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Blersch BP, Sax FH, Fink B. How Useful Is Preoperative Aspiration before Revision of Unicompartmental Knee Prostheses Because of Osteoarthritis in the Other Compartments? Antibiotics (Basel) 2024; 13:361. [PMID: 38667037 PMCID: PMC11047497 DOI: 10.3390/antibiotics13040361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 04/29/2024] Open
Abstract
AIM Periprosthetic joint infections (PJIs) of unicompartmental knee arthroplasties (UKAs) can lead to secondary osteoarthritis of the other compartments. The objective of this study was to identify the frequency of PJIs in cases of UKA with progressed secondary osteoarthritis and the result of septic one-stage revision in these cases to verify the value of preoperative aspiration in cases of secondary osteoarthritis of UKA. METHODS We retrospectively reviewed 97 patients with a unicompartmental arthroplasty who underwent revision surgery to a total knee arthroplasty (TKA) between January 2013 and March 2021 because of subsequent osteoarthritis. Preoperative aspiration and sample collection during the revision surgery were employed to identify potential periprosthetic joint infections (PJIs). The post-revision period was monitored for septic complications over an average duration of 55.7 ± 25.2 months (24-113). RESULTS PJIs were identified in 5.2% of cases through preoperative aspiration. In all instances of PJIs, a one-stage septic revision was performed, and notably, none of these cases experienced septic complications during the follow-up period. CONCLUSIONS Preoperative aspiration is essential in order to exclude the presence of a PJI before performing revision surgery of UKA due to secondary osteoarthritis.
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Affiliation(s)
- Benedikt Paul Blersch
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (B.P.B.); (F.H.S.)
| | - Florian Hubert Sax
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (B.P.B.); (F.H.S.)
| | - Bernd Fink
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (B.P.B.); (F.H.S.)
- Orthopaedic Department, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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Sax FH, Hoyka M, Blersch BP, Fink B. Diagnostics in Late Periprosthetic Infections-Challenges and Solutions. Antibiotics (Basel) 2024; 13:351. [PMID: 38667027 PMCID: PMC11047502 DOI: 10.3390/antibiotics13040351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/29/2024] Open
Abstract
The rising number of arthroplasties is combined with a rising number of periprosthetic joint infections, which leads to life-concerning consequences for the patients, including extended antibiotic treatment, further surgery and increased mortality. The heterogeneity of the symptoms and inflammatory response of the patients due to, e.g., age and comorbidities and the absence of a single diagnostic test with 100% accuracy make it very challenging to choose the right parameters to confirm or deny a periprosthetic joint infection and to establish a standardized definition. In recent years, additional diagnostic possibilities have emerged primarily through the increasing availability of new diagnostic methods, such as genetic techniques. The aim of the review is to provide an overview of the current state of knowledge about the various tests, including the latest developments. The combination of different tests increases the accuracy of the diagnosis. Each physician or clinical department must select the tests from the available methods that can be best implemented for them in organizational and technical terms. Serological parameters and the cultivation of the samples from aspiration or biopsy should be combined with additional synovial tests to create an accurate figure for the failure of the prosthesis, while imaging procedures are used to obtain additional information for the planned therapeutic procedure.
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Affiliation(s)
- Florian Hubert Sax
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
| | - Marius Hoyka
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
| | - Benedikt Paul Blersch
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
| | - Bernd Fink
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
- Orthopaedic Department, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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Poursalehian M, Lotfi M, Mortazavi SMJ. Latent infections in conversion total hip arthroplasty following internal fixation of femoral neck fractures: a systematic review and meta-analysis of diagnostic methods. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05216-6. [PMID: 38367062 DOI: 10.1007/s00402-024-05216-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/29/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Accurate diagnosis of latent infections prior to conversion total hip arthroplasty (THA) following internal fixation of femoral neck fractures is crucial for successful surgical outcomes. This systematic review aimed to provide a comprehensive evaluation of the current literature regarding the diagnosis of latent infections before conversion THA. METHODS Systematic search of PubMed, EMBASE, and Cochrane (CENTRAL) databases was conducted, and the diagnostic accuracy of various markers and techniques was assessed. The quality of the included studies was evaluated using the QUADAS-2 instrument. RESULTS Five studies comprising 661 patients were included in the review. Pooled analysis using C-reactive protein (CRP) as a diagnostic marker resulted in a sensitivity and specificity of 72% and 76%, respectively, while using erythrocyte sedimentation rate (ESR) yielded a sensitivity and specificity of 75% and 78%, respectively. Fibrinogen and platelet count showed lower sensitivity and specificity compared to CRP and ESR. The best combined markers were CRP and serum platelet count, with a sensitivity of 76% and specificity of 86% based on one study. CONCLUSION Our review underscored the limitations and inconsistencies present in current diagnostic methods for latent infections in conversion surgery. Future research needs to focus on standardizing threshold values, exploring the potential of synovial fluid analysis, imaging techniques, and molecular methods, as well as developing tailored diagnostic algorithms. PROSPERO CRD42023394757.
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Affiliation(s)
- Mohammad Poursalehian
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohadeseh Lotfi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Javad Mortazavi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Orthopedic Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
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Judl T, Popelka S, Tomšík E, Hrubý M, Daniel M, Fojt J, Melicherčík P, Landor I, Jahoda D. Acidity Is an Excellent Marker of Infection in Hip and Knee Arthroplasty. J Clin Med 2024; 13:688. [PMID: 38337382 PMCID: PMC10856596 DOI: 10.3390/jcm13030688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/28/2023] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND The diagnosis of joint replacement infection is a difficult clinical challenge that often occurs when the implant cannot be salvaged. We hypothesize that the pH value of synovial fluid could be an important indicator of the inflammatory status of the joint. However, in the literature, there is a lack of data on the pH changes in hip and knee joint replacements and their relation to infection and implant failure. In this study, we aimed to measure the pH levels of synovial fluid in patients with hip and knee joint replacements. We also investigated the potential of pH measurement as a diagnostic tool for joint replacement infection. In this study, we recorded the pH values to be 7.55 and 7.46 in patients where Pseudomonas aeruginosa was identified as the cause of the prosthetic joint infection. We attribute this to the different environments created by this specific bacterium. In other cases where the pH was higher, chronic mitigated infections were diagnosed, caused by strains of Staphylococcus aureus, Streptococcus agalactiase, and coagulase negative staphylococcus. MATERIALS AND METHODS In our cohort of 155 patients with implanted hip (THA; n = 85) or knee (TKA; n = 70) joint replacements, we conducted a prospective study with a pH measurement. Out of the whole cohort, 44 patients had confirmed joint replacement infection (28.4%) (44/155). In 111 patients, infection was ruled out (71.6%) (111/155). Joint replacement infection was classified according to the criteria of the Musculoskeletal Infection Society (MSIS) from 2018. Based on the measured values, we determined the cut-off level for the probability of ongoing inflammation. We also determined the sensitivity and specificity of the measurement. RESULTS The group of patients with infection (n = 44) had a significantly lower synovial fluid pH (pH = 6.98 ± 0.48) than the group of patients with no infection (n = 111, pH = 7.82 ± 0.29, p < 0.001). The corresponding median pH values were 7.08 for the patients with infection and 7.83 for the patients with no infection. When we determined the cut-off level of pH 7.4, the sensitivity level of infected replacements was 88.6%, and the specificity level of the measurement was 95.5%. The predictive value of a positive test was 88.6%, and the predictive value of a negative test was 95.5%. CONCLUSIONS Our results confirm that it is appropriate to include a pH measurement in the diagnostic spectrum of hip and knee replacements. This diagnostic approach has the potential to provide continuous in vivo feedback, facilitated by specialized biosensors. The advantage of this method is the future incorporation of a pH-detecting sensor into intelligent knee and hip replacements that will assess pH levels over time. By integrating these biosensors into intelligent implants, the early detection of joint replacement infections could be achieved, enhancing proactive intervention strategies.
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Affiliation(s)
- Tobiáš Judl
- Department of Orthopaedics, 1st Faculty of Medicine, Charles University in Prague and University Hospital in Motol, V Úval 84, 150 06 Prague 5, Czech Republic; (S.P.); (D.J.)
| | - Stanislav Popelka
- Department of Orthopaedics, 1st Faculty of Medicine, Charles University in Prague and University Hospital in Motol, V Úval 84, 150 06 Prague 5, Czech Republic; (S.P.); (D.J.)
| | - Elena Tomšík
- Institute of Macromolecular Chemistry CAS, Heyrovsého nám. 2, 162 00 Prague 6, Czech Republic (M.H.)
| | - Martin Hrubý
- Institute of Macromolecular Chemistry CAS, Heyrovsého nám. 2, 162 00 Prague 6, Czech Republic (M.H.)
| | - Matěj Daniel
- Faculty of Mechanical Engineering, Czech Technical University, Technická 4, 166 07 Prague 6, Czech Republic;
| | - Jaroslav Fojt
- Department of Metals and Corrosion Engineering, University of Chemistry and Technology, Technická 5, 166 28 Prague 6, Czech Republic;
| | - Pavel Melicherčík
- Department of Orthopaedics, 1st Faculty of Medicine, Charles University in Prague and University Hospital in Motol, V Úval 84, 150 06 Prague 5, Czech Republic; (S.P.); (D.J.)
| | - Ivan Landor
- Department of Orthopaedics, 1st Faculty of Medicine, Charles University in Prague and University Hospital in Motol, V Úval 84, 150 06 Prague 5, Czech Republic; (S.P.); (D.J.)
| | - David Jahoda
- Department of Orthopaedics, 1st Faculty of Medicine, Charles University in Prague and University Hospital in Motol, V Úval 84, 150 06 Prague 5, Czech Republic; (S.P.); (D.J.)
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Fink B, Hoyka M, Blersch B, Baum H, Sax FH. Graphic type differentiation of cell count data for diagnosis of early and late periprosthetic joint infection: A new method. Technol Health Care 2023:THC231006. [PMID: 37980584 DOI: 10.3233/thc-231006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
BACKGROUND Graphic type differentiation of cell count data of synovial aspirates is a new method for the diagnosis of early and late periprosthetic joint infection. OBJECTIVE The aim of the study was to analyse if the same 6 LMNE-types can be differentiated in the new Yumizen H500 cell counter as it was the case for the old cell counter ABX Pentra XL 80 of previous publications, to verify if the erythrocyte and thrombocyte curves of the new device give additional information and to calculate the difference of cell count in LMNE-type I and III (with abrasion) in the cell counter and in the manual counting chamber (Neubauer improved). METHODS 450 aspirates of 152 total hip arthroplasties and 298 knee arthroplasties obtained for the diagnosis of periprosthetic joint infection were analysed with the Yumizen H500. RESULTS All LMNE-matrices of the 450 aspirates could assigned to one of the six LMNE-types. There were 76 LMNE-type I, 72 LMNE-type II, 14 LMNE-type III, 241 LMNE-type IV, 36 LMNE-type V and 12 LMNE-type VI. The erythrocyte and thrombocyte distribution curves were very helpful for differentiation of hematoma and infection. The cell count in the manual counting procedure was lower than in the cell counter: for the LMNE-type I (abrasion type) the median of the difference was 925/μL (median) and for the LMNE-type III (combined type of infection and abrasion) 3570/μL (median). CONCLUSION The described graphic type differentiation is a new and helpful method for differentiation of hematoma and early PJI as well as abrasion and late PJI.
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Affiliation(s)
- Bernd Fink
- Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Markgröningen, Germany
- Orthopaedic Department, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marius Hoyka
- Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Markgröningen, Germany
| | - Benedikt Blersch
- Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Markgröningen, Germany
| | - Hannsjörg Baum
- Institute for Laboratory Medicine and Transfusion Medicine, RKH Regionale Kliniken Holding und Services GmbH, Ludwigsburg, Germany
| | - Florian Hubert Sax
- Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Markgröningen, Germany
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Li C, Margaryan D, Perka C, Trampuz A. The role of biopsy in diagnosing infection after hip and knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 2023; 143:1779-1792. [PMID: 35061082 PMCID: PMC10030426 DOI: 10.1007/s00402-021-04323-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 12/14/2021] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Early diagnosis of periprosthetic hip and knee infection still represents a major challenge, as no single test can achieve ideal results. Currently, multiple preoperative indicators were performed to diagnose periprosthetic joint infection (PJI) to confirm or exclude infection in the early stage. However, the diagnostic value of biopsy-related tests in diagnosing periprosthetic hip and knee infection remains unclear. MATERIALS AND METHODS Publications in PubMed, Embase, and the Web of Science databases were searched systematically until October 2020. Inclusion and exclusion criteria were used for screening biopsy-related studies of the diagnosis of periprosthetic hip and knee infection. RESULTS Three biopsy-related tests were identified in 14 articles and further analyzed in the present meta-analysis. The combined method had the highest value for the area under the curve (0.9805), followed by histology (0.9425) and microbiological tests (0.9292). In the subgroup, statistical differences were identified in sensitivity and specificity for PJI diagnosis between the synovial fluid culture and biopsy culture group, as well as in the biopsy-related combined method and serum C-reactive protein. CONCLUSIONS Biopsy culture does not appear to be advantageous compared to synovial fluid culture in the preoperative diagnosis of periprosthetic hip and knee infection. In contrast, combined biopsy microbial culture with histology analysis shows great potential in improving the preoperative diagnosis of PJI. The standard procedure of biopsy needs to be further explored. Further research is required to verify our results.
