controls were included. From both microbiological methods (conventional culture / sonication), Staphyloccus (S.) epidermidis and S. aureus were detected most frequently. However, compared to the conventional microbiology, a higher sensitivity was calculated for sonication, albeit with a lower specificity in relation to a PJI. In two logistic regression models for the significance of all diagnostic parameters in PJI, the AUC was 0.92 and 0.96 with histology in particular making the decisive contribution in both models (p < 0. 001, both models). CONCLUSION Since histology showed the highest accuracy in the current study, its importance in the PJI criteria should be reevaluated. Sonication shows a high sensitivity for germ detection with a lower specificity and should only be used in combination with the conventional culture for microbiolgical diagnostics.
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Affiliation(s)
- Alexander Röhrl
- Department of Trauma Surgery, Orthopaedics & Sports Medicine, Hospital of Brothers of Mercy, Regensburg, Germany
| | - Frank Klawonn
- Biostatistics, Helmholtz Centre for Infection Research, Brunswick, Germany
- Institute for Information Engineering, Ostfalia University, Wolfenbüttel, Germany
| | - Bernd Füchtmeier
- Department of Trauma Surgery, Orthopaedics & Sports Medicine, Hospital of Brothers of Mercy, Regensburg, Germany
| | - Christian Wulbrand
- Department of Trauma Surgery, Orthopaedics & Sports Medicine, Hospital of Brothers of Mercy, Regensburg, Germany
| | - Andre Gessner
- Institute of Clinical Microbiology and Infection Prevention, University Hospital, Regensburg, Germany
| | - Jozef Zustin
- Private Histopathology Service, Regensburg, Germany
- Gerhard Domagk Institute of Pathology, University Medical Center, Münster, Germany
| | - Andreas Ambrosch
- Institute of Laboratory Medicine, Microbiology and Infection Prevention, Hospital of Brothers of Mercy, Prüfeninger Straße 86, 93049, Regensburg, Germany.
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Akkaya M, Zanna L, Sangaletti R, Bokhari A, Gehrke T, Citak M. What Is the Most Reliable Concordance Rate of Preoperative Synovial Fluid Aspiration and Intraoperative Biopsy to Detect Periprosthetic Joint Infection in Knee, Hip and Shoulder Arthroplasty? Antibiotics (Basel) 2023; 12:1482. [PMID: 37887183 PMCID: PMC10604270 DOI: 10.3390/antibiotics12101482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/28/2023] Open
Abstract
The accuracy of preoperative synovial fluid microbe detection in periprosthetic joint infection (PJI) is widely reported. However, the reliability of this diagnostic modality amongst the different joints is not yet described. We aimed to compare the concordance rate between preoperative synovial fluid and intraoperative tissue cultures in shoulder, knee and hip PJIs. A total of 150 patients who met the 2018 International Consensus Meeting criteria for shoulder, hip and knee PJI were retrospectively reviewed. This cohort was divided into three groups based on the involved joint (should, hip or knee), with 50 patients in each group. Cultures were collected and held for culture for 14 days. The overall concordance rate was 56.7%. Concordance rates between preoperative and intraoperative cultures were 60%, 56% and 54% for the knee, shoulder and hip joints, respectively. The analysis of high- or low-virulence and difficult- or not-difficult-to-treat germs did not reveal any significant differences between preoperative and intraoperative cultures in any of the groups. However, even considering the higher concordance in knee PJI, the overall discordance between preoperative and intraoperative cultures should prompt surgeons not to rely solely on preoperative synovial fluid culture data in determining appropriate treatment and antibiotics.
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Affiliation(s)
| | | | | | | | | | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, 22767 Hamburg, Germany; (M.A.); (L.Z.); (R.S.); (A.B.)
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Hackenberg RK, Schmitt-Sánchez F, Endler C, Tischler V, Surendar J, Welle K, Kabir K, Schildberg FA. Value of Diagnostic Tools in the Diagnosis of Osteomyelitis: Pilot Study to Establish an Osteomyelitis Score. J Clin Med 2023; 12:jcm12093057. [PMID: 37176498 PMCID: PMC10179525 DOI: 10.3390/jcm12093057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Osteomyelitis (OM) remains one of the most feared complications in bone surgery and trauma. Its diagnosis remains a major challenge due to lack of guidelines. The aim of this study was to prospectively analyze the value of the most common and available diagnostic tools and to establish an OM score to derive treatment recommendations. All patients with suspected OM were included in a prospective pilot study. All patients underwent blood sampling for C-reactive protein and white blood cell count analysis. Magnetic resonance imaging (MRI), and microbiologic and histopathologic samples, were taken from representative sites of initial debridement. All patients were treated according to their OM test results and followed for at least one year. Subsequently, the value of individual or combined diagnostic tools was analyzed in patients with confirmed OM and in patients in whom OM was ruled out. Based on these findings, an OM score was developed that included MRI, microbiology, and histopathology. The score identified all control patients and all but one OM patient, resulting in a correct diagnosis of 93.3%, which was validated in a second independent larger cohort. This was the first study to analyze the value of the most commonly used tools to diagnose OM. The proposed OM score provides a simple scoring system to safely interpret test results with high accuracy.
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Affiliation(s)
- Roslind K Hackenberg
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, 53127 Bonn, Germany
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Fabio Schmitt-Sánchez
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Christoph Endler
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, 53127 Bonn, Germany
| | - Verena Tischler
- Institute of Pathology, University Hospital Bonn, 53127 Bonn, Germany
| | - Jayagopi Surendar
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Kristian Welle
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Koroush Kabir
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Frank A Schildberg
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, 53127 Bonn, Germany
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Fourcade C, Gomez-Brouchet A, Bouige A, Krin G, Bicart-See A, Marlin P, Gautie L, Giordano G, Bonnet E. Can we rely on histopathological results for the diagnostic of prosthetic joint infection? Infect Dis Now 2023; 53:104706. [PMID: 37030627 DOI: 10.1016/j.idnow.2023.104706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 03/01/2023] [Accepted: 03/31/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Histopathology is one of the diagnostic criteria for prosthetic joint infection (PJI) proposed by all academic societies. The aim of this study was to compare histopathological and microbiological results from samples taken intraoperatively at the same site in patients with suspected or proven PJI. PATIENTS AND METHODS We conducted a monocenter retrospective study including all patients having undergone surgery from 2007 to 2015 with suspected or proven PJI. During surgery, both histopathological and microbiological samples were taken. Patients with a history of antimicrobial treatment 2 weeks prior to surgery were excluded. We considered as major criteria and gold standard for PJI diagnosis the presence of a sinus tract communication and/or the same microorganism in at least two cultures. RESULTS Finally, 181 patients who underwent 309 surgeries were included. The median number of samples per surgery was 4 (interquartile range (IQR) = 3-5) for histopathology and 5 (IQR=4-6) for microbiology. Major criteria were observed in 177 patients (57.3%), while positive histology in at least one intraoperative sample was present in 119 (38.5%). The concordance was 74%. The sensitivity and specificity of histopathology were 61% and 92% respectively. Available "histopathology-culture" sample pairs numbered 1247. Among them, positive histopathology was found in 292 samples (23%) and culture in 563 (45%). Concordance was 64%. The highest correlation was observed for very early infection (< 1 month) (OR: 9.1, 95% CI: 3.6-23) and for virulent microorganisms, such as Staphylococcus aureus (OR: 7.8, 95% CI: 5.2-11.8), Streptococci (OR:7.8; 95% CI: 4-15.2) or Enterobacterales (OR: 7.4; 95% CI: 4.2-13.1). CONCLUSION Histopathologic examination is a valuable criterion for PJI diagnosis, but it may lack sensitivity for chronic infections or due to low-virulence pathogens.
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Ciccullo C, Neri T, Farinelli L, Gigante A, Philippot R, Farizon F, Boyer B. Antibiotic Prophylaxis in One-Stage Revision of Septic Total Knee Arthroplasty: A Scoping Review. Antibiotics (Basel) 2023; 12:antibiotics12030606. [PMID: 36978473 PMCID: PMC10044675 DOI: 10.3390/antibiotics12030606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/28/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Total knee replacement (TKA) is becoming a routine procedure in orthopedic surgery. One of the possible complications of this surgery is periprosthetic joint infection (PJI). The purpose of this study is to identify, through a literature review, which antibiotic is used as prophylaxis for septic one-stage revision TKA and what is the rationale for its use. METHODS We searched: MEDLINE, Embase, PsycINFO on Ovid, the Cochrane Library, and the Google Scholar Database. The searches were limited by date (January 2005 to September 2022) and to the English language. All types of original research were considered, including prospective or retrospective longitudinal studies, cross-sectional studies, and randomized trials. The specific search terms were ((antibiotic [MeSH]) AND (prophylaxis)) and (TKA OR TKR OR "Arthroplasty, Replacement, Knee" [MeSH] OR ((knee) adj2 (replace* OR arthroplasty* OR prosthe*))). RESULTS Despite our research efforts, we found no article capable of answering the question of which antibiotic to use as surgical prophylaxis for a septic revision one-stage TKA. CONCLUSIONS Although the research results are inconclusive, we would recommend using the same antibiotic prophylaxis as for primary joint replacement, i.e., cefazolin, as it was recommended for its low side effect rate and relative effectiveness.
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Affiliation(s)
- Carlo Ciccullo
- Clinical Ortopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, 60121 Ancona, Italy
| | - Thomas Neri
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Hôpital Nord, 42055 Saint-Étienne, France
- Laboratoire Interuniversitaire de Biologie de la Motricité, Université de Lyon, 69361 Lyon, France
| | - Luca Farinelli
- Clinical Ortopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, 60121 Ancona, Italy
| | - Antonio Gigante
- Clinical Ortopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, 60121 Ancona, Italy
| | - Rémi Philippot
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Hôpital Nord, 42055 Saint-Étienne, France
- Laboratoire Interuniversitaire de Biologie de la Motricité, Université de Lyon, 69361 Lyon, France
| | - Frederic Farizon
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Hôpital Nord, 42055 Saint-Étienne, France
- U 1059 Sainbiose, Mines Saint-Étienne, Universitè Jean Monnet, INSERM, 42023 Saint-Étienne, France
| | - Bertrand Boyer
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Hôpital Nord, 42055 Saint-Étienne, France
- U 1059 Sainbiose, Mines Saint-Étienne, Universitè Jean Monnet, INSERM, 42023 Saint-Étienne, France
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Zanna L, Sangaletti R, Akkaya M, Shen T, Abuljadail S, Gehrke T, Citak M. What is the concordance rate of preoperative synovial fluid aspiration and intraoperative biopsy in detecting periprosthetic joint infection of the shoulder? J Shoulder Elbow Surg 2023; 32:492-499. [PMID: 36343792 DOI: 10.1016/j.jse.2022.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The accuracy of preoperative synovial fluid culture for microbe detection in shoulder periprosthetic joint infection (PJI) is poorly described. To evaluate the utility of preoperative culture data for early pathogen identification for shoulder PJI, we determined the concordance between preoperative synovial fluid culture results and intraoperative tissue culture results. METHODS Fifty patients who met the 2014 Musculoskeletal Infection Society criteria for shoulder PJI between January 2016 and December 2019 were retrospectively reviewed for clinical and demographic data. This cohort of patients was divided into 2 groups based on the concordance between preoperative and intraoperative culture results. The pathogens identified on preoperative and intraoperative cultures were classified as high-virulence or low-virulence. Student's t tests and Mann-Whitney U tests were used as appropriate for continuous variables, and χ2 and Fisher's exact tests were used as appropriate for categorical variables. RESULTS Concordance between preoperative aspiration and intraoperative tissue culture was identified in 28 of 50 patients (56%). Preoperative cultures positive for Gram-positive species were more likely to be concordant than discordant (P = .015). Preoperative cultures positive for Cutibacterium acnes were more likely to be concordant with intraoperative cultures (P = .022). There were more patients with polymicrobial infection in the discordant group compared with the concordant group (P < .001). No statistically significant correlation between the preoperative serum C-reactive protein level and the intraoperative category of bacteria was reported. Staphylococcus aureus and coagulase-negative Staphylococci were associated with high specificity and negative predictive value. Preoperative cultures positive for C. acnes demonstrated sensitivity, specificity, positive predictive value, and negative predictive value lower than 0.8. Gram-negative pathogens demonstrated the highest sensitivity (1) and specificity (1), whereas polymicrobial infections exhibited the lowest sensitivity and positive predictive value. CONCLUSION Preoperative synovial fluid aspiration for shoulder PJI poorly predicts intraoperative culture results, with a discordance of 44%. More favorable concordance was observed for monomicrobial preoperative cultures, particularly for Gram-negative organisms and methicillin-sensitive S. aureus. The overall high rate of discordance between preoperative and intraoperative culture may prompt surgeons to base medical and surgical management on patient history and other factors and avoid relying solely on preoperative synovial fluid culture data.
