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Baroudi M, Daher M, Parks RD, Gregoryczyk JG, Balmaceno-Criss M, McDonald CL, Diebo BG, Daniels AH. Cutibacterium acnes in spine surgery: pathophysiology, diagnosis, and treatment. Spine J 2024; 24:1545-1552. [PMID: 38679079 DOI: 10.1016/j.spinee.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 04/23/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Abstract
Cutibacterium acnes (C. acnes) previously named Propionibacterium acnes (P. acnes) has been increasingly recognized by spine surgeons as a cause of indolent postsurgical spinal infection. Patients infected with C. acnes may present with pseudarthrosis or nonspecific back pain. Currently, microbiological tissue cultures remain the gold standard in diagnosing C. acnes infection. Ongoing research into using genetic sequencing as a diagnostic method shows promising results and may be another future way of diagnosis. Optimized prophylaxis involves the use of targeted antibiotics, longer duration of antibiotic prophylaxis, antibacterial-coated spinal implants, and evidence-based sterile surgical techniques all of which decrease contamination. Antibiotics and implant replacement remain the mainstay of treatment, with longer durations of antibiotics proving to be more efficacious. Local guidelines must consider the surge of antimicrobial resistance worldwide when treating C. acnes.
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Affiliation(s)
- Makeen Baroudi
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Mohammad Daher
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Russell D Parks
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Jerzy George Gregoryczyk
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Mariah Balmaceno-Criss
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Christopher L McDonald
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA.
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Krane F, Wegmann K, Hackl M, Harbrecht A, Müller LP, Leschinger T. Evaluation of interleukin-6 in synovial fluid in periprosthetic joint infection of the elbow. INTERNATIONAL ORTHOPAEDICS 2024; 48:2421-2427. [PMID: 39031202 DOI: 10.1007/s00264-024-06255-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 07/10/2024] [Indexed: 07/22/2024]
Abstract
PURPOSE Searching for quick determinable biomarkers with high sensitivity and specificity is necessary to improve and optimise the early diagnosis of periprosthetic elbow infection (PEI). Therefore, this study's objective was to evaluate the diagnostic value of synovial fluid interleukin-6 (IL-6) levels for diagnosing PEI in total elbow arthroplasty. METHOD Twelve prospective enrolled patients underwent total elbow arthroplasty revision surgery, during which synovial fluid was obtained. Between the initial implantation and the revision procedure were 33.5 ± 41 months (range, 2-144 months). Synovial fluid was collected for immediate IL-6 analysis parallel to the revision surgery. Furthermore, microbiological samples were obtained and analysed. Two groups were defined based on the microbiological results: non-infection and infection group. The ability of synovial fluid IL-6 analysis to predict infection status was explored using receiver operating characteristic curves and further statistical analysis. RESULTS Synovial fluid IL-6 analysis had a good diagnostic accuracy of 83% for PEI with an area under the curve of 0,79 and an ideal cutoff value (determined using Youden's criterion) of 15244 pg/mL. DISCUSSION This is the first study to clinically evaluate IL-6 as a diagnostical marker for periprosthetic joint infection (PJI) in total elbow arthroplasty. Our results suggest a good accuracy and high sensitivity for IL-6 to identify a PEI. The analysis of IL-6 can improve surgical decision-making regarding managing total elbow arthroplasty in terms of one- or two-staged revision. CONCLUSION IL-6 can play an important role in the perioperative differentiation of infected and non-infected situations.
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Affiliation(s)
- Felix Krane
- University Hospital, Center for Orthopedic and Trauma Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Kilian Wegmann
- Orthopädische Chirurgie München, Steinerstr. 6, 81369, München, Germany
| | - Michael Hackl
- University Hospital, Center for Orthopedic and Trauma Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Andreas Harbrecht
- University Hospital, Center for Orthopedic and Trauma Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Lars Peter Müller
- University Hospital, Center for Orthopedic and Trauma Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Tim Leschinger
- University Hospital, Center for Orthopedic and Trauma Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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Tsantes AG, Domouchtsidou A, Tsante KA, Ioannou P, Mpakosi A, Petrou E, Goumenos S, Trikoupis IG, Roustemis AG, Fortis SP, Koutserimpas C, Papagelopoulos PJ, Samonis G, Bonovas S, Papadopoulos DV. Diagnostic Accuracy of Rotational Thromboelastometry for Low-Virulence Periprosthetic Joint Infections: A Pilot Study. Microorganisms 2024; 12:1740. [PMID: 39203582 PMCID: PMC11357059 DOI: 10.3390/microorganisms12081740] [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: 08/11/2024] [Revised: 08/18/2024] [Accepted: 08/21/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND Periprosthetic joint infections (PJIs) are associated with altered coagulation dynamics; therefore, coagulation laboratory studies could be valuable for diagnosing PJI. This study aimed to evaluate the diagnostic role of Rotational Thromboelastometry (ROTEM) in detecting PJIs caused by low-virulence pathogens. METHODS A retrospective study was conducted, enrolling 78 patients who underwent exchange arthroplasty due to PJI due to high-virulence pathogens (Group A, n = 16), low-virulence pathogens (Group B, n = 20), or due to aseptic loosening (Group C, n = 20). Preoperative laboratory findings were compared among the three groups. RESULTS Several ROTEM parameters differed in patients with PJIs caused by low-virulence pathogens, indicating a link between these infections and hypercoagulability. The development of low-virulence PJIs was associated with a higher maximum clot firmness (MCF) (Odds Ratio, 1.12; 95% Confidence Interval, 1.04-1.21; p = 0.001). Additionally, EXTEM MCF was found to have the highest diagnostic accuracy for these infections (Area Under the Curve, 0.841; sensitivity 90.0%; specificity 90.4%), surpassing that of C-reactive protein and the Erythrocyte Sedimentation Rate (p = 0.006 and p = 0.019, respectively). CONCLUSIONS Our findings suggest that ROTEM analysis is a promising method for detecting the altered hemostatic dynamics associated with PJI caused by low-virulence pathogens.
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Affiliation(s)
- Andreas G. Tsantes
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (K.A.T.); (E.P.)
- Microbiology Department, “Saint Savvas” Oncology Hospital, 11522 Athens, Greece;
| | - Aglaia Domouchtsidou
- Microbiology Department, “Saint Savvas” Oncology Hospital, 11522 Athens, Greece;
| | - Konstantina A. Tsante
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (K.A.T.); (E.P.)
| | - Petros Ioannou
- Department of Internal Medicine & Infectious Diseases, University General Hospital of Heraklion, 71110 Heraklion, Greece;
| | - Alexandra Mpakosi
- Department of Microbiology, General Hospital of Nikaia “Agios Panteleimon”, 18454 Piraeus, Greece;
| | - Eleni Petrou
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (K.A.T.); (E.P.)
| | - Stavros Goumenos
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 15771 Athens, Greece; (S.G.); (I.G.T.); (A.G.R.); (P.J.P.)
| | - Ioannis G. Trikoupis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 15771 Athens, Greece; (S.G.); (I.G.T.); (A.G.R.); (P.J.P.)
| | - Anastasios G. Roustemis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 15771 Athens, Greece; (S.G.); (I.G.T.); (A.G.R.); (P.J.P.)
| | - Sotirios P. Fortis
- Laboratory of Reliability and Quality Control in Laboratory Hematology (HemQcR), Department of Biomedical Sciences, Section of Medical Laboratories, School of Health & Caring Sciences, University of West Attica (UniWA), 12244 Athens, Greece;
| | - Christos Koutserimpas
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Centre of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 69004 Lyon, France;
| | - Panayiotis J. Papagelopoulos
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 15771 Athens, Greece; (S.G.); (I.G.T.); (A.G.R.); (P.J.P.)
| | - George Samonis
- Metropolitan Hospital, Neon Faliron, 18547 Athens, Greece;
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy;
- IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Dimitrios V. Papadopoulos
- Second Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece;
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Tarabichi S, Lizcano JD, Abe EA, Goh GS, Baker CM, Parvizi J. Finding the Optimal Screening Test for Periprosthetic Joint Infection: A Prospective Study. J Arthroplasty 2024; 39:1919-1925.e2. [PMID: 38452860 DOI: 10.1016/j.arth.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Serological markers are often used as screening tools to avoid unnecessary joint aspiration in cases with a low probability of infection. This study aimed to determine the utility of standard-of-care serological tests as a screening tool for PJI in patients undergoing revision arthroplasty. METHODS This prospective study enrolled 502 patients undergoing revision hip or knee arthroplasty between May 2017 and August 2021. A PJI was defined using a modified definition of the 2018 International Consensus Meeting criteria. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. There were 82 patients undergoing reimplantation who were excluded. Additionally, 8 patients who had an inconclusive International Consensus Meeting score were also excluded. Of the 412 included patients, 317 (76.9%) underwent revision for aseptic failure, and 95 (23.1%) had PJI. Receiver operating characteristic curves were used to assess the diagnostic utility of each serological test. A pairwise comparison with Bonferroni correction was performed to determine whether the differences in areas under the curve (AUCs) between the tests were significant. Additional analyses were performed to find the threshold for each test that offered 100% sensitivity, allowing it to be the optimal screening test. RESULTS All 4 serological markers, D-dimer (AUC 0.860, sensitivity 81.3%, specificity 81.7%), CRP (AUC 0.862, sensitivity 90.4%, specificity 70.0%), ESR (AUC 0.833, sensitivity 73.9%, specificity 85.2%), and fibrinogen (AUC 0.798, sensitivity 74.7%, specificity 75.4%), demonstrated comparable accuracy for the diagnosis of PJI (all P > .05). When maximizing sensitivity to 100%, D-dimer demonstrated the highest specificity (AUC 0.860, specificity 40.2%), outperforming ESR (AUC 0.833, specificity 3.3%), fibrinogen (AUC 0.798, specificity 2.3%), and CRP (AUC 0.862, specificity 0%). A plasma D-dimer level of ≥ 244 ng/mL was identified as the optimal cutoff for use as a screening test. CONCLUSIONS Although plasma D-dimer demonstrated similar diagnostic accuracy as CRP, ESR, and fibrinogen, it outperformed all 3 aforementioned serological markers when used as a screening test for PJI. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Saad Tarabichi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Elizabeth A Abe
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts
| | - Colin M Baker
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Cleveland Clinic South Pointe, Cleveland, Ohio
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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Tarabichi S, Goh GS, Fraval A, Lizcano JD, Abe EA, Courtney PM, Namdari S, Parvizi J. Serum and Synovial Markers in the Diagnosis of Periprosthetic Joint Infection of the Hip, Knee, and Shoulder: An Algorithmic Approach. J Bone Joint Surg Am 2024; 106:1221-1230. [PMID: 38776388 DOI: 10.2106/jbjs.23.00669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
➤ No single test has demonstrated absolute accuracy for the diagnosis of periprosthetic joint infection (PJI).➤ Physicians rely on a combination of serological tests, synovial markers, and clinical findings plus clinical judgment to help to guide preoperative decision-making.➤ Several organizations have proposed criteria for the diagnosis of hip or knee PJI on which we now rely.➤ Given that shoulder arthroplasty has only recently become popular, it is possible that a shoulder-specific definition of PJI will be introduced in the coming years.➤ Although a number of serum and synovial markers have demonstrated high accuracy for the diagnosis of PJI of the hip and knee, further research is needed in order to identify markers that may be more suitable for the diagnosis of shoulder PJI and for the potential development and identification of specific serological tests as screening tools for PJI.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrew Fraval
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Elizabeth A Abe
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Surena Namdari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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Paksoy A, Meller S, Schwotzer F, Moroder P, Trampuz A, Imiolczyk JP, Perka C, Hackl M, Plachel F, Akgün D. MicroRNA expression analysis in peripheral blood and soft-tissue of patients with periprosthetic hip infection. Bone Jt Open 2024; 5:479-488. [PMID: 38839054 PMCID: PMC11152758 DOI: 10.1302/2633-1462.56.bjo-2023-0172.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Aims Current diagnostic tools are not always able to effectively identify periprosthetic joint infections (PJIs). Recent studies suggest that circulating microRNAs (miRNAs) undergo changes under pathological conditions such as infection. The aim of this study was to analyze miRNA expression in hip arthroplasty PJI patients. Methods This was a prospective pilot study, including 24 patients divided into three groups, with eight patients each undergoing revision of their hip arthroplasty due to aseptic reasons, and low- and high-grade PJI, respectively. The number of intraoperative samples and the incidence of positive cultures were recorded for each patient. Additionally, venous blood samples and periarticular tissue samples were collected from each patient to determine miRNA expressions between the groups. MiRNA screening was performed by small RNA-sequencing using the miRNA next generation sequencing (NGS) discovery (miND) pipeline. Results Overall, several miRNAs in plasma and tissue were identified to be progressively deregulated according to ongoing PJI. When comparing the plasma samples, patients with a high-grade infection showed significantly higher expression levels for hsa-miR-21-3p, hsa-miR-1290, and hsa-miR-4488, and lower expression levels for hsa-miR-130a-3p and hsa-miR-451a compared to the aseptic group. Furthermore, the high-grade group showed a significantly higher regulated expression level of hsa-miR-1260a and lower expression levels for hsa-miR-26a-5p, hsa-miR-26b-5p, hsa-miR-148b-5p, hsa-miR-301a-3p, hsa-miR-451a, and hsa-miR-454-3p compared to the low-grade group. No significant differences were found between the low-grade and aseptic groups. When comparing the tissue samples, the high-grade group showed significantly higher expression levels for 23 different miRNAs and lower expression levels for hsa-miR-2110 and hsa-miR-3200-3p compared to the aseptic group. No significant differences were found in miRNA expression between the high- and low-grade groups, as well as between the low-grade and aseptic groups. Conclusion With this prospective pilot study, we were able to identify a circulating miRNA signature correlating with high-grade PJI compared to aseptic patients undergoing hip arthroplasty revision. Our data contribute to establishing miRNA signatures as potential novel diagnostic and prognostic biomarkers for PJI.