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Affiliation(s)
- Cheng Li
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, People's Republic of China.
- 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.
| | - Donara Margaryan
- 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
| | - 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
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Klaber I, Scholz F, Citak M, Zahar A, Gehrke T, Haasper C, Hawi N, Lausmann C. Diagnostic utility of open biopsy in patients with two culture-negative aspirations in the diagnostic work-up of periprosthetic joint infection. Arch Orthop Trauma Surg 2023; 143:749-754. [PMID: 34487240 DOI: 10.1007/s00402-021-04142-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/22/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Different approaches have been proposed for bacterial identification in patients with a suspected periprosthetic joint infection (PJI). If a one-stage procedure is considered, a higher rate of preoperative bacterial identification can be achieved if biopsy is included in the diagnostic work-up. The performance of open biopsy (OB) in the context of PJI has not been clearly determined yet. The purpose of this study was to determine the value of an OB added to two consecutive culture-negative joint aspirations during PJI workup. MATERIALS AND METHODS We retrospectively analyzed the OB data from a single institution. Patients under PJI work-up of the hip or knee with two culture-negative periprosthetic aspirations who underwent OB were included. Sensitivity and specificity were calculated using the musculoskeletal infection society (MSIS) criteria as gold standard. Patients undergoing urgent irrigation and debridement and patients with history of surgery to the affected joint in the prior 6 weeks were excluded. RESULTS 126 patients were included in this study. 62 (49.2%) patients had prior revisions, 48 of them due to PJI. The sensitivity and specificity of OB was 69.4% and 89.1%, respectively. The OB procedure led to the identification of the causative germ in 50 out of 126 (40%) cases so they could undergo one-stage (septic) exchange. CONCLUSION The OB is a valuable resource if preoperative synovial fluid cultures are negative, a high suspicion of infection persists and a one-stage procedure is preferred. It intends bacteria identification and allows surgeons to evaluate prosthetic complications for further surgical procedures.
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Affiliation(s)
- Ianiv Klaber
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany.,Department of Orthopedic Surgery, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Fabian Scholz
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
| | - Akos Zahar
- Department of Orthopaedic Surgery and Traumatology, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
| | - Carl Haasper
- Department of Orthopaedic Surgery, AMEOS Klinikum Seepark, Geestland, Germany
| | - Nael Hawi
- Department of Trauma Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Lausmann
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany.
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Sigmund IK, Yeghiazaryan L, Luger M, Windhager R, Sulzbacher I, McNally MA. Three to six tissue specimens for histopathological analysis are most accurate for diagnosing periprosthetic joint infection. Bone Joint J 2023; 105-B:158-165. [PMID: 36722061 DOI: 10.1302/0301-620x.105b2.bjj-2022-0859.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIMS The aim of this study was to evaluate the optimal deep tissue specimen sample number for histopathological analysis in the diagnosis of periprosthetic joint infection (PJI). METHODS In this retrospective diagnostic study, patients undergoing revision surgery after total hip or knee arthroplasty (n = 119) between January 2015 and July 2018 were included. Multiple specimens of the periprosthetic membrane and pseudocapsule were obtained for histopathological analysis at revision arthroplasty. Based on the Infectious Diseases Society of America (IDSA) 2013 criteria, the International Consensus Meeting (ICM) 2018 criteria, and the European Bone and Joint Infection Society (EBJIS) 2021 criteria, PJI was defined. Using a mixed effects logistic regression model, the sensitivity and specificity of the histological diagnosis were calculated. The optimal number of periprosthetic tissue specimens for histopathological analysis was determined by applying the Youden index. RESULTS Based on the EBJIS criteria (excluding histology), 46 (39%) patients were classified as infected. Four to six specimens showed the highest Youden index (four specimens: 0.631; five: 0.634; six: 0.632). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of five tissue specimens were 76.5% (95% confidence interval (CI) 67.6 to 81.4), 86.8% (95% CI 81.3 to 93.5), 66.0% (95% CI 53.2 to 78.7), and 84.3% (95% CI 79.4 to 89.3), respectively. The area under the curve (AUC) was calculated with 0.81 (as a function of the number of tissue specimens). Applying the ICM and IDSA criteria (excluding histology), 40 (34%) and 32 (27%) patients were categorized as septic. Three to five specimens had the highest Youden index (ICM 3: 0.648; 4: 0.651; 5: 0.649) (IDSA 3: 0.627; 4: 0.629; 5: 0.625). CONCLUSION Three to six tissue specimens of the periprosthetic membrane and pseudocapsule should be collected at revision arthroplasty and analyzed by a pathologist experienced and skilled in interpreting periprosthetic tissue.Cite this article: Bone Joint J 2023;105-B(2):158-165.
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Affiliation(s)
- Irene K Sigmund
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Lusine Yeghiazaryan
- Medical University of Vienna, Centre for Medical Statistics, Informatics and Intelligent Systems, Institute of Medical Statistics, Vienna, Austria
| | - Markus Luger
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Irene Sulzbacher
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
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Dmitrov IA, Zagorodniy NV, Obolenskiy VN, Leval' PS, Zakharyan NG, Apresyan VS, Panin MA, Samkovich DA, Aliev RN, Grigoryan AA. Diagnosis and treatment of periprosthetic infection after hip replacement (a review). BULLETIN OF THE MEDICAL INSTITUTE "REAVIZ" (REHABILITATION, DOCTOR AND HEALTH) 2022. [DOI: 10.20340/vmi-rvz.2022.6.clin.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction. The frequency of hip arthroplasty is steadily increasing throughout the world and, although this operation has become routine, the likelihood of postoperative complications reaches 4.3 % [1]. The most dangerous of them are infectious lesions in the area of the endoprosthesis and adjacent tissues. At the same time, in addition to the threat of generalization of the infectious process, there are functional disorders in the joint area and a general deterioration in the quality of life of the patient. Timely diagnosis and treatment of the infectious process and related disorders can minimize the adverse effects of infection.Target. The purpose of this review is to analyze modern methods for diagnosing and treating periprosthetic infection resulting from hip replacement.Materials and methods. The subject literature was searched using the PubMed and Google Sholar databases.Results. The main methods for diagnosing periprosthetic infection include histological and bacteriological examination of the biopsy specimen, determination of sensitivity to antibiotics, blood, and synovial fluid analysis for the content of leukocytes, IL-6, CRP, PCR diagnostics of infectious agents. Treatment consists of re-intervention and/or antibiotic therapy.Conclusion. The most optimal method for diagnosing periprosthetic infection is a bacteriological study of biopsy specimens taken intraoperatively. The preferred method of treatment is determined by the severity of the infection, the degree of involvement of tissues adjacent to the prosthesis, the comorbid background, the nature of the infectious agent, and includes repeated revision surgery.
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Affiliation(s)
| | - N. V. Zagorodniy
- RUDN University; Pirogov Russian National Research Medical University
| | - V. N. Obolenskiy
- Pirogov Russian National Research Medical University; City Clinical Hospital No. 13
| | - P. Sh. Leval'
- City Clinical Hospital No. 13; European Clinic of Traumatology and Orthopedics (ECSTO)
| | | | | | - M. A. Panin
- RUDN University; City Clinical Hospital No. 17
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Rieber H, Frontzek A, Heinrich S, Barden B, Kortstegge T, Dienstknecht T, Breil-Wirth A, Herwig M, Jerosch J, Pinkernell R, Ulatowski M. Evaluation of two different semi-automated homogenization techniques in microbiological diagnosis of periprosthetic joint infection: disperser vs. bead milling method. BMC Infect Dis 2022; 22:790. [PMID: 36253761 PMCID: PMC9575308 DOI: 10.1186/s12879-022-07775-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/16/2022] [Accepted: 10/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background In microbiological diagnosis of periprosthetic joint infection (PJI) there is no consensus regarding the most suitable and optimal number of specimens to be cultured or the most effective technique of tissue processing. This comparative study analysed the accuracy of two semi-automated homogenization methods with special focus on the volume and exact origin of each sample. Methods We investigated a total of 722 periprosthetic tissue samples. PJI was defined according to the new scoring system for preoperative and intraoperative criteria. We compared the performance of our routinely used single tissue processing by disposable high-frequency disperser with the bead milling method. Results Eighty patients were included. Among forty classified PJIs, 34 patients yielded positive culture results. In 23 cases (68%) exact concordant results were generated with both techniques. However, in seven cases (20%) processing by the disperser and in four cases (12%) by bead milling provided additional positive samples, but without significant difference since the major definition criteria were met in all cases. The percentage of positive results was influenced by the volume and origin of the tissue samples. Results for small tissue samples tended to be better using the bead milling method. This might lead to improved preoperative arthroscopic diagnosis, as the volume of biopsies is generally limited. Six patients had negative results due to previous antimicrobial therapy. Forty other patients were classified as aseptic failures. Neither procedure resulted in any contamination. Conclusion Both methods enable reliable processing of tissue samples for diagnosis of PJI and are suitable for routine use.
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Affiliation(s)
- Heime Rieber
- MVZ Dr. Stein and Colleagues, Division of Microbiology, Tomphecke 45, D-41169, Mönchengladbach, Germany.
| | - Andre Frontzek
- MVZ Dr. Stein and Colleagues, Division of Microbiology, Tomphecke 45, D-41169, Mönchengladbach, Germany
| | - Stephanie Heinrich
- Klinik für Orthopädie und Unfallchirurgie, Krankenhaus Düren, Düren, Germany
| | - Bertram Barden
- Klinik für Orthopädie und Unfallchirurgie, Krankenhaus Düren, Düren, Germany
| | - Thomas Kortstegge
- Klinik für Orthopädie und Unfallchirurgie, Krankenhaus Düren, Düren, Germany
| | - Thomas Dienstknecht
- Klinik für Orthopädie und Unfallchirurgie, Krankenhaus Düren, Düren, Germany
| | - Andreas Breil-Wirth
- Klinik für Orthopädie und Unfallchirurgie, Johanna-Etienne-Krankenhaus, Neuss, Germany
| | - Mathias Herwig
- Klinik für Orthopädie und Unfallchirurgie, Johanna-Etienne-Krankenhaus, Neuss, Germany
| | - Jörg Jerosch
- Klinik für Orthopädie und Unfallchirurgie, Johanna-Etienne-Krankenhaus, Neuss, Germany
| | - Ralf Pinkernell
- Klinik für Orthopädie und Unfallchirurgie, Sana Krankenhaus, Radevormwald, Germany
| | - Martin Ulatowski
- Klinik für Orthopädie und Unfallchirurgie, Sana Krankenhaus, Radevormwald, 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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12
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Sigmund IK, Luger M, Windhager R, McNally MA. Diagnosing periprosthetic joint infections : a comparison of infection definitions: EBJIS 2021, ICM 2018, and IDSA 2013. Bone Joint Res 2022; 11:608-618. [PMID: 36047011 PMCID: PMC9533249 DOI: 10.1302/2046-3758.119.bjr-2022-0078.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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
AIMS This study evaluated the definitions developed by the European Bone and Joint Infection Society (EBJIS) 2021, the International Consensus Meeting (ICM) 2018, and the Infectious Diseases Society of America (IDSA) 2013, for the diagnosis of periprosthetic joint infection (PJI). METHODS In this single-centre, retrospective analysis of prospectively collected data, patients with an indicated revision surgery after a total hip or knee arthroplasty were included between 2015 and 2020. A standardized diagnostic workup was performed, identifying the components of the EBJIS, ICM, and IDSA criteria in each patient. RESULTS Of 206 included patients, 101 (49%) were diagnosed with PJI with the EBJIS definition. IDSA and ICM diagnosed 99 (48%) and 86 (42%) as infected, respectively. A total of 84 cases (41%) had an infection based on all three criteria. In 15 cases (n = 15/206; 7%), PJI was present when applying only the IDSA and EBJIS criteria. No infection was detected by one definition alone. Inconclusive diagnoses occurred more frequently with the ICM criteria (n = 30/206; 15%) compared to EBJIS (likely infections: n = 16/206; 8%) (p = 0.029). A better preoperative performance of the EBJIS definition was seen compared with the ICM and IDSA definitions (p < 0.001). CONCLUSION The novel EBJIS definition identified all PJIs diagnosed by any other criteria. Use of the EBJIS definition significantly reduced the number of uncertain diagnoses, allowing easier clinical decision-making.Cite this article: Bone Joint Res 2022;11(9):608-618.