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Affiliation(s)
- Luigi Zanna
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany; Department of Orthopaedic Surgery, Aou Careggi, University Hospital of Florence, Florence, Italy.
| | - Rudy Sangaletti
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Akkaya
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Tony Shen
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Salahulddin Abuljadail
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany; College of Medicine, King Faisal University, Hofuf, Saudi Arabia
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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Tang H, Xu J, Yuan W, Wang Y, Yue B, Qu X. Reliable Diagnostic Tests and Thresholds for Preoperative Diagnosis of Non-Inflammatory Arthritis Periprosthetic Joint Infection: A Meta-analysis and Systematic Review. Orthop Surg 2022; 14:2822-2836. [PMID: 36181336 PMCID: PMC9627080 DOI: 10.1111/os.13500] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 02/06/2023] Open
Abstract
Objective The current diagnostic criteria for periprosthetic joint infection (PJI) are diverse and controversial, leading to delayed diagnosis. This study aimed to evaluate and unify their diagnostic accuracy and the threshold selection of serum and synovial routine tests for PJI at an early stage. Methods We searched the MEDLINE and Embase databases for retrospective or prospective studies which reported preoperative‐available assays (serum, synovial, or culture tests) for the diagnosis of chronic PJI among inflammatory arthritis (IA) or non‐IA populations from January 1, 2000 to June 30, 2022. Threshold effective analysis was performed on synovial polymorphonuclear neutrophils (PMN%), synovial white blood cell (WBC), serum C‐reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to find the relevant cut‐offs. Results Two hundred and sixteen studies and information from 45,316 individuals were included in the final analysis. Synovial laboratory‐based α‐defensin and calprotectin had the best comprehensive sensitivity (0.91 [0.86–0.94], 0.95 [0.88–0.98]) and specificity (0.96 [0.94‐0.97], 0.95 [0.89–0.98]) values. According to the threshold effect analysis, the recommended cut‐offs are 70% (sensitivity 0.89 [0.85–0.92], specificity 0.90 [0.87–0.93]), 4100/μL (sensitivity 0.90 [0.87–0.93], specificity 0.97 [0.93–0.98]), 13.5 mg/L (sensitivity 0.84 [0.78–0.89], specificity 0.83 [0.73–0.89]), and 30 mm/h (sensitivity 0.79 [0.74–0.83], specificity 0.78 [0.72–0.83]) for synovial PMN%, synovial WBC, serum CRP, and ESR, respectively, and tests seem to be more reliable among non‐IA patients. Conclusions The laboratory‐based synovial α‐defensin and synovial calprotectin are the two best independent preoperative diagnostic tests for PJI. A cut off of 70% for synovial PMN% and tighter cut‐offs for synovial WBC and serum CRP could have a better diagnostic accuracy for non‐IA patients with chronic PJI.
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Affiliation(s)
- Haozheng Tang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jialian Xu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei'en Yuan
- Ministry of Education Engineering Research Center of Cell & Therapeutic Antibody, School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - You Wang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Yue
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Cichos KH, Detweiler M, Parvizi J, McGwin G, Heatherly AR, Ghanem ES. The fate of positive intraoperative cultures following conversion total hip arthroplasty. Hip Int 2022; 32:17-24. [PMID: 32573261 DOI: 10.1177/1120700020936628] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The objectives of this study are to report the rates of positive intraoperative cultures obtained during conversion total hip arthroplasty (THA) according to index surgery, and to describe the natural history of treatment for a consecutive series of patients with unexpected positive intraoperative cultures during conversion THA. METHODS We reviewed all patients at 2 institutions undergoing conversion THA from prior open reduction and internal fixation (ORIF) of acetabular and hip fractures or hemiarthroplasty for displaced femoral neck fractures from 2011 to 2018. Intraoperative cultures were taken in 105 patients. Positive intraoperative cultures during conversion were recorded and managed with an infectious diseases consult. The outcomes including PJI at 90 days and 1 year follow-up were documented. RESULTS Overall, 19 of 105 patients (18%) undergoing conversion THA had positive intraoperative cultures, with the highest rates in the hemiarthroplasty 7/16 (44%) and acetabular ORIF 9/48 (19%) groups. All 19 patients were initially treated conservatively: 8 received IV antibiotics, 10 received no additional therapy, and 1 received oral antibiotics. 4/9 acetabular fracture conversions developed PJI at 1 year, with 3 requiring multiple irrigation and debridement/polyethylene exchanges to control the infection while the 4th patient required 2-stage exchange. There were no 1-year PJI from any of the other index procedures after conversion. All 7 hemiarthroplasty patients with positive cultures were treated to resolution with 4-8 weeks IV antibiotics alone. CONCLUSIONS Patients undergoing conversion THA from prior hip or acetabular fracture have a high rate of positive intraoperative cultures. As such, all patients undergoing conversion THA from prior hip or acetabular fracture fixation should undergo thorough diagnostic workup prior to surgery, and have intraoperative cultures obtained during surgery if infection remains suspicious. Further work should be performed to develop MSIS criteria for preoperative management of patients undergoing conversion THA.
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Affiliation(s)
- Kyle H Cichos
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Maxwell Detweiler
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Gerald McGwin
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Elie S Ghanem
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Van Belkum A, Gros MF, Ferry T, Lustig S, Laurent F, Durand G, Jay C, Rochas O, Ginocchio CC. Novel strategies to diagnose prosthetic or native bone and joint infections. Expert Rev Anti Infect Ther 2021; 20:391-405. [PMID: 34384319 DOI: 10.1080/14787210.2021.1967745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Bone and Joint Infections (BJI) are medically important, costly and occur in native and prosthetic joints. Arthroplasties will increase significantly in absolute numbers over time as well as the incidence of Prosthetic Joint Infections (PJI). Diagnosis of BJI and PJI is sub-optimal. The available diagnostic tests have variable effectiveness, are often below standard in sensitivity and/or specificity, and carry significant contamination risks during the collection of clinical samples. Improvement of diagnostics is urgently needed. AREAS COVERED We provide a narrative review on current and future diagnostic microbiology technologies. Pathogen identification, antibiotic resistance detection, and assessment of the epidemiology of infections via bacterial typing are considered useful for improved patient management. We confirm the continuing importance of culture methods and successful introduction of molecular, mass spectrometry-mediated and next-generation genome sequencing technologies. The diagnostic algorithms for BJI must be better defined, especially in the context of diversity of both disease phenotypes and clinical specimens rendered available. EXPERT OPINION Whether interventions in BJI or PJI are surgical or chemo-therapeutic (antibiotics and bacteriophages included), prior sensitive and specific pathogen detection remains a therapy-substantiating necessity. Innovative tests for earlier and more sensitive and specific detection of bacterial pathogens in BJI are urgently needed.
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Affiliation(s)
- Alex Van Belkum
- bioMérieux, Open Innovation and Partnerships, 3 Route De Port Michaud, La Balme Les Grottes, France
| | | | - Tristan Ferry
- Service Des Maladies Infectieuses Et Tropicales, Hospices Civils De Lyon, Hôpital De La Croix-Rousse, Lyon, France.,Maladies Infectieuses, Université Claude Bernard Lyon 1, Villeurbanne, France.,Centre Interrégional De Référence Pour La Prise En Charge Des Infections Ostéo-articulaires Complexes (Crioac Lyon), Hôpital De La Croix-Rousse, Lyon, France.,Ciri - Centre International De Recherche En Infectiologie, Inserm, U1111, Université́ Claude Bernard Lyon 1CNRS, UMR5308, Ecole Normale Supérieure De Lyon, Univ Lyon, Lyon, France
| | - Sebastien Lustig
- Maladies Infectieuses, Université Claude Bernard Lyon 1, Villeurbanne, France.,Service De Chirurgie Orthopédique, Hôpital De La Croix-Rousse, Lyon, France
| | - Frédéric Laurent
- Service Des Maladies Infectieuses Et Tropicales, Hospices Civils De Lyon, Hôpital De La Croix-Rousse, Lyon, France.,Ciri - Centre International De Recherche En Infectiologie, Inserm, U1111, Université́ Claude Bernard Lyon 1CNRS, UMR5308, Ecole Normale Supérieure De Lyon, Univ Lyon, Lyon, France
| | | | - Corinne Jay
- bioMérieux, BioFire Development Emea, Grenoble, France
| | - Olivier Rochas
- Corporate Business Development, bioMérieux, Marcy-l'Étoile, France
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Gramlich Y, Kremer M, Brüning C, Breuer J, Hofmann L, Klug A, Hoffmann R. Implementation of a standardized clinical test kit for diagnostics of periprosthetic infections in the clinical routine. Unfallchirurg 2021; 124:247-254. [PMID: 34338839 DOI: 10.1007/s00113-021-01016-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The number of primary arthroplasties is increasing and the proportion of revision arthroplasties is becoming increasingly more important. The need for standardized and guideline-based diagnostics for the safe detection of a periprosthetic joint infection (PJI) is becoming apparent. In the past 10 years various organizations have published definitions and diagnostic guidelines. The implementation of an inhouse standard test kit could help to simplify the process and could improve the diagnostic quality. METHOD In 2016 a test kit was compiled in a monocentric prospective study, taking the International Consensus Meeting (ICM) criteria 2014 and the Infectious Diseases Society of America (IDSA) criteria into account, which also fulfils the definitions of the ICM criteria 2018 and criteria of the European Bone and Joint Infection Society 2021. The test kit was implemented in the clinical setting of a special department for aseptic and septic revision arthroplasty. The usability and accuracy of the test kit were examined. RESULTS The test kit was implemented using blood samples (leukocyte count; C‑reactive protein, CRP), samples for examining the synovial fluid (white blood cell count, PMN cell differentiation, microbiological culture for incubation over 14 days, alpha-defensin enzyme-linked immunosorbent assay, ELISA, leukocyte esterase test strips) together with information and request forms. Between April 2016 and February 2020 a total of 405 patients were investigated. Within 3 calendar years, the use of the test kit increased from 59% initially to 86%, and finally to 96% of cases in the third calendar year. The leukocyte esterase test strip was reliable in only 72%, due to undifferentiated readability or blood contamination. The costs increased by the only commercially available alpha-defensin ELISA test by approx. 52€ per puncture. The best individual test showed a sensitivity/specificity of 92.8%/95.2% with alpha-defensin. It was calculated which combinations showed a similar test quality and different combinations, such as CRP+ cell count+ microbiology showed a sensitivity/specificity both of around 90%. Metallosis is a challenge for preoperative PJI diagnostics. DISCUSSION In a prospective study it was shown, that the implementation of the standardized test kit lead to a guideline based PJI diagnostic in all cases and thus to a significantly increase of the diagnostic quality. There is currently no single test that reliably excludes or proves an infection. The alpha-defensin laboratory ELISA test showed the best test accuracy, whereby the consideration of test combinations is obligatory and at the same time safe.
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Affiliation(s)
- Y Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany.
| | - M Kremer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - C Brüning
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - J Breuer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - L Hofmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - A Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - R Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
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11
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Gramlich Y, Kremer M, Brüning C, Breuer J, Hofmann L, Klug A, Hoffmann R. [Implementation of a standardized clinical test kit for diagnostics of periprosthetic infections in the clinical routine. German version]. Unfallchirurg 2021; 125:381-388. [PMID: 34189589 DOI: 10.1007/s00113-021-01017-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The number of primary arthroplasties is increasing and the proportion of revision arthroplasties is becoming increasingly more important. The need for standardized and guideline-based diagnostics for the safe detection of a periprosthetic joint infection (PJI) is becoming apparent. In the past 10 years various organizations have published definitions and diagnostic guidelines. The implementation of an inhouse standard test kit could help to simplify the process and could improve the diagnostic quality. METHOD In 2016 a test kit was compiled in a monocentric prospective study, taking the International Consensus Meeting (ICM) criteria 2014 and the Infectious Diseases Society of America (IDSA) criteria into account, which also fulfils the definitions of the ICM criteria 2018 and criteria of the European Bone and Joint Infection Society 2021. The test kit was implemented in the clinical setting of a special department for aseptic and septic revision arthroplasty. The usability and accuracy of the test kit were examined. RESULTS The test kit was implemented using blood samples (leukocyte count; C‑reactive protein, CRP), samples for examining the synovial fluid (white blood cell count, PMN cell differentiation, microbiological culture for incubation over 14 days, alpha-defensin enzyme-linked immunosorbent assay, ELISA, leukocyte esterase test strips) together with information and request forms. Between April 2016 and February 2020 a total of 405 patients were investigated. Within 3 calendar years, the use of the test kit increased from 59% initially to 86%, and finally to 96% of cases in the third calendar year. The leukocyte esterase test strip was reliable in only 72%, due to undifferentiated readability or blood contamination. The costs increased by the only commercially available alpha-defensin ELISA test by approx. 52€ per puncture. The best individual test showed a sensitivity/specificity of 92.8%/95.2% with alpha-defensin. It was calculated which combinations showed a similar test quality and different combinations, such as CRP+ cell count+ microbiology showed a sensitivity/specificity both of around 90%. Metallosis is a challenge for preoperative PJI diagnostics. DISCUSSION In a prospective study it was shown, that the implementation of the standardized test kit lead to a guideline based PJI diagnostic in all cases and thus to a significantly increase of the diagnostic quality. There is currently no single test that reliably excludes or proves an infection. The alpha-defensin laboratory ELISA test showed the best test accuracy, whereby the consideration of test combinations is obligatory and at the same time safe.