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Affiliation(s)
- Alp Paksoy
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Sebastian Meller
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Florian Schwotzer
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | | | - Andrej Trampuz
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | | | - Carsten Perka
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | | | | | - Doruk Akgün
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
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Coelho A, Alier A, Martínez-Diaz S, Puig-Verdié L, Gómez-Junyent J, García-Bernedo C, Pérez-Prieto D. High Rate of Undetected Infections in Failed Osteosynthesis of Pertrochanteric Fractures. J Orthop Trauma 2024; 38:327-332. [PMID: 38466816 DOI: 10.1097/bot.0000000000002801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE The objective of this study was to assess the incidence of infection in patients with cutout after proximal femur fracture (PFF) osteosynthesis. METHODS DESIGN Retrospective cohort study. SETTING Third-level trauma center. PATIENT SELECTION CRITERIA Patients presenting with a cutout following PFF (OTA/AO 31A) osteosynthesis, between January 2007 and December 2020. OUTCOME MEASUREMENTS AND COMPARISONS The primary outcome was infection according to the European Bone and Joint Infection Society criteria. RESULTS Sixty-seven patients presenting with a cutout were included, with mean age of 83.3 years (range 63-96), and 51 (76.1%) were women. Of all cases, 16 (24.7%) presented a concomitant infection. The presence of concomitant infection was suspected preoperatively in only 3 of the cases. A subgroup analysis was performed between the cases with infection and those without infection, the groups being comparable in terms of demographic data and postoperative radiological criteria. Patients with underlying infection had a higher rate of surgical wound complication (56.3% vs. 22%, P = 0.014) and higher rates of leukocytosis (11.560 vs. 7.890, P = 0.023). CONCLUSION Faced with a cutout after osteosynthesis of a PFF, underlying infection should be considered as a possible etiological factor. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexandre Coelho
- Department of Orthopaedics, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Albert Alier
- Department of Orthopaedics, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Santos Martínez-Diaz
- Department of Orthopaedics, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Lluis Puig-Verdié
- Department of Orthopaedics, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Joan Gómez-Junyent
- Department of Infectious Diseases, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain; and
| | - Carlos García-Bernedo
- Department of Anesthesiology, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Daniel Pérez-Prieto
- Department of Orthopaedics, Hospital del Mar, Universitat Autònoma Barcelona, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
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Shi T, Chen H, Liu Y, Wu Y, Lin F. Clinical applications of metagenomic next-generation sequencing in the identification of pathogens in periprosthetic joint infections: a retrospective study. J Orthop Surg Res 2024; 19:301. [PMID: 38760817 PMCID: PMC11102132 DOI: 10.1186/s13018-024-04745-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/16/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND This study aimed to evaluate the application of metagenomic next-generation sequencing (mNGS) technology to identify pathogens in periprosthetic joint infection (PJI). METHODS A retrospective analysis was conducted on 65 patients suspected of having PJI between April 2020 and July 2023. The patients were categorized into PJI (46 patients) and non-PJI (19 patients) groups based on the 2018 International Consensus Meeting criteria. Clinical data were collected, and both conventional bacterial culture and mNGS were performed. The diagnostic performance of the two methods was compared and analyzed. RESULTS mNGS exhibited a sensitivity of 89.13%, a specificity of 94.74%, a positive predictive value of 97.62%, a negative predictive value of 78.26%, and an overall diagnostic accuracy of 90.77%. Compared to microbial culture, mNGS demonstrated superior diagnostic sensitivity while maintaining similar specificity. A total of 48 pathogens were successfully identified using mNGS, with Coagulase-negative staphylococci, Streptococci, Staphylococcus aureus, and Cutibacterium acnes being the most common infectious agents. Notably, mNGS was used to identify 17 potential pathogens in 14 culture-negative PJI samples, highlighting its ability to detect rare infectious agents, including Cutibacterium acnes (n = 5), Granulicatella adiacens (n = 1), Mycobacterium tuberculosis complex (n = 1), and Coxiella burnetii (n = 1), among others, which are not detectable by routine culture methods. However, mNGS failed to detect the pathogen in 4 culture-positive PJI patients, indicating its limitations. Among the 46 PJI patients, 27 had positive culture and mNGS results. The results of mNGS were concordant with those of culture at the genus level in 6 patients with PJI and at the species level in 18 patients. Furthermore, the present study revealed a significantly greater proportion of Staphylococcus aureus in the sinus tract group (45.45%) than in the non-sinus tract group (14.29%), indicating the association of this pathogen with sinus formation in PJI (P = 0.03). Additionally, there was no significant difference in the occurrence of polymicrobial infections between the sinus tract group (27.27%) and the non-sinus tract group (33.33%) (P = 0.37). CONCLUSIONS Metagenomic next-generation sequencing can serve as a valuable screening tool in addition to traditional culture methods to improve diagnostic accuracy through optimized culture strategies.
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Affiliation(s)
- Tengfei Shi
- Department of Clinical Laboratory, Fuzhou Second General Hospital, Fuzhou, Fujian, China
| | - Huiyu Chen
- Department of Clinical Laboratory, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, China
| | - Yinhuan Liu
- Department of Clinical Laboratory, Fuzhou Second General Hospital, Fuzhou, Fujian, China
| | - Yexin Wu
- Department of Clinical Laboratory, Fuzhou Second General Hospital, Fuzhou, Fujian, China
| | - Feitai Lin
- Department of Orthopaedic Surgery, Fuzhou Second General Hospital, Shang Teng Road No. 47 Cang'shan District, Fuzhou, Fujian, China.
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Klott J, Brolin TJ. Diagnostic Evaluation of Prosthetic Joint Infections of the Shoulder: What Does the Literature Say? Orthop Clin North Am 2024; 55:257-264. [PMID: 38403371 DOI: 10.1016/j.ocl.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
The total number of patients with a total shoulder arthroplasty (TSA) is increasing, and the number of patients experiencing a (TSA) prosthetic joint infection (PJI) also will increase. It is important that physicians know how to identify signs of infection, know the common pathogens, and know how to work up a shoulder PJI. This publication reviewed the current literature about presenting signs and symptoms, common shoulder pathogens and how they differ from total knee and hip pathogens, and what images, tests, and procedures can aid in identification of infection.
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Affiliation(s)
- Jeffrey Klott
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center- Campbell Clinic, 1211 Union Avenue, Suite 520, Memphis, TN 38104, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center- Campbell Clinic, 1211 Union Avenue, Suite 520, Memphis, TN 38104, USA.
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Nairn L, Sivaratnam S, Bali K, Wood TJ. Neutrophil to Lymphocyte Ratio as an Indicator of Periprosthetic Joint Infection: A Retrospective Cohort Study. J Am Acad Orthop Surg 2024; 32:271-278. [PMID: 38127888 DOI: 10.5435/jaaos-d-23-00600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/02/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) is a serious complication posing notable clinical implications for patients and substantial economic burdens. Neutrophil to lymphocyte ratio (NLR) is an emerging biomarker of inflammation, which may better predict PJI. The objective of this review was to evaluate NLR changes in patients with confirmed PJI, to compare NLR between an aseptic revision and a revision for PJI, and to establish whether an NLR of 2.45 is an appropriate cutoff for predicting infection. METHODS A retrospective review of patients who underwent revision TJA for PJI at a single center between January 1, 2005, and December 31, 2018, was performed and compared with an aseptic cohort who underwent aseptic revision TJA. NLR was calculated from complete blood counts performed at index surgery and at the time of revision surgery. Receiver operating characteristic curves were analyzed, along with sensitivity, specificity, and positive and negative likelihood ratios. RESULTS There were 89 patients included in each cohort. Mean NLR in patients who underwent revision for PJI was 2.85 (± 1.27) at the time of index surgery and 6.89 (± 6.64) at the time of revision surgery ( P = 0.017). Mean NLR in patients undergoing revision for PJI (6.89) was significantly higher than aseptic revisions (3.17; P < 0.001). DISCUSSION In patients who underwent revision surgery for PJI, NLR was markedly elevated at time of revision compared with the time of index surgery. Because it is a cost-effective and readily available test, these findings suggest that NLR may be a useful triage test in the diagnosis of PJI. LEVEL OF EVIDENCE Level III Diagnostic Study.
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Affiliation(s)
- Leah Nairn
- From the Division of Orthopaedic Surgery, McMaster University, Hamilton, ON (Nairn, Bali, and Wood), the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (Sivaratnam), and the Hamilton Health Sciences Juravinski Hospital, Hamilton, ON (Bali and Wood), Canada
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Offerhaus C, Leutheuser S, Jaecker V, Shafizadeh S, Bardtke L, Wisplinghoff H, Jazmati N. Evidence of Bacterial Metabolism in Synovial Fluid of Patients With Graft Failure After Anterior Cruciate Ligament Reconstruction: A Microbiological Comparison of Primary Anterior Cruciate Ligament and Hamstring Tendon Autograft Ruptures. Arthroscopy 2024; 40:400-408. [PMID: 37437788 DOI: 10.1016/j.arthro.2023.06.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE To investigate whether the bacterial presence in a primary ruptured native anterior cruciate ligament (ACL) differs from that in a ruptured hamstrings ACL autograft and whether low-grade infections cumulatively can be detected in the case of graft failure. METHODS In a retrospective case-control study with prospectively collected data, synovial fluid aspirates and tissue samples of failed ACL grafts were examined for evidence of bacterial colonization and compared to samples of the native ACL in primary ACL reconstruction (ACLR) using microbiological culture, 16S rRNA-PCR and histopathological examination. Furthermore, synovial fluid aspiration was investigated for possible future biomarkers for a low-grade infection. RESULTS A total of 112 consecutive patients undergoing primary ACLR without history of previous surgeries to the affected knee (n = 59) and revision ACLR after reconstruction with a hamstring tendon autograft (n = 53) were recruited from one center. No patient had a history or showed clinical signs of infection. A total of 389 samples were analyzed by culture. Bacteria were detected in 9.4% of patients with a graft rupture (n = 5/53) compared to 3.4% of patients with a primary ACL rupture (n = 2/59) showing no statistical difference (P = .192). One patient with a "true" low-grade infection was found in our study population, resulting in a prevalence of 1.9% (1/53) in the graft group. The percentage of polymorphonuclear leukocytes (PMN%) as a highly sensitive marker for joint infections was significantly higher in aspirated synovial fluid of graft ruptures (27% ± 3% vs 20% ± 4%; P = .032), as well as glucose levels were significantly lower (83 mg/dL ± 2 mg/dL vs 88 mg/dL ± 2 mg/dL; P = .042). CONCLUSIONS Synovial fluid obtained before revision ACLR showed a higher percentage of polymorphonuclear leukocytes and lower glucose levels compared with primary ACLR, suggesting bacterial metabolism and demonstrating that the intra-articular milieu changes significantly after ACLR. Tissue samples of ACL grafts revealed a low-grade infection in one case, although overall cultivable bacterial presence did not differ significantly when compared to samples of a native ACL. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Christoph Offerhaus
- Department of Orthopedic Surgery and Sports Traumatology, Witten/Herdecke University, Sana Medical Centre, Cologne, Germany.
| | - Sebastian Leutheuser
- Department of Orthopedic Surgery and Sports Traumatology, Witten/Herdecke University, Sana Medical Centre, Cologne, Germany
| | - Vera Jaecker
- Department of Trauma Surgery, Orthopaedic Surgery and Sports Traumatology, Witten/Herdecke University, Cologne Merheim Medical Centre, Cologne, Germany
| | - Sven Shafizadeh
- Department of Orthopedic Surgery and Sports Traumatology, Witten/Herdecke University, Sana Medical Centre, Cologne, Germany
| | | | - Hilmar Wisplinghoff
- Labor Dr. Wisplinghoff, Cologne, Germany; Institute for Virology and Microbiology, Witten/Herdecke University, Witten, Germany
| | - Nathalie Jazmati
- Labor Dr. Wisplinghoff, Cologne, Germany; Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany
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Akçaalan S, Akbulut B, Çağlar C, Innocenti M, Uğurlu M, Dogan M, Akkaya M. Is large unstained cell percentage (%LUC) a novel diagnostic marker for periprosthetic joint infections? Technol Health Care 2024; 32:3659-3667. [PMID: 38073350 DOI: 10.3233/thc-230903] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
BACKROUND Periprosthetic joint infection (PJI) is a very important complication that occurs after total joint replacement. Diagnosing PJI is at least as difficult as this disease. There is no biomarker that alone can diagnose PJI. OBJECTIVE This study aimed to evaluate the effectiveness of large unstained cell percentage (%LUC) in diagnosing PJI and deciding on re-implantation in two stage septic exchange arthroplasty. METHODS Patients who underwent revision arthroplasty between 2019 and 2023 were screened retrospectively. These patients were grouped as those who underwent two-stage septic exchange and those who underwent aseptic exchange. Prosthesis removal from the patients who underwent two-stage septic exchange, before spacer application, and on the 3rd post-operative day after spacer application, Blood parameters were collected at the 1st month and before the second stage after the spacer application, and before the revision surgery from the patients who underwent aseptic exchange. White blood cell, neutrophil percentage, %LUC, albumin, sedim and CRP values were checked and recorded one by one from all patients. RESULTS The data of a total of 233 patients, including 133 patients in the two stage septic exchange group and 100 patients in the aseptic exchange group, were included in the study. When the predictive value of %LUC in PJI was accepted as cut-off 1.75, the sensitivity was 69.2% and the specificity was 73%. The change in %LUC over time in patients who underwent two-stage septic exchange was statistically significant (p= 0.0001). A positive correlation was found between the value of .%LUC after spacer application and the value of CRP before prosthesis protrusion/spacer application surgery, and the Spearman correlation coefficient was found to be 0.005. CONCLUSION %LUC value can be a promising biomarker for the diagnosis of PJI by considering both sensitivity and specificity rates. Apart from this, it is an easily accessible and effective biomarker for re-implantation decision making and evaluation of response to treatment, especially in two-stage septic exchange surgeries.
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Affiliation(s)
- Serhat Akçaalan
- Orthopedics and Traumatology Department, Ankara City Hospital, Ankara, Turkey
| | - Batuhan Akbulut
- Orthopedics and Traumatology Department, Ankara City Hospital, Ankara, Turkey
| | - Ceyhun Çağlar
- Orthopedics and Traumatology Department, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Matteo Innocenti
- Department of Orthopaedics, University Hospital of Florence, Florence, Italy
| | - Mahmut Uğurlu
- Orthopedics and Traumatology Department, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Metin Dogan
- Orthopedics and Traumatology Department, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Mustafa Akkaya
- Orthopedics and Traumatology Department, Ankara Yıldırım Beyazıt University, Ankara, Turkey
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Dong M, Wang Y, Fan H, Yang D, Wang R, Feng Y. The Albumin to Globulin Ratio Performs Well for Diagnosing Periprosthetic Joint Infection: A Single-Center Retrospective Study. J Arthroplasty 2024; 39:229-235.e4. [PMID: 37557968 DOI: 10.1016/j.arth.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Accurate diagnosis of the periprosthetic joint infection (PJI) remains a challenge for surgeons. The purpose of this study was to assess the value of albumin to globulin ratio (AGR) and globulin (GLB) for diagnosing PJI. METHODS A total of 182 patients undergoing revision after arthroplasty were included and divided into 2 groups, 61 in knee group (PJI: 38; non-PJI: 23) and 121 in hip group (PJI: 26; non-PJI: 95). We used receiver operating characteristic curves to determine the diagnostic value of AGR, GLB, inflammatory markers (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]). RESULTS The receiver operating characteristic curves showed the areas under the curve of AGR, GLB, ESR, and CRP in the knee group were 0.940, 0.928, 0.867, and 0.848, respectively, and they were 0.855, 0.831, 0.886, and 0.912 in the hip group. The optimal predictive cut-off values for AGR in knee and hip groups were 1.375 and 1.295, respectively. The sensitivity and specificity of AGR, respectively, were 94.7% and 87.0% (knee group) and 84.6% and 75.8% (hip group) for diagnosing PJI. The sensitivity of "AGR or ESR" and specificity of "AGR and GLB" in the knee group were 99.6% and 98.9%, respectively. CONCLUSION For knee or hip groups, the AGR exhibits good value for the diagnosis of PJI comparable with ESR and CRP. The AGR and GLB, together with CRP and ESR, should be used as the preferred indicators for diagnosing PJI. The "AGR or ESR" and "AGR and GLB" in the knee group have an excellent diagnostic value in sensitivity and specificity, respectively.