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Affiliation(s)
- Irene K Sigmund
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Markus Luger
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
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13
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Treatment outcomes of patients with Cutibacterium acnes-positive cultures during total joint replacement revision surgery: a minimum 2-year follow-up. Arch Orthop Trauma Surg 2022; 143:2951-2958. [PMID: 35759014 DOI: 10.1007/s00402-022-04489-z] [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] [Received: 02/11/2022] [Accepted: 05/16/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is a devastating complication following total joint replacement (TJR). Cutibacterium acnes (C. acnes) is a low virulent skin commensal, commonly found during TJR revision surgery for "aseptic" causes. The purpose of the present study was to report the treatment outcomes of patients with C. acnes contamination or infection in the presence of a TJR treated with a revision surgery ± implant exchange ± prolonged (≥ 8 weeks) postoperative antibiotics. METHODS Medical records of patients with at least one positive C. acnes culture in intraoperative tissue samples or sonication fluid from a TJR revision surgery between January 2005 and December 2014 were retrospectively evaluated. The primary endpoint was infection eradication according to Delphi criteria. The diagnostic accuracy of preoperative TJR aspiration regarding the diagnosis of C. acnes PJI was also investigated. RESULTS A total of 52 TJR (28 shoulders, 17 hips, 7 knees) in 52 patients (35 males, 17 females) with an average age of 63 ± 11 (33-86) years were included. At an average follow-up of 67 ± 33 (24-127) months, the infection eradication of C. acnes PJI was 97% regardless of the surgical treatment or administration of prolonged postoperative antibiotics. The incidence of unsuspected C. acnes PJI was 28.8%. The sensitivity and specificity of preoperative joint aspiration in detecting C. acnes PJI were 59% and 88%, whereas the PPV and NNV were 83% and 67%, respectively. CONCLUSION Infection eradication of C. acnes PJI was very high at a minimum follow-up of 24 months, suggesting that C. acnes PJI could be adequately treated with a combination of revision surgery and prolonged postoperative antibiotics. The preoperative diagnosis of C. acnes PJI might be challenging with more than one-quarter of patients presenting without suspicion of C. acnes PJI. The appropriate treatment of patients with a single positive culture remains still unclear. A negative TJR aspiration should not rule out a C. acnes PJI, especially in the presence of clinical correlates of infection. LEVEL OF EVIDENCE Retrospective case-control study, Level III. IRB APPROVAL Kantonale Ethikkommission Zürich, BASEC Nr.:2017-00567.
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14
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The significance of synovial biopsy in the diagnostic workup of the low-grade periprosthetic joint infection of shoulder arthroplasty. Arch Orthop Trauma Surg 2022; 142:3157-3164. [PMID: 33991235 PMCID: PMC9522757 DOI: 10.1007/s00402-021-03932-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/30/2021] [Indexed: 12/02/2022]
Abstract
INTRODUCTION A common reason for painful shoulder arthroplasties and revision surgery is a low-grade periprosthetic joint infection (PJI). Diagnosing a low-grade infection is, however, a major diagnostic challenge. This applies even more to the shoulder, which differs from other large joints in terms of clinical features and microbiological spectrum. Aim of this study was to evaluate the diagnostic value of the synovial biopsy in the diagnostic workup of low-grade PJI of the shoulder. MATERIALS AND METHODS A retrospective evaluation was conducted on 56 patients receiving revision surgery on their shoulder arthroplasty. A standardized preoperative workup was performed comprising CRP value, leukocyte blood count, synovial fluid microbiological analyses and leukocyte count from joint aspiration, and five synovial biopsy samples for bacteriologic and histologic analysis obtained through an arthroscopic approach. During revision surgery, five samples of periprosthetic tissue were harvested for bacteriologic and histologic analyses. The MSIS-Criteria 2014 were used to evaluate the diagnostic results. RESULTS In total, 15 of 56 revised prostheses turned out as PJI (27%). When applying our diagnostic workup, we obtained a sensitivity of 67% with a specificity of 95%. When performing a subgroup analysis on those patients that had received diagnostic biopsy, a sensitivity of 100% and a specificity of 83% could be achieved. With a sensitivity and specificity of 90% and 83%, respectively, the biopsy is the single method with the highest diagnostic value. CONCLUSIONS The sensitivity of only 67% of our standard workup emphasizes the difficulty to adequately diagnose low-grade infections after shoulder arthroplasty. The excellent specificity of 95% ensures, however, that non-infected prostheses are not incorrectly explanted. This study highlights that synovial biopsy has a high diagnostic value and should be done prior to complex revision surgeries to raise sensitivity in diagnosing a PJI.
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15
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Clarke MJH, Salar O, Evans JP, Bayley MGR, Waterson BH, Toms AD, Phillips JRA. Prosthetic joint infection of the knee - arthroscopic biopsy identifies more and different organisms than aspiration alone. Knee 2021; 32:183-191. [PMID: 34500431 DOI: 10.1016/j.knee.2021.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/08/2021] [Accepted: 08/13/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Prosthetic joint infection (PJI) causes significant morbidity and mortality following knee replacement surgery. Identifying causative organisms and antibiotic sensitivities is critical in increasing the chance of infection eradication. This study investigated whether biopsy alone was superior to aspiration alone for serological diagnosis in PJI following knee replacement. Secondly, we investigated whether biopsy identifies the same or new/different microbiological flora as aspiration. METHODS Since December 2014, the Exeter Knee Reconstruction Unit (EKRU) has prospectively collated data regarding all PJIs referred from our local/regional network which have been reviewed via our Multi-Disciplinary Team (MDT). We identified and included consecutive patients from this MDT from Dec.2014-Mar.2020 and analysed their electronic records. Statistical analysis was performed using Stata. RESULTS 65/100 patients studied had both pre-operative aspiration and biopsy. 31/65 (48%) had positive aspiration and biopsies. No aspirate samples were positive with corresponding biopsies negative. In 19/65 (29%) of infection positive patients, biopsy identified new (7) or additional (12) organisms not identified by aspiration. Aspiration had a sensitivity of 70%, specificity of 88%, positive predictive value of 90.3% and negative predictive value of 64.7%. Biopsy had a sensitivity of 97.5%, specificity of 88%, positive predictive value of 92.9% and negative predictive value of 95.7%. CONCLUSION In 29% of confirmed PJI cases, arthroscopic biopsy identified either additional organisms in a polymicrobial PJI when compared to aspiration, or new positive results when aspiration alone was negative. This study demonstrates the benefits of arthroscopic biopsy for serological diagnosis in cases of knee PJI and aids treatment planning.
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Affiliation(s)
- Michael J H Clarke
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK.
| | - Omer Salar
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - Jonathan P Evans
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - Morgan G R Bayley
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - Ben H Waterson
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - Andrew D Toms
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - Jonathan R A Phillips
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
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16
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Introducing image-guided synovial aspiration and biopsy in assessing peri-prosthetic joint infection: an early single-centre experience. Skeletal Radiol 2021; 50:2031-2040. [PMID: 33825021 DOI: 10.1007/s00256-021-03774-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/25/2021] [Accepted: 03/28/2021] [Indexed: 02/02/2023]
Abstract
AIM Synovial sampling can be used in the diagnosis of peri-prosthetic joint infection (PJI). The purpose of this study was to establish the role of simultaneous image-guided synovial aspiration and biopsy (SAB) during an initial 2-year experience at our institution. METHODS Retrospective review of consecutive SABs performed during 2014-2016 at a tertiary referral musculoskeletal centre. Radiological SAB microbiology culture results were compared with intra-operative surgical samples or multidisciplinary team (MDT) meeting outcome at 1-year follow-up if surgery was not undertaken. Sensitivity, specificity and accuracy of synovial aspiration (SA), synovial biopsy (SB) and simultaneous SAB were calculated. RESULTS 103 patients (46 male, 57 female) totalling 111 procedures were analysed with mean age 65 years (range 31-83). Image-guided synovial procedures were performed on 52 (46.9%) hip and 59 (53.1%) knee joint prostheses. The mean combined sensitivity, specificity and accuracy for the entire cohort was 72.6%, 96.9% and 90%, respectively. When only SB was obtained, diagnostic accuracy (92.5%) was similar to SA alone (94.1%). In total, there were 21 (18.9%) true-positive, 80 (72.1%) true-negative, 2 (1.8%) false-positive and 8 (7.2%) false-negative cases (PPV 91.3% and NPV 90.9%). No post-procedural complications were recorded at 1-year follow-up. CONCLUSION Percutaneous image-guided SAB is a valuable technique in assessing suspected PJI, with most samples indicative of infective status and causative organisms when validated against intra-operative results and specialist MDT evaluation. Image-guided SB is a safe and useful additional procedure following failed SA with equivalent levels of diagnostic accuracy.
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17
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Wijayaratna U, Kiridena S, Adams JD, Behrend CJ, Anker JN. Synovial fluid pH sensor for early detection of prosthetic hip infections. ADVANCED FUNCTIONAL MATERIALS 2021; 31:2104124. [PMID: 36478668 PMCID: PMC9725744 DOI: 10.1002/adfm.202104124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Indexed: 05/11/2023]
Abstract
We describe an implantable sensor developed to measure synovial fluid pH for noninvasive early detection and monitoring of hip infections using standard-of-care plain radiography. The sensor was made of a pH responsive polyacrylic acid-based hydrogel, which expands at high pH and contracts at low pH. A radiodense tantalum bead and a tungsten wire were embedded in the two ends of the hydrogel in order to monitor the change in length of the hydrogel sensor in response to pH via plain radiography. The effective pKa of the hydrogel-based pH sensor was 5.6 with a sensitivity of 3 mm/pH unit between pH 4 and 8. The sensor showed a linear response and reversibility in the physiologically relevant pH range of pH 6.5 and 7.5 in both buffer and bovine synovial fluid solutions with a 30-minute time constant. The sensor was attached to an explanted prosthetic hip and the pH response determined from the X-ray images by measuring the length between the tantalum bead and the radiopaque wire. Therefore, the developed sensor would enable noninvasive detection and studying of implant hip infection using plain radiography.
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Affiliation(s)
- Uthpala Wijayaratna
- Department of Chemistry, Clemson University, 102 BRC, 105 Collings St., Clemson, SC 29634, USA
| | - Sachindra Kiridena
- Department of Chemistry, Clemson University, 102 BRC, 105 Collings St., Clemson, SC 29634, USA
| | - John D Adams
- Prisma Health-Upstate, Department of Orthopedic Surgery, Second Floor Support Tower, 701 Grove Road, Greenville, SC 29605, USA
| | | | - Jeffrey N Anker
- Departments of Chemistry and BioEngineering, and Center for Optical Materials Science and Engineering Technology (COMSET), Clemson University, 102 BRC, 105 Collings St., Clemson, SC 29634, USA
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18
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Sigmund IK, McNally MA, Luger M, Böhler C, Windhager R, Sulzbacher I. Diagnostic accuracy of neutrophil counts in histopathological tissue analysis in periprosthetic joint infection using the ICM, IDSA, and EBJIS criteria. Bone Joint Res 2021; 10:536-547. [PMID: 34409845 PMCID: PMC8414440 DOI: 10.1302/2046-3758.108.bjr-2021-0058.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Aims Histology is an established tool in diagnosing periprosthetic joint infections (PJIs). Different thresholds, using various infection definitions and histopathological criteria, have been described. This study determined the performance of different thresholds of polymorphonuclear neutrophils (≥ 5 PMN/HPF, ≥ 10 PMN/HPF, ≥ 23 PMN/10 HPF) , when using the European Bone and Joint Infection Society (EBJIS), Infectious Diseases Society of America (IDSA), and the International Consensus Meeting (ICM) 2018 criteria for PJI. Methods A total of 119 patients undergoing revision total hip (rTHA) or knee arthroplasty (rTKA) were included. Permanent histology sections of periprosthetic tissue were evaluated under high power (400× magnification) and neutrophils were counted per HPF. The mean neutrophil count in ten HPFs was calculated (PMN/HPF). Based on receiver operating characteristic (ROC) curve analysis and the z-test, thresholds were compared. Results Using the EBJIS criteria, a cut-off of ≥ five PMN/HPF showed a sensitivity of 93% (95% confidence interval (CI) 81 to 98) and specificity of 84% (95% CI 74 to 91). The optimal threshold when applying the IDSA and ICM criteria was ≥ ten PMN/HPF with sensitivities of 94% (95% CI 79 to 99) and 90% (95% CI 76 to 97), and specificities of 86% (95% CI 77 to 92) and 92% (95% CI 84 to 97), respectively. In rTKA, a better performance of histopathological analysis was observed in comparison with rTHA when using the IDSA criteria (p < 0.001). Conclusion With high accuracy, histopathological analysis can be supported as a confirmatory criterion in diagnosing periprosthetic joint infections. A threshold of ≥ five PMN/HPF can be recommended to distinguish between septic and aseptic loosening, with an increased possibility of detecting more infections caused by low-virulence organisms. However, neutrophil counts between one and five should be considered suggestive of infection and interpreted carefully in conjunction with other diagnostic test methods. Cite this article: Bone Joint Res 2021;10(8):536–547.