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Affiliation(s)
- Y Gramlich
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland.
| | - M Kremer
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - Chr Brüning
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - J Breuer
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - L Hofmann
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - A Klug
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - R Hoffmann
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
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12
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Karczewski D, Pumberger M, Müller M, Andronic O, Perka C, Winkler T. Implications for diagnosis and treatment of peri-spinal implant infections from experiences in periprosthetic joint infections-a literature comparison and review. JOURNAL OF SPINE SURGERY 2020; 6:800-813. [PMID: 33447686 DOI: 10.21037/jss-20-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Both, periprosthetic joint infection (PJI) and peri-spinal implant infection (PSII) are serious complications occurring in arthroplasty and spine instrumentation with absolute numbers expected to rise in the next years. The currently existing literature data describing the characteristics of PSII are limited when compared to PJI studies. However, both PJI and PSII exhibit similarities concerning pathogenesis, symptoms, diagnosis, treatment and prognosis. This literature review aims at comparing PJI and PSII and to develop implications for diagnosis and treatment of PSII from existing studies about PJI. The review was performed on the basis of a structured PubMed, Cochrane Library, and Medline analysis and existing guidelines, with 99 references being included. The results indicate that specific terms like re-infection should be defined in the context of PSII based on existing definitions of PJI, that in vitro biofilm studies and studies analyzing different prosthesis surfaces in arthroplasty could be used for PSII, and that histopathology as an additional standard tool in PSII diagnosis might be helpful. In addition, the development of a standardized algorithm-based treatment system with antibiotic protocols, including long term suppression, for PSII similar to the ones existing for PJI is necessary.
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Affiliation(s)
- Daniel Karczewski
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Michael Müller
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Octavian Andronic
- Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Tobias Winkler
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany.,Julius Wolff Institute, Charité - Universit tsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Charité - Universit tsmedizin Berlin, Berlin, Germany
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13
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Schulz P, Dlaska CE, Perka C, Trampuz A, Renz N. Preoperative synovial fluid culture poorly predicts the pathogen causing periprosthetic joint infection. Infection 2020; 49:427-436. [PMID: 33141393 PMCID: PMC8159841 DOI: 10.1007/s15010-020-01540-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/12/2020] [Indexed: 11/09/2022]
Abstract
Purpose We investigated the value of preoperative pathogen detection and evaluated its concordance with intraoperative cultures in patients with culture-positive periprosthetic joint infection (PJI). Methods Culture-positive PJI episodes with available preoperative (synovial fluid) and intraoperative cultures (periprosthetic tissue, synovial or sonication fluid) were analyzed. The pathogen detection rate in preoperative and intraoperative cultures was compared using Fisher’s exact test and their concordance was calculated. Results Among 167 included PJI episodes, 150 were monomicrobial with coagulase-negative staphylococci (n = 55, 37%), S. aureus (n = 34, 23%), and streptococci (n = 21, 14%) being the most common pathogens. Seventeen episodes (10%) were polymicrobial infections. The pathogen(s) grew in preoperative culture in 110 and in intraoperative cultures in 153 episodes (66% vs. 92%, p < 0.001). The pathogen detection rate was lower in preoperative compared to intraoperative cultures for low-virulent pathogens (40% vs. 94%, p < 0.001), polymicrobial infections (59% vs. 100%, p = 0.007), and in delayed and late PJI (63% vs. 94%, and 66% vs. 91%, respectively, p < 0.001). Full concordance of preoperative and intraoperative cultures was found in 87 episodes (52%). The pathogen was detected solely preoperatively in 14 episodes (8%) and solely intraoperatively in 57 cases (34%); an additional pathogen was found in 3 episodes (2%) preoperatively and in 6 episodes (4%) intraoperatively. Conclusion The concordance of preoperative and intraoperative cultures was poor (52%). The sole or an additional pathogen was found exclusively in intraoperative cultures in 38% of PJI episodes, hence preoperative synovial fluid cultures are considered unreliable for pathogen detection in PJI.
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Affiliation(s)
- Philipp Schulz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Constantin E Dlaska
- Orthopaedic Research Institute of Queensland, 7 Turner Street, Pimlico, Townsville, QLD, 4812, Australia
| | - Carsten Perka
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Nora Renz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany.
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14
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Wasterlain AS, Goswami K, Ghasemi SA, Parvizi J. Diagnosis of Periprosthetic Infection: Recent Developments. J Bone Joint Surg Am 2020; 102:1366-1375. [PMID: 32769605 DOI: 10.2106/jbjs.19.00598] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ There is no absolute test for the preoperative diagnosis of periprosthetic joint infection (PJI); thus, clinical practice relies on a combination of supportive tests and criteria.➤ Novel serum and synovial tests have improved our ability to diagnose PJI. The 2018 evidence-based algorithm for PJI diagnosis provides weighted scores for serum markers, as well as synovial markers, to facilitate diagnosis when major criteria such as positive cultures or a sinus tract are not present.➤ Culture-independent technologies such as next-generation sequencing can facilitate pathogen identification, particularly in the setting of culture-negative PJI.➤ Despite recent developments, PJI diagnosis remains challenging and warrants further innovation.
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Affiliation(s)
- Amy S Wasterlain
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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15
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Kim HJ, Kim S, Mun JU, Bae KC, Kim J, Kyung HS. Diagnosis of periprosthetic joint bacterial infections by culture of sonication fluid from infected implants. J Orthop Surg (Hong Kong) 2020; 27:2309499019832417. [PMID: 30803320 DOI: 10.1177/2309499019832417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE This study compared the results of a culture method using sonication with those yielded by the conventional culture method, for patients with infected total knee arthroplasty (TKA). We also evaluated the usefulness of sonication for the identification of pathogens in infected TKA cases. METHODS Isolates were cultured from 13 implants that had been removed from 13 patients with infected TKA. Preoperative culture was performed on aspirated joint fluid, and during the operation, infected tissue was collected for culture. The removed prosthetic implants were cultured before and after sonication. Next, we identified the cultured bacteria using API biochemical kits and 16 S rRNA sequencing. RESULTS The cultures from preoperative joint fluid and intraoperative tissue were positive in 9 of 13 cases (69.2%). For the removed implants, 10 cases were positive before sonication. After sonication, 12 cases (92.3%) had positive cultures. The pathogen most commonly isolated from the cultures was Staphylococcus aureus. CONCLUSIONS This study found that a culturing workflow incorporating sonication diagnosed pathogens in patients with infected TKA with higher sensitivity than did the conventional culturing method.
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Affiliation(s)
- Hee-June Kim
- 1 Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Shukho Kim
- 2 Department of Microbiology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jong-Uk Mun
- 3 Department of Orthopaedic Surgery, Changwon Gyeongsang National University Hospital, Changwon, South Korea
| | - Ki-Cheor Bae
- 4 Department of Orthopaedic Surgery, Keimyung University School of Medicine, Daegu, South Korea
| | - Jungmin Kim
- 2 Department of Microbiology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Hee-Soo Kyung
- 1 Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
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16
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Green M, Tung E, Al-Dadah O. The value of ring-fenced beds in elective lower limb arthroplasty. Br J Hosp Med (Lond) 2020; 80:405-409. [PMID: 31283397 DOI: 10.12968/hmed.2019.80.7.405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Infection is a serious complication of prosthetic joint arthroplasty, associated with high rates of morbidity resulting in further surgical intervention and prolonged inpatient hospital admission. Rates of prosthetic joint infection have been reported as 1.5-2.5% following lower limb arthroplasty. This study compared infection rates in patients receiving primary hip and knee joint replacements before and after implementation of ring-fenced beds. METHODS Retrospective study of all patients undergoing primary total hip replacement and total knee replacement from April 2013 to February 2014. Group 1 included pre-ring-fencing patients, group 2 included post-ring-fencing patients. RESULTS The overall infection rate pre-ring-fencing was 6.3% (n=8). This reduced to 2.7% (n=3) post-ring-fencing. The mean inpatient length of stay for group 1 was 6 days vs 4 days for group 2. CONCLUSIONS Ring-fencing beds for patients undergoing elective lower limb arthroplasty significantly reduced rates of prosthetic joint infection and inpatient length of stay.
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Affiliation(s)
- Matthew Green
- Senior House Officer, Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, South Shields NE34 0PL
| | - Eleanor Tung
- Senior House Officer, Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, South Shields NE34 0PL
| | - Oday Al-Dadah
- Consultant Orthopaedic Surgeon, Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, South Shields, Tyne and Wear, and Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne
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17
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The Quality of Diagnostic Studies in Periprosthetic Joint Infections: Can We Do Better? J Arthroplasty 2019; 34:2737-2743. [PMID: 31324355 DOI: 10.1016/j.arth.2019.06.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The diagnosis of periprosthetic joint infections (PJIs) continues to be a subject of extensive debate. This is in part due to the lack of a single "gold standard" test, and the marked heterogeneity in the design of studies evaluating the accuracy of different diagnostic modalities. The goal of this review is to critically analyze the evidence cited by the proceedings of the 2013 International Consensus Meeting (ICM) on PJI with regards to the diagnosis of PJI. METHODS References from the Proceedings of the ICM on PJI related to PJI minor criteria were retrieved and manually reviewed. A total of 25 studies were analyzed using a Validated Quality Assessment of Diagnostic Accuracy Studies tool. RESULTS A large number of studies were determined to have a high risk of bias for flow and timing domains due to the large numbers of exclusions. Studies of synovial white blood cells count and polymorphonuclear neutrophils percentage suffered from threshold optimization and lack of internal validity. Furthermore, due to the lack of homogeneity across studies, index test and reference standard domains showed high risk of bias for white blood cell/polymorphonuclear neutrophil percentage and the utility histological analysis, respectively. Leukocyte esterase testing lacked standardization with regard to the strip reagent used, and the exclusion of bloody samples limited sample sizes. CONCLUSION The 2013 ICM minor criteria were based on studies with a low quality of evidence. As the committee continues to adjust these guidelines, they should encourage future studies with sound clinical design, patient selection, and testing procedures.