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Affiliation(s)
- Mingjie Dong
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Yushan Wang
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Hao Fan
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Dinglong Yang
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Renwei Wang
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Yi Feng
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, TaiYuan, China
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Balta O, Astan S, Altınayak H, Uçar C, Aytekin FY, Kurnaz R. Can C-Reactive Protein-Lymphocyte Ratio Be Used as a Screening Tool to Confirm the Diagnosis of Periprosthetic Joint Infection? Clin Orthop Surg 2023; 15:917-927. [PMID: 38045571 PMCID: PMC10689224 DOI: 10.4055/cios22313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 08/13/2023] [Accepted: 08/13/2023] [Indexed: 12/05/2023] Open
Abstract
Background This study aimed to investigate whether periprosthetic joint infection (PJI) can be predicted by the C-reactive protein-to-lymphocyte ratio (CLR), whether this ratio increases the accuracy of PJI diagnosis, and whether it is more sensitive than other blood values and ratios. Methods The patients were divided into two groups: the septic revision (SR) group and the aseptic revision (AR) group. In cases of septic revision, the diagnosis of PJI was made based on the criteria proposed by the European Bone and Joint Infection Society (EBJIS). The groups were compared in terms of age, sex, body mass index, comorbidity, and preoperative laboratory results. The sensitivity, specificity, and diagnostic performance of the values and ratios were analyzed and compared. Results The receiver operating characteristic (ROC) analysis for the CLR gave a diagnostic value of 15.52, which provided a sensitivity of 91.1% and a specificity of 64.2% for PJI. The CLR gave lower specificity and higher sensitivity compared to the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values. The ROC analysis showed that the CLR had a similar area under the curve (AUC) with the ESR and CRP (0.808). The CLR had a higher specificity than other ratios (platelet volume ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and monocyte-to-lymphocyte ratio) and a higher value of the AUC. In the multivariate analysis, the CLR (hazard ratio, 1.088; 95% confidence interval, 1.063-1.113; p < 0.001) was found to be a significant risk factor. As CLR increased by one unit, the risk of PJI increased by 1.088 times, and it was statistically significant (p < 0.001). Conclusions The findings of this study suggest that CLR can serve as a valuable screening tool for diagnosing PJI. CLR demonstrated higher sensitivity in predicting PJI compared to ESR and CRP, and it exhibited greater specificity than other infection markers.
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Affiliation(s)
- Orhan Balta
- Department of Orthopaedics and Traumatology, Gaziosmanpasa University Hospital, Tokat, Türkiye
| | - Sezer Astan
- Department of Orthopaedics and Traumatology, Tokat State Hospital, Tokat, Türkiye
| | - Harun Altınayak
- Department of Orthopedics and Traumatology, Samsun Training and Research Hospital, Health Sciences University, Samsun, Türkiye
| | - Cihan Uçar
- Department of Orthopedics and Traumatology, Trabzon Kanuni Training and Research Hospital, Trabzon, Türkiye
| | - Feyza Yildiz Aytekin
- Department of Infectious Diseases and Clinical Microbiology, Ministry of Health Prof. Dr. A. Ilhan Özdemir State Hospital, Giresun, Türkiye
| | - Recep Kurnaz
- Department of Orthopaedics and Traumatology, Acıbadem State Hospital, Eskişehir, Türkiye
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Schmidutz F, Schreiner AJ, Ahrend MD, Stöckle U, Maier S, Histing T, Hemmann P. Risk of Periprosthetic Joint Infection after Posttraumatic Hip Arthroplasty following Acetabular Fractures. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023; 161:671-677. [PMID: 35605966 DOI: 10.1055/a-1810-7379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Raised complication rates have been reported for total hip arthroplasty (THA) in posttraumatic hip joints after acetabular fractures with prior open reduction and internal fixation (ORIF). The present study evaluated (I) postoperative surgical site infection and the risk of early infection following THA in posttraumatic hip joints after acetabular fractures and (II) the discriminatory ability of preoperative C-reactive protein (CRP) blood levels for periprosthetic joint infection (PJI). MATERIALS AND METHODS Patients were included who had undergone THA (2014-2019) after prior ORIF, and nonsurgically treated acetabular fractures. Patients' demographics and the duration between fracture and THA implantation were assessed. Preoperative diagnostic testing (laboratory results, hip aspirations) as well as the results of intraoperative microbiological swabs and sonication were also evaluated. Postoperative complications were recorded. RESULTS Sixty-seven patients (51 men/16 women) were included, with a mean age of 54.7 ± 14.0 years (range: 18.0-82.9). The mean time between acetabular fracture and THA was 13.5 ± 14.9 years (0.2-53.5). Four subgroups were classified: subgroup I (nonsurgical, n = 15), subgroup II (complete removal of osteosynthesis, n = 8), subgroup III (partial removal of osteosynthesis, n = 15), and subgroup IV (remaining osteosynthesis, n = 29). Preoperative CRP blood levels were normal. CRP levels had no discriminatory ability to predict PJI (AUC: 0.43). Positive microbiological swabs were assessed in subgroups III (n = 1) and IV (n = 2). Complications during follow-up occurred in subgroups I (one aseptic loosening [6.7%]), III (one wound revision [6.7%], two low-grade infections [13.3%]), and IV (three low-grade infections [10.3%]). CONCLUSION High infection rates were found in patients with THA after acetabular fracture with remaining implants or partial implant removal. Serum CRP alone seems to be a poor predictor. Therefore, an extensive diagnostic algorithm can help to detect an occult infection, including preoperative hip aspiration (microbiological samples and measurements of synovial CRP, WBC, and alpha-defensin levels). Intraoperative tissue samples and sonication results should be obtained during THA implantation.
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Affiliation(s)
- Florian Schmidutz
- Department of Traumatology and Reconstructive Surgery, Berufsgenossenschaftliche Unfallklinik Tübingen, Tübingen, Germany
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, Ludwig-Maximilians-Universität München, München, Germany
| | - Anna Janine Schreiner
- Department of Traumatology and Reconstructive Surgery, Berufsgenossenschaftliche Unfallklinik Tübingen, Tübingen, Germany
| | - Marc-Daniel Ahrend
- Department of Traumatology and Reconstructive Surgery, Berufsgenossenschaftliche Unfallklinik Tübingen, Tübingen, Germany
| | - Ulrich Stöckle
- Center for Musculoskeletal Surgery (CMSC), Charite University Hospital Berlin, Berlin, Germany
| | - Sven Maier
- Department of Traumatology and Reconstructive Surgery, Berufsgenossenschaftliche Unfallklinik Tübingen, Tübingen, Germany
| | - Tina Histing
- Department of Traumatology and Reconstructive Surgery, Berufsgenossenschaftliche Unfallklinik Tübingen, Tübingen, Germany
| | - Philipp Hemmann
- Department of Traumatology and Reconstructive Surgery, Berufsgenossenschaftliche Unfallklinik Tübingen, Tübingen, Germany
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Mozella ADP, Cobra HADAB, Minamoto STN, Salim R, Leal AC. Accuracy of Serological Markers, Synovial Fluid, Microbiological Culture, and Histopathological Examination for Diagnosing Periprosthetic Knee Infection. Rev Bras Ortop 2023; 58:e917-e923. [PMID: 38077763 PMCID: PMC10708974 DOI: 10.1055/s-0043-1776907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/18/2023] [Indexed: 08/03/2024] Open
Abstract
Objective This study assessed the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of serological tests, synovial fluid markers, microbiological tissue culture, and histopathological examination of the periprosthetic membrane in diagnosing periprosthetic knee infection. Methods This study is prospective, and it includes patients undergoing total knee arthroplasty revision surgery from November 2019 to December 2021. The analysis consisted of serological tests (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], and D-dimer), synovial fluid markers (leukocyte and polymorphonuclear cell counts), periprosthetic tissue culture, and histopathological examination of the periprosthetic membrane of all patients. Results Sixty-two patients had periprosthetic joint infection (PJI) according to the 2018 International Consensus Meeting criteria (infection group), while 22 subjects had no infection. ESR sensitivity and specificity were 83.6% and 45.4%, respectively. CRP sensitivity and specificity were 64.5% and 100%, whereas D-dimer sensitivity and specificity were 78.9% and 25%, respectively. Leukocyte count sensitivity and specificity were 75.6% and 100%, polymorphonuclear cell count sensitivity and specificity were 33% and 100%, respectively. Periprosthetic tissue culture sensitivity and specificity culture were, respectively, 77.4% and 100%. Histopathological examination sensitivity and specificity were 43.7% and 100%, respectively. Conclusions In our study, the total blood cell count in synovial fluid and microbiological cultures of periprosthetic tissues were the most accurate tests for PJI diagnosis. In contrast, polymorphonuclear cell percentage was the least accurate test for PJI diagnosis.
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Affiliation(s)
- Alan de Paula Mozella
- Médico ortopedista e traumatologista do Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
| | - Hugo Alexandre de Araújo Barros Cobra
- Médico ortopedista e traumatologista do Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
| | - Sandra Tie Nishibe Minamoto
- Médico ortopedista e traumatologista do Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
| | - Rodrigo Salim
- Médico ortopedista e traumatologista do Departamento de Ortopedia e Anestesiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP-RP), Ribeirão Preto, São Paulo, Brasil
| | - Ana Carolina Leal
- Pesquisadora da Divisão de Ensino e Pesquisa, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
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Tak LJ, Shin MK, Yoo JI, Cho MC, Kim W. Development of droplet digital PCR-based detection of bacterial pathogens in prosthetic joint infection: a preliminary study using a synthesized model plasmid. Front Cell Infect Microbiol 2023; 13:1301446. [PMID: 38029245 PMCID: PMC10651726 DOI: 10.3389/fcimb.2023.1301446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Periprosthetic joint infection (PJI) can be diagnosed to characterize the microorganisms constituting a biofilm, which is an essential procedure for proper treatment. The gold standard method for detecting and identifying the causative microorganism is culture of microorganisms from patients-derived sample.; however, this method takes a long time and has low sensitivity. To compensate for these limitations, identification methods based on real-time PCR (RT-PCR) have been widely used. However, RT-PCR also has limitations, including low sensitivity and the requirement of a standard curve for quantification. Therefore, to prevent significant proliferation of pathogenic bacteria, it is important to detect a limited number of infectious bacteria during early stages of PJI. In the present study, we developed droplet digital PCR-based detection of bacterial pathogens in PJI. And we evaluated the analytical performance of the assay using a model plasmid, based on the 16S ribosomal DNA sequence of target bacteria commonly found in PJI. We also prepared genomic DNA extracted from E. coli, S. aureus, and S. epidermidis to test whether ddPCR provides better sensitivity and quantification of the target sequences. ddPCR detected 400 attograms of target DNA, which was more than 10 times less than that detected by real-time PCR using synthesized plasmid. In addition, ddPCR detected target regions from genomic DNA of 50 femtograms for E. coli, 70 femtograms for S. epidermidis, and 90 femtograms for S. aureus. The results indicate that ddPCR has the potential to decrease the microbial detection limit and provide precise detection, signifying its effectiveness for early PJI.
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Affiliation(s)
- Lee-Jung Tak
- Department of Convergence Medical Science, Gyeongsang National University, Jinju, Republic of Korea
| | - Min-Kyoung Shin
- Department of Microbiology, Department of Convergence Medical Science, and Institute of Health Sciences, School of Medicine, Gyeongsang National University, Jinju, Republic of Korea
| | - Jun-Il Yoo
- Department of Orthopedic Surgery, Inha University Hospital, Incheon, Republic of Korea
| | - Min-Chul Cho
- Departments of Laboratory Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Wanil Kim
- Department of Biochemistry, Department of Convergence Medical Science, and Institute of Health Sciences, School of Medicine, Gyeongsang National University, Jinju, Republic of Korea
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Yilmaz MK, Abbaszadeh A, Tarabichi S, Azboy I, Parvizi J. Diagnosis of Periprosthetic Joint Infection: The Utility of Biomarkers in 2023. Antibiotics (Basel) 2023; 12:1054. [PMID: 37370373 DOI: 10.3390/antibiotics12061054] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a rare yet devastating complication following total joint arthroplasty (TJA). Early and accurate diagnosis of PJI is paramount in order to maximize the chances of successful treatment. However, we are yet to identify a single "gold standard" test for the diagnosis of PJI. As a result, the diagnosis of PJI is often challenging. Currently, the 2018 ICM definition of PJI is the only validated diagnostic criteria available. This article will review the importance of serum and synovial biomarkers in the diagnosis of PJI. In addition, it will provide a brief overview of the emerging modalities for the identification of infections in this setting.