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Affiliation(s)
- Irene K Sigmund
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Markus Luger
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Böhler
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Irene Sulzbacher
- Department of Pathology, Medical University of Vienna, Vienna, Austria
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Zmistowski B, Chang M, Shahi A, Nicholson T, Abboud J, Lazarus M, Williams G, Parvizi J, Namdari S. Is D-dimer a Reliable Serum Marker for Shoulder Periprosthetic Joint Infection? Clin Orthop Relat Res 2021; 479:1447-1454. [PMID: 33929986 PMCID: PMC8208387 DOI: 10.1097/corr.0000000000001774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 03/15/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The diagnosis of periprosthetic shoulder infection continues to be difficult to make with confidence. Serum D-dimer has proven to be effective as a screening tool for periprosthetic joint infection in other major joints; however, it has yet to be evaluated for use in periprosthetic shoulder infection. QUESTIONS/PURPOSES (1) Is D-dimer elevated in patients with probable or definite periprosthetic shoulder infections? (2) What is the diagnostic accuracy of D-dimer for periprosthetic shoulder infections? (3) What are the diagnostic accuracies of serum tests (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], and D-dimer), singly and in combination? METHODS Between March 2016 and March 2020, 94 patients undergoing revision total shoulder arthroplasty (anatomic or reverse) at a single institution had preoperative serum testing with CRP, ESR, and D-dimer. These 94 patients were a subset of 189 revision shoulder arthroplasties performed at this institution during the study period who met inclusion criteria and consented to participate. Included patients had a mean ± SD age of 69 ± 8 years, and 56% (53 of 94) were men. Patient records were reviewed to classify patients as definitely having infection, probably having infection, possibly having infection, or unlikely to have an infection, according to the International Consensus Meeting (ICM) definition of periprosthetic shoulder infection. Statistical analyses, including a receiver operating characteristic curve analysis, were performed to quantify the diagnostic value of D-dimer for periprosthetic shoulder infection. Based on the ICM definition, 4% (4 of 94), 15% (14 of 94), 14% (13 of 94), and 67% (63 of 94) of patients had definite, probable, possible, or unlikely periprosthetic shoulder infections. RESULTS D-dimer was elevated in patients with definite or probable infections (median [range] 661 ng/mL [150 to 8205]) compared with those with possible infections or those who were unlikely to have an infection (263 ng/mL [150 to 3060]; median difference 143 ng/mL [95% CI 40 to 503]; p = 0.01). In the receiver operating characteristic curve analysis, D-dimer had an area under the curve of 0.71 (0.50-0.92), demonstrating weak diagnostic value. A D-dimer level of 598 ng/mL provided a sensitivity and specificity of 61% (95% CI 36% to 82%) and 74% (95% CI 62% to 83%), respectively, for diagnosing a definite or probable infection according to the ICM definitions. The specificity of detecting periprosthetic joint infection (88% [95% CI 79% to 94%]) was high when three positive serum markers (ESR, CRP, and D-dimer) were required, at the expense of sensitivity (28% [95% CI 10% to 53%]). CONCLUSION In periprosthetic shoulder infection, D-dimer is elevated. However, similar to other serum tests, it has limited diagnostic utility in identifying patients with periprosthetic shoulder infection. Further work is needed to understand the process by which D-dimer is associated with active infection. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Benjamin Zmistowski
- Department of Orthopaedic Surgery, Thomas Jefferson
University Hospital, Philadelphia, PA, USA
| | - Michael Chang
- Department of Orthopaedic Surgery, Thomas Jefferson
University Hospital, Philadelphia, PA, USA
| | - Alisina Shahi
- Department of Orthopaedic Surgery, the Rothman
Institute, Thomas Jefferson University Hospital, Philadelphia, PA,
USA
| | - Thema Nicholson
- Department of Orthopaedic Surgery, the Rothman
Institute, Thomas Jefferson University Hospital, Philadelphia, PA,
USA
| | - Joseph Abboud
- Department of Orthopaedic Surgery, the Rothman
Institute, Thomas Jefferson University Hospital, Philadelphia, PA,
USA
| | - Mark Lazarus
- Department of Orthopaedic Surgery, the Rothman
Institute, Thomas Jefferson University Hospital, Philadelphia, PA,
USA
| | - Gerald Williams
- Department of Orthopaedic Surgery, the Rothman
Institute, Thomas Jefferson University Hospital, Philadelphia, PA,
USA
| | - Javad Parvizi
- Department of Orthopaedic Surgery, the Rothman
Institute, Thomas Jefferson University Hospital, Philadelphia, PA,
USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, the Rothman
Institute, Thomas Jefferson University Hospital, Philadelphia, PA,
USA
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20
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Macke C, Lenhof S, Graulich T, Örgel M, Omar-Pacha T, Stübig T, Krettek C, Omar M. Low Diagnostic Value of Synovial Aspiration Culture Prior to Reimplantation in Periprosthetic Joint Infection. In Vivo 2021; 35:2409-2416. [PMID: 34182524 DOI: 10.21873/invivo.12518] [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: 03/16/2021] [Revised: 03/26/2021] [Accepted: 04/12/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM We aimed to determine the diagnostic value of the synovial aspiration culture prior to reimplantation in two- (or more) stage exchange of periprosthetic joint infection. PATIENTS AND METHODS This was a retrospective study, spanning over ten years including all synovial cultures of patients with two- (or more) stage exchange due to periprosthetic joint infection. RESULTS A total of 183 patients were included, mean age was 66.6 years (range=12.8-93.4 years). Overall sensitivity of synovial aspiration cultures before reimplantation was 56.6%, specificity 84.6%, negative predictive value (NPV) 63.8%, positive predictive value (PPV) 80.2%, area under the curve (AUC) 70.6%. Sensitivity of the knee in comparison to the hip culture was significantly higher, as well as the NPV and the AUC (p=0.038). In case of complete removal of prosthesis, the sensitivity and AUC were significantly reduced, whereas the specificity was comparable with prosthesis in situ, partial removal or complete removal. CONCLUSION Due to the low sensitivity, obtaining several synovial cultures in the prosthesis-free interval to exclude persistence of infection, does not seem reasonable.
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Affiliation(s)
- Christian Macke
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
| | - Stefan Lenhof
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
| | - Tilman Graulich
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
| | - Marcus Örgel
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
| | - Tarek Omar-Pacha
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
| | - Timo Stübig
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
| | | | - Mohamed Omar
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
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21
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Salar O, Phillips J, Porter R. Diagnosis of knee prosthetic joint infection; aspiration and biopsy. Knee 2021; 30:249-253. [PMID: 33964686 DOI: 10.1016/j.knee.2020.12.023] [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] [Received: 07/03/2020] [Revised: 10/04/2020] [Accepted: 12/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Prosthetic joint infection (PJI) is a significant cause of morbidity and mortality following knee replacement surgery. The diagnosis can be challenging and is based on a combination of clinical suspicion, radiographic findings and also biochemical/ microbiological investigations. Our Aim was to review the role of aspiration and biopsy in the diagnosis of PJI in Total Knee Arthroplasty (TKA). METHOD/RESULTS Aspirated synovial fluid should be analysed by direct culture, via blood culture bottles, EDTA bottles for cell count and 'point of care' testing such as leucocyte esterase or alpha defensin. Synovial WCC and PMN cell percentage are important steps in diagnosis of both acute and chronic PJI. A minimum of 5 deep samples using a 5 clean instrument technique should be obtained and sent for tissue culture done either blind or arthroscopic. Formal fluoroscopic guided interface biopsy has also been described with excellent results. In a recent series of 86 TKRs preoperative arthroscopic biopsy group had a sensitivity of 100%, specificity of 94.7%, positive predictive value of 87.4% and a negative predictive value of 100%. CONCLUSION In the presence of clinical suspicion with raised biomarkers, it is recommended that aspiration +/- biopsy with synovial fluid testing is performed. Direct culture and cell count are recommended. 'Point of care tests' such as Leucocyte Esterase testing should be considered. Duration of culture, including pathogen and host factors, should be discussed with a local microbiology/ID department in the context of a formal multi-disciplinary team.
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Affiliation(s)
- Omer Salar
- Department of Trauma and Orthopaedics, Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospitals, Barrack Road, EX2 5DW, United Kingdom.
| | - Jonathan Phillips
- Department of Trauma and Orthopaedics, Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospitals, Barrack Road, EX2 5DW, United Kingdom
| | - Robert Porter
- Department of Microbiology, Royal Devon and Exeter Hospitals, Barrack Road, United Kingdom
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22
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Poor performance of open incisional biopsy for the microbiological diagnosis of periprosthetic knee joint infection. Sci Rep 2021; 11:10989. [PMID: 34040084 PMCID: PMC8155057 DOI: 10.1038/s41598-021-90475-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/10/2021] [Indexed: 12/27/2022] Open
Abstract
The accurate preoperative diagnosis of periprosthetic joint infection (PJI) of total knee arthroplasty (TKA) can be difficult despite the use of a combination of serum and synovial markers. In such inconclusive cases, incisional open biopsy might be considered. This study investigates the usefulness of biopsies in patients with inconclusive diagnostic findings. We retrospectively identified 63 patients who underwent incisional biopsy for chronic PJI in the operation theatre following TKA revision between 2010 and 2018 after inconclusive preoperative diagnostics for PJI. In all cases, 5 independent biopsies were taken. Results from open biopsy for PJI were analyzed for diagnostic accuracy using the intraoperative results from following revision surgery as gold standard. 27 patients (43%) had a positive culture taken during biopsy. 15 cases (24%) met the diagnostic criteria for a chronic PJI. Most common organisms were Coagulase-negative staphylococci (67%) and Cutibacterium acnes (30%). Compared to the findings during revision surgery, biopsies showed a sensitivity of 47% and a specificity of 77% for PJI. Open incisional biopsy following inconclusive serum- and synovial diagnostics for low grade PJI may be considered for identification of microorganisms. Due to its low sensitivity and moderate specificity found in the present cohort, microbiological analysis should be combined with additional diagnostic markers and histological investigation. Level of Evidence. Retrospective cohort study (Level III).
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23
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Gross CE, Della Valle CJ, Rex JC, Traven SA, Durante EC. Fungal Periprosthetic Joint Infection: A Review of Demographics and Management. J Arthroplasty 2021; 36:1758-1764. [PMID: 33267978 DOI: 10.1016/j.arth.2020.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/03/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is one of the most feared complications of total joint arthroplasty (TJA). Although commonly the result of colonization by Staphylococcal species, a growing number of cases of PJI with fungal pathogens have been reported within the last decade. Although standard treatment with two-stage exchange mirrors that of bacterial PJI, the variability in virulence between fungal species makes for an unpredictable and challenging treatment course. METHODS A review of Pubmed and Scopus from years 2009 to 2019 was conducted with the search terms fungal, infection, Candida, arthroplasty, periprosthetic, and prosthesis. Publications were reviewed and screened, yielding data for 286 patients with fungal PJI in the hip, knee, shoulder, and elbow prosthetics. RESULTS Patient comorbidities generally included conditions impairing wound healing and immune response such as diabetes mellitus. Candida species were the most common fungal pathogens identified (85%); 30% had a concomitant bacterial infection. A two-stage exchange was most utilized, with a mean success rate of 65%. Antifungal impregnated spacers were utilized in 82 cases, with a comparatively high success rate (81%). Attempts at debridement with implant retention had substantially lower cure rates (15%). CONCLUSIONS Two-stage exchange is the favored approach to treating fungal PJI. Debridement with implant retention does not appear adequate to control infection, and retrieval of implanted materials should be prioritized. The use of antifungal impregnated spacers is an important area of ongoing research, with uncertainty regarding the type and quantity of antifungal agent to incorporate, although recent reports support the use of these agents.