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18
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Carli AV, Abdelbary H, Ahmadzai N, Cheng W, Shea B, Hutton B, Sniderman J, Philip Sanders BS, Esmaeilisaraji L, Skidmore B, Gauthier-Kwan OY, Bunting AC, Gauthier P, Crnic A, Logishetty K, Moher D, Fergusson D, Beaulé PE. Diagnostic Accuracy of Serum, Synovial, and Tissue Testing for Chronic Periprosthetic Joint Infection After Hip and Knee Replacements: A Systematic Review. J Bone Joint Surg Am 2019; 101:635-649. [PMID: 30946198 DOI: 10.2106/jbjs.18.00632] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint replacement. Patients with chronic PJI report a substantially lower quality of life and face a higher risk of short-term mortality. Establishing a diagnosis of chronic PJI is challenging because of conflicting guidelines, numerous tests, and limited evidence. Delays in diagnosing PJI are associated with poorer outcomes and morbid revision surgery. The purpose of this systematic review was to compare the diagnostic accuracy of serum, synovial, and tissue-based tests for chronic PJI. METHODS This review adheres to the Cochrane Collaboration's diagnostic test accuracy methods for evidence searching and syntheses. A detailed search of MEDLINE, Embase, the Cochrane Library, and the grey literature was performed to identify studies involving the diagnosis of chronic PJI in patients with hip or knee replacement. Eligible studies were assessed for quality and bias using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Meta-analyses were performed on tests with sufficient data points. Summary estimates and hierarchical summary receiver operating characteristic (HSROC) curves were obtained using a bivariate model. RESULTS A total of 12,616 citations were identified, and 203 studies met the inclusion criteria. Of these 203 studies, 170 had a high risk of bias. Eighty-three unique PJI diagnostic tests were identified, and 17 underwent meta-analyses. Laboratory-based synovial alpha-defensin tests and leukocyte esterase reagent (LER) strips (2+) had the best performance, followed by white blood-cell (WBC) count, measurement of synovial C-reactive protein (CRP) level, measurement of the polymorphonuclear neutrophil percentage (PMN%), and the alpha-defensin lateral flow test kit (Youden index ranging from 0.78 to 0.94). Tissue-based tests and 3 serum tests (measurement of interleukin-6 [IL-6] level, CRP level, and erythrocyte sedimentation rate [ESR]) had a Youden index between 0.61 to 0.75 but exhibited poorer performance compared with the synovial tests mentioned above. CONCLUSIONS The quality of the literature pertaining to chronic PJI diagnostic tests is heterogeneous, and the studies are at a high risk for bias. We believe that greater transparency and more complete reporting in studies of diagnostic test results should be mandated by peer-reviewed journals. The available literature suggests that several synovial fluid-based tests perform well for diagnosing chronic PJI and their use is recommended in the work-up of any suspected case of chronic PJI. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alberto V Carli
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Nadera Ahmadzai
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Beverley Shea
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jhase Sniderman
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Leila Esmaeilisaraji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Becky Skidmore
- Independent Information Specialist, Ottawa, Ontario, Canada
| | | | | | - Paul Gauthier
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Agnes Crnic
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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19
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Abdel MP, Akgün D, Akin G, Akinola B, Alencar P, Amanatullah DF, Babazadeh S, Borens O, Vicente Cabral RM, Cichos KH, Deirmengian C, de Steiger R, Ghanem E, Radtke Gonçalves JR, Goodman S, Hamlin B, Hwang K, Klatt BA, Lee GC, Manrique J, Moon AS, Ogedegbe F, Salib CG, Tian S, Winkler T. Hip and Knee Section, Diagnosis, Pathogen Isolation, Culture: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S361-S367. [PMID: 30343972 DOI: 10.1016/j.arth.2018.09.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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20
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Karczewski D, Winkler T, Renz N, Trampuz A, Lieb E, Perka C, Müller M. A standardized interdisciplinary algorithm for the treatment of prosthetic joint infections. Bone Joint J 2019; 101-B:132-139. [PMID: 30700114 DOI: 10.1302/0301-620x.101b2.bjj-2018-1056.r1] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIMS In 2013, we introduced a specialized, centralized, and interdisciplinary team in our institution that applied a standardized diagnostic and treatment algorithm for the management of prosthetic joint infections (PJIs). The hypothesis for this study was that the outcome of treatment would be improved using this approach. PATIENTS AND METHODS In a retrospective analysis with a standard postoperative follow-up, 95 patients with a PJI of the hip and knee who were treated with a two-stage exchange between 2013 and 2017 formed the study group. A historical cohort of 86 patients treated between 2009 and 2011 not according to the standardized protocol served as a control group. The success of treatment was defined according to the Delphi criteria in a two-year follow-up. RESULTS Patients in the study group had a significantly higher Charlson Comorbidity Index (3.9 vs 3.1; p = 0.009) and rate of previous revisions for infection (52.6% vs 36%; p = 0.025), and tended to be older (69.0 vs 66.2 years; p = 0.075) with a broader polymicrobial spectrum (47.3% vs 33.7%; p = 0.062). The rate of recurrent infection (3.1% vs 10.4%; p = 0.048) and the mean time interval between the two stages of the procedure (66.6 vs 80.7 days; p < 0.001) were reduced significantly in the study group compared with the control group. CONCLUSION We were able to show that the outcome following the treatment of PJIs of the hip and knee is better when managed in a separate department with an interdisciplinary team using a standard algorithm.
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Affiliation(s)
- D Karczewski
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - T Winkler
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - N Renz
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - A Trampuz
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - E Lieb
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - C Perka
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - M Müller
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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21
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Lippmann T, Braubach P, Ettinger M, Kuehnel M, Laenger F, Jonigk D. Fluorescence in Situ Hybridization (FISH) for the Diagnosis of Periprosthetic Joint Infection in Formalin-Fixed Paraffin-Embedded Surgical Tissues. J Bone Joint Surg Am 2019; 101:e5. [PMID: 30653049 DOI: 10.2106/jbjs.18.00243] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND As the number of arthroplasties performed increases, periprosthetic joint infection (PJI) represents a common and challenging problem. The Musculoskeletal Infection Society (MSIS) recommends diagnosing PJI according to its guidelines. The aim of the current study was to assess whether fluorescence in situ hybridization (FISH) analysis of formalin-fixed paraffin-embedded periprosthetic membranes can successfully improve the diagnosis of infection in patients with orthopaedic implants. METHODS We retrospectively analyzed 88 periprosthetic membranes of joint prostheses using FISH analysis according to a standard protocol, with a probe targeting a sequence found in most bacteria. We compared the results with routine clinical classification according to the guidelines of the MSIS, microbiological culture, and histopathological classification according to Morawietz and Krenn. We additionally performed FISH analysis using 2 species-specific probes for several culture-positive cases. RESULTS FISH successfully detected bacteria in 38 (95%) of 40 periprosthetic membranes that were rated positive by clinical classification. FISH results compared with clinical classification demonstrated a sensitivity of 95% (95% confidence interval [CI], 83.08% to 99.39%), a specificity of 85.42% (95% CI, 72.24% to 93.93%), a positive predictive value of 84.44% (95% CI, 70.55% to 93.50%), and a negative predictive value of 95.35% (95% CI, 84.19% to 99.43%). FISH results compared with histopathological classification demonstrated a sensitivity of 95.12% (95% CI, 83.47% to 99.40%), a specificity of 87.23% (95% CI, 74.26% to 95.17%), a positive predictive value of 86.67% (95% CI, 73.21% to 94.95%), and a negative predictive value of 95.35% (95% CI, 84.19% to 99.43%). We successfully detected Pseudomonas aeruginosa and Staphylococcus aureus with species-specific FISH probes in all cases that were positive for these respective bacteria by microbiological culture. CONCLUSIONS FISH-based diagnosis of PJI is feasible and can be used as an additional diagnostic criterion. FISH not only can detect bacteria in periprosthetic membranes but can also differentiate pathogens at the species level. FISH represents a fast and reliable tool for detecting PJI in periprosthetic membranes, especially in combination with clinical and histopathological classification. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Torsten Lippmann
- Institute of Pathology (T.L., P.B., M.K., F.L., and D.J.) and Department of Orthopaedic Surgery (M.E.), Hannover Medical School (MHH), Hannover, Germany
| | - Peter Braubach
- Institute of Pathology (T.L., P.B., M.K., F.L., and D.J.) and Department of Orthopaedic Surgery (M.E.), Hannover Medical School (MHH), Hannover, Germany
| | - Max Ettinger
- Institute of Pathology (T.L., P.B., M.K., F.L., and D.J.) and Department of Orthopaedic Surgery (M.E.), Hannover Medical School (MHH), Hannover, Germany
| | - Mark Kuehnel
- Institute of Pathology (T.L., P.B., M.K., F.L., and D.J.) and Department of Orthopaedic Surgery (M.E.), Hannover Medical School (MHH), Hannover, Germany
| | - Florian Laenger
- Institute of Pathology (T.L., P.B., M.K., F.L., and D.J.) and Department of Orthopaedic Surgery (M.E.), Hannover Medical School (MHH), Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (Deutsches Zentrum für Lungenforschung [DZL]), Hannover, Germany
| | - Danny Jonigk
- Institute of Pathology (T.L., P.B., M.K., F.L., and D.J.) and Department of Orthopaedic Surgery (M.E.), Hannover Medical School (MHH), Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (Deutsches Zentrum für Lungenforschung [DZL]), Hannover, Germany
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Abstract
Periprosthetic joint infection (PJI) is a serious complication after arthroplasty, which is associated with pain, prolonged hospital stay, multiple surgeries, functional incapacitation, and even mortality. Using scientific and efficient management protocol including modern diagnosis and treatment of PJI and eradication of infection is possible in a high percentage of affected patients. In this article, we review the current knowledge in epidemiology, classification, pathogenesis, diagnosis and treatment of PJI.
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Affiliation(s)
- Cheng Li
- Center for Musculoskeletal Surgery (CMSC), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Nora Renz
- Center for Musculoskeletal Surgery (CMSC), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery (CMSC), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Bémer P, Léger J, Milin S, Plouzeau C, Valentin AS, Stock N, Jolivet-Gougeon A, Moreau A, Corvec S, Quintin-Roue I, Tandé D, Héry-Arnaud G, Rousselet MC, Lemarié C, Kempf M, Michenet P, Bret L, de Pinieux G, Burucoa C. Histopathological Diagnosis of Prosthetic Joint Infection: Does a Threshold of 23 Neutrophils Do Better than Classification of the Periprosthetic Membrane in a Prospective Multicenter Study? J Clin Microbiol 2018; 56:e00536-18. [PMID: 29976593 PMCID: PMC6113493 DOI: 10.1128/jcm.00536-18] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/26/2018] [Indexed: 01/07/2023] Open
Abstract
No gold standard exists for histopathological diagnosis of a prosthetic joint infection (PJI). The historical criterion considers the presence of neutrophil infiltration upon examination of periprosthetic tissue. Morawietz et al. proposed a classification of periprosthetic membranes (Morawietz et al., Clin Pathol 59:591-597, 2006, https://doi.org/10.1136/jcp.2005.027458) and a more recently described classification with a new cutoff value of 23 neutrophils in 10 high-power fields (Morawietz et al., Histopathology 54:847-853, 2009. https://doi.org/10.1111/j.1365-2559.2009.03313.x). We performed a multicenter prospective study, which compared both methods for the diagnosis of PJI. All suspicions of PJI (n = 264) between December 2010 and March 2012 in seven centers were prospectively included. Five perioperative specimens were collected per patient for cultures, and one was collected for histology. Diagnosis of PJI was made according to the Infectious Diseases Society of America (IDSA) guidelines. Histopathological analysis classified the patients according to the threshold of 23 neutrophils and according to the classification of Morawietz. Performances of both methods were compared by using clinical and/or bacteriological criteria as the gold standard. Among 264 patients with suspected PJI, a diagnosis of infection was confirmed in 215 and unconfirmed in 49 patients. Histopathological analysis was available for 150 confirmed PJI and 40 unconfirmed PJI cases. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 78.7%, 90.0%, 96.7%, 52.9%, and 81.1%, respectively, for the Morawietz classification, and 82.0%, 90.0%, 96.9%, 57.1%, and 83.7%, respectively, for the 23-neutrophil threshold. The new algorithm using a threshold of 23 neutrophils can be proposed as a new gold standard for the histopathological diagnosis of PJI.