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Affiliation(s)
- Mehmet Kursat Yilmaz
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Department of Orthopaedics and Traumatology, School of Medicine, Istanbul Medipol University, Istanbul 34810, Turkey
| | - Ahmad Abbaszadeh
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Saad Tarabichi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Ibrahim Azboy
- Department of Orthopaedics and Traumatology, School of Medicine, Istanbul Medipol University, Istanbul 34810, Turkey
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Domecky P, Rejman Patkova A, Mala-Ladova K, Maly J. Inflammatory blood parameters as prognostic factors for implant-associated infection after primary total hip or knee arthroplasty: a systematic review. BMC Musculoskelet Disord 2023; 24:383. [PMID: 37189111 PMCID: PMC10184423 DOI: 10.1186/s12891-023-06500-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 05/07/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Implant-associated infection (IAI) is a potential complication following total hip (THA) or knee arthroplasty (TKA). The initial phase of the inflammatory process can be measured by applying one of the inflammatory blood parameters (IBP). This systematic review aims to assess the response of IBP to trauma caused by orthopedic surgery and evaluate the clinical utility of quantitative measurements of IBP as prognostic factors for infection. METHODS All studies indexed in Ovid MEDLINE (PubMed), Ovid EMBASE, the Cochrane Library and the ISI Web of Science databases, from inception until January 31, 2020, were analyzed. Studies included were those on adults who underwent THA or TKA with minimum follow up of 30 days after surgery. In addition to minimum follow up, data on the prognostic factors for pre- or post-THA/TKA IAI were mandatory. The Quality Assessment of Diagnostic Accuracy tool (version 2) (QUADAS-2) and Standards for Reporting of Diagnostic Accuracy Studies guideline 2015 (STARD) were used for quality assessment. RESULTS Twelve studies fulfilled the inclusion and exclusion criteria. C-reactive protein was analyzed in seven studies, interleukin-6 in two studies and erythrocyte sedimentation rate in eight studies. White blood cell count and procalcitonin were analyzed in the only study. The overall quality of included studies was low. A potential for other cytokines (IL-1ra, IL-8) or MCP-1 was observed. CONCLUSIONS This is the first systematic review of IBP response to orthopedic surgery which identified some IBP for pre/post-operative screening, despite insufficient data supporting their prognostic potential for patient risk stratification.
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Affiliation(s)
- Petr Domecky
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Ak. Heyrovskeho 1203/8, 500 05 Hradec Kralove, Czech Republic
| | - Anna Rejman Patkova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Ak. Heyrovskeho 1203/8, 500 05 Hradec Kralove, Czech Republic
| | - Katerina Mala-Ladova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Ak. Heyrovskeho 1203/8, 500 05 Hradec Kralove, Czech Republic
| | - Josef Maly
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Ak. Heyrovskeho 1203/8, 500 05 Hradec Kralove, Czech Republic
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20
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Zhang B, Li M, Liu Y, Zhang B, Liu Z, Chen X, Huo J, Han Y. The diagnostic value of blood sample NGS in patients with early periprosthetic joint infection after total hip arthroplasty. Int Wound J 2023; 20:961-970. [PMID: 36054590 PMCID: PMC10030938 DOI: 10.1111/iwj.13943] [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: 07/26/2022] [Revised: 08/14/2022] [Accepted: 08/15/2022] [Indexed: 11/27/2022] Open
Abstract
The diagnostic value of next-generation sequencing (NGS) of blood samples from patients with periprosthetic joint infection (PJI) after total hip arthroplasty (THA) was evaluated by comparing it with drainage fluid NGS and bacterial culture. The study was designed as a retrospective diagnostic test. Thirty-six infected patients were diagnosed with PJI according to the Musculoskeletal Infection Society (MSIS) criteria and 57 volunteers were included in our study. NGS and bacterial culture were chosen to detect PJI after THA. Blood samples and drainage fluid were collected for NGS, and the drainage fluid, which was collected at the same time as the NGS drainage fluid sample, was used for bacterial culture. The primary outcomes of interest were sensitivity, specificity, and accuracy. In the infection group, 31 patients showed positive results by blood sample NGS, 33 patients showed positive results by drainage fluid NGS, and 17 patients showed positive bacterial culture results. In the control group, the results of 2 blood sample NGS, 16 drainage fluid NGS, and 3 bacterial cultures were positive. The sensitivity, specificity, and accuracy of the blood sample were 0.86, 0.96, and 0.92, respectively. The sensitivity, specificity, and accuracy of the drainage fluid samples were 0.92, 0.72, and 0.80, respectively. The sensitivity, specificity, and accuracy of bacterial culture were 0.47, 0.95, and 0.79, respectively. The study demonstrated that both the sensitivity and specificity of NGS were higher than those of bacterial culture, regardless of the kind of sample. Compared with drainage fluid NGS, the sensitivity of blood sample NGS was slightly lower (0.86 vs 0.92), but blood sample NGS showed higher specificity (0.96 vs 0.72). In total, the diagnostic value of blood sample NGS was superior to that of drainage fluid NGS and bacterial culture. The majority of infected patients could be identified by blood sample NGS. Moreover, because of its high specificity, blood sample NGS can not only detect infectious bacteria but also distinguish infectious from non-infectious bacteria, which is dramatically different from using drainage fluid NGS.
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Affiliation(s)
- Bingshi Zhang
- Department of Osteonecrosis and Hip Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Mengnan Li
- Department of Osteonecrosis and Hip Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Yawei Liu
- Department of Osteonecrosis and Hip Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Binquan Zhang
- Department of Osteonecrosis and Hip Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Zeming Liu
- Department of Osteonecrosis and Hip Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Xiao Chen
- Department of Osteonecrosis and Hip Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Jia Huo
- Department of Osteonecrosis and Hip Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Yongtai Han
- Department of Osteonecrosis and Hip Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
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21
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Zanna L, Sangaletti R, Akkaya M, Shen T, Abuljadail S, Gehrke T, Citak M. What is the concordance rate of preoperative synovial fluid aspiration and intraoperative biopsy in detecting periprosthetic joint infection of the shoulder? J Shoulder Elbow Surg 2023; 32:492-499. [PMID: 36343792 DOI: 10.1016/j.jse.2022.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The accuracy of preoperative synovial fluid culture for microbe detection in shoulder periprosthetic joint infection (PJI) is poorly described. To evaluate the utility of preoperative culture data for early pathogen identification for shoulder PJI, we determined the concordance between preoperative synovial fluid culture results and intraoperative tissue culture results. METHODS Fifty patients who met the 2014 Musculoskeletal Infection Society criteria for shoulder PJI between January 2016 and December 2019 were retrospectively reviewed for clinical and demographic data. This cohort of patients was divided into 2 groups based on the concordance between preoperative and intraoperative culture results. The pathogens identified on preoperative and intraoperative cultures were classified as high-virulence or low-virulence. Student's t tests and Mann-Whitney U tests were used as appropriate for continuous variables, and χ2 and Fisher's exact tests were used as appropriate for categorical variables. RESULTS Concordance between preoperative aspiration and intraoperative tissue culture was identified in 28 of 50 patients (56%). Preoperative cultures positive for Gram-positive species were more likely to be concordant than discordant (P = .015). Preoperative cultures positive for Cutibacterium acnes were more likely to be concordant with intraoperative cultures (P = .022). There were more patients with polymicrobial infection in the discordant group compared with the concordant group (P < .001). No statistically significant correlation between the preoperative serum C-reactive protein level and the intraoperative category of bacteria was reported. Staphylococcus aureus and coagulase-negative Staphylococci were associated with high specificity and negative predictive value. Preoperative cultures positive for C. acnes demonstrated sensitivity, specificity, positive predictive value, and negative predictive value lower than 0.8. Gram-negative pathogens demonstrated the highest sensitivity (1) and specificity (1), whereas polymicrobial infections exhibited the lowest sensitivity and positive predictive value. CONCLUSION Preoperative synovial fluid aspiration for shoulder PJI poorly predicts intraoperative culture results, with a discordance of 44%. More favorable concordance was observed for monomicrobial preoperative cultures, particularly for Gram-negative organisms and methicillin-sensitive S. aureus. The overall high rate of discordance between preoperative and intraoperative culture may prompt surgeons to base medical and surgical management on patient history and other factors and avoid relying solely on preoperative synovial fluid culture data.
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Affiliation(s)
- Luigi Zanna
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany; Department of Orthopaedic Surgery, Aou Careggi, University Hospital of Florence, Florence, Italy.
| | - Rudy Sangaletti
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Akkaya
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Tony Shen
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Salahulddin Abuljadail
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany; College of Medicine, King Faisal University, Hofuf, Saudi Arabia
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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22
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Advances in the Microbiological Diagnosis of Prosthetic Joint Infections. Diagnostics (Basel) 2023; 13:diagnostics13040809. [PMID: 36832297 PMCID: PMC9954824 DOI: 10.3390/diagnostics13040809] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/31/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023] Open
Abstract
A significant number of prosthetic joint infections (PJI) are culture-negative and/or misinterpreted as aseptic failures in spite of the correct implementation of diagnostic culture techniques, such as tissue sample processing in a bead mill, prolonged incubation time, or sonication of removed implants. Misinterpretation may lead to unnecessary surgery and needless antimicrobial treatment. The diagnostic value of non-culture techniques has been investigated in synovial fluid, periprosthetic tissues, and sonication fluid. Different feasible improvements, such as real-time technology, automated systems and commercial kits are now available to support microbiologists. In this review, we describe non-culture techniques based on nucleic acid amplification and sequencing methods. Polymerase chain reaction (PCR) is a frequently used technique in most microbiology laboratories which allows the detection of a nucleic acid fragment by sequence amplification. Different PCR types can be used to diagnose PJI, each one requiring the selection of appropriate primers. Henceforward, thanks to the reduced cost of sequencing and the availability of next-generation sequencing (NGS), it will be possible to identify the whole pathogen genome sequence and, additionally, to detect all the pathogen sequences present in the joint. Although these new techniques have proved helpful, strict conditions need to be observed in order to detect fastidious microorganisms and rule out contaminants. Specialized microbiologists should assist clinicians in interpreting the result of the analyses at interdisciplinary meetings. New technologies will gradually be made available to improve the etiologic diagnoses of PJI, which will remain an important cornerstone of treatment. Strong collaboration among all specialists involved is essential for the correct diagnosis of PJI.
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23
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Tarabichi S, Goh GS, Baker CM, Chisari E, Shahi A, Parvizi J. Plasma D-Dimer Is Noninferior to Serum C-Reactive Protein in the Diagnosis of Periprosthetic Joint Infection. J Bone Joint Surg Am 2023; 105:501-508. [PMID: 36758110 DOI: 10.2106/jbjs.22.00784] [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] [Indexed: 02/11/2023]
Abstract
BACKGROUND No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Serological markers are often used as screening tools in the workup of patients with suspected PJI. This study aimed to determine the diagnostic utility of plasma D-dimer for PJI in a variety of clinical scenarios. METHODS This prospective study enrolled 502 patients undergoing revision hip or knee arthroplasty. PJI was defined per a modified version of the 2018 International Consensus Meeting (ICM) criteria. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. Receiver operating characteristic curves were used to assess the utility of each biomarker in the diagnosis of PJI. Pairwise comparison with Bonferroni correction was performed to determine whether the differences in areas under the curve (AUCs) between the markers were significant. RESULTS Of the 412 patients included, 317 (76.9%) did not have an infection (aseptic group) and 95 (23.1%) had an infection (PJI group). All 4 serological markers, D-dimer (AUC, 0.860; sensitivity, 81.3%; specificity, 81.7%), CRP (AUC, 0.862; sensitivity, 90.4%; specificity, 70.0%), ESR (AUC, 0.833; sensitivity, 73.9%; specificity, 85.2%), and fibrinogen (AUC, 0.798; sensitivity, 74.7%; specificity, 75.4%), demonstrated comparable accuracy for the diagnosis of PJI (all p > 0.05). When examining the performance of the different inflammatory markers in diagnosing infection caused by indolent organisms, D-dimer demonstrated the highest sensitivity at 93.8%. CONCLUSIONS We found that plasma D-dimer was noninferior to serum CRP and ESR in the diagnosis of PJI and may be a useful adjunct when screening patients undergoing revision total joint arthroplasty. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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24
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Wang R, Shi G, Zhang H, Wang T, Ren W, Jiao Q. Globulin and Albumin/Globulin Ratios as Potential Biomarkers for the Diagnosis of Acute and Chronic Peri-Prosthetic Joint Infections: A Retrospective Study. Surg Infect (Larchmt) 2023; 24:58-65. [PMID: 36706257 DOI: 10.1089/sur.2022.215] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background: Peri-prosthetic joint infection (PJI) is the most serious complication after prosthetic joint replacement. However, the diagnosis of PJI remains challenging for clinicians because of the lack of a gold standard. The purpose of this study was to investigate the diagnostic significance of serum globulin, albumin/globulin, and other biomarkers in acute and chronic periprosthetic infections. Patients and Methods: A retrospective study of 162 patients with PJI and aseptic loosening between January 2016 and March 2021 at our institution was performed in three groups. There were 20 patients with acute infection in group A, 36 patients with chronic infection in group B, and 106 patients with aseptic loosening in group C. Globulin, albumin/globulin, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), platelet count (PLT), mean platelet volume (MPV), d-dimer, and platelet count/mean platelet volume ratio (PMR) levels were recorded. The area under the curve (AUC) was used to measure the diagnostic value of globulin and albumin/globulin with other biomarkers for PJI. Results: Compared with the aseptic loosening group, the acute and chronic PJI group had higher levels of CRP, ESR, d-dimer, globulin, PLT, and PMR (p < 0.01) and lower levels of albumin/globulin and MPV (p < 0.01). The optimal cutoff, AUC, sensitivity, and specificity of CRP, albumin/globulin, ESR, and globulin were: CRP, 8.3 mg/L, 0.903, 78.57%, and 88.68%; albumin/globulin, 1.31, 0.899, 91.07%, and 73.58%; ESR, 32 mm/h, 0.888, 75.%, and 85.85%; globulin, 29.5 g/L, 0.880, 91.07%, and 72.64%. Conclusions: Globulin and albumin/globulin have excellent diagnostic value for acute and chronic PJI and are promising potential biomarkers for the diagnosis of PJI. The diagnostic performance of albumin/globulin is superior to that of ESR and similar to that of CRP.
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Affiliation(s)
- Renwei Wang
- Department of Orthopedic, Linfen Central Hospital, Linfen, Shanxi Province, China.,Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Guang Shi
- Department of Orthopedic, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong Province, P.R. China
| | - Hui Zhang
- Department of Orthopedic, Xi'an International Medical Center Hospital, Xi'an, Shaanxi Province, China
| | - Tao Wang
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Weiping Ren
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Qiang Jiao
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
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25
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Balato G, Ascione T, Festa E, De Vecchi E, Pagliano P, Pellegrini A, Pandolfo G, Siciliano R, Logoluso N. The combined evaluation of fibrinogen and D-dimer levels are a helpful tool to exclude periprosthetic knee infection. J Orthop Res 2023. [PMID: 36606419 DOI: 10.1002/jor.25515] [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: 08/10/2022] [Revised: 12/08/2022] [Accepted: 01/04/2023] [Indexed: 01/07/2023]
Abstract
This retrospective study was undertaken to (i) define the most appropriate thresholds for serum d-dimer and fibrinogen for differentiating aseptic failure from periprosthetic joint infection (PJI) and (ii) evaluate the predictive value of our d-dimer and fibrinogen threshold compared to previously proposed thresholds. This observational cohort study included consecutive patients who had undergone total knee arthroplasty (TKA) revision between January 2019 and December 2020. International Consensus Meeting diagnostic criteria were used to identify patients affected by the prosthetic infection. Receiver operating characteristic curve analyses assessed the predictive value of the parameters, and the areas under the curves were evaluated. We included 125 patients with a median age of 69 years (53-82) affected by painful TKA. Fifty-seven patients (47%) had PJI. Patients with PJI had higher median d-dimer, fibrinogen, ESR, and CRP when compared to patients believed to be free of PJI. The best threshold values for d-dimer and fibrinogen were 1063 ng/ml (sensitivity 0.72, specificity 0.74) and 420 mg/dl (sensitivity 0.67 and specificity 0.82), respectively. A d-dimer level >1063 ng/ml combined with a fibrinogen level >420 mg/dl had a sensitivity of 0.52, and a specificity of 0.90. We found that an increased d-dimer beyond 1063 ng/ml showed a better predictive value than the previously proposed threshold. The combined determination of d-dimer and fibrinogen displayed high specificity and should be considered an excellent tool to rule out an infection. The accuracy of the proposed cutoffs is more effective than previously reported.