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Affiliation(s)
- Christopher E Gross
- Department of Orthopedics, Medical University of South Carolina, Charleston, SC
| | | | - James C Rex
- Department of Orthopedics, Medical University of South Carolina, Charleston, SC
| | - Sophia A Traven
- Department of Orthopedics, Medical University of South Carolina, Charleston, SC
| | - Elizabeth C Durante
- Department of Orthopedics, Medical University of South Carolina, Charleston, SC
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24
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[Diagnosis of periprosthetic joint infection : Development of an evidence-based algorithm by the work group of implant-associated infection of the AE-(German Society for Arthroplasty)]. DER ORTHOPADE 2021; 50:312-325. [PMID: 32666142 PMCID: PMC7990870 DOI: 10.1007/s00132-020-03940-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hintergrund Die Behandlung periprothetischer Infektionen (PPI) ist eine der größten Herausforderungen im Bereich der Endoprothetik. Der möglichst sichere Ausschluss oder die Bestätigung einer periprothetischen Infektion ist die Voraussetzung für jede Revisionsoperation und kann für den behandelnden Orthopäden und Unfallchirurgen eine große Herausforderung darstellen. Eine sichere evidenzbasierte präoperative Diagnostik ist im Sinne des Patienten notwendig, um einerseits eine periprothetische Infektion zu erkennen sowie die entsprechende chirurgische und antibiotische Therapie zu planen und andererseits unnötige zweizeitige Wechsel zu vermeiden. Ziel der Arbeit Ziel ist es, ein evidenzbasiertes problem- und prioritätenbasiertes Vorgehen zu entwickeln und dies in einem transparenten und standardisierten Algorithmus zusammenzufassen. Methode Durch systematische Literaturrecherche wurden relevante Arbeiten identifiziert und im Rahmen von Expertenrunden bewertet. Nach Extraktion der Daten erfolgte die Berechnung von Sensitivität, Spezifität, positiver und negativer Likelihood-Ratio sowie positiver und negativer prädiktiver Werte. Im Rahmen von 4 Treffen wurden die entsprechenden Studien der Arbeitsgruppe für implantatassoziierte Infektionen präsentiert und analog zu Standard-Delphi-Runden durch die einzelnen Experten bearbeitet und bewertet. Gemäß der Prioritätenliste der Expertenrunde erfolgte die Entwicklung eines zur ISO (International Organization for Standardisation) konformen Algorithmus. Ergebnisse Der entwickelte Algorithmus ist eine Abfolge von evidenzbasierten Prozessen gemäß der verwendeten ISO-Norm. Gemäß der durch die Expertenrunde priorisierten Haupt- und Nebenkriterien erfolgte die Entwicklung logisch strukturiert und problemorientiert. Schlussfolgerung Der Ausschluss einer periprothetischen Infektion ist von enormer Bedeutung vor einer Revisionsoperation und entscheidet in vielen Fällen über den Erfolg und die Invasivität der Operation. Die Diagnose „periprothetische Infektion“ erfordert eine substanzielle Veränderung der therapeutischen Strategie. Der durch die Arbeitsgruppe entwickelte Algorithmus fasst Positionen aus der aktuellen Literatur und spezielle Expertenmeinungen zusammen, dies ermöglicht einen transparenten diagnostischen Ansatz im Sinne einer Standard Operation Procedure.
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25
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Suren C, Lazic I, Stephan M, Lenze FW, Pohlig F, von Eisenhart-Rothe R. Diagnostic algorithm in septic total knee arthroplasty failure - What is evidence-based? J Orthop 2021; 23:208-215. [PMID: 33603316 DOI: 10.1016/j.jor.2020.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 11/25/2022] Open
Abstract
Prosthetic joint infection (PJI) is among the most common differential diagnoses of total knee arthroplasty failure. It is a challenging complication, not least because of the difficulty of establishing the correct diagnosis. The fact that no single diagnostic parameter or test has been identified that can accurately rule in or out PJI has led to an evolution of similar but competing definitions of PJI on the grounds of an array of criteria. This development has had very positive effects on the scientific evaluation of various methods of PJI diagnostics and treatment because of an increased comparability. However, it can be challenging to stay abreast of the evidence these definitions are based on. Also, the definitions alone do not necessarily entail an algorithm to aid in evaluating the right criteria in a sound order to be able to use the definitions as a sensible tool. The aim of this overview is to state the most recent evidence on the diagnostic parameters included in the most established PJI definitions and to exhibit and compare the few algorithmic approaches published. Clinical symptoms of PJI are very rarely reported on in the literature, hence the evidence on their diagnostic value is poor. The only symptom that is part of the established PJI definitions is the presence of a fistula. Concerning serological markers, CRP and ESR are still the common denominator in the literature, most recently accompanied by D-Dimer as a potentially suitable marker that has been included in the most recent update of the International Consensus Meeting (ICM) criteria. Imaging plays a minor role in the diagnostic cascade because of inconsistent evidence, and no role whatsoever in the established definitions. The most important preoperative diagnostic measure is arthrocentesis and cultural and cytological analysis of the synovial fluid. The much acclaimed α-Defensin test has so far not been included in the established criteria due to inconsistent reports on its diagnostic accuracy, it is, however, in wide use and considered an optional diagnostic tool for inconclusive cases. The most diagnostic accuracy lies in the cultural and histological analysis of periprosthetic tissue biopsies, whether they are gathered in a small procedure or during arthroplasty revision. Published algorithmic approaches to PJI diagnosis are much rarer than the well-established definitions by various associations. With their PJI definition, the American Academy of Orthopedic Surgeons (AAOS) published a consensus based flowchart for PJI diagnosis. Another algorithm was proposed as part of the endeavor of the MSIS and the first consensus meeting, also based on a consensus among experts. There have been two more recent publications of flowcharts based on the current evidence, one introduced at our institution in 2013, one established in 2020 by the German Society for Arthroplasty (AE).
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Affiliation(s)
- Christian Suren
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Igor Lazic
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Maximilian Stephan
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Florian Walter Lenze
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Florian Pohlig
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
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26
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Trebse R, Roskar S. Evaluation and interpretation of prosthetic joint infection diagnostic investigations. INTERNATIONAL ORTHOPAEDICS 2021; 45:847-855. [PMID: 33555351 DOI: 10.1007/s00264-021-04958-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/29/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Total joint arthroplasty (TJA) is considered one of the most successful surgical procedures ever developed. It can successfully provide pain relief, restore joint function, and improve mobility and quality of life. Prosthetic joint infection (PJI) presents with a wide variety and severity of signs and symptoms. It remains a major threat to the outcome of TJA procedures and usually necessitates surgical intervention and prolonged courses of antibiotics. Inappropriate treatment of an unrecognized PJI usually ends with unacceptable and sometimes catastrophic results. THE AIM The understanding and evaluation of diagnostic investigations are extremely important to properly diagnose PJI, including frequently unrecognized low-grade infections, and to provide healthcare professionals with needed information for the care of patients affected by this condition. This article aims to review most of the methods available in PJI diagnostics, to emphasize the strengths and the weaknesses of each of them, and to provide a guideline on how to select the surgical treatment strategy based on the level of diagnostic certainty during the evaluation period. To safely accomplish this, it is crucial to be aware of the limitations of each diagnostic modality. THE FOCUS The emphasis will be on the use and interpretation of the core criteria for PJI diagnosis, including the pathognomonic sinus tract communicating with the implant, purulent synovial fluid, inflammation in the periprosthetic tissue, cell count with differential, microbial growth in the synovial fluid culture, tissue sample cultures, and sonication samples.
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Affiliation(s)
- Rihard Trebse
- Valdoltra Orthopaedic Hospital, Jadranska cesta 31, SI-6280, Ankaran, Slovenia.
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, SI, 1000, Ljubljana, Slovenia.
| | - Samo Roskar
- Valdoltra Orthopaedic Hospital, Jadranska cesta 31, SI-6280, Ankaran, Slovenia
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27
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Garcia D, Gardezi M, Suliman Y, Glasser J, Spake CS, Barrett C, Berns E, Jenkins D, Evans A, Cohen E, Eberson C, Hayda R, Daniels A, Green A, Owens B, Antoci V, Born CT. Fluorescent-conjugated antibodies as rapid ex vivo markers for bacterial presence on orthopedic surgical explants and synovium: A pilot study. J Orthop Res 2021; 39:299-307. [PMID: 33225467 DOI: 10.1002/jor.24924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/20/2020] [Accepted: 11/19/2020] [Indexed: 02/04/2023]
Abstract
Surgical infection is one of the most pressing problems in the field of orthopedic surgery; however, current detection methods are plagued by high costs and long wait times. This study seeks to demonstrate the ability of a novel assay using fluorescently conjugated antibodies and confocal laser scanning microscopy (CLSM) to accurately detect bacterial presence on orthopedic surgical explants, tissue, and synovial fluid in 30 min. Explanted hardware, tissue, and synovial fluid samples suspected to be infected were collected from human subjects with institutional review board consent. Samples were prepared using a 30-min protocol, consisting of rinsing, nonspecific blocking and staining steps, and imaged using CLSM. Images were analyzed using ImageJ (National Institute of Health) to determine the percent area of Gram positive and Gram negative bacteria. Results of the assay were compared to the hospital's microbiological laboratory and Gram staining results. Ninety three samples were collected and tested using the 30-min testing protocol; 75 samples were synovial fluid and 18 were tissue and explants. Seventy four of 75 (98.6%) synovial fluid samples correlated with the hospital laboratory's microbiological findings. Of the 18 explant and tissue samples, our assay found bacterial presence in 14 of 18 samples, while the hospital microbiology laboratory found bacterial presence in 13 of 18 samples. This assay reliably stained and rapidly identified the presence of Gram negative and Gram positive bacteria on surgical explants, tissue and synovial fluid in 30 min. This methodology may serve as a point of service tool for the determination of bacterial presence during surgical procedures.
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Affiliation(s)
- Dioscaris Garcia
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University Department of Orthopedic Surgery, Providence, Rhode Island, USA
| | - Mursal Gardezi
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Yasmine Suliman
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jillian Glasser
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Carole Sl Spake
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Caitlin Barrett
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ellis Berns
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Derek Jenkins
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University Department of Orthopedic Surgery, Providence, Rhode Island, USA
| | - Andrew Evans
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University Department of Orthopedic Surgery, Providence, Rhode Island, USA
| | - Eric Cohen
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University Department of Orthopedic Surgery, Providence, Rhode Island, USA
| | - Craig Eberson
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University Department of Orthopedic Surgery, Providence, Rhode Island, USA
| | - Roman Hayda
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University Department of Orthopedic Surgery, Providence, Rhode Island, USA
| | - Alan Daniels
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University Department of Orthopedic Surgery, Providence, Rhode Island, USA
| | - Andrew Green
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University Department of Orthopedic Surgery, Providence, Rhode Island, USA
| | - Brett Owens
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University Department of Orthopedic Surgery, Providence, Rhode Island, USA
| | - Valentin Antoci
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University Department of Orthopedic Surgery, Providence, Rhode Island, USA
| | - Christopher T Born
- The Diane N. Weiss Center for Orthopedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Brown University Department of Orthopedic Surgery, Providence, Rhode Island, USA
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28
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Letter to editor "Risk factors for aseptic loosening in complex revision total knee arthroplasty using rotating hinge implants". INTERNATIONAL ORTHOPAEDICS 2021; 45:801-802. [PMID: 33432399 DOI: 10.1007/s00264-021-04946-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022]
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29
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Lauri C, Lauretti G, Galli F, Campagna G, Tetti S, Riolo D, Signore A. Handling of Doubtful WBC Scintigraphies in Patients with Suspected Prosthetic Joint Infections. J Clin Med 2020; 9:jcm9124031. [PMID: 33322146 PMCID: PMC7763501 DOI: 10.3390/jcm9124031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 11/26/2022] Open
Abstract
Despite the application of EANM recommendations for radiolabelled white-blood-cells (WBC) scintigraphy, some cases still remain doubtful based only on visual analysis. The aim of this study was to investigate the role of semi-quantitative analysis and bone marrow scan (BMS) in solving doubtful cases. We retrospectively evaluated all [99mTc]HMPAO-WBC scintigraphies performed, in the last 7 years, for a suspected monolateral prosthetic joint infection (PJI). In doubtful cases, we used five different thresholds of increase of target-to-background (T/B) ratio, between delayed and late images, as criteria of positivity (5%, 10%, 15%, 20% and 30%). BMS were also analysed and sensitivity, specificity and accuracy of different methods were calculated according to final diagnosis. The sensitivity, specificity and accuracy were, respectively, 77.8%, 43.8% and 53.0% for the cut-off at 5%; 72.2%, 66.7% and 68.2% for the cut-off at 10%; 66.7%, 75.0% and 72.7% for the cut-off at 15%; 66.7%, 85.4% and 80.3% for the cut-off at 20%; 33.3%, 93.8% and 77.3% for the cut-off at 30%. BMS provided a significantly higher diagnostic performance than 5%, 10% and 15% thresholds. Conversely, we did not observe any statistically significant difference between BMS and the cut-off of more than 20%. Therefore, doubtful cases should be analysed semi-quantitatively. An increase in T/B ratio of more than 20% between delayed and late images, should be considered as a criterion of positivity, thus avoiding BMS.
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Affiliation(s)
- Chiara Lauri
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.L.); (F.G.); (G.C.); (S.T.); (D.R.)