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Affiliation(s)
- Pascale Bémer
- Department of Bacteriology, Nantes University Hospital, Nantes, France
| | - Julie Léger
- Inserm, CIC 1415, Tours, France
- Tours University Hospital, Tours, France
| | - Serge Milin
- Department of Anatomopathology, Poitiers University Hospital, Poitiers, France
| | - Chloé Plouzeau
- Department of Bacteriology, Poitiers University Hospital, Poitiers, France
| | | | - Nathalie Stock
- Department of Anatomopathology, Rennes University Hospital, Rennes, France
| | | | - Anne Moreau
- Department of Anatomopathology, Nantes University Hospital, Nantes, France
| | - Stéphane Corvec
- Department of Bacteriology, Nantes University Hospital, Nantes, France
| | | | - Didier Tandé
- Department of Bacteriology, Brest University Hospital, Brest, France
| | | | | | - Carole Lemarié
- Department of Bacteriology, Angers University Hospital, Angers, France
| | - Marie Kempf
- Department of Bacteriology, Angers University Hospital, Angers, France
| | - Patrick Michenet
- Department of Anatomopathology, Orléans Hospital, Orléans, France
| | - Laurent Bret
- Department of Bacteriology, Orléans Hospital, Orléans, France
| | | | - Christophe Burucoa
- Department of Bacteriology, Poitiers University Hospital, Poitiers, France
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Bosch P, van den Kieboom J, Plate JDJ, IJpma FFA, Houwert RM, Huisman A, Hietbrink F, Leenen LPH, Govaert GAM. Limited Predictive Value of Serum Inflammatory Markers for Diagnosing Fracture-Related Infections: results of a large retrospective multicenter cohort study. J Bone Jt Infect 2018; 3:130-137. [PMID: 30013894 PMCID: PMC6043470 DOI: 10.7150/jbji.26492] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/12/2018] [Indexed: 01/09/2023] Open
Abstract
Introduction: Diagnosing Fracture-Related Infections (FRI) based on clinical symptoms alone can be challenging and additional diagnostic tools such as serum inflammatory markers are often utilized. The aims of this study were 1) to determine the individual diagnostic performance of three commonly used serum inflammatory markers: C-Reactive Protein (CRP), Leukocyte Count (LC) and Erythrocyte Sedimentation Rate (ESR), and 2) to determine the diagnostic performance of a combination of these markers, and the additional value of including clinical parameters predictive of FRI. Methods: This cohort study included patients who presented with a suspected FRI at two participating level I academic trauma centers between February 1st 2009 and December 31st 2017. The parameters CRP, LC and ESR, determined at diagnostic work-up of the suspected FRI, were retrieved from hospital records. The gold standard for diagnosing or ruling out FRI was defined as: positive microbiology results of surgically obtained tissue samples, or absence of FRI at a clinical follow-up of at least six months. The diagnostic accuracy of the individual serum inflammatory markers was assessed. Analyses were done with both dichotomized values using hospital thresholds as well as with continuous values. Multivariable logistic regression analyses were performed to obtain the discriminative performance (Area Under the Receiver Operating Characteristic, AUROC) of (1) the combined inflammatory markers, and (2) the added value of these markers to clinical parameters. Results: A total of 168 patients met the inclusion criteria and were included for analysis. CRP had a 38% sensitivity, 34% specificity, 42% positive predictive value (PPV) and 78% negative predictive value (NPV). For LC this was 39%, 74%, 46% and 67% and for ESR 62%, 64%, 45% and 76% respectively. The diagnostic accuracy was 52%, 61% and 80% respectively. The AUROC was 0.64 for CRP, 0.60 for LC and 0.58 for ESR. The AUROC of the combined inflammatory markers was 0.63. Serum inflammatory markers combined with clinical parameters resulted in AUROC of 0.66 as opposed to 0.62 for clinical parameters alone. Conclusion: The added value of CRP, LC and ESR for diagnosing FRI is limited. Clinicians should be cautious when interpreting the results of these tests in patients with suspected FRI.
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Affiliation(s)
- Paul Bosch
- Department of General Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Janna van den Kieboom
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost D J Plate
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank F A IJpma
- Department of General Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Marijn Houwert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Albert Huisman
- Department of Clinical Chemistry and Haematology, University Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Geertje A M Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
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The Preoperative Microbial Detection is No Prerequisite for the Indication of Septic Revision in Cases of Suspected Periprosthetic Joint Infection. BIOMED RESEARCH INTERNATIONAL 2018; 2018:1729605. [PMID: 30035117 PMCID: PMC6032972 DOI: 10.1155/2018/1729605] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/11/2018] [Accepted: 05/29/2018] [Indexed: 12/20/2022]
Abstract
Aim of This Study Periprosthetic joint infections (PJIs) require a special antimicrobial regimen, fundamentally different from an aseptic treatment, making a correct preoperative diagnosis essential. However, a successful preoperative microbe detection is not always possible. We wanted to find out (1) if a preoperative microbe detection is a prerequisite before starting a septic revision in suspected PJIs or if the preoperative diagnosis can solely be based on (para)clinical signs (persistent CRP >1 mg/dl, early X-ray loosening signs in the first 5 years, leucocytes joint aspiration >1700/µl, conspicuous history, and clinical signs like redness, pain, hyperthermia, swelling, and loss of function); (2) if patients with and without preoperative microbe detection have a different outcome; and (3) if the microbial growth is the most important criterion of a multifactorial PJI definition. Methods We included all first-line two-stage hip (49) and knee (47) revisions, performed in our department from 06/2013 on, with an available 2-year follow-up. A PJI was defined as one of the following four criteria: fistula or purulence, Krenn Morawietz type 2 or 3, joint aspirate > 2000/μl leukocytes or >70% granulocytes, and microbial growth. This multifactorial PJI definition was based on the European Bone and Joint Infection Society (EBJIS). The standardized diagnostic algorithm is described in detail. Results (1) 24 hip and 16 knee cases were treated without preoperative microbe detection solely on the basis of a (para)clinical diagnosis (see above). In the hip 91.6% (22 of 24 cases) showed an intraoperative microbe detection. In the knee, in 68.7% (11 of 16 cases) a microbe was detected intraoperatively and in 93.7% (15 of 16) at least one secure PJI criterion could be confirmed intraoperatively. (2) No statistical significant (p .517) difference between patients with (n = 56, reinfection rate 8.9%) and without (n = 40, 15%) preoperative microbe detection was found in a 2-year follow-up. (3) Microbial growth remains the overall (pre- and intraoperatively) most important criterion (hip 95.9%; knee 89.3%), followed by Krenn Morawietz for the intraoperative diagnosis (hip 67.3%, knee 48.9%), and joint aspiration for the knee and fistula for the hip, respectively, as preoperative criteria. Conclusion High rates of intraoperatively fulfilled EBJIS PJI criteria show that a preoperative microbe detection is not necessary before intervening in suspected PJIs. The indication for a septic revision can solely be based on (para)clinical signs. The new established diagnostic algorithm based on a multifactorial PJI definition showed high precision in finding PJIs.
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de Saint Vincent B, Migaud H, Senneville E, Loiez C, Pasquier G, Girard J, Putman S. Diagnostic accuracy of the alpha defensin lateral flow device (Synovasure) for periprosthetic infections in microbiologically complex situations: A study of 42 cases in a French referral centre. Orthop Traumatol Surg Res 2018; 104:427-431. [PMID: 29581070 DOI: 10.1016/j.otsr.2018.01.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 12/24/2017] [Accepted: 01/03/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Joint aspiration is currently the reference standard test for diagnosing periprosthetic joint infection (PJI) despite the high rate of false-negative results, of which a major cause is the fastidious nature of some microorganisms. A rapid diagnostic test that detects alpha defensin (Synovasure™, Zimmer, Warsaw, IN, USA) in joint fluid can provide the diagnosis of PJI within a few minutes across the full spectrum of causative organisms (including mycobacteria and yeasts). Its performance in detecting bacterial infections is unaltered by concomitant antibiotic therapy. Few studies of Synovasure™ have been conducted by groups that were involved in designing the test, which has not been validated in France. Assessments in referral centres where complex microbiological situations are common hold considerable interest. The objective of this prospective study was to determine the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and causes of error of Synovasure™ used to diagnose periprosthetic infection in complex microbiological situations. HYPOTHESIS The rapid diagnostic test Synovasure™ has greater than 90% NPV for detecting periprosthetic infections in complex microbiological infections. MATERIAL AND METHODS Synovasure™ was used 42 times in 39 patients between October 2015 and October 2017 in challenging microbiological situations [discordant joint aspiration results (n=20), negative cultures with clinical or laboratory evidence of infection, (n=21), and concomitant antibiotic therapy (n=1)]. Of the 39 patients, 23 had total knee prostheses, 13 total hip prostheses, and 3 total femoral prostheses. The reference standard to which the Synovasure™ results were compared was the PJI criteria set developed by the Musculoskeletal Infection Society (MSIS). RESULTS Synovasure™ was negative in 30 cases with negative joint fluid cultures (30/42, 71.4%). Of the 12 (28.6%) cases with positive Synovasure™ results, only 7 (7/12, 58.3%) had positive joint fluid cultures. According to the MSIS criteria 9 cases were infected, including 8 with positive and 1 with negative Synovasure™ results. Of the 33 cases that were not infected according to MSIS criteria, 29 had negative and 3 positive Synovasure™ results; the remaining case had a positive Synovasure™ result but was excluded when metallosis was found intra-operatively. NPV was 96.7%, PPV 72.7%, sensitivity 88.9%, and specificity 90.6%. DISCUSSION The high NPV of Synovasure™ suggests a role for this test in microbiologically complex situations as a new tool for ruling in and, most importantly, ruling out infection in doubtful cases. LEVEL OF EVIDENCE III, prospective study of diagnostic accuracy.
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Affiliation(s)
- B de Saint Vincent
- Centre de référence pour le traitement des infections ostéo-articulaires complexes (CRIOAC), avenue du Professeur-Émile-Laine, 59037 Lille-Tourcoing, France; Université Lille-Nord-de-France, 59000 Lille, France; Service d'orthopédie, hôpital Salengro, CHU de Lille, place de Verdun, 59037 Lille, France.
| | - H Migaud
- Centre de référence pour le traitement des infections ostéo-articulaires complexes (CRIOAC), avenue du Professeur-Émile-Laine, 59037 Lille-Tourcoing, France; Université Lille-Nord-de-France, 59000 Lille, France; Service d'orthopédie, hôpital Salengro, CHU de Lille, place de Verdun, 59037 Lille, France
| | - E Senneville
- Centre de référence pour le traitement des infections ostéo-articulaires complexes (CRIOAC), avenue du Professeur-Émile-Laine, 59037 Lille-Tourcoing, France; Université Lille-Nord-de-France, 59000 Lille, France; Service des maladies infectieuses, hôpital Dron, 59200 Tourcoing, France
| | - C Loiez
- Centre de référence pour le traitement des infections ostéo-articulaires complexes (CRIOAC), avenue du Professeur-Émile-Laine, 59037 Lille-Tourcoing, France; Université Lille-Nord-de-France, 59000 Lille, France; Service de bactériologie-hygiène, centre de biologie-pathologie, CHU de Lille, 59000 Lille, France
| | - G Pasquier
- Centre de référence pour le traitement des infections ostéo-articulaires complexes (CRIOAC), avenue du Professeur-Émile-Laine, 59037 Lille-Tourcoing, France; Université Lille-Nord-de-France, 59000 Lille, France; Service d'orthopédie, hôpital Salengro, CHU de Lille, place de Verdun, 59037 Lille, France
| | - J Girard
- Centre de référence pour le traitement des infections ostéo-articulaires complexes (CRIOAC), avenue du Professeur-Émile-Laine, 59037 Lille-Tourcoing, France; Université Lille-Nord-de-France, 59000 Lille, France; Service d'orthopédie, hôpital Salengro, CHU de Lille, place de Verdun, 59037 Lille, France; Département de médecine du sport, faculté de médecine de Lille, université de Lille 2, 59045 Lille, France
| | - S Putman
- Centre de référence pour le traitement des infections ostéo-articulaires complexes (CRIOAC), avenue du Professeur-Émile-Laine, 59037 Lille-Tourcoing, France; Université Lille-Nord-de-France, 59000 Lille, France; Service d'orthopédie, hôpital Salengro, CHU de Lille, place de Verdun, 59037 Lille, France; EA 2694 - Santé publique, épidémiologie et qualité des soins, CHU de Lille, Lille university, 59000 Lille, France
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Histopathology in Periprosthetic Joint Infection: When Will the Morphomolecular Diagnosis Be a Reality? BIOMED RESEARCH INTERNATIONAL 2018; 2018:1412701. [PMID: 29862251 PMCID: PMC5971260 DOI: 10.1155/2018/1412701] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/07/2018] [Indexed: 02/07/2023]
Abstract
The presence of a polymorphonuclear neutrophil infiltrate in periprosthetic tissues has been shown to correlate closely with the diagnosis of septic implant failure. The histological criterion considered by the Musculoskeletal Infection Society to be diagnostic of periprosthetic joint infection is “greater than five neutrophils per high-power field in five high-power fields observed from histologic analysis of periprosthetic tissue at ×400 magnification.” Surgeons and pathologists should be aware of the qualifications introduced by different authors during the last years in the histological techniques, samples for histological study, cutoffs used for the diagnosis of infection, and types of patients studied. Recently, immunohistochemistry and histochemistry studies have appeared which suggest that the cutoff point of five polymorphonuclear neutrophils in five high-power fields is too high for the diagnosis of many periprosthetic joint infections. Therefore, morphomolecular techniques could help in the future to achieve a more reliable histological diagnosis of periprosthetic joint infection.
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Gupta S, Loh KJ. Noncontact Electrical Permittivity Mapping and pH-Sensitive Films for Osseointegrated Prosthesis and Infection Monitoring. IEEE TRANSACTIONS ON MEDICAL IMAGING 2017; 36:2193-2203. [PMID: 28541895 DOI: 10.1109/tmi.2017.2707390] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The objective of this paper is to develop a noncontact, noninvasive system for detecting and monitoring subcutaneous infection occurring at the tissue and osseointegrated prosthesis interface. It is known that the local pH of tissue can change due to infection. Therefore, the sensing system integrates two parts, namely, pH-sensitive thin films that can be coated onto prosthesis surfaces prior to them being implanted and an electrical capacitance tomography (ECT) algorithm that can reconstruct the spatial permittivity distribution of a region of space in a noncontact fashion. First, a thin film pH sensor was fabricated by spray coating, and tests confirmed that the film exhibited changes in its permittivity due to pH. Second, the ECT forward and inverse problems were implemented. Third, an aluminum rod was employed as a representative phantom of an osseointegrated prosthesis and then spray coated with the pH sensor. Finally, the film-coated phantom was immersed in different pH buffers, dried, and subjected to ECT interrogation and spatial permittivity reconstruction. The results validated that ECT was able to detect and localize permittivity variations correlated to pH changes.