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Affiliation(s)
- Giovanni Balato
- Department of Public Health, Section of Orthopedic Surgery, Federico II University, Naples, Italy
| | - Tiziana Ascione
- Service of Infectious Diseases, Cardarelli Hospital, Naples, Italy.,Department of Infectious Diseases, D. Cotugno Hospital, AORN dei Colli, Naples, Italy
| | - Enrico Festa
- Department of Public Health, Section of Orthopedic Surgery, Federico II University, Naples, Italy
| | - Elena De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Pasquale Pagliano
- Department of Medicine and Surgery, Unit of Infectious Diseases, University of Salerno, Baronissi, Italy
| | - Antonio Pellegrini
- IRCCS Istituto Ortopedico Galeazzi (Centro di Chirurgia Ricostruttiva e delle Infezioni Osteoarticolari - CRIO Unit), Milano, Italy
| | - Giuseppe Pandolfo
- Department of Industrial Engineering, "Federico II" University, Naples, Italy
| | - Roberta Siciliano
- Department of Electrical Engineering and Information Technologies, Federico II University, Naples, Italy
| | - Nicola Logoluso
- IRCCS Istituto Ortopedico Galeazzi (Centro di Chirurgia Ricostruttiva e delle Infezioni Osteoarticolari - CRIO Unit), Milano, Italy
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26
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Hipfl C, Karczewski D, Oronowicz J, Pumberger M, Perka C, Hardt S. Total hip arthroplasty for destructive septic arthritis of the hip using a two-stage protocol without spacer placement. Arch Orthop Trauma Surg 2023; 143:19-28. [PMID: 34097122 PMCID: PMC9886611 DOI: 10.1007/s00402-021-03981-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/26/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The optimal treatment of patients with a degenerative joint disease secondary to an active or chronic septic arthritis of the hip is unclear. The aim of the present study was to report on our experience with two-stage total hip arthroplasty (THA) using a contemporary treatment protocol without spacer insertion. MATERIALS AND METHODS Our prospective institutional database was used to identify all patients with degenerative septic arthritis treated with a non-spacer two-stage protocol between 2011 and 2017. Clinical outcomes included interim revision, periprosthetic infection (PJI) and aseptic revision rates. Restoration of leg-length and offset were assessed radiographically. Modified Harris hip score (mHHS) were obtained. Treatment success was defined using the modified Delphi consensus criteria. Mean follow-up was 62 months (13-110). RESULTS A total of 33 patients with a mean age of 60 years (13-85) were included. 55% of the cohort was male and average Charlson Comorbidity Index (CCI) was 3.7 (0-12). 21 patients (64%) had an active/acute infection and 12 patients (36%) were treated for chronic/quiescent septic arthritis. Overall, 11 patients (33%) had treatment failure, including 5 patients who failed to undergo THA, 2 interim re-debridement for persistent infection, and 4 patients who developed PJI after an average of 7 months (0.3-13) following THA. The most common identified pathogen was Staphylococcus aureus (42.4%). No aseptic revision was recorded following THA. Leg-length and offset were successfully restored. Mean mHHS improved from 35.2 points to 73.4 points. CONCLUSION Two-stage THA without spacer placement is a viable treatment option for destructive septic arthritis of the hip, demonstrating comparable rates of infection control and functional outcome. However, definitive resection arthroplasty is not uncommon in these often critically ill patients.
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Affiliation(s)
- Christian Hipfl
- grid.6363.00000 0001 2218 4662Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Daniel Karczewski
- grid.6363.00000 0001 2218 4662Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jakub Oronowicz
- grid.6363.00000 0001 2218 4662Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Matthias Pumberger
- grid.6363.00000 0001 2218 4662Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Carsten Perka
- grid.6363.00000 0001 2218 4662Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Sebastian Hardt
- grid.6363.00000 0001 2218 4662Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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27
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Torrens C, Pérez-Prieto D, Puig L, Prim N, Santana F, Alier A. Minimal number of cultures needed to detect Cutibacterium acnes in primary reverse shoulder arthroplasty: a prospective study. J Shoulder Elbow Surg 2023; 32:89-95. [PMID: 35961500 DOI: 10.1016/j.jse.2022.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/07/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of this study was to determine the minimum number of cultures needed to detect Cutibacterium acnes in primary reverse shoulder arthroplasties (RSAs). METHODS It is a prospective study including 160 primary RSAs. Exclusion criteria included an active infection, an invasive shoulder treatment in the last 6 months before surgery, an Arthro-SCAN or Arthro-MRI in the last 6 months before surgery, previous shoulder surgeries and revision cases. In 90 cases, 11 cultures were obtained. Another 10 cultures were obtained in the other 70 cases (culture 10 was a sterile sponge to detect false positives). To determine the minimum number of cultures needed to detect C acnes, the prevalence of C acnes contamination of the 160 patients included was determined. RESULTS There were 128 females and 32 males, with a mean age of 74 years. There were 1690 cultures obtained from the 160 primary RSA surgeries, and 132 of them turned out to be positive for C acnes. There were 42 patients with positive cultures. Twenty of them were males and 22 females. When considering the skin and the deep tissue cultures altogether, the prevalence of positive cultures for C acnes was of 26.25%. If only deep tissues cultures were considered, the prevalence of positive cultures for C acnes was of 23.13%. When considering the skin and the deep tissue cultures together, the sensitivity to detect the C acnes is 19% if only 1 culture is obtained, 31% if 2 cultures are obtained, 50% if 3 cultures are obtained, 59.5% if 4 cultures are obtained, 66.7% if 5 cultures are obtained, 73.8% if 6 cultures are obtained, 85.7% if 7 cultures are obtained, and 92.9% if 8 cultures are obtained. When considering only the deep tissue cultures, if only 1 culture is obtained, the sensitivity to detect the C acnes is 24.3%, 40.5% if 2 cultures are obtained, 54.1% if 3 cultures are obtained, 73% if 4 cultures are obtained, 89.2% if 5 cultures are obtained, and 97.3% if 6 or 7 cultures are obtained. DISCUSSION A minimum number of 8 cultures are needed to detect C acnes in skin. Moreover, a minimum of 6 cultures are needed to detect it in deep tissues when performing an RSA.
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Affiliation(s)
- Carlos Torrens
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain.
| | - Daniel Pérez-Prieto
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Lluís Puig
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Nuria Prim
- Microbiology Service, Laboratori de Referència de Catalunya, Hospital del Mar, Barcelona, Spain
| | - Fernando Santana
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Albert Alier
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
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Epidemiology of Fungal Periprosthetic Joint Infection: A Systematic Review of the Literature. Microorganisms 2022; 11:microorganisms11010084. [PMID: 36677376 PMCID: PMC9864285 DOI: 10.3390/microorganisms11010084] [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: 10/27/2022] [Revised: 12/15/2022] [Accepted: 12/24/2022] [Indexed: 12/29/2022] Open
Abstract
Fungal prosthetic joint infection (fPJI) is a rare complication; nonetheless, it represents a significant diagnostic and therapeutic challenge. There are no official guidelines on the most effective approach to identify and treat fPJIs. This systematic review aims to review the current literature on fPJI management and provide a comprehensive overview of this topic, especially from an epidemiologic point of view. Studies eligible for this systematic review were identified through an electronic systematic search of PubMed, Scopus, and Web of Science until 30 September 2022. Further references were obtained by cross-referencing. Sixty-three studies met the inclusion criteria, reporting on 372 cases of fPJI; such cases were described mostly in case reports and small case series with only a few larger cohort studies. Diagnosis of fPJI is challenging because of its chronic and indolent clinical course; it is further complicated by the technical difficulty of harvesting fungal cultures. A two-stage revision was the primary procedure in 239 (64.2%) patients whereas DAIR and one-stage approaches were reported in 30 (8.0%) and 18 (4.8 %) cases. In conclusion, our study highlights the heterogeneity of the reported treatments of fPJI, particularly in terms of medical management. With concern to a surgical approach, a two-stage revision arthroplasty is generally suggested, considering fPJI a delayed or late infection. The need for multicenter, prospective studies to provide standardized protocols and improve the treatment of fungal PJI clearly emerges.
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29
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Fuchs M, Faschingbauer M, Riklin-Dold M, Morovic P, Reichel H, Trampuz A, Karbysheva S. D-lactate is a promising biomarker for the diagnosis of periprosthetic joint infection. Front Surg 2022; 9:1082591. [PMID: 36570804 PMCID: PMC9772613 DOI: 10.3389/fsurg.2022.1082591] [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: 10/28/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Reliable biomarkers for the diagnosis of periprosthetic joint infection (PJI) are of paramount clinical value. To date, synovial fluid leukocyte count is the standard surrogate parameter indicating PJI. As D-lactate is almost solely produced by bacteria, it represents a promising molecule in the diagnostic workflow of PJI evaluation. Therefore, the purpose of this study was to assess the performance of synovial fluid D-lactate for diagnosing PJI of the hip and knee. Materials and Methods These are preliminary results of a prospective multicenter study from one academic center. Seventy-two consecutive patients after total hip arthroplasty (THA) or total knee arthroplasty (TKA) were prospectively included. All patients received a joint aspiration in order to rule out or confirm PJI, which was diagnosed according to previously published institutional criteria. Synovial fluid D-lactate was determined spectrophotometrically at 450 nm. Receiver operating characteristic (ROC) analysis was performed to assess the diagnostic performance. Results Eighteen patients (25%) were diagnosed with PJI and 54 patients (75%) were classified as aseptic. Synovial fluid D-lactate showed a sensitivity of 90.7% (95% CI: 79.7%-96.9%) and specificity of 83.3% (95% CI: 58.6%-96.4%) at a cut-off of 0.04 mmol/L. The median concentration of D-lactate was significantly higher in patients with PJI than in those with aseptic conditions (0.048 mmol/L, range, 0.026-0.076 mmol/L vs. 0.024 mmol/L, range, 0.003-0.058 mmol/L, p < 0.0001). The predominat microogranisms were staphylococci, followed by streptococci and gram-negative bacteria. Conclusion D-lactate bears a strong potential to act as a valuable biomarker for diagnosing PJI of the hip and knee. In our study, a cutoff of 0.04 mmol/L showed a comparable sensitivity to synovial fluid leukocyte count. However, its specificity was higher compared to conventional diagnostic tools. The additional advantages of D-lactate testing are requirement of low synovial fluid volume, short turnaround time and low cost.
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Affiliation(s)
- M. Fuchs
- RKU University Department of Orthopaedics, University of Ulm, Ulm, Germany
| | - M. Faschingbauer
- RKU University Department of Orthopaedics, University of Ulm, Ulm, Germany
| | - M. Riklin-Dold
- RKU University Department of Orthopaedics, University of Ulm, Ulm, Germany
| | - P. Morovic
- Center for Musculoskeletal Surgery, Charité – Universitaetsmedizin Berlin, Berlin, Germany
| | - H. Reichel
- RKU University Department of Orthopaedics, University of Ulm, Ulm, Germany
| | - A. Trampuz
- Center for Musculoskeletal Surgery, Charité – Universitaetsmedizin Berlin, Berlin, Germany
| | - S. Karbysheva
- Center for Musculoskeletal Surgery, Charité – Universitaetsmedizin Berlin, Berlin, Germany
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Shao H, Bian T, Zhou Y, Huang Y, Song Y, Yang D. Which serum markers predict the success of reimplantation after periprosthetic joint infection? J Orthop Traumatol 2022; 23:45. [PMID: 36112243 PMCID: PMC9481767 DOI: 10.1186/s10195-022-00664-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/29/2022] [Indexed: 11/10/2022] Open
Abstract
Purpose In clinical practice, serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels are routinely used to screen for periprosthetic joint infection (PJI), but the effectiveness of predicting the success of reimplantation is variable. This study aimed to evaluate the diagnostic effectiveness of serum CRP, ESR, plasma D-dimer, and fibrinogen values in groups achieving treatment success or failure for PJI. Methods A total of 119 PJI cases between January 2012 and January 2017 were identified and included in this study. The most recent serum CRP, ESR, plasma D-dimer, and fibrinogen values obtained prior to performing second-stage revision or spacer exchange were collected for analysis. Treatment failure was defined as having been unable to undergo reimplantation due to clinically persistent infection or reinfection after reimplantation. Results All these tests showed significantly lower values in the treatment success group than in the treatment failure group. The optimal cutoff serum CRP, ESR, plasma D-dimer, and fibrinogen levels for predicting the success of reimplantation were 9.4 mg/L, 29 mm/h, 1740 ng/mL, and 365.6 mg/dL, respectively. All tests had the same sensitivity (72.7%) except for ESR (63.6%), while their specificities were 92.6%, 88.0%, 72.3%, and 83.2%, respectively. Plasma fibrinogen had the highest AUC value of 0.831 [95% confidence interval (CI), 0.685 to 0.978], followed by serum CRP (0.829) and ESR (0.795); plasma D-dimer had the lowest AUC value of 0.716 (95% CI, 0.573 to 0.859). Conclusion Plasma CRP and fibrinogen are good tests for predicting reimplantation success after two-stage revision procedures for patients with PJI.