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands
| | - Giancarlo Lauretti
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.L.); (F.G.); (G.C.); (S.T.); (D.R.)
| | - Filippo Galli
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.L.); (F.G.); (G.C.); (S.T.); (D.R.)
| | - Giuseppe Campagna
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.L.); (F.G.); (G.C.); (S.T.); (D.R.)
| | - Simone Tetti
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.L.); (F.G.); (G.C.); (S.T.); (D.R.)
| | - Donatella Riolo
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.L.); (F.G.); (G.C.); (S.T.); (D.R.)
| | - Alberto Signore
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.L.); (F.G.); (G.C.); (S.T.); (D.R.)
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands
- Correspondence: ; Tel.: +39-(06)-33775538
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30
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Brown M, Eseonu K, Rudge W, Warren S, Majed A, Bayley I, Higgs D, Falworth M. The management of infected shoulder arthroplasty by two-stage revision. Shoulder Elbow 2020; 12:70-80. [PMID: 33343718 PMCID: PMC7726183 DOI: 10.1177/1758573219841057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 12/24/2018] [Accepted: 03/11/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND There remains no gold standard management for deep shoulder periprosthetic joint infection (PJI). This case series aims to present our experience of two-stage revision arthroplasty, including eradication of infection and reoperation rates. METHODS We retrospectively reviewed patients undergoing revision arthroplasty for shoulder PJI between 2006 and 2015. Cases were confirmed using Musculoskeletal Infection Society (MSIS) and American Academy of Orthopaedic Surgeons (AAOS) guidelines. TSA removal, debridement and irrigation preceded antibiotic-loaded cement spacer insertion and a minimum of six weeks intravenous antibiotics. Reimplantation was performed as a second stage following a negative aspirate. RESULTS Twenty-eight patients underwent a first stage procedure (mean age 69 years; 16 male, 12 female). Propionibacterium acnes, Methicillin-sensitive Staphylococcus aureus, Coagulase-negative Staphylococcus and Staphylococcus epidermidis were the commonest microorganisms cultured. Five cases had mixed growths and six cases provided no growth. Three patients did not proceed to a second stage. Twenty-five patients underwent reimplantation (mean interval 6.7 months), with 80% remaining infection-free (mean follow-up 38.3 months). DISCUSSION Managing complex and late presentation shoulder PJI with two-stage revision is associated with high rates of infection eradication (80%). In the absence of a management consensus, our experience supports two-stage revision arthroplasty for eradicating infection in this complex patient group.
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Affiliation(s)
- Matthew Brown
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK,Matthew Brown, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK.
| | - Kelechi Eseonu
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Will Rudge
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Simon Warren
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK,Department of Microbiology, Royal Free Hospital, Hampstead, London, UK,Department of Microbiology, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Addie Majed
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Ian Bayley
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Deborah Higgs
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Mark Falworth
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK
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31
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Fink B, Schlumberger M. Antibiotic therapy alone does not have a high success rate in cases of unexpected positive cultures in intraoperative samples from hip and knee prosthesis revision. BMC Musculoskelet Disord 2020; 21:786. [PMID: 33248455 PMCID: PMC7700714 DOI: 10.1186/s12891-020-03799-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/17/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Unexpectedly positive bacterial cultures during prosthesis revision surgery still occur on occasion despite good preoperative diagnostics. In such cases a six-week antibiotic therapy without further surgical intervention is recommended. The aim of this study was to find out how successful this procedure is. METHODS In a study of 508 patients, who required revision surgery of total hip (THA, n = 231) or knee arthroplasties (TKA, n = 277) because of component loosening, biopsy was carried out before their surgery. The collected tissue samples (5) from the biopsy and the revision surgery procedure itself were analyzed according the criteria of the International Consensus Meeting (ICM). Tests revealed 11 patients (7 THA, 4 TKA) with unexpectedly positive bacterial cultures from tissue samples obtained during the revision surgery due to false negative preoperative diagnostic results. These 11 patients were treated with 6 weeks antibiotic therapy and examined with a follow-up of at least 2 years (42.2 ± 16.5 months). RESULTS Five patients (2 TKA, 3 THA) became reinfected, resulting in a success rate of 54.5%. CONCLUSION Antibiotic therapy alone of an unexpected positive intraoperative bacterial culture in prosthesis revision surgery seems to be less successful than previously assumed.
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Affiliation(s)
- Bernd Fink
- Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Kurt-Lindemann-Weg 10, 71706, Markgröningen, Germany.
- Orthopaedic Department, University Hospital Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20251, Germany.
| | - Michael Schlumberger
- Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Kurt-Lindemann-Weg 10, 71706, Markgröningen, Germany
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Abdelbary H, Cheng W, Ahmadzai N, Carli AV, Shea BJ, Hutton B, Fergusson DA, Beaulé PE. Combination Tests in the Diagnosis of Chronic Periprosthetic Joint Infection: Systematic Review and Development of a Stepwise Clinical Decision-Making Tool. J Bone Joint Surg Am 2020; 102:114-124. [PMID: 32870618 DOI: 10.2106/jbjs.20.00097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Our objective was to identify combination tests used to diagnose chronic periprosthetic joint infection (PJI) and develop a stepwise decision-making tool to facilitate diagnosis. METHODS We conducted a systematic review of existing combinations of serum, synovial, and tissue-based tests for diagnosing chronic PJI after hip or knee replacement. This work is an extension of our systematic review of single tests, from which we chose eligible studies that also described the diagnostic performance of combination tests. RESULTS Thirty-seven eligible articles described the performance of 56 combination tests, of which 8 combinations had at least 2 studies informing both sensitivity and specificity. We also identified 5 types of combination tests: (1) a type-I Boolean combination, which uses Boolean logic (AND, OR) and usually increases specificity at the cost of sensitivity; (2) a type-II Boolean combination, which usually increases sensitivity at the cost of specificity; (3) a triage-conditional rule, in which the value of 1 test serves to triage the use of another test; (4) an arithmetic operation on the values of 2 tests; and (5) a model-based prediction rule based on a fitted model applied to biomarker values. CONCLUSIONS Clinicians can initiate their diagnostic process with a type-II Boolean combination of serum C-reactive protein (CRP) and interleukin-6 (IL-6). False negatives of the combination can be minimized when the threshold is chosen to reach 90% to 95% sensitivity for each test. Once a joint infection is suspected on the basis of serum testing, joint aspiration should be performed. If joint aspiration yields a wet tap, a leukocyte esterase (LER) strip is highly recommended for point-of-care testing, with a reading of ++ or greater indicating PJI; a reading below ++ should be followed by one of the laboratory-based synovial tests. If joint aspiration yields a dry tap, clinicians should rely on preoperative tissue culture and histological analysis for diagnosis. Combinations based on triage-conditional, arithmetic, and model-based prediction rules require further research. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hesham Abdelbary
- Division of Orthopaedic Surgery (H.A. and P.E.B.) and School of Epidemiology and Public Health (B.J.S. and B.H.), University of Ottawa, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nadera Ahmadzai
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Beverley J Shea
- Division of Orthopaedic Surgery (H.A. and P.E.B.) and School of Epidemiology and Public Health (B.J.S. and B.H.), University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Brian Hutton
- Division of Orthopaedic Surgery (H.A. and P.E.B.) and School of Epidemiology and Public Health (B.J.S. and B.H.), University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery (H.A. and P.E.B.) and School of Epidemiology and Public Health (B.J.S. and B.H.), University of Ottawa, Ottawa, Ontario, Canada
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Kuo FC, Chien CC, Lee MS, Wang JW, Lin PC, Lee CH. Rapid diagnosis of periprosthetic joint infection from synovial fluid in blood culture bottles by direct matrix-assisted laser desorption ionization time-of-flight mass spectrometry. PLoS One 2020; 15:e0239290. [PMID: 32970712 PMCID: PMC7515592 DOI: 10.1371/journal.pone.0239290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/03/2020] [Indexed: 11/18/2022] Open
Abstract
Background The aim of this prospective study was to use direct matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) to rapidly diagnose periprosthetic joint infections (PJIs). Method Synovial fluid was taken from 77 patients (80 joints, 41 hips and 39 knees) who met the International Consensus Meeting criteria for PJI, and inoculated into blood culture bottles (BCBs) and onto conventional swabs. Positive blood cultures were analyzed using either direct or routine MALDI-TOF MS. Pathogen identification and the time to identification was recorded. Differences between groups were analyzed using the Kruskal-Wallis test and Bonferroni's post-hoc test. Results Direct and routine MALDI-TOF MS both detected 64 positive results (80%), compared to 47 (59%) by conventional swabs (p = 0.002). Direct MALDI-TOF MS identified 85.3% of the gram-positive organisms and 92.3% of the gram-negative organisms. No fungi were identified by direct MALDI-TOF MS. In 17 BCBs that were flagged positive, identification by direct MALDI-TOF MS failed. Among the positive results in the direct MALDI-TOF MS group, Staphylococcus aureus accounted for 47%, followed by Staphylococcus epidermidis (17%), Escherichia coli (9%) and Klebsiella pneumoniae (9%). The median time to microorganism identification was significantly shorter with direct MALDI-TOF MS (12.7 h, IQR: 8.9–19.6 h) than with routine MALDI-TOF MS (39.5 h, IQR: 22.8–46.0 h) or swabs (44.4 h, IQR: 27.2–72.6 h) (p < 0.0001). In pairwise comparisons, there were significant differences in the time of microorganism identification between direct MALDI-TOF MS and routine MALDI-TOF MS (p < 0.0001) or swab culture (p < 0.0001). There was no significant difference between routine MALDI-TOF MS and swab culture (p = 0.0268). Conclusion Compared with current laboratory practice, direct MALDI-TOF MS shortened the time to microorganism identification and had superior results compared to conventional swabs, except for fungi. Further studies should investigate whether the earlier administration of appropriate antimicrobial agents can improve the treatment outcomes of PJIs.
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Affiliation(s)
- Feng-Chih Kuo
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Chun-Chih Chien
- Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Mel S. Lee
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Jun-Wen Wang
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Po-Chun Lin
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Chen-Hsiang Lee
- College of Medicine, Chang Gung University, Kaohsiung, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- * E-mail:
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Declercq P, Neyt J, Depypere M, Goris S, Van Wijngaerden E, Verhaegen J, Wauters J, Spriet I. Preoperative joint aspiration culture results and causative pathogens in total hip and knee prosthesis infections: mind the gap. Acta Clin Belg 2020; 75:284-292. [PMID: 31057053 DOI: 10.1080/17843286.2019.1611718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES In prosthetic joint infections (PJIs), there is no consensus about the utility of the preoperative joint aspiration culture to guide antimicrobial treatment. The main objective of this retrospective study was to investigate the value of these preoperative samples to narrow immediate postoperative empirical antimicrobial treatment in patients with a knee or hip PJI. METHODS Adult patients admitted for an exchange procedure between June 2007 and July 2016 for whom a preoperative joint aspiration within 6 months prior to the procedure was available and with an antibiotic-free interval before sampling, were eligible. Per PJI, taking both preoperative joint aspiration and intraoperative deep samples into account, causative pathogen(s) were assessed by the current Infectious Diseases Society of America (IDSA) guidelines. Per PJI, agreement of preoperative joint aspiration cultures corresponding to the causative pathogen(s) was investigated both on species and on Gram/fungi level. RESULTS From the 85 PJIs, on species level, the total agreement was found in 58 (68%) PJIs. On Gram/fungi level, when preoperative joint aspiration cultures yielded exclusively Gram-positive microorganisms (n = 61), a 100% predictive value for Gram positive causing pathogens was attained. Insufficient predictive value was observed in PJIs with preoperative joint aspiration yielding Gram-negative microorganisms (n = 4), a fungus (n = 1) or with sterile results (n = 19). CONCLUSION In the immediate postoperative setting, the treating team might consider a broad spectrum empirical antibiotic regime, guided by the local epidemiology and susceptibility, which can be narrowed to Gram-positive coverage if preoperative joint aspiration cultures yield exclusively Gram-positive microorganisms.