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Randelli F, Brioschi M, Randelli P, Ambrogi F, Sdao S, Aliprandi A. Fluoroscopy- vs ultrasound-guided aspiration techniques in the management of periprosthetic joint infection: which is the best? Radiol Med 2017; 123:28-35. [PMID: 28932957 DOI: 10.1007/s11547-017-0811-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Fluid samples obtained from an affected joint still play a central role in the diagnosis of periprosthetic joint infection (PJI). It is the only preoperative test able to discover the causative microbiological agent. In the hip, fluid aspiration can be performed through fluoroscopy, ultrasound, or, less commonly, computed tomography. However, there is still a lack of consensus on which method is preferable in terms of efficacy and costbenefit. PURPOSES We, therefore, asked whether (1) the benefits in terms of sensitivity and specificity and (2) the costs were comparable between fluoroscopy- and ultrasound-guided joint aspirations in a suspicious of hip PJI. METHODS Between 2013 and 2016, 52 hip aspirations were performed on 49 patients with clinical, radiological, or serological suspicion of PJI, waiting for a revision surgery. The patients were divided in two groups: fluoroscopy- (n = 26) vs ultrasound-guided hip aspiration group (n = 26). These groups were also divided in control and infected patients. The criteria of MusculoSkeletal Infection Society (MSIS) were used, as gold standard, to define PJI. RESULTS (1) Ultrasound-guided aspiration revealed valid sensitivity (89% vs 60%) and specificity (94% vs 81%) in comparison with fluoroscopic-guided aspiration. (2) The cost analysis was also in favor of ultrasound-guided aspiration (125.30€) than fluoroscopic-guided aspiration (343.58€). CONCLUSIONS We concluded that ultrasound-guided hip aspiration could represent a valid, safe, and less expensive diagnostic alternative to fluoroscopic-guided aspiration in hip PJI.
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Affiliation(s)
- Filippo Randelli
- Hip Department, Orthopedics and Trauma V, IRCCS Policlinico San Donato, S. Donato Milanese, Milan, Italy
| | - Marco Brioschi
- Hip Department, Orthopedics and Trauma V, IRCCS Policlinico San Donato, S. Donato Milanese, Milan, Italy. .,Department of Biomedical Sciences for Health, University of Milan, Piazza Malan 2, San. Donato Milanese, 20097, Milan, Italy.
| | - Pietro Randelli
- Department of Biomedical Sciences for Health, University of Milan, Piazza Malan 2, San. Donato Milanese, 20097, Milan, Italy
| | - Federico Ambrogi
- IRCCS Policlinico San Donato, Piazza Edmondo Malan 1, San. Donato Milanese, 20097, Milan, Italy
| | - Silvana Sdao
- Radiology Department, IRCCS Policlinico San Donato, S. Donato Milanese, Milan, Italy
| | - Alberto Aliprandi
- Radiology Department, IRCCS Policlinico San Donato, S. Donato Milanese, Milan, Italy
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Intravenous drug abuse is a risk factor in the failure of two-stage treatment for infected total hip arthroplasty. Kaohsiung J Med Sci 2017; 33:623-629. [PMID: 29132552 DOI: 10.1016/j.kjms.2017.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 08/01/2017] [Accepted: 08/16/2017] [Indexed: 12/15/2022] Open
Abstract
Reinfection after two-stage revision hip arthroplasty (RHA) is still a complex issue. Only few studies revealed the factors affecting the success rate in the treatment of periprosthetic hip infection (PHI), especially risk factors. A retrospective study was conducted using records of 30 patients underwent two-stage RHA for infected total hip arthroplasty (THA). Treatment was defined as successful if a patient did not need any reoperation or invasive procedure such as image-guided drainage during the two years after reimplantation. Treatment was defined as failure if any surgery or invasive procedure or long-term antibiotic suppression was considered necessary to control infection. Four patients had infection recurrence defined as failed and three of them had intravenous drug abuse. Twenty-six patients had no infection recurrence at the end of follow-up and one of them had intravenous drug abuse but quitting after surgery. We suggest that once adequate cleaning up achieved, risk of reinfection may be little even in immunocompromised patients with RHA because of relative less old age than those with revisional total knee arthroplasty. Patients of the reinfection group were younger and non-obese with adequate nutritional status. We may consider intravenous drug abuse could take a great toll on health and lead to reinfection. Finally, we suggest performing the gold-standard two-stage reimplantation technique to manage cases with infection, educating drug abusers regarding the risk of surgical failure, and implementing a quitting program at least 1 year before the index surgery.
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Preoperative joint aspiration in the diagnosis of non-acute hip and knee prosthetic joint infections. Med Mal Infect 2017; 47:364-369. [DOI: 10.1016/j.medmal.2017.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/06/2016] [Accepted: 04/10/2017] [Indexed: 11/23/2022]
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Fernández-Sampedro M, Fariñas-Alvarez C, Garces-Zarzalejo C, Alonso-Aguirre MA, Salas-Venero C, Martínez-Martínez L, Fariñas MC. Accuracy of different diagnostic tests for early, delayed and late prosthetic joint infection. BMC Infect Dis 2017; 17:592. [PMID: 28841913 PMCID: PMC6389211 DOI: 10.1186/s12879-017-2693-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 08/17/2017] [Indexed: 01/16/2023] Open
Abstract
Background A combination of laboratory, histopathological and microbiological tests for diagnosis of prosthetic joint infection (PJI) have been strongly recommended. This study aims to characterize the accuracy of individual or group tests, such as culture of sonicate fluid, synovial fluid and peri-implant tissue, C-reactive protein (CRP) and histopathology for detection of early, delayed and late PJI. Methods A prospective study of patients undergoing hip or knee arthroplasty from February 2009 to February 2014 was performed in a Spanish tertiary health care hospital. The diagnostic accuracy of the different methods was evaluated constructing receiver-operating-characteristic (ROC) curve areas. Results One hundred thirty consecutive patients were included: 18 (13.8%) early PJI, 35 (27%) delayed PJI and 77 (59.2%) late PJI. For individual parameters, the area under the ROC curve for peri-implant tissue culture was larger for early (0.917) than for delayed (0.829) and late PJI (0.778), p = 0.033. There was a significantly larger difference for ROC area in the synovial fluid culture for delayed (0.803) than for early (0.781) and late infections (0.679), p = 0.039. The comparison of the areas under the ROC curves for the two microbiological tests showed that sonicate fluid was significantly different from peri-implant tissue in delayed (0.951 vs 0.829, p = 0.005) and late PJI (0.901 vs 0.778, p = 0.000). The conjunction of preoperative parameters, synovial fluid culture and CRP, improved the accuracy for late PJI (p = 0.01). The conjunction of histopathology and sonicate fluid culture increased the area under ROC curve of sonication in early (0.917 vs 1.000); p = 0.06 and late cases (0.901 vs 0.999); p < 0.001. Conclusion For early PJI, sonicate fluid and peri-implant tissue cultures achieve the same best sensitivity. For delayed and late PJI, sonicate fluid culture is the most sensitive individual diagnostic method. By combining histopathology and peri-implant tissue, all early, 97% of delayed and 94.8% of late cases are diagnosed. The conjunction of histopathology and sonicate fluid culture yields a sensitivity of 100% for all types of infection.
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Affiliation(s)
- M Fernández-Sampedro
- Infectious Diseases Unit, Department of Medicine, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain.
| | - C Fariñas-Alvarez
- Division of Health Care Quality Hospital, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - C Garces-Zarzalejo
- Department of Orthopaedic Surgery, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - M A Alonso-Aguirre
- Department of Orthopaedic Surgery, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - C Salas-Venero
- Service of Microbiology, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - L Martínez-Martínez
- Service of Microbiology, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - M C Fariñas
- Infectious Diseases Unit, Department of Medicine, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain.
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Van Diek FM, Albers CGM, Van Hooff ML, Meis JF, Goosen JHM. Low sensitivity of implant sonication when screening for infection in revision surgery. Acta Orthop 2017; 88:294-299. [PMID: 28287012 PMCID: PMC5434598 DOI: 10.1080/17453674.2017.1300021] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and purpose - Prosthetic-joint infection (PJI) is the most serious complication of arthroplasty, and accurate identification of a potentially responsible microorganism is essential for successful antibiotic treatment. We therefore determined the diagnostic accuracy of sonication and compared it with tissue culture as a screening tool in detecting prosthetic joint infection in revision arthroplasty. Patients and methods - 252 consecutive revision arthroplasty cases were enrolled. These cases were determined as being suspected or unsuspected of having infection according to standard criteria. Perioperatively, 6 periprosthetic interface tissue biopsies were obtained from each patient and the implants removed were sonicated. The sensitivity and specificity of periprosthetic tissue culture and sonication fluid cultures were determined. Results - Preoperatively, 75 revision cases were classified as having PJI (33 early and 42 late) and 177 were unsuspected of having infection. Compared with tissue culture, the sensitivity of the sonication fluid analysis was low: 0.47 (95% CI: 0.35-0.59) for sonication as compared to 0.68 (95% CI: 0.56-0.78) for tissue culture. The specificity of the sonication fluid analysis was higher than that for tissue culture: 0.99 (95% CI: 0.96-1.0) as compared to 0.80 (95% CI: 0.74-0.86). Interpretation - Sonication is a highly specific test for diagnosis of PJI. However, due to the low sensitivity, a negative sonication result does not rule out the presence of PJI. Thus, sonication is not of value for screening of microorganisms during revision surgery.
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Affiliation(s)
- Floor M Van Diek
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek;,Correspondence:
| | - Christiaan G M Albers
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek
| | | | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Ziekenhuis;,Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
| | - Jon H M Goosen
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek
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Vilchez-Cavazos F, Villarreal-Villarreal G, Peña-Martinez V, Acosta-Olivo C. Management of periprosthetic infections. World J Clin Infect Dis 2017; 7:11-20. [DOI: 10.5495/wjcid.v7.i2.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 12/06/2016] [Accepted: 01/22/2017] [Indexed: 02/06/2023] Open
Abstract
Periprosthetic joint infection (PJI) is considered one of the most challenging complications compromising patient health and is considered an economic burden. Despite all strategies PJI prevalence is between 1%-2%. Considerable efforts have been investigated in the past decade to diminish or erradicate PJI prevalence. This article manages the definition of PJI and the new major and minor criteria from Parvizi et al Then a scientific analysis of every minor and major criteria. Multidisciplinary management is reccommended according to guidelines. A numerous of surgical options exist each and everyone with its indications, contraindications and specific antibiotic therapy regimen. Surgical options are: (1) irrigation and cleaning with retention of the prosthesis with a success rate 0%-89%; (2) single-stage revision surgery with a succes rate of > 80%; and (3) two-stage revision surgery (authors preferred method) with a succes rate of 87%. Radical treatment options like arthrodesis and amputation are reserved for specific group of patients, with a succes rate varying from 60%-100%. The future of PJI is focused on improving the diagnostic tools and to combat biofilm. The cornerstone of management consists in a rapid diagnosis and specific therapy. This article presents the most current diagnostic and treatment criteria as well as the different surgical treatment options depending on the type of infection, bacterial virulence and patient comorbidities.