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Jiang W, Xu H, Wang X, Xie J, Huang Q, Zhou Z, Pei F. Poor performance of monocyte-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, and fibrinogen when screening for occult infection among patients with sequelae of suppurative hip arthritis before total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2022; 46:1929-1935. [PMID: 35718825 DOI: 10.1007/s00264-022-05474-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/05/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Total hip arthroplasty (THA) is considered the best treatment for sequelae of suppurative hip arthritis, but such patients are more likely to have occult infection and therefore to suffer post-operative periprosthetic joint infection. Our study examined (1) the occult infection rate among patients with sequelae of suppurative hip arthritis, and whether (2) neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), or fibrinogen levels can be used to screen such patients for occult infection before THA. METHODS We retrospectively enrolled 428 patients who underwent primary THA at our hospital between 2010 and 2021, of whom 31 had occult infection and 397 did not. The maximum sensitivity and specificity were determined for the three indicators using receiver operating characteristic curves, and positive and negative predictive values were calculated. RESULTS Patients with occult infection showed significantly higher erythrocyte sedimentation rate (ESR) and higher levels of C-reactive protein (CRP) and fibrinogen than those without occult infection. The various potential indicators gave the following areas under the receiver operating characteristic curves: ESR, 0.586; CRP, 0.599; interleukin-6, 0.651; NLR, 0.506; MLR, 0.600; and fibrinogen, 0.589. Sensitivity and specificity were as follows: ESR, 30.8% and 92.5%; CRP, 50.0% and 70.2%; interleukin-6, 57.7% and 67.5%; NLR, 46.7% and 62.9%; MLR, 60.0% and 61.7%; and fibrinogen, 43.3% and 81.7%. CONCLUSION The rate of occult infection was 7.24% among our patients. ESR, NLR, MLR, and levels of CRP, interleukin-6, and fibrinogen may be unreliable for screening such patients for occult infection before THA according to sensitivity and specificity.
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Affiliation(s)
- Wenyu Jiang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, SiChuan University, No.37, Guoxue Road, Wuhou district, Chengdu, 610041, Sichuan, People's Republic of China
| | - Hong Xu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, SiChuan University, No.37, Guoxue Road, Wuhou district, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xing Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, SiChuan University, No.37, Guoxue Road, Wuhou district, Chengdu, 610041, Sichuan, People's Republic of China
| | - Jinwei Xie
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, SiChuan University, No.37, Guoxue Road, Wuhou district, Chengdu, 610041, Sichuan, People's Republic of China
| | - Qiang Huang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, SiChuan University, No.37, Guoxue Road, Wuhou district, Chengdu, 610041, Sichuan, People's Republic of China.
| | - Zongke Zhou
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, SiChuan University, No.37, Guoxue Road, Wuhou district, Chengdu, 610041, Sichuan, People's Republic of China
| | - Fuxing Pei
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, SiChuan University, No.37, Guoxue Road, Wuhou district, Chengdu, 610041, Sichuan, People's Republic of China
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Spellberg B, Aggrey G, Brennan MB, Footer B, Forrest G, Hamilton F, Minejima E, Moore J, Ahn J, Angarone M, Centor RM, Cherabuddi K, Curran J, Davar K, Davis J, Dong MQ, Ghanem B, Hutcheon D, Jent P, Kang M, Lee R, McDonald EG, Morris AM, Reece R, Schwartz IS, So M, Tong S, Tucker C, Wald-Dickler N, Weinstein EJ, Williams R, Yen C, Zhou S, Lee TC. Use of Novel Strategies to Develop Guidelines for Management of Pyogenic Osteomyelitis in Adults: A WikiGuidelines Group Consensus Statement. JAMA Netw Open 2022; 5:e2211321. [PMID: 35536578 PMCID: PMC9092201 DOI: 10.1001/jamanetworkopen.2022.11321] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Traditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence. OBJECTIVE To construct a clinical guideline for pyogenic osteomyelitis management, with a new standard of evidence to resolve the gap between strength of recommendation and quality of evidence, through the use of a novel open access approach utilizing social media tools. EVIDENCE REVIEW This consensus statement and systematic review study used a novel approach from the WikiGuidelines Group, an open access collaborative research project, to construct clinical guidelines for pyogenic osteomyelitis. In June 2021 and February 2022, authors recruited via social media conducted multiple PubMed literature searches, including all years and languages, regarding osteomyelitis management; criteria for article quality and inclusion were specified in the group's charter. The GRADE system for evaluating evidence was not used based on previously published concerns regarding the potential dissociation between strength of recommendation and quality of evidence. Instead, the charter required that clear recommendations be made only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were drafted to discuss pros and cons of care choices. Both clear recommendations and clinical reviews were planned with the intention to be regularly updated as new data become available. FINDINGS Sixty-three participants with diverse expertise from 8 countries developed the group's charter and its first guideline on pyogenic osteomyelitis. These participants included both nonacademic and academic physicians and pharmacists specializing in general internal medicine or hospital medicine, infectious diseases, orthopedic surgery, pharmacology, and medical microbiology. Of the 7 questions addressed in the guideline, 2 clear recommendations were offered for the use of oral antibiotic therapy and the duration of therapy. In addition, 5 clinical reviews were authored addressing diagnosis, approaches to osteomyelitis underlying a pressure ulcer, timing for the administration of empirical therapy, specific antimicrobial options (including empirical regimens, use of antimicrobials targeting resistant pathogens, the role of bone penetration, and the use of rifampin as adjunctive therapy), and the role of biomarkers and imaging to assess responses to therapy. CONCLUSIONS AND RELEVANCE The WikiGuidelines approach offers a novel methodology for clinical guideline development that precludes recommendations based on low-quality data or opinion. The primary limitation is the need for more rigorous clinical investigations, enabling additional clear recommendations for clinical questions currently unresolved by high-quality data.
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Affiliation(s)
- Brad Spellberg
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
| | - Gloria Aggrey
- Montgomery Medical Associates PC, Rockville, Maryland
| | - Meghan B. Brennan
- University of Wisconsin Hospital and Clinics, William S. Middleton Memorial Veterans Hospital, Madison
| | - Brent Footer
- Providence Portland Medical Center, Portland, Oregon
| | | | | | - Emi Minejima
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles
| | - Jessica Moore
- Providence Little Company of Mary Medical Center, San Pedro, California
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, Michigan Medicine, University of Michigan, Ann Arbor
| | | | - Robert M. Centor
- Department of Medicine, Birmingham Veterans Affairs (VA) Medical Center, Birmingham, Alabama
| | | | - Jennifer Curran
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor
| | - Kusha Davar
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
| | - Joshua Davis
- Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Mei Qin Dong
- New York Health and Hospitals Bellevue Hospital, New York, New York
| | | | - Doug Hutcheon
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
| | - Philipp Jent
- Department of Infectious Diseases, Inselspital Bern University Hospital, Bern, Switzerland
| | - Minji Kang
- University of Texas Southwestern, Dallas
| | - Rachael Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham
| | - Emily G. McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Canada
| | - Andrew M. Morris
- Department of Medicine, Division of Infectious Diseases, Sinai Health, University Health Network, and University of Toronto, Toronto, Canada
| | - Rebecca Reece
- Section of Infectious Diseases, Department of Medicine, West Virginia University School of Medicine, Morgantown
| | - Ilan S. Schwartz
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, UHN and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Steven Tong
- Victorian Infectious Diseases Service, Royal Melbourne Hospital and University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Christopher Tucker
- Hospital Medicine, Magnolia Regional Health Center, Corinth, Mississippi
| | - Noah Wald-Dickler
- Los Angeles County+University of Southern California (USC) Medical Center, Los Angeles
| | - Erica J. Weinstein
- Division of Infectious Diseases, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Riley Williams
- Pharmacy Service, Oklahoma City VA Health Care System, Oklahoma City, Oklahoma
| | | | - Shiwei Zhou
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor
| | - Todd C. Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Canada
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Ackmann T, Schwarze J, Gosheger G, Schmidt-Braekling T, Puetzler J, Moellenbeck B, Theil C. Serum calprotectin: a potential biomarker to diagnose chronic prosthetic joint infection after total hip or knee arthroplasty. Sci Rep 2022; 12:5777. [PMID: 35388089 PMCID: PMC8986873 DOI: 10.1038/s41598-022-09724-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 03/21/2022] [Indexed: 11/09/2022] Open
Abstract
The preoperative detection of prosthetic joint infection (PJI) prior to revision of total hip or knee arthroplasty is still a challenge. Serum Calprotectin (CP) is a heterodimer of two calcium-binding proteins present in the cytoplasm of neutrophils that is released in inflammatory processes and infections. The objective of this study is to determine the reliability of serum CP in the diagnosis of chronic PJI. 81 patients (40 women, 41 men) that presented a potential indication for revision arthroplasty of the hip (THA; n = 18) or knee (TKA, n = 63) at a single institution were prospectively evaluated. The joints were diagnosed as chronically infected or aseptic based on the musculoskeletal infection society (MSIS) criteria of 2018. Receiver operating characteristics and the Youden's index were used to define an ideal cutoff value. The median serum CP level was significantly higher in the group with chronic PJI (15,120 vs. 4980 ng/ml; p < 0.001) compared to the aseptic cases. The calculated optimal cut-off value was 9910 ng/ml (AUC 0.899, 95% CI 0.830-0.968) with a specificity of 91% and sensitivity of 81%. The present investigation suggests that serum CP has a high specificity and good sensitivity to diagnose chronic PJI after TJA of the knee or hip.
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Affiliation(s)
- Thomas Ackmann
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Jan Schwarze
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Georg Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Tom Schmidt-Braekling
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Jan Puetzler
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Burkhard Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Christoph Theil
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
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Chen Y, Wang H, Chen X, Ma H, Zheng J, Cao L. Serum D-lactate, a novel serological biomarker, is promising for the diagnosis of periprosthetic joint infection. BMC Musculoskelet Disord 2022; 23:292. [PMID: 35346149 PMCID: PMC8962196 DOI: 10.1186/s12891-022-05199-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Although many markers are used for diagnosis of periprosthetic joint infection (PJI), serological screening and diagnosis for PJI are still challenging. We evaluated the performance of serum D-lactate and compared it with ESR, coagulation-related biomarkers and synovial D-lactate for the diagnosis of PJI. Methods Consecutive patients with preoperative blood and intraoperative joint aspiration of a prosthetic hip or knee joint before revision arthroplasty were prospectively included. The diagnosis of PJI was based on the criteria of the Musculoskeletal Infection Society, and the diagnostic values of markers were estimated based on receiver operating characteristic (ROC) curves by maximizing sensitivity and specificity using optimal cutoff values. Results Of 52 patients, 26 (50%) were diagnosed with PJI, and 26 (50%) were diagnosed with aseptic failure. ROC curves showed that serum D-lactate, fibrinogen (FIB) and ESR had equal areas under the curve (AUCs) of 0.80, followed by D-dimer and fibrin degradation product, which had AUCs of 0.67 and 0.69, respectively. Serum D-lactate had the highest sensitivity of 88.46% at the optimal threshold of 1.14 mmol/L, followed by FIB and ESR, with sensitivities of 80.77% and 73.08%, respectively, while there were no significant differences in specificity (73.08%, 73.08% and 76.92%, respectively). Conclusion Serum D-lactate showed similar performance to FIB and ESR for diagnosis of PJI. The advantages of serum D-lactate are pathogen-specific, highly sensitive, minimally invasive and rapidly available making serum D-lactate useful as a point-of-care screening test for PJI.
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Affiliation(s)
- Yanyang Chen
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, No.137 South Li Yu Shan Road, Urumqi, 830054, Xinjiang, China
| | - Huhu Wang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, No.137 South Li Yu Shan Road, Urumqi, 830054, Xinjiang, China
| | - Xiyao Chen
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, No.137 South Li Yu Shan Road, Urumqi, 830054, Xinjiang, China
| | - Hairong Ma
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, No.137 South Li Yu Shan Road, Urumqi, 830054, Xinjiang, China
| | - Jingjie Zheng
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, No.137 South Li Yu Shan Road, Urumqi, 830054, Xinjiang, China
| | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, No.137 South Li Yu Shan Road, Urumqi, 830054, Xinjiang, China.
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Battaglia AG, Ali-Zade C, Monti L, Al Khawashki H, Winkler H, Del Sel H, Mavrogenis AF, Benzakour T, Drago L, Romanò CL. Metal Hypersensitivity or Missed Periprosthetic Joint Infection? A Critical Review. Orthopedics 2022; 45:e73-e78. [PMID: 34978510 DOI: 10.3928/01477447-20211227-04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The World Association Against Infection in Orthopedics And Trauma (W.A.I.O.T.) Study Group on Bone And Joint Infection Definitions Metal hypersensitivity (MHS) has been investigated by several authors as a possible reason for painful total joint arthroplasty, with controversial results. Periprosthetic joint infection (PJI) is another possible source of unexplained pain and implant failure that may be difficult to diagnose if not properly investigated. We performed this critical review to assess whether the current literature on MHS includes an adequate diagnostic workup to discern metal allergy from PJI. The results of this review highlight the importance of assessing patients for PJI before making a diagnosis of MHS and emphasize that the methods currently used to exclude PJI are substantially inadequate. Therefore, well-designed clinical trials with adequate diagnostic protocols and definitions of PJI that can differentiate MHS from low-grade PJI are needed. [Orthopedics. 2022;45(2):e73-e78.].
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Huang J, Wang J, Qin L, Zhu B, Huang W, Hu N. Combination of Synovial Fluid IL-4 and Polymorphonuclear Cell Percentage Improves the Diagnostic Accuracy of Chronic Periprosthetic Joint Infection. Front Surg 2022; 9:843187. [PMID: 35356501 PMCID: PMC8959493 DOI: 10.3389/fsurg.2022.843187] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 02/03/2022] [Indexed: 11/21/2022] Open
Abstract
Background Synovial fluid biomarkers have been found to improve the diagnosis of chronic periprosthetic joint infection (PJI); however, no “gold standard” exists yet. Interleukin-4 (IL-4) and polymorphonuclear cell (neutrophil) count in the synovial fluid are crucial in mediating local inflammation during bacterial infections and could be valuable biomarkers for PJI. Methods This prospective study was conducted to investigate the diagnostic potential of synovial fluid IL-4 (SF-IL4) and polymorphonuclear cell percentage (SF-PMN%) for chronic PJI. A total of 110 patients who underwent revision arthroplasty between January 2019 and October 2020 were enrolled, and 11 patients were excluded. Of 99 patients, 43 were classified as having PJI and 56 as having aseptic failures according to the 2013 Musculoskeletal Infections Society criteria. In all patients, SF-IL4, SF-PMN%, serum C-reactive protein (CRP), and serum erythrocyte sedimentation rate (ESR) were quantified preoperatively. The diagnostic value for each biomarker was analyzed, and optimal cutoff values were calculated. Results The patient demographics did not significantly vary. The area under the curve of SF-IL4 and SF-PMN% was 0.97 and 0.89, respectively, higher than that for serum ESR (0.72) and serum CRP (0.83). The combination of SF-IL4 and SF-PMN% provided higher specificity (97.0%) and accuracy (96.0%) when the cut-off values were 1.7 pg/mL and 75%, respectively. Conclusion SF-IL4 is a valuable biomarker for chronic PJI detection, and the combination of SF-IL4 and SF-PMN% improved the diagnostic value of chronic PJI, and further studies are needed until its clinical application.