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Affiliation(s)
- Peter Declercq
- Pharmacy Dpt. and Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Jeroen Neyt
- Department of Orthopedic Surgery, Head Division Septic Orthopedic and Trauma Surgery, Faculty of Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Microbiology and Immunology, Laboratory of Clinical Bacteriology and Mycology, University Hospitals Leuven, Leuven, Belgium
| | - Stefanie Goris
- Pharmacy Dpt. and Department of Pharmaceutical and Pharmacological Sciences, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Eric Van Wijngaerden
- Department of General Internal Medicine, Faculty of Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jan Verhaegen
- Department of Microbiology and Immunology, Laboratory of Clinical Bacteriology and Mycology, University Hospitals Leuven, Leuven, Belgium
| | - Joost Wauters
- Department of General Internal Medicine, Faculty of Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Dpt. and Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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Akgün D, Maziak N, Plachel F, Siegert P, Minkus M, Thiele K, Moroder P. The role of implant sonication in the diagnosis of periprosthetic shoulder infection. J Shoulder Elbow Surg 2020; 29:e222-e228. [PMID: 31924518 DOI: 10.1016/j.jse.2019.10.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/04/2019] [Accepted: 10/20/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to investigate the validity of implant sonication fluid cultures in the diagnosis of shoulder periprosthetic joint infection (PJI) compared with tissue culture. METHODS This was a retrospective case-control study analyzing all patients who underwent a revision surgery for any kind of suspected septic or aseptic event due to failed shoulder arthroplasty at our institution between July 2014 and December 2018. The diagnostic validity of implant sonication was analyzed on the basis of the last proposed definition criteria of the International Consensus Meeting and compared with standard tissue cultures. RESULTS Of the 72 patients, a total of 28 (38.9%) were classified as infected. Of the 28 infected patients, 20 (71.4%) had an identified organism by tissue cultures, and Cutibacterium acnes was the most commonly isolated pathogen. The sensitivities of sonicate fluid (≥50 CFU/mL) and periprosthetic tissue culture for the diagnosis of periprosthetic shoulder infection were 36% and 61% (P = .016), and the specificities were 97.7% and 100% (P > .99), respectively. If no cutoff value was used in sonication culture, the sensitivity increased to 75% whereas the specificity dropped to 82%. Although there was no significant difference in sensitivity between tissue culture and the no-cutoff sonication fluid culture (61% vs. 75%, P = .125), the specificity of tissue culture was significantly higher (100% vs. 82%, P = .01). CONCLUSION Tissue culture showed a higher sensitivity and specificity than implant sonication in the diagnosis of shoulder PJI and should remain the gold standard for microbiological diagnosis of shoulder PJI.
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Affiliation(s)
- Doruk Akgün
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin; Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany.
| | - Nina Maziak
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin; Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Fabian Plachel
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin; Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Paul Siegert
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin; Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Marvin Minkus
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin; Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Kathi Thiele
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin; Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Philipp Moroder
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin; Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
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Banousi A, Evangelopoulos DS, Stylianakis A, Fandridis E, Chatziioannou S, Sipsas NV, Pneumaticos SG. A comparative study of heterogeneous antibiotic resistance of microbial populations in conventional periprosthetic tissue cultures and sonication fluid cultures of orthopaedics explanted prostheses. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1307-1318. [PMID: 32449081 DOI: 10.1007/s00590-020-02704-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 05/11/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND "Heterogeneity" describes a phenomenon where subpopulations of seemingly isogenic bacteria exhibit a range of susceptibilities to a particular antibiotic. We aim to investigate the frequency of heterogeneity among microbes isolated from infected prostheses, and its possible correlation with microbial resistance. METHODS Between May 2014 and June 2019, we investigated 234 patients, at our institution, undergoing revision arthroplasty because of loosening of the prostheses or because of periprosthetic joint infection. All patients had periprosthetic tissue culture, sonication of prosthesis and direct inoculation of Sonication fluid into blood culture bottles. We assessed the presence of heterogeneity among all pathogens isolated from infected prostheses. RESULTS Using standard non-microbiological criteria to determine periprosthetic joint infection, it was found that 143 patient (61.1%) had aseptic loosening while 91 patients (38.9%) had periprosthetic joint infection. Comparing the two methods, the results of our study showed that the method of sonication was significantly more sensitive than tissue culture [91% (83-96) vs. 43% (33-54); p < 0.005]. In this study, heterogeneity was reported in 15 cases, 16.5% of all infections and 6.4% in the total population. In our study, Staphylococcus epidermidis was the most commonly isolated strain followed by Staphylococcus aureus, at a rate of 35.2% and 19.8%, respectively. Antibiotics in which the microorganisms exhibited heterogeneous bacterial behavior most frequently were Gendamicin (5.3%), Vancomycin (4.9%). CONCLUSION There is increasing evidence that heterogeneity can lead to therapeutic failure and that the detection of this phenotype is a prerequisite for a proper antibiotic choice to have a successful therapeutic effect.
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Affiliation(s)
- Angeliki Banousi
- 3rd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Dimitrios S Evangelopoulos
- 3rd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Stylianakis
- Laboratory of Implant Associated Infections, Department of Microbiology, General Hospital KAT, Athens, Greece
| | - Emmanouil Fandridis
- Hand-Upper Limb and Microsurgery Department, General Hospital KAT, Athens, Greece
| | - Sofia Chatziioannou
- Nuclear Medicine Division, PET/CT section, Foundation for Biomedical Research of the Academy of Athens, Athens, Greece
- 2nd Department of Radiology, Medical School, National and Kapodistrian University of Athens, General University Hospital "ATTIKON", Athens, Greece
| | - Nikolaos V Sipsas
- Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon G Pneumaticos
- 3rd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Suren C, Feihl S, Cabric S, Banke IJ, Haller B, Trampuz A, von Eisenhart-Rothe R, Prodinger PM. Improved pre-operative diagnostic accuracy for low-grade prosthetic joint infections using second-generation multiplex Polymerase chain reaction on joint fluid aspirate. INTERNATIONAL ORTHOPAEDICS 2020; 44:1629-1637. [PMID: 32296908 PMCID: PMC7452934 DOI: 10.1007/s00264-020-04552-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/26/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND A major obstacle for the treatment of prosthetic joint infection (PJI) is the identification of the underlying causative organism. While the diagnostic criteria ruling PJI in or out have become ever more accurate, the detection of the causative pathogen(s) still relies mostly on conventional and time-consuming microbial culture. The aim of this study was to evaluate the diagnostic potential of a second-generation multiplex PCR assay (Unyvero ITI G2, Curetis AG, Holzgerlingen, Germany) used on synovial fluid specimens. Our hypothesis was that the method would yield a higher diagnostic accuracy in the pre-operative workup than synovial fluid culture. Thus, a more precise classification of septic and aseptic prosthesis failure could be achieved before revision surgery. METHODS Prospectively collected frozen joint fluid specimens from 26 patients undergoing arthroplasty revision surgery of the hip or knee were tested as per the manufacturer's protocol. Sensitivities, specificities, positive and negative predictive values as well as positive and negative likelihood ratios with corresponding confidence intervals were estimated using the statistical software R. A combination of the serum C-reactive protein (CRP) level, leukocyte count, erythrocyte sedimentation rate, joint fluid culture, tissue biopsy culture, and tissue biopsy histology served as the gold standard. RESULTS Of the 26 patients included in the study, 15 were infected and 11 were aseptic. Conventional joint fluid culture showed a sensitivity of 0.67 and a specificity of 0.91. Joint fluid multiplex PCR yielded a sensitivity of 0.8 and a specificity of 1.0. CONCLUSIONS Using the second-generation Unyvero ITI cartridge on joint fluid aspirate for the detection of prosthetic joint infection, we were able to achieve a higher diagnostic accuracy than with conventional culture. We conclude that to improve pathogen detection before revision surgery, this method represents a valuable and practicable tool.
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Affiliation(s)
- Christian Suren
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Susanne Feihl
- Institut für Medizinische Mikrobiologie, Immunologie und Hygiene, Technische Universität München, Trogerstr. 30, 81675, Munich, Germany
| | - Sabrina Cabric
- Centrum für Muskuloskeletale Chirurgie (CMSC), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Ingo J Banke
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Haller
- Institut für medizinische Informatik, Statistik und Epidemiologie, Technische Universität München, Grillparzerstr. 18, 81675, Munich, Germany
| | - Andrej Trampuz
- Centrum für Muskuloskeletale Chirurgie (CMSC), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Rüdiger von Eisenhart-Rothe
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Peter M Prodinger
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
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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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Stupina TA, Sudnitsyn AS, Subramanyam KN, Migalkin NS, Kirsanova AY, Umerjikar S. Applicability of histopathological osteomyelitis evaluation score (HOES) in chronic osteomyelitis of the foot - A feasibility study. Foot Ankle Surg 2020; 26:273-279. [PMID: 31000385 DOI: 10.1016/j.fas.2019.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/10/2019] [Accepted: 03/23/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Diagnosis and classification of chronic osteomyelitis is not based on any objective criteria. None of the available methods for this is completely reliable. Tienmann et al. (2014) has described the so called histopathological osteomyelitis evaluation score (HOES) to overcome this limitation. But this has not been externally validated or tested in cases with foot osteomyelitis. METHODS We prospectively reviewed the histopathological samples of 30 consecutive patients (30 feet) with foot osteomyelitis managed operatively. There were 19 males and 11 females with an average age of 41.6 (range, 27-63) years. The underlying pathology was spina bifida in 12, Charcot's arthropathy in eleven and post-traumatic in seven patients. The bones involved were calcaneum, talus and fifth metatarsal. Pathological diagnosis was made based on HOES by a single pathologist blinded to the clinical diagnosis and both were compared. Intra- and inter-observer reliability of HOES was assessed by analysing the scores of each patient assigned independently by four different pathologists (blinded to the clinical diagnoses and to each other) at two different occasions one week apart. RESULTS All samples showed features of long-standing osteomyelitis. When attempting to classify to "acute on chronic", "chronic" and "quiescent" forms, the pathological diagnosis correlatead with the clinical diagnosis only in 16 cases (53.3 percent). Histological classification to Tienmann's types as per the scoring system yielded three distinct pathological entities that had common histological features with regard to bone, soft tissue and inflammatory infiltration. HOES exhibited excellent intra- and inter-observer reliability. CONCLUSIONS HOES is well applicable in foot osteomyelitis both for diagnosis and classification by unambiguous and precise scoring system. This makes diagnostic labelling more accurate and repeatable. The clinical relevance of these histopathological types in guiding management and determining prognosis needs to be investigated further.
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Affiliation(s)
- Tatiana Anatolievna Stupina
- Laboratory of Morphology, Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics, 6, M. Ulianova Street, 640014 Kurgan, Russian Federation.
| | - Anatoliy Sergeyevich Sudnitsyn
- Laboratory of Bone Infection Osteology and Limb Lengthening, Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics, 6, M. Ulianova Street, 640014 Kurgan, Russian Federation.
| | - Koushik Narayan Subramanyam
- Dept. of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134 India.
| | - Nikolai Sergeevich Migalkin
- Laboratory of Morphology, Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics, 6, M. Ulianova Street, 640014 Kurgan, Russian Federation.
| | - Anastasia Yrievna Kirsanova
- Laboratory of Morphology, Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics, 6, M. Ulianova Street, 640014 Kurgan, Russian Federation.
| | - Sagar Umerjikar
- Dept. of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134 India.
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Fink B, Schuster P, Braun R, Tagtalianidou E, Schlumberger M. The diagnostic value of routine preliminary biopsy in diagnosing late prosthetic joint infection after hip and knee arthroplasty. Bone Joint J 2020; 102-B:329-335. [PMID: 32114807 DOI: 10.1302/0301-620x.102b3.bjj-2019-0684.r1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIMS Biopsy of the periprosthetic tissue is an important diagnostic tool for prosthetic joint infection (PJI) as it enables the detection of the responsible microorganism with its sensitivity to antibiotics. We aimed to investigate how often the bacteria identified in the tissue analysis differed between samples obtained from preoperative biopsy and intraoperative revision surgery in cases of late PJI; and whether there was a therapeutic consequence. METHODS A total of 508 patients who required revision surgery of total hip arthroplasty (THA) (n = 231) or total knee arthroplasty (TKA) (n = 277) because of component loosening underwent biopsy before revision surgery. The tissue samples collected at biopsy and during revision surgery were analyzed according to the criteria of the Musculoskeletal Infection Society (MSIS). RESULTS In total, 178 (113 THA, 65 TKA) were classified as infected. The biopsy procedure had a sensitivity of 93.8%, a specificity of 97.3%, a positive predictive value (PPV) of 94.9%, a negative predictive value (NPV) of 96.7%, and an accuracy of 96.1%. Of the 178 infected patients, 26 showed a difference in the detected bacteria from the biopsy and the revision surgery (14.6%). This difference required a change to antibiotic therapy in only two cases (1.1%). CONCLUSION Biopsy is a useful tool to diagnose PJI, but there may be a difference in the detected bacteria between the biopsy and revision surgery. However, this did not affect the choice of antibiotic therapy in most cases, rendering the clinical relevance of this phenomenon as low. Cite this article: Bone Joint J 2020;102-B(3):329-335.