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Pohlig F, Mühlhofer HML, Lenze U, Lenze FW, Suren C, Harrasser N, von Eisenhart-Rothe R, Schauwecker J. Diagnostic accuracy of arthroscopic biopsy in periprosthetic infections of the hip. Eur J Med Res 2017; 22:6. [PMID: 28259167 PMCID: PMC5336685 DOI: 10.1186/s40001-017-0246-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 02/28/2017] [Indexed: 01/26/2023] Open
Abstract
Background Diagnosis of a low-grade periprosthetic joint infection (PJI) prior to revision surgery can be challenging, despite paramount importance for further treatment. Arthroscopic biopsy of synovial and periprosthetic tissue with subsequent microbiological and histological examination can be beneficial but its specific diagnostic value has not been clearly defined. Methods 20 consecutive patients who underwent percutaneous synovial fluid aspiration as well as arthroscopic biopsy due to suspected PJI of the hip and subsequent one- or two-stage revision surgery at our institution between January 2012 and May 2015 were enrolled. Indication was based on the criteria (1) history of PJI and increased levels of erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), (2) suspicious cell count and differential but negative bacterial culture in synovial aspirate, (3) early loosening (<less than 2 years), or (4) persisting pain without loosening but history of a PJI. At least two criteria had to be fulfilled in order to perform an arthroscopic biopsy. Results Best overall diagnostic value was identified for arthroscopic biopsy and a combination of bacteriological and histological analysis with a sensitivity of 87.5%, specificity of 100% and accuracy of 95%. Bacteriological assessment of synovial aspirate revealed a sensitivity of 50.0%, specificity of 91.7%, and accuracy of 75%. ESR and CRP yielded a sensitivity of 75.0% for either hematologic test and specificities of 87.5 and 66.7%, respectively. Conclusions In conclusion, our data indicate that arthroscopic biopsy is superior to ESR and CRP as well as joint aspiration and their combinations. Concurrent microbiological and histological examination of the biopsy specimens allows for identification of the causative pathogen and its susceptibility pattern in order to preoperatively plan the surgical strategy as well as the antibiotic regimen. Moreover, intraarticular mechanical failure can be detected during hip arthroscopy emphasizing its diagnostic value. Level II diagnostic study.
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Affiliation(s)
- Florian Pohlig
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Heinrich M L Mühlhofer
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Ulrich Lenze
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Florian W Lenze
- Department of Traumatology, Klinikum Traunstein, Cuno-Niggl-Str. 3, 83278, Traunstein, Germany
| | - Christian Suren
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Norbert Harrasser
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Johannes Schauwecker
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
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Gallazzi E, Drago L, Baldini A, Stockley I, George DA, Scarponi S, Romanò CL. "Combined Diagnostic Tool" APPlication to a Retrospective Series of Patients Undergoing Total Joint Revision Surgery. J Bone Jt Infect 2017; 2:107-113. [PMID: 28540146 PMCID: PMC5441141 DOI: 10.7150/jbji.18308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Differentiating between septic and aseptic joint prosthesis may be challenging, since no single test is able to confirm or rule out infection. The choice and interpretation of the panel of tests performed in any case often relies on empirical evaluation and poorly validated scores. The "Combined Diagnostic Tool (CDT)" App, a smartphone application for iOS, was developed to allow to automatically calculate the probability of having a of periprosthetic joint infection, on the basis of the relative sensitivity and specificity of the positive and negative diagnostic tests performed in any given patient. Objective: The aim of the present study was to apply the CDT software to investigate the ability of the tests routinely performed in three high-volume European centers to diagnose a periprosthetic infection. Methods: This three-center retrospective study included 120 consecutive patients undergoing total hip or knee revision, and included 65 infected patients (Group A) and 55 patients without infection (Group B). The following parameters were evaluated: number and type of positive and negative diagnostic tests performed pre-, intra- and post-operatively and resultant probability calculated by the CDT App of having a peri-prosthetic joint infection, based on pre-, intra- and post-operative combined tests. Results: Serological tests were the most common performed, with an average 2.7 tests per patient for Group A and 2.2 for Group B, followed by joint aspiration (0.9 and 0.8 tests per patient, respectively) and imaging techniques (0.5 and 0.2 test per patient). Mean CDT App calculated probability of having an infection based on pre-operative tests was 79.4% for patients in Group A and 35.7 in Group B. Twenty-nine patients in Group A had > 10% chance of not having an infection, and 29 of Group B had > 10% chance of having an infection. Conclusion: This is the first retrospective study focused on investigating the number and type of tests commonly performed prior to joint revision surgery and aimed at evaluating their combined ability to diagnose a peri-prosthetic infection. CDT App allowed us to demonstrate that, on average, the routine combination of commonly used tests is unable to diagnose pre-operatively a peri-prosthetic infection with a probability higher than 90%.
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Affiliation(s)
- Enrico Gallazzi
- Department of Reconstructive Surgery of Osteo-articular Infections, I.R.C.C.S. Galeazzi Orthopaedic Institute, Milano, Italy
| | - Lorenzo Drago
- Laboratory of Clinical Chemistry and Microbiology, I.R.C.C.S. Galeazzi Orthopaedic Institute, Milan, Italy
| | - Andrea Baldini
- Department for Orthopaedics, Istituto Clinico Humanitas, Rozzano (MI), Italy
| | - Ian Stockley
- Department for Orthopaedics, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - David A George
- Department of Trauma and Orthopaedics, University College London Hospitals, London, United Kingdom
| | - Sara Scarponi
- Department of Reconstructive Surgery of Osteo-articular Infections, I.R.C.C.S. Galeazzi Orthopaedic Institute, Milano, Italy
| | - Carlo L Romanò
- Department of Reconstructive Surgery of Osteo-articular Infections, I.R.C.C.S. Galeazzi Orthopaedic Institute, Milano, Italy
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Kwiecien G, George J, Klika AK, Zhang Y, Bauer TW, Rueda CAH. Intraoperative Frozen Section Histology: Matched for Musculoskeletal Infection Society Criteria. J Arthroplasty 2017; 32:223-227. [PMID: 27449715 DOI: 10.1016/j.arth.2016.06.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/19/2016] [Accepted: 06/11/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The current gold standard to diagnose periprosthetic joint infection (PJI)-the Musculoskeletal Infection Society (MSIS) criteria, requires a battery of tests, the results of which may not be available at the time of decision-making. Thus, surgeons often rely on intraoperative frozen section histology. However, the accuracy of frozen sections has not been determined when matched for the MSIS criteria. We aimed to (1) assess the value of intraoperative histology in the diagnosis of PJI and (2) evaluate discrepancy rate between frozen and permanent section analysis. METHODS A retrospective review of patients who underwent revision total hip or total knee arthroplasty for either PJI or mechanical failure in 2013 was conducted. Two hundred procedures where tissue samples for frozen sections had been collected were identified and included into the study. Results of frozen sections were compared to the modified MSIS criteria. Discrepancy rate between frozen and permanent sections was also calculated. RESULTS Frozen sections had sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 73.7% (95% confidence interval [CI], 59.7%-87.7%), 98.8% (95% CI, 97.1%-100.0%), 94.1% (95% CI, 90.6%-97.6%), 93.3.4% (95% CI, 84.4%-100.0%), 94.0% (95% CI, 90.7%-97.3%), respectively. There were 10 discrepancies between the results of frozen and permanent sections (N = 421 samples), thereby yielding 97.6% concordance. CONCLUSION When matched to the MSIS criteria, intraoperative frozen section histology yields a high specificity, positive predictive value, negative predictive value, accuracy, and moderate sensitivity. The discrepancy rate between frozen and permanent sections is low and both demonstrate good approximation of MSIS criteria.
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Affiliation(s)
- Grzegorz Kwiecien
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Jaiben George
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Yaxia Zhang
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Thomas W Bauer
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
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Single-stage revision for periprosthetic hip infection using antibiotic loaded impaction graft. Hip Int 2016; 26:573-579. [PMID: 27739567 DOI: 10.5301/hipint.5000401] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Staged revision for periprosthetic infection of the hip is an accepted and widely used technique by many surgeons. However, single-stage exchange of the hip prosthesis remains an attractive option to others because of the advantages of reduced morbidity, shorter treatment time and hospital stay in addition to the reduced cost of treatment. HYPOTHESIS Single-stage revision for periprosthetic hip infection can achieve excellent results if a specific protocol for patients' selection and management is followed. METHODS 52 patients with evidence of periprosthetic infection had preoperative aspiration of the affected hip. The infecting organisms were identified in 33/52 and single-stage revision was performed. The remaining 19 patients had a 2-stage exchange arthroplasty. Patients in the single-stage revision protocol had antibiotic loaded morsellized bone graft, a cemented cup and a long cementless stem. RESULTS At an average follow up of 6 (range 4-8) years postoperatively, only 1 case of persistent infection was found in the single-stage group - a 97% rate of eradicating infection was achieved. DISCUSSION Single-stage exchange achieves excellent success rate in patients with periprosthetic infection when a specific protocol for patient selection and management is followed.
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Utility of Serum Inflammatory and Synovial Fluid Counts in the Diagnosis of Infection in Taper Corrosion of Dual Taper Modular Stems. J Arthroplasty 2016; 31:1997-2003. [PMID: 26994651 DOI: 10.1016/j.arth.2016.02.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 01/12/2016] [Accepted: 02/08/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND An accurate diagnosis of periprosthetic joint infection (PJI) is critical as treatment of the infected total hip arthroplasty differs from aseptic failure. The clinical presentation of PJI may mimic symptoms of taper corrosion. Our aim was to evaluate the utility of serum inflammatory markers and synovial fluid white blood cell (WBC)/differential counts in diagnosis of PJI in failed dual taper total hip arthroplasty due to taper corrosion. METHODS We retrospectively reviewed 62 dual taper modular stem patients who underwent revision surgery for symptomatic adverse local tissue reaction due to taper corrosion. All patients had preoperative hip synovial aspirations, serum inflammatory markers, metal ion levels, and intraoperative cultures. Using Musculoskeletal Infection Society PJI criteria, we divided the cohort into infected and noninfected groups. Receiver-operating characteristic curves were constructed to determine the relationship and optimal cutoff values for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and synovial fluid counts. RESULTS Infection group had significantly higher mean ESR (P = .002), CRP (P = .01), synovial fluid WBC (P < .001), and neutrophil percentage (P = .02). Cobalt levels were significantly elevated in noninfection group (P = .02). Using receiver-operating characteristic curve analysis, the most ideal tests for diagnosis of PJI were synovial fluid WBC (area under the curve = 86%, optimal cutoff 730 WBC/uL) and neutrophil percentage (area under the curve = 83%, optimal cutoff 65%). ESR and CRP thresholds of 22 mm/h and 3 mg/L demonstrated 57% sensitivity and 95% specificity and 29% sensitivity and 93% specificity for detection of PJI, respectively. CONCLUSION Our study suggests that ESR and CRP are useful in excluding PJI in dual taper modular implants with corrosion, whereas both synovial WBC count and neutrophil percentage are useful markers for diagnosing infection.
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Zhang XM, Zhang HH, McLeroth P, Berkowitz RD, Mont MA, Stabin MG, Siegel BA, Alavi A, Barnett TM, Gelb J, Petit C, Spaltro J, Cho SY, Pomper MG, Conklin JJ, Bettegowda C, Saha S. [(124)I]FIAU: Human dosimetry and infection imaging in patients with suspected prosthetic joint infection. Nucl Med Biol 2016; 43:273-9. [PMID: 27150029 DOI: 10.1016/j.nucmedbio.2016.01.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/10/2015] [Accepted: 01/27/2016] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Fialuridine (FIAU) is a nucleoside analog that is a substrate for bacterial thymidine kinase (TK). Once phosphorylated by TK, [(124)I]FIAU becomes trapped within bacteria and can be detected with positron emission tomography/computed tomography (PET/CT). [(124)I]FIAU PET/CT has been shown to detect bacteria in patients with musculoskeletal bacterial infections. Accurate diagnosis of prosthetic joint infections (PJIs) has proven challenging because of the lack of a well-validated reference. In the current study, we assessed biodistribution and dosimetry of [(124)I]FIAU, and investigated whether [(124)I]FIAU PET/CT can diagnose PJIs with acceptable accuracy. METHODS To assess biodistribution and dosimetry, six subjects with suspected hip or knee PJI and six healthy subjects underwent serial PET/CT after being dosed with 74MBq (2mCi) [(124)I]FIAU intravenously (IV). Estimated radiation doses were calculated with the OLINDA/EXM software. To determine accuracy of [(124)I]FIAU, 22 subjects with suspected hip or knee PJI were scanned at 2-6 and 24-30h post IV injection of 185MBq (5mCi) [(124)I]FIAU. Images were interpreted by a single reader blinded to clinical information. Representative cases were reviewed by 3 additional readers. The utility of [(124)I]FIAU to detect PJIs was assessed based on the correlation of the patient's infection status with imaging results as determined by an independent adjudication board (IAB). RESULTS The kidney, liver, spleen, and urinary bladder received the highest radiation doses of [(124)I]FIAU. The effective dose was 0.16 to 0.20mSv/MBq and doses to most organs ranged from 0.11 to 0.76mGy/MBq. PET image quality obtained from PJI patients was confounded by metal artifacts from the prostheses and pronounced FIAU uptake in muscle. Consequently, a correlation with infection status and imaging results could not be established. CONCLUSIONS [(124)I]FIAU was well-tolerated in healthy volunteers and subjects with suspected PJI, and had acceptable dosimetry. However, the utility of [(124)I]FIAU for the clinical detection of PJIs is limited by poor image quality and low specificity.