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Affiliation(s)
- Jiaxing Huang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Jiawei Wang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Leilei Qin
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Bo Zhu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Ning Hu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
- *Correspondence: Ning Hu
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Kopechek KJ, Cvetanovich GL, Everhart JS, Frantz TL, Samade R, Bishop JY, Neviaser AS. Factors Associated With Elevated Inflammatory Markers Prior to Shoulder Arthroplasty. HSS J 2022; 18:70-77. [PMID: 35087335 PMCID: PMC8753553 DOI: 10.1177/1556331621998662] [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: 09/07/2020] [Accepted: 10/09/2020] [Indexed: 02/03/2023]
Abstract
Background: Preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) ranges for several shoulder arthroplasty indications are not well understood. Purpose: We sought to compare preoperative ESR and CRP values for a variety of shoulder arthroplasty indications and evaluate risk factors for elevated preoperative ESR and CRP values. Methods: We conducted a retrospective cohort study of shoulder arthroplasty cases performed at a single academic medical institution from 2013 to 2018. Preoperative ESR and CRP values for 235 shoulder arthroplasties with various indications were recorded. Independent risk factors for elevated values (CRP > 10.0 mg/L and ESR > 30.0 mm/h) were determined via multiple variable logistic regression. Results: Patients undergoing shoulder arthroplasty for osteoarthritis had an ESR (mean ± SD) of 22.6 ± 17.8, with 29.8% of patients elevated, and a CRP of 6.5 ± 6.4, with 25.5% of patients elevated. Arthroplasty for acute fracture and prosthetic joint infection (PJI) had higher preoperative ESR and CRP values. Multivariate analysis identified several predictors of elevated ESR, including infection, acute fracture, diabetes, and female sex. It also identified predictors of elevated CRP, including infection, acute fracture, and younger age. Conclusions: Preoperative ESR and CRP values may be elevated in 25% to 30% of patients undergoing primary shoulder arthroplasty. Arthroplasty for both acute fracture and PJI, along with several other patient factors, was associated with elevated preoperative ESR and CRP. Thus, routine collection of ESR and CRP preoperatively may not be of benefit, as elevated values are common. Further study is warranted.
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Affiliation(s)
- Kyle J. Kopechek
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gregory L. Cvetanovich
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua S. Everhart
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Travis L. Frantz
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Richard Samade
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Julie Y. Bishop
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Andrew S. Neviaser
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA,Andrew S. Neviaser, MD, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.
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Ottink KD, Gelderman SJ, Wouthuyzen-Bakker M, Ploegmakers JJW, Glaudemans AWJM, Jutte PC. Nuclear imaging does not have clear added value in patients with low a priori chance of periprosthetic joint infection. A retrospective single-center experience. J Bone Jt Infect 2022; 7:1-9. [PMID: 35047347 PMCID: PMC8759077 DOI: 10.5194/jbji-7-1-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/05/2021] [Indexed: 11/21/2022] Open
Abstract
Background: A low-grade periprosthetic joint infection (PJI) may present without specific symptoms, and its diagnosis remains a challenge. Three-phase bone scintigraphy (TPBS) and white blood cell (WBC) scintigraphy are incorporated into recently introduced diagnostic criteria for PJI, but their exact value in diagnosing low-grade PJI in patients with nonspecific symptoms remains unclear. Methods: In this retrospective study, we evaluated patients with a prosthetic joint of the hip or knee who underwent TPBS and/or WBC scintigraphy between 2009 and 2016 because of nonspecific symptoms. We reviewed and calculated diagnostic accuracy of the TPBS and/or WBC scintigraphy to diagnose or exclude PJI. PJI was defined based on multiple cultures obtained during revision surgery. In patients who did not undergo revision surgery, PJI was ruled out by clinical follow-up of at least 2 years absent of clinical signs of infection based on MSIS 2011 criteria. Results: A total of 373 patients were evaluated, including 340 TPBSs and 142 WBC scintigraphies. Thirteen patients (3.5 %) were diagnosed with a PJI. TPBS sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were 71 %, 65 %, 8 % and 98 %, respectively. Thirty-five percent of TPBS showed increased uptake. Stratification for time intervals between the index arthroplasty and the onset of symptoms did not alter its diagnostic accuracy. WBC scintigraphy sensitivity, specificity, PPV and NPV were 30 %, 90 %, 25 % and 94 %, respectively. Conclusion: Nuclear imaging does not have clear added value in patients with low a priori chance of periprosthetic joint infection.
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Affiliation(s)
- Karsten D. Ottink
- Department of Orthopaedics, University of Groningen, University
Medical Centre Groningen, Groningen, the Netherlands
| | - Stefan J. Gelderman
- Department of Orthopaedics, University of Groningen, University
Medical Centre Groningen, Groningen, the Netherlands
- Department of Nuclear Medicine and Molecular Imaging, University of
Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention,
University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Joris J. W. Ploegmakers
- Department of Orthopaedics, University of Groningen, University
Medical Centre Groningen, Groningen, the Netherlands
| | - Andor W. J. M. Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of
Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Paul C. Jutte
- Department of Orthopaedics, University of Groningen, University
Medical Centre Groningen, Groningen, the Netherlands
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Single-stage total hip arthroplasty after failed fixation of proximal femoral fractures: an increased risk for periprosthetic joint infections? Arch Orthop Trauma Surg 2022; 142:2911-2917. [PMID: 34453205 PMCID: PMC9474588 DOI: 10.1007/s00402-021-04119-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 08/09/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Higher complication rates have been reported for total hip arthroplasty (THA) after osteosynthesis of proximal femur fractures (PFF). This study evaluated the infection risk for conversion of internal fixation of PFF to THA by a single-staged procedure in the absence of clear infection signs. METHODS Patients undergoing a one-staged conversion to THA (2013-2018) after prior internal fixation of the proximal femur were included. Preoperative diagnostics with laboratory results, hip aspirations as well as intraoperative microbiology and sonication were assessed. Postoperative complications were recorded as well as patient demographics, duration between initial and conversion to THA, explanted osteosynthesis and implanted THA. RESULTS Fifty-eight patients (24 male/34 female, 62.8 ± 14.5 years) were included with a mean time of 3.8 ± 7.5 years between internal fixation and conversion to THA (45 cementless, 3 cemented, 3 hybrid and 7 hybrid inverse THAs). Preoperative mean blood level CRP was 8.36 ± 14 mg/l (reference value < 5 mg/l) and leukocyte count was 7.11 ± 1.84^3/µl (4.5-10.000^3/µl). Fifty patients had intraoperative microbiological diagnostics, with either swabs in 86.2% and/or sonication in 29.3%. Positive microbiological results were recorded in 10% (5 of 50 patients), with pathogens identified being mainly Staphylococcus. Complications after conversion occurred in 9.6% including a postoperative low-grade infection rate of 5.8% after a mean of 2.5 years. CONCLUSION This study found a positive microbiological test result in 10% of a one-stage conversion of PFF fixation to THA. Moreover, we found a high infection rate (5.8%) for early postoperative periprosthetic joint infection. Interestingly, CRP has not been proven to be an adequate parameter for low-grade infections or occult colonized implants. Therefore, we recommend a comprehensive pre- and intraoperative diagnostic including hip aspiration, swabs and sonication when considering one-staged revision.
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Akgün D, Wiethölter M, Siegert P, Danzinger V, Minkus M, Braun KF, Moroder P. The role of serum C-reactive protein in the diagnosis of periprosthetic shoulder infection. Arch Orthop Trauma Surg 2022; 142:1715-1721. [PMID: 33515325 PMCID: PMC9296386 DOI: 10.1007/s00402-021-03779-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/06/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION There is a paucity of literature regarding serum C-reactive protein (CRP) in the evaluation of a shoulder periprosthetic joint infection (PJI). The purpose of the current study was to establish cutoff values for diagnosing shoulder PJI and evaluate the influence of the type of infecting microorganism and the classification subgroups according to last proposed International Consensus Meeting (ICM) criteria on the CRP level. MATERIALS AND METHODS A retrospective analysis of all 136 patients, who underwent septic or aseptic revision shoulder arthroplasty in our institution between January 2010 and December 2019, was performed. Shoulder PJI was defined according to the last proposed definition criteria of the ICM. Serum CRP levels were compared between infected and non-infected cases, between infection subgroups, as well as between different species of infecting microorganisms. A receiver-operating characteristic (ROC) analysis was performed to display sensitivity and specificity of serum CRP level for shoulder PJI. RESULTS A total of 52 patients (38%) were classified as infected, 18 meeting the criteria for definitive infection, 26 for probable infection and 8 for possible infection. According to the ROC curve, an optimized serum CRP threshold of 7.2 mg/l had a sensitivity of 69% and specificity of 74% (area under curve = 0.72). Patients with definitive infection group demonstrated significantly higher median serum CRP levels (24.3 mg/l), when compared to probable, possible infection groups and PJI unlikely group (8 mg/l, 8.3 mg/l, 3.6 mg/l, respectively, p < 0.05). The most common isolated microorganism was Cutibacterium acnes in 25 patients (48%) followed by coagulase-negative staphylococci (CNS) in 20 patients (39%). Patients with a PJI caused by high-virulent microorganisms had a significantly higher median serum CRP level compared to patients with PJI caused by low-virulent microorganisms (48 mg/l vs. 11.3 mg/l, p = 0.04). CONCLUSIONS Serum CRP showed a low sensitivity and specificity for the diagnosis of shoulder PJI, even applying cutoffs optimized by receiver-operating curve analysis. Low-virulent microorganisms and patients with probable and possible infections are associated with lower CRP levels compared to patients with definitive infection and infections caused by high-virulent microorganisms. LEVEL OF EVIDENCE Diagnostic Level III.
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Affiliation(s)
- Doruk Akgün
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Mats Wiethölter
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Paul Siegert
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Victor Danzinger
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Marvin Minkus
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Karl Friedrich Braun
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Philipp Moroder
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
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Shi W, Wang Y, Zhao X, Yu T, Li T. CRP/Albumin Has a Promising Prospect as a New Biomarker for the Diagnosis of Periprosthetic Joint Infection. Infect Drug Resist 2021; 14:5145-5151. [PMID: 34908848 PMCID: PMC8664647 DOI: 10.2147/idr.s342652] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/20/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose In the present study, we aimed to identify more effective biomarkers for the diagnosis of periprosthetic joint infection (PJI) by comparing the diagnostic ability of C-reactive protein (CRP)/albumin, systemic immune-inflammation index (SII), and existing biomarkers. Methods In this single-center retrospective analysis, 216 patients who underwent revision knee or hip arthroplasty from June 2013 to June 2021 and met the inclusion and exclusion criteria were analyzed, including 80 patients in the PJI group and 136 patients in the non-PJI group. The following information was collected for analysis, including CRP, fibrinogen, erythrocyte sedimentation rate (ESR), D-dimer, platelet count (PC), neutrophil count (N), lymphocyte count (Lym), and albumin count on the second day of admission. The receiver operating characteristic (ROC) curve was used to compare the diagnostic ability of various biomarkers, and further subgroup analysis was carried out in the PJI group. Results Compared with the non-PJI group, CRP, fibrinogen, D-dimer, ESR, CRP/albumin, and SII in the PJI group were significantly increased (P < 0.001), and their area under the curve (AUC) was 0.937, 0.878, 0.777, 0.914, 0.941, and 0.765, respectively. In the three subgroup analyses, there was no significant difference in appeal biomarker (P > 0.05) based on PJI culture results, infection time, and infection site. Conclusion CRP/albumin had a promising prospect as a new biomarker for the diagnosis of PJI, while it had insufficient predictive ability in the PJI subgroup analysis. However, SII had insufficient ability to diagnose PJI. Therefore, SII was not suitable to be used as a diagnostic biomarker.
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Affiliation(s)
- Weipeng Shi
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266003, People's Republic of China.,Medical Department of Qingdao University, Qingdao, Shandong, 266071, People's Republic of China
| | - Yingzhen Wang
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266003, People's Republic of China
| | - Xuan Zhao
- Department of Rheumatism and Immunology, The Affiliated Hospital of Jining Medical University, Jining, 272007, People's Republic of China
| | - Tengbo Yu
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266003, People's Republic of China
| | - Tao Li
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266003, People's Republic of China
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Attiq A, Yao LJ, Afzal S, Khan MA. The triumvirate of NF-κB, inflammation and cytokine storm in COVID-19. Int Immunopharmacol 2021; 101:108255. [PMID: 34688149 PMCID: PMC8516728 DOI: 10.1016/j.intimp.2021.108255] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/30/2021] [Accepted: 10/09/2021] [Indexed: 01/08/2023]
Abstract
The coronavirus disease (COVID-19) has once again reminded us of the significance of host immune response and consequential havocs of the immune dysregulation. The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) inflicts severe complications to the infected host, including cough, dyspnoea, fever, septic shock, acute respiratory distress syndrome (ARDs), and multiple organ failure. These manifestations are the consequence of the dysregulated immune system, which gives rise to excessive and unattended production of pro-inflammatory mediators. Elevated circulatory cytokine and chemokine levels are accompanied by spontaneous haemorrhage, thrombocytopenia and systemic inflammation, which are the cardinal features of life-threatening cytokine storm syndrome in advanced COVID-19 diseases. Coronavirus hijacked NF-kappa B (NF-κB) is responsible for upregulating the expressions of inflammatory cytokine, chemokine, alarmins and inducible enzymes, which paves the pathway for cytokine storm. Given the scenario, the systemic approach of simultaneous inhibition of NF-κB offers an attractive therapeutic intervention. Targeted therapies with proteasome inhibitor (VL-01, bortezomib, carfilzomib and ixazomib), bruton tyrosine kinase inhibitor (acalabrutinib), nucleotide analogue (remdesivir), TNF-α monoclonal antibodies (infliximab and adalimumab), N-acetylcysteine and corticosteroids (dexamethasone), focusing the NF-κB inhibition have demonstrated effectiveness in terms of the significant decrease in morbidity and mortality in severe COVID-19 patients. Hence, this review highlights the activation, signal transduction and cross-talk of NF-κB with regard to cytokine storm in COVID-19. Moreover, the development of therapeutic strategies based on NF-κB inhibition are also discussed herein.