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Affiliation(s)
- Bernd Fink
- Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Markgröningen, Germany; Orthopaedic Department, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Schuster
- Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Markgröningen, Germany; Department of Orthopedics and Traumatology, Clinic Nuremberg, Paracelsus Medical Private University, Nuremberg, Germany
| | - Rüdiger Braun
- Department of Microbiology, MVZ-Labor Ludwigsburg, Ludwigsburg, Germany
| | - Eli Tagtalianidou
- Department of Microbiology, MVZ-Labor Ludwigsburg, Ludwigsburg, Germany
| | - Michael Schlumberger
- Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Markgröningen, Germany
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Fink B, Schlumberger M, Beyersdorff J, Schuster P. C-reactive protein is not a screening tool for late periprosthetic joint infection. J Orthop Traumatol 2020; 21:2. [PMID: 32095896 PMCID: PMC7040136 DOI: 10.1186/s10195-020-0542-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 01/02/2020] [Indexed: 01/24/2023] Open
Abstract
Background Preoperative diagnosis of periprosthetic joint infection (PJI) is important because of the therapeutic consequences. The aim of the present study is to investigate whether the serum C-reactive protein (CRP) level can be used as a screening tool for late PJI. Materials and methods A cohort of 390 patients with revision surgery of total hip prostheses (200) or total knee prostheses (190) was assessed for late PJI by determining CRP serum level and performing preoperative aspiration with cultivation and intraoperative tissue analyses with cultivation and histologic examination, using the Musculoskeletal Infection Society (MSIS) and International Consensus Meeting (ICM) criteria. Results A total of 180 joints were rated as PJI (prevalence 46%). Of these, 42.8% (77) showed a CRP level below 10 mg/L and 28.3% (51) showed a normal CRP level of less than 5 mg/L. The 76.9% of the cases with slow-growing bacteria showed a CRP level below 10 mg/L, and 61.5% showed a normal CRP level. Conclusions Serum CRP level should not be used as a screening tool to rule out late PJI. Level of evidence Level 2 (diagnostic study).
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Affiliation(s)
- Bernd Fink
- Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Kurt-Lindemann-Weg 10, 71706, Markgröningen, Germany. .,Orthopaedic Department, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
| | - Michael Schlumberger
- Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Kurt-Lindemann-Weg 10, 71706, Markgröningen, Germany
| | - Julian Beyersdorff
- Orthopaedic Department, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Schuster
- Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Kurt-Lindemann-Weg 10, 71706, Markgröningen, Germany.,Department of Orthopedics and Traumatology, Clinic Nuremberg,, Paracelsus Medical Private University, Nuremberg, Germany
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Sconfienza LM, Signore A, Cassar-Pullicino V, Cataldo MA, Gheysens O, Borens O, Trampuz A, Wörtler K, Petrosillo N, Winkler H, Vanhoenacker FMHM, Jutte PC, Glaudemans AWJM. Diagnosis of peripheral bone and prosthetic joint infections: overview on the consensus documents by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur Radiol 2019; 29:6425-6438. [PMID: 31250170 DOI: 10.1007/s00330-019-06326-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/27/2019] [Accepted: 06/12/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Peripheral bone infection (PBI) and prosthetic joint infection (PJI) are two different infectious conditions of the musculoskeletal system. They have in common to be quite challenging to be diagnosed and no clear diagnostic flowchart has been established. Thus, a conjoined initiative on these two topics has been initiated by the European Society of Radiology (ESR), the European Association of Nuclear Medicine (EANM), the European Bone and Joint Infection Society (EBJIS), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). The purpose of this work is to provide an overview on the two consensus documents on PBI and PJI that originated by the conjoined work of the ESR, EANM, and EBJIS (with ESCMID endorsement). METHODS AND RESULTS After literature search, a list of 18 statements for PBI and 25 statements for PJI were drafted in consensus on the most debated diagnostic challenges on these two topics, with emphasis on imaging. CONCLUSIONS Overall, white blood cell scintigraphy and magnetic resonance imaging have individually demonstrated the highest diagnostic performance over other imaging modalities for the diagnosis of PBI and PJI. However, the choice of which advanced diagnostic modality to use first depends on several factors, such as the benefit for the patient, local experience of imaging specialists, costs, and availability. Since robust, comparative studies among most tests do not exist, the proposed flowcharts are based not only on existing literature but also on the opinion of multiple experts involved on these topics. KEY POINTS • For peripheral bone infection and prosthetic joint infection, white blood cell and magnetic resonance imaging have individually demonstrated the highest diagnostic performance over other imaging modalities. • Two evidence- and expert-based diagnostic flowcharts involving variable combination of laboratory tests, biopsy methods, and radiological and nuclear medicine imaging modalities are proposed by a multi-society expert panel. • Clinical application of these flowcharts depends on several factors, such as the benefit for the patient, local experience, costs, and availability.
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Affiliation(s)
- Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy. .,Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy.
| | - Alberto Signore
- Nuclear Medicine Unit, Faculty of Medicine and Psychology, Department of Medical-Surgical Sciences and Translational Medicine, "Sapienza" University, Rome, Italy
| | - Victor Cassar-Pullicino
- Department of Diagnostic Imaging, The Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Oswestry, Shropshire, UK
| | - Maria Adriana Cataldo
- Infectious Disease Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS, Rome, Italy
| | - Olivier Gheysens
- Department of Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Olivier Borens
- Division of Orthopaedic Surgery and Traumatology, Septic surgical unit, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - 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
| | - Klaus Wörtler
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Munich, Germany
| | - Nicola Petrosillo
- Infectious Disease Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS, Rome, Italy
| | - Heinz Winkler
- Osteitis-Centre, Privatklinik Döbling, Vienna, Austria
| | - Filip M H M Vanhoenacker
- Department of Radiology, Antwerp University Hospital and Antwerp University, Antwerp, Belgium.,AZ Sint-Maarten, Belgium, Mechelen, Belgium.,University of Ghent, Ghent, Belgium
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Li C, Ojeda-Thies C, Trampuz A. Culture of periprosthetic tissue in blood culture bottles for diagnosing periprosthetic joint infection. BMC Musculoskelet Disord 2019; 20:299. [PMID: 31228938 PMCID: PMC6589180 DOI: 10.1186/s12891-019-2683-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/14/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The purpose of this meta-analysis was to evaluate the diagnostic accuracy of periprosthetic tissue culture in blood culture bottles (BCB) for periprosthetic joint infection (PJI). METHODS PubMed, Web of Science, and Embase were systematically searched for eligible studies evaluating the diagnostic performance of periprosthetic tissue culture in BCB for the diagnosis of PJI. The pooled data were analysed by Meta-Disc software. RESULTS Four studies with a total of 1071 patients were included in this meta-analysis. The summarized estimates showed that periprosthetic tissue culture in BCB may be of great value in PJI diagnosis with a pooled sensitivity of 0.70 (95% confidence interval [CI]; 0.66-0.75), specificity of 0.97 (95% CI: 0.95-0.98); positive likelihood ratio (PLR) of 20.98 (95% CI: 11.52-38.2); negative likelihood ratio (NLR) of 0.28 (95% CI: 0.20-0.40); and diagnostic odds ratio (DOR) of 92.26 (95% CI: 43.93-193.78). CONCLUSIONS The present meta-analysis showed that periprosthetic tissue in BCB improves the results of microorganism cultures, with a sensitivity of 70% and a specificity of 97%. However, more large-scale, well-performed studies are needed to verify our findings.
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Affiliation(s)
- Cheng Li
- Charité - Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
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Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: evaluation of periprosthetic shoulder infection. J Shoulder Elbow Surg 2019; 28:S32-S66. [PMID: 31196514 DOI: 10.1016/j.jse.2019.04.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/20/2019] [Indexed: 02/01/2023]
Abstract
The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. More than 800 experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form the International Consensus Group. The shoulder workgroup reached consensus on 27 questions related to culture techniques, inflammatory markers, and diagnostic criteria used to evaluate patients for periprosthetic shoulder infection. This document contains the group's recommendations and rationale for each question related to evaluating periprosthetic shoulder infection.
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45
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Manzo A, Bugatti S, Rossi S. Clinical Applications of Synovial Biopsy. Front Med (Lausanne) 2019; 6:102. [PMID: 31134204 PMCID: PMC6524205 DOI: 10.3389/fmed.2019.00102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/25/2019] [Indexed: 11/13/2022] Open
Abstract
The synovial tissue is a primary target of multiple diseases characterized by different pathogenic mechanisms, including infective, deposition, neoplastic, and chronic immune-inflammatory pathologies. Synovial biopsy can have a relevant role in differential diagnosis of specific conditions in clinical practice, although its exploitation remains relatively limited. In particular, no validated synovial-tissue-derived biomarkers are currently available in the clinic to aid in the diagnosis and management in most frequent forms of chronic inflammatory arthropathies, namely rheumatoid arthritis (RA) and the spondyloarthritides (SpA). In this brief review, we will discuss the current spectrum of clinical applications of synovial biopsy in routine rheumatologic care and will provide an analysis of the perspectives for its potential exploitation in patients with chronic inflammatory arthritides.
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Affiliation(s)
- Antonio Manzo
- Rheumatology and Translational Immunology Research Laboratories, Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Serena Bugatti
- Rheumatology and Translational Immunology Research Laboratories, Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Silvia Rossi
- Rheumatology and Translational Immunology Research Laboratories, Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
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46
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Chen MF, Chang CH, Yang LY, Hsieh PH, Shih HN, Ueng SWN, Chang Y. Synovial fluid interleukin-16, interleukin-18, and CRELD2 as novel biomarkers of prosthetic joint infections. Bone Joint Res 2019; 8:179-188. [PMID: 31069072 PMCID: PMC6498892 DOI: 10.1302/2046-3758.84.bjr-2018-0291.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objectives Prosthetic joint infection (PJI) diagnosis is a major challenge in orthopaedics, and no reliable parameters have been established for accurate, preoperative predictions in the differential diagnosis of aseptic loosening or PJI. This study surveyed factors in synovial fluid (SF) for improving PJI diagnosis. Methods We enrolled 48 patients (including 39 PJI and nine aseptic loosening cases) who required knee/hip revision surgery between January 2016 and December 2017. The PJI diagnosis was established according to the Musculoskeletal Infection Society (MSIS) criteria. SF was used to survey factors by protein array and enzyme-linked immunosorbent assay to compare protein expression patterns in SF among three groups (aseptic loosening and first- and second-stage surgery). We compared routine clinical test data, such as C-reactive protein level and leucocyte number, with potential biomarker data to assess the diagnostic ability for PJI within the same patient groups. Results Cut-off values of 1473 pg/ml, 359 pg/ml, and 8.45 pg/ml were established for interleukin (IL)-16, IL-18, and cysteine-rich with EGF-like domains 2 (CRELD2), respectively. Receiver operating characteristic curve analysis showed that these factors exhibited an accuracy of 1 as predictors of PJI. These factors represent potential biomarkers for decisions associated with prosthesis reimplantation based on their ability to return to baseline values following the completion of debridement. Conclusion IL-16, IL-18, and CRELD2 were found to be potential biomarkers for PJI diagnosis, with SF tests outperforming blood tests in accuracy. These factors could be useful for assessing successful debridement based on their ability to return to baseline values following the completion of debridement.Cite this article: M-F. Chen, C-H. Chang, L-Y. Yang, P-H. Hsieh, H-N. Shih, S. W. N. Ueng, Y. Chang. Synovial fluid interleukin-16, interleukin-18, and CRELD2 as novel biomarkers of prosthetic joint infections. Bone Joint Res 2019;8:179-188. DOI: 10.1302/2046-3758.84.BJR-2018-0291.R1.
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Affiliation(s)
- M-F Chen
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - C-H Chang
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - L-Y Yang
- Biostatistics Unit, Clinical Trial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - P-H Hsieh
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - H-N Shih
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - S W N Ueng
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Y Chang
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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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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Ascione T, Barrack R, Benito N, Blevins K, Brause B, Cornu O, Frommelt L, Gant V, Goswami K, Hu R, Klement MR, Komnos G, Malhotra R, Mirza Y, Munhoz Lima AL, Nelson C, Noor SS, O'Malley M, Oussedik S, Portillo ME, Prieto H, Saxena A, Sessa G. General Assembly, Diagnosis, Pathogen Isolation - Culture Matters: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S197-S206. [PMID: 30360977 DOI: 10.1016/j.arth.2018.09.071] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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49
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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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50
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Consensus document for the diagnosis of prosthetic joint infections: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur J Nucl Med Mol Imaging 2019; 46:971-988. [PMID: 30683987 PMCID: PMC6450843 DOI: 10.1007/s00259-019-4263-9] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/02/2019] [Indexed: 12/13/2022]
Abstract
Background For the diagnosis of prosthetic joint infection, real evidence-based guidelines to aid clinicians in choosing the most accurate diagnostic strategy are lacking. Aim and Methods To address this need, we performed a multidisciplinary systematic review of relevant nuclear medicine, radiological, orthopaedic, infectious, and microbiological literature to define the diagnostic accuracy of each diagnostic technique and to address and provide evidence-based answers on uniform statements for each topic that was found to be important to develop a commonly agreed upon diagnostic flowchart. Results and Conclusion The approach used to prepare this set of multidisciplinary guidelines was to define statements of interest and follow the procedure indicated by the Oxford Centre for Evidence-based Medicine (OCEBM). Electronic supplementary material The online version of this article (10.1007/s00259-019-4263-9) contains supplementary material, which is available to authorized users.
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