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Affiliation(s)
| | - Halle H Zhang
- BioMed Valley Discoveries Inc., Kansas City, Missouri
| | | | | | - Michael A Mont
- The Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, Maryland
| | - Michael G Stabin
- Department of Radiology and Radiological Sciences, Vanderbilt University, Nashville, Tennessee
| | - Barry A Siegel
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | - Steve Y Cho
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Martin G Pomper
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland
| | | | - Chetan Bettegowda
- Department of Neurology, The Johns Hopkins Medical Institutes, Baltimore, Maryland
| | - Saurabh Saha
- BioMed Valley Discoveries Inc., Kansas City, Missouri.
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Winkler T, Trampuz A, Renz N, Perka C, Bozhkova SA. CLASSIFICATION AND ALGORITHM FOR DIAGNOSIS AND TREATMENT OF HIP PROSTHETIC JOINT INFECTION. TRAVMATOLOGIYA I ORTOPEDIYA ROSSII 2016. [DOI: 10.21823/2311-2905-2016-0-1-33-45] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Abstract
The diagnosis of periprosthetic joint infection (PJI) has been performed by obtaining a history and physical examination, blood tests, and analysis of the synovial fluid and tissue samples. The measurement of serum biomarkers are routinely used to diagnose PJI. These markers may be elevated in other inflammatory conditions, necessitating the need for more specific biomarkers to diagnose PJI. Serum biomarkers may be more specific to PJI. Synovial CRP, α-defensin, human β-defensin-2 and -3, leukocyte esterase, and cathelicidin LL-37 biomarkers hold promise for the diagnosis of PJI.
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Affiliation(s)
- Laura Matsen Ko
- Rothman Institute, Thomas Jefferson University, 4703 33rd Avenue Northeast, Seattle, WA 98105, USA.
| | - Javad Parvizi
- Sidney Kimmel School of Medicine, Rothman Institute, Thomas Jefferson University, Sheridan Building, Suite 1000, 125 South 9th Street, Philadelphia, PA 19107, USA
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Gravius S, Randau TM, Casadonte R, Kriegsmann M, Friedrich MJ, Kriegsmann J. Investigation of neutrophilic peptides in periprosthetic tissue by matrix-assisted laser desorption ionisation time-of-flight imaging mass spectrometry. INTERNATIONAL ORTHOPAEDICS 2014; 39:559-67. [PMID: 25277763 DOI: 10.1007/s00264-014-2544-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 09/17/2014] [Indexed: 01/11/2023]
Abstract
PURPOSE The accurate diagnosis of periprosthetic joint infection (PJI) relies on clinical investigation, laboratory parameters, radiological methods, sterile joint aspiration for synovial fluid leucocyte count and microbiological analysis and tissue sampling for histopathology. Due to the limits in specificity and sensitivity of these methods, molecular techniques and new biomarkers were introduced into the diagnostic procedure. Histological examination is related to the amount of neutrophils in the periprosthetic tissue in frozen sections and formalin-fixed paraffin embedded material (FFPE). However, the threshold of neutrophils per defined area of tissue among various studies is very inconsistent. METHODS We have applied matrix-assisted laser desorption ionisation time-of-flight imaging mass spectrometry (MALDI IMS) to a total of 32 periprosthetic tissue samples of patients with PJI to detect peptides associated with areas of neutrophil infiltration. RESULTS Specific peaks associated with a high amount of neutrophils were detected. Of these m/z peaks, four could be assigned to predictive neutrophil molecules. These peptides include annexin A1, calgizzarin (S100A11), calgranulin C (S100A12) and histone H2A. By MALDI IMS, these peptides could be shown to be co-localised with the infiltration of neutrophils in the immediate vicinity of the periprosthetic interface, whereas more distant areas did not show neutrophil invasion or infection-related peptides. CONCLUSIONS MALDI IMS is a new method allowing identification of neutrophil peptides in periprosthetic tissues and may be a surrogate for counting neutrophils as an objective parameter for PJI.
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Affiliation(s)
- Sascha Gravius
- Department of Orthopedics and Trauma Surgery, University Clinic of Bonn, Sigmund Freud Str. 25, 53105, Bonn, Germany,
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VOLPE LUIGI, INDELLI PIERFRANCESCO, LATELLA LEONARDO, POLI PAOLO, YAKUPOGLU JALE, MARCUCCI MASSIMILIANO. Periprosthetic joint infections: a clinical practice algorithm. JOINTS 2014; 2:169-174. [PMID: 25750905 PMCID: PMC4334216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE periprosthetic joint infection (PJI) accounts for 25% of failed total knee arthroplasties (TKAs) and 15% of failed total hip arthroplasties (THAs). The purpose of the present study was to design a multidisciplinary diagnostic algorithm to detect a PJI as cause of a painful TKA or THA. METHODS from April 2010 to October 2012, 111 patients with suspected PJI were evaluated. The study group comprised 75 females and 36 males with an average age of 71 years (range, 48 to 94 years). Eighty-four patients had a painful THA, while 27 reported a painful TKA. The stepwise diagnostic algorithm, applied in all the patients, included: measurement of serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels; imaging studies, including standard radiological examination, standard technetium-99m-methylene diphosphonate (MDP) bone scan (if positive, confirmation by LeukoScan was obtained); and joint aspiration with analysis of synovial fluid. RESULTS following application of the stepwise diagnostic algorithm, 24 out of our 111 screened patients were classified as having a suspected PJI (21.7%). CRP and ESR levels were negative in 84 and positive in 17 cases; 93.7% of the patients had a positive technetium-labeled bone scan, and 23% a positive LeukoScan. Preoperative synovial fluid analysis was positive in 13.5%; analysis of synovial fluid obtained by preoperative aspiration showed a leucocyte count of > 3000 cells μ/l in 52% of the patients. CONCLUSIONS the present study showed that the diagnosis of PJI requires the application of a multimodal diagnostic protocol in order to avoid complications related to surgical revision of a misdiagnosed "silent" PJI. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- LUIGI VOLPE
- Articular Replacements Excellence Center (CESAT) – Fondazione Onlus “...In Cammino...”, Fucecchio, Italy
| | - PIER FRANCESCO INDELLI
- New Mexico Veterans Affairs Health Care System (NMVAHCS) and Adult Reconstruction University of New Mexico, Department of Orthopaedics and Rehabilitation, Albuquerque, New Mexico, USA
| | - LEONARDO LATELLA
- Articular Replacements Excellence Center (CESAT) – Fondazione Onlus “...In Cammino...”, Fucecchio, Italy
- Orthopedic Clinic, University of Florence School of Medicine, Italy
| | - PAOLO POLI
- Articular Replacements Excellence Center (CESAT) – Fondazione Onlus “...In Cammino...”, Fucecchio, Italy
| | - JALE YAKUPOGLU
- The Breyer Center for Overseas Studies, Stanford University in Florence, Italy
| | - MASSIMILIANO MARCUCCI
- Articular Replacements Excellence Center (CESAT) – Fondazione Onlus “...In Cammino...”, Fucecchio, Italy
- Orthopedic Clinic, University of Florence School of Medicine, Italy
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Yuan K, Chen HL, Cui ZM. Diagnostic Accuracy of C-Reactive Protein for Periprosthetic Joint Infection: A Meta-Analysis. Surg Infect (Larchmt) 2014; 15:548-59. [PMID: 24833084 DOI: 10.1089/sur.2013.066] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Kun Yuan
- 1 Department of Orthopedics, Nantong First People's Hospital , Nantong, China
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Wu C, Qu X, Mao Y, Li H, Dai K, Liu F, Zhu Z. Utility of intraoperative frozen section in the diagnosis of periprosthetic joint infection. PLoS One 2014; 9:e102346. [PMID: 25025886 PMCID: PMC4099375 DOI: 10.1371/journal.pone.0102346] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 06/17/2014] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Intraoperative frozen section (FS) is an effective diagnostic test for periprosthetic joint infection (PJI). We evaluated the diagnostic characteristics of single- and multiplex-site intraoperative FS, and evaluated the results of single-site FS combined with those of C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) for assessing PJI. METHODS We studied 156 painful joint arthroplasties in 152 consecutive patients presenting for revision total joint arthroplasty due to PJI. Receiver operating characteristic analysis was used to determine the optimal cutoff values for CRP level, ESR, and intraoperative FS histopathology. Sensitivity, specificity, positive and negative predictive values, and accuracy of the diagnostic tests were assessed using a 2×2 table. RESULTS We investigated the diagnostic utility of polymorphonuclear leukocyte number (PMN) per high-power field (HPF) on FS. Our data showed that 5 PMNs per HPF is a suitable diagnostic threshold, with a high accuracy in single- and multiplex-site FS. Five PMNs in any 1 of 5 sites had the highest sensitivity of 0.86 and a specificity of 0.96. Five PMNs in every 1 of 5 sites had greater diagnostic utility, with a specificity of 1; however, the sensitivity of this measure fell to 0.62. Five PMNs in single-site FS had a sensitivity of 0.70 and a specificity of 0.94. Five PMNs in single-site FS or CRP level ≥15 mg/L increased the sensitivity to 0.92; however, the specificity decreased to 0.79. CONCLUSION Compared with single-site FS, any 1 positive site on multiplex-site FS may improve sensitivity, while every 1 positive site on multiplex-site FS may improve specificity. Five PMNs in any 1 of 5 sites on FS has excellent utility for the diagnosis of PJI. Additional systematic large-scale studies are needed to verify this result.
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Affiliation(s)
- Chuanlong Wu
- Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, PR China
| | - Xinhua Qu
- Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, PR China
| | - Yuanqing Mao
- Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, PR China
| | - Huiwu Li
- Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, PR China
| | - Kerong Dai
- Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, PR China
| | - Fengxiang Liu
- Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, PR China
- * E-mail: (FL); (ZZ)
| | - Zhenan Zhu
- Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, PR China
- * E-mail: (FL); (ZZ)
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Minassian AM, Newnham R, Kalimeris E, Bejon P, Atkins BL, Bowler ICJW. Use of an automated blood culture system (BD BACTEC™) for diagnosis of prosthetic joint infections: easy and fast. BMC Infect Dis 2014; 14:233. [PMID: 24885168 PMCID: PMC4101863 DOI: 10.1186/1471-2334-14-233] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 04/25/2014] [Indexed: 12/02/2022] Open
Abstract
Background For the diagnosis of prosthetic joint infection (PJI) automated BACTEC™ blood culture bottle methods have comparable sensitivity, specificity and a shorter time to positivity than traditional cooked meat enrichment broth methods. We evaluate the culture incubation period required to maximise sensitivity and specificity of microbiological diagnosis, and the ability of BACTEC™ to detect slow growing Propionibacteria spp. Methods Multiple periprosthetic tissue samples taken by a standardised method from 332 patients undergoing prosthetic joint revision arthroplasty were cultured for 14 days, using a BD BACTEC™ instrumented blood culture system, in a prospective study from 1st January to 31st August 2012. The “gold standard” definition for PJI was the presence of at least one histological criterion, the presence of a sinus tract or purulence around the device. Cases where > =2 samples yielded indistinguishable isolates were considered culture-positive. 1000 BACTEC™ bottle cultures which were negative after 14 days incubation were sub-cultured for Propionibacteria spp. Results 79 patients fulfilled the definition for PJI, and 66 of these were culture-positive. All but 1 of these 66 culture-positive cases of PJI were detected within 3 days of incubation. Only one additional (clinically-insignificant) Propionibacterium spp. was identified on terminal subculture of 1000 bottles. Conclusions Prolonged microbiological culture for 2 weeks is unnecessary when using BACTEC™ culture methods. The majority of clinically significant organisms grow within 3 days, and Propionibacteria spp. are identified without the need for terminal subculture. These findings should facilitate earlier decisions on final antimicrobial prescribing.
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Affiliation(s)
- Angela M Minassian
- Department of Microbiology, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK.
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Zmistowski B, Della Valle C, Bauer TW, Malizos KN, Alavi A, Bedair H, Booth RE, Choong P, Deirmengian C, Ehrlich GD, Gambir A, Huang R, Kissin Y, Kobayashi H, Kobayashi N, Krenn V, Drago L, Marston SB, Meermans G, Perez J, Ploegmakers JJ, Rosenberg A, Simpendorfer C, Thomas P, Tohtz S, Villafuerte JA, Wahl P, Wagenaar FC, Witzo E. Diagnosis of periprosthetic joint infection. J Arthroplasty 2014; 29:77-83. [PMID: 24342275 DOI: 10.1016/j.arth.2013.09.040] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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