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Affiliation(s)
- Ali Attiq
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, MAHSA University, Bandar Saujana Putra, 42610 Jenjarom, Selangor, Malaysia.
| | - Lui Jin Yao
- Kuala Balah Health Clinic (Klinik Kesihatan Kuala Balah), Kuala Balah, 17600 Jeli, Kelantan, Malaysia
| | - Sheryar Afzal
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, MAHSA University, Bandar Saujana Putra, 42610 Jenjarom, Selangor, Malaysia
| | - Mansoor Ali Khan
- COVID-19 Vaccination Centres, University College London Hospitals, National Health Service, N10QH London, England
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Ye Y, Chen W, Gu M, Liu Q, Xian G, Pan B, Zheng L, Chen X, Zhang Z, Sheng P. Limited value of serum neutrophil-to-lymphocyte ratio in the diagnosis of chronic periprosthetic joint infection. J Orthop Traumatol 2021; 22:37. [PMID: 34536150 PMCID: PMC8449752 DOI: 10.1186/s10195-021-00599-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 09/01/2021] [Indexed: 01/10/2023] Open
Abstract
Background Diagnosing chronic periprosthetic joint infection (PJI) is challenging. No single biomarker can accurately recognize PJI preoperatively in a timely manner. Therefore, the aim of the present study was to investigate the usefulness of the serum neutrophil-to-lymphocyte ratio (NLR) in aiding the diagnosis of chronic PJI. Materials and methods We retrospectively evaluated the medical records of 158 patients who had undergone revision arthroplasty (104 with aseptic mechanic failure and 54 with chronic PJI) from July 2011 to July 2020. Univariate analysis followed by multivariate logistic regression was applied to compare NLR, C-reactive protein (CRP), and erythrocyte sedimentation ratio (ESR) between the two groups. The receiver operating characteristic (ROC) curve was used to assess the diagnostic performance of NLR alone and in combination with CRP and ESR. Results NLR, CRP, and ESR were significantly higher in patients with chronic PJI than in the aseptic revision group (p < 0.05). ROC curve analysis revealed that NLR had a sensitivity of 57.41% and a specificity of 77.88% with an optimal threshold of 2.56. The optimal threshold for CRP and ESR was 7.00 mg/L (sensitivity 62.50% and specificity 83.12%) and 43 mm/h (sensitivity 59.38% and specificity 80.52%), respectively. The combined diagnostic value of NLR with CRP and ESR was shown to have no additional diagnostic value in predicting chronic PJI. Conclusion Compared with traditional inflammatory biomarkers (ESR and CRP), the value of serum NLR alone or combined with CRP and ESR for diagnosing chronic PJI is limited. Level of evidence Level 3.
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Affiliation(s)
- Yongyu Ye
- Department of Orthopedics, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Weishen Chen
- Department of Orthopedics, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Minghui Gu
- Department of Orthopedics, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Qiaoli Liu
- Department of Orthopedics, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Guoyan Xian
- Department of Orthopedics, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Baiqi Pan
- Department of Orthopedics, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Linli Zheng
- Department of Orthopedics, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Xiaoling Chen
- Department of Orthopedics, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Ziji Zhang
- Department of Orthopedics, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.
| | - Puyi Sheng
- Department of Orthopedics, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.
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Palmowski Y, Pumberger M, Perka C, Hardt S, Hipfl C. Is implant sonication useful when screening for infection in conversion of prior hip fracture fixation to total hip arthroplasty? J Int Med Res 2021; 49:3000605211028123. [PMID: 34515558 PMCID: PMC8442504 DOI: 10.1177/03000605211028123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective To examine sonication results in presumed aseptic conversion total hip
arthroplasty (THA) after hip fracture fixation and to evaluate its
implications on the treatment outcome. Methods This retrospective cohort study reviewed the data from presumed aseptic
patients that underwent conversion of prior internal fixation of proximal
femoral fractures to THA between 2012 and 2018. Microbiological analysis was
performed using sonication of osteosynthesis material and tissue samples.
Treatment outcome including the occurrence of periprosthetic joint infection
(PJI) was recorded. Results A total of 32 patients were included in the study. Of these, five patients
(15.6%) had positive intraoperative cultures. The mean follow-up following
conversion THA was 43.0 months (range, 19.0–91.5 months). Sonication was
positive in three patients (9.4%), all of whom were deemed contaminated and
did not develop PJI. Tissue cultures were positive in two patients (6.3%).
One patient with Enterococcus faecalis received antibiotic
treatment and did not develop PJI. Another patient with growth of
Cutibacterium acnes that was initially classified as a
contaminant later developed acute PJI caused by the same pathogen. Overall,
PJI occurred in two patients (6.3%) after conversion THA. Conclusion Sonication of internal fixation devices did not add diagnostic value in
clinically aseptic conversion THA. Further studies are needed to better
understand the relevance of unexpected positive cultures, and to develop
diagnostic criteria for the management of these patients.
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Affiliation(s)
- Yannick Palmowski
- Centre for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Matthias Pumberger
- Centre for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Carsten Perka
- Centre for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Sebastian Hardt
- Centre for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Christian Hipfl
- Centre for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
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Sigmund IK, Puchner SE, Windhager R. Serum Inflammatory Biomarkers in the Diagnosis of Periprosthetic Joint Infections. Biomedicines 2021; 9:biomedicines9091128. [PMID: 34572314 PMCID: PMC8467465 DOI: 10.3390/biomedicines9091128] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/16/2021] [Accepted: 08/21/2021] [Indexed: 11/23/2022] Open
Abstract
Accurate preoperative diagnosis of periprosthetic joint infections (PJIs) can be very challenging, especially in patients with chronic PJI caused by low-virulence microorganisms. Serum parameters, such as serum C-reactive protein (CRP) or the erythrocyte sedimentation rate (ESR), are—among other diagnostic test methods—widely used to distinguish septic from aseptic failure after total hip or knee arthroplasty and are recommended by the AAOS in the preoperative setting. However, they are systemic parameters, and therefore, unspecific. Nevertheless, they may be the first and occasionally the only preoperative indication, especially when clinical symptoms are lacking. They are easy to obtain, cheap, and are available worldwide. In the last decade, different novel serum biomarkers (percentage of neutrophils, neutrophils to lymphocytes ratio, platelet count to mean platelet volume ratio, fibrinogen, D-Dimer, Il-6, PCT) were investigated to find a more specific and accurate serum parameter in the diagnosis of PJI. This article reviews the diagnostic value of established (serum CRP, ESR, WBC) and ‘novel’ serum inflammatory biomarkers (fibrinogen, D-dimer, interleukin-6 (IL-6), procalcitonin, percentage of neutrophils (%N), neutrophils to lymphocytes ratio (NLR), platelet count to mean platelet volume ratio (PC/mPV)) for the preoperative diagnosis of periprosthetic joint infections.
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Ghassibi M, Yen TC, Harris S, Si Z, Leary E, Choma TJ. Responsiveness of routine diagnostic tests for vertebral osteomyelitis may be influenced by the infecting organism. Spine J 2021; 21:1479-1488. [PMID: 33857669 DOI: 10.1016/j.spinee.2021.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/05/2021] [Accepted: 04/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Vertebral osteomyelitis (VO) becomes increasingly more prevalent as people age, and it is a condition seen frequently by referral center spine surgeons. It can take as long as 6 months for a proper diagnosis to be made. Staphylococcus aureus (S. aureus) is the most common isolated organism in up to 80% of the affected population. The clinical presentation of vertebral osteomyelitis is typically non specific (back pain), which can make timely diagnosis challenging. Fever is often absent. Serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC) and serum polymorphonuclear leukocyte percentage (PMN%) are traditionally used as first-line tests because of their perceived sensitivity to help diagnose vertebral osteomyelitis. It is not known whether these test values are affected by the infecting organism. PURPOSE To determine whether individual first-line diagnostics differed based on infecting organism and whether certain organisms are associated with lower lab values. Additionally, this study sought to determine if VO caused by lower virulent (eg, culture-negative and nonpyogenic organisms) could contribute to delays in treatment due to lack of elevated biomarkers. STUDY DESIGN/SETTING Single-center retrospective cohort study. PATIENT SAMPLE We reviewed clinical data of 133 patients (60% male) diagnosed with VO from 2015-2019 in a US Midwest academic hospital. OUTCOMES MEASURES Primary outcome measures included the maximum temperature upon presentation, serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC), and percentage neutrophils during the hospital admission. METHODS Inclusion criteria were adult patients diagnosed with vertebral osteomyelitis who underwent blood culture and/or biopsy prior to treatment. All patients enrolled in the study were diagnosed with VO and confirmed via magnetic resonance imaging (MRI). MRI findings associated with VO included destruction of endplates, increased signal in vertebral bodies, and the surrounding disc on T2-weighted imaging were confirmed. The patients had laboratory work up and clinical follow up regardless of positive culture or negative culture. The mean peak inflammatory marker levels were compared among organisms with student's t test. Demographics, comorbidities, and CCI were collected and multivariable logistic regression models were used. Receiver operating characteristic curve analysis was performed to delineate separate, optimal cut offs for CRP, ESR, WBC, and PMN% for patients with culture positive osteomyelitis RESULTS: Patients' average age was 57.0±13.7 years with a mean BMI of 30.5±9.70 kg/m2, and a mean Charleston Comorbidity Index (CCI) of 3.17±2.35. Staphylococcus aureus and antibiotic resistant organisms (MRSA and VRE) demonstrated a higher mean CRP and ESR than culture negative, fungal and TB cases. Staphylococcus aureus, antibiotic resistant organisms, and coagulase negative Staphylococcus demonstrated a higher mean WBC than culture negative as well as fungal and TB cases. Staphylococcus aureus, antibiotic resistant organisms, coagulase negative Staphylococcus, and Streptococcus species had a higher mean peak PMN%, than culture negative as well as fungal and TB case. Temperature did not correlate with a diagnosis of osteomyelitis. CONCLUSIONS Serum laboratory markers in the diagnosis of VO appear to be influenced by the infecting organism type. Laboratory values in patients diagnosed with VO with culture negative or non-pyogenic organisms are lower compared to antibiotic resistant and S. aureus organisms. Fever did not correlate with a diagnosis of VO.
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Affiliation(s)
- Michael Ghassibi
- University of Missouri, Department of Orthopaedic Surgery, Columbia, MO, USA
| | - Tzu Chuan Yen
- University of Missouri, Department of Orthopaedic Surgery, Columbia, MO, USA
| | - Shelby Harris
- University of Missouri, School of Medicine, Columbia, MO, USA
| | - Zhengye Si
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO, USA
| | - Emily Leary
- University of Missouri, Department of Orthopaedic Surgery, Columbia, MO, USA
| | - Theodore J Choma
- University of Missouri, Department of Orthopaedic Surgery, Columbia, MO, USA.
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Pérez-Prieto D, Hinarejos P, Alier A, Sorlí L, Martínez S, Puig L, Monllau JC. Adherence to a reliable PJI diagnostic protocol minimizes unsuspected positive cultures rate. BMC Musculoskelet Disord 2021; 22:653. [PMID: 34340666 PMCID: PMC8330036 DOI: 10.1186/s12891-021-04431-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/06/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The aim of the present study was to evaluate the incidence of unsuspected PJI when prosthetic revisions are thoroughly evaluated by PJI dedicated orthopedic surgeon before surgery. The hypothesis is that the incidence of unsuspected PJI is reduced by applying this protocol. METHODS This is a historical cohort study carried out in one university hospital. The prosthetic revision assessment was carried out in January 2019. From that date on, all patients that were programmed for hip or knee revision (either by an orthopedic surgeon specialized or not in septic revisions) were scheduled for a preoperative visit with the same orthopedic surgeon specialized in septic revisions. The diagnostic algorithm applied was based on the Pro-Implant Foundation diagnostic criteria. Prior to the revision assessment, the indication for joint aspiration was done at the surgeons' discretion (non-specialized in septic revisions) and the preoperative identification of PJI was also done by a hip or knee surgeon (not specialized in septic surgery). RESULTS Based on the PIF criteria, there were 15 infections among the revisions in group 1 and 18 PJI in group 2 (p > 0.05). The most interesting finding was that there were 7 patients with unsuspected positive cultures in group 1. That represents 11% of all revisions. No patient in group 2 was found with unsuspected positive cultures (p < 0.001). CONCLUSION A thorough PJI diagnostic algorithm should be implemented before prosthetic revision to avoid unsuspected positive cultures.
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Affiliation(s)
- Daniel Pérez-Prieto
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
- Catalan Institute for Traumatology and Sports Medicine (ICATME), Hospital Universitari Dexeus. - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
| | - Pedro Hinarejos
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Albert Alier
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Lluïsa Sorlí
- Department of Infectious Diseases, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Santos Martínez
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Lluís Puig
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Juan C Monllau
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- Catalan Institute for Traumatology and Sports Medicine (ICATME), Hospital Universitari Dexeus. - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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Xu H, Xie JW, Liu L, Wang D, Huang ZY, Zhou ZK. Combination of CRP with NLR is a sensitive tool for screening fixation-related infection in patients undergoing conversion total hip arthroplasty after failed internal fixation for femoral neck fracture. Bone Joint J 2021; 103-B:1534-1540. [PMID: 34223770 DOI: 10.1302/0301-620x.103b.bjj-2021-0105.r1] [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] [Indexed: 02/05/2023]
Abstract
AIMS Monocyte-lymphocyte ratio (MLR) or neutrophil-lymphocyte ratio (NLR) are useful for diagnosing periprosthetic joint infection (PJI), but their diagnostic values are unclear for screening fixation-related infection (FRI) in patients for whom conversion total hip arthroplasty (THA) is planned after failed internal fixation for femoral neck fracture. METHODS We retrospectively included 340 patients who underwent conversion THA after internal fixation for femoral neck fracture from January 2008 to September 2020. Those patients constituted two groups: noninfected patients and patients diagnosed with FRI according to the 2013 International Consensus Meeting Criteria. Receiver operating characteristic (ROC) curves were used to determine maximum sensitivity and specificity of these two preoperative ratios. The diagnostic performance of the two ratios combined with preoperative CRP or ESR was also evaluated. RESULTS The numbers of patients with and without FRI were 19 (5.6%) and 321 (94.4%), respectively. Areas under the ROC curve for diagnosing FRI were 0.763 for MLR, 0.686 for NLR, 0.905 for CRP, and 0.769 for ESR. Based on the Youden index, the optimal predictive cutoffs were 0.25 for MLR and 2.38 for NLR. Sensitivity and specificity were 78.9% and 71.0% for MLR, and 78.9% and 56.4% for NLR, respectively. The combination of CRP with MLR showed a sensitivity of 84.2% and specificity of 94.6%, while the corresponding values for the combination of CRP with NLR were 89.5% and 91.5%, respectively. CONCLUSION The presence of preoperative FRI among patients undergoing conversion THA after internal fixation for femoral neck fracture should be determined. The combination of preoperative CRP with NLR is sensitive tool for screening FRI in those patients. Cite this article: Bone Joint J 2021;103-B(9):1534-1540.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Jin-Wei Xie
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Li Liu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Duan Wang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ze-Yu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zong-Ke Zhou
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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49
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Hipfl C, Carganico T, Leopold V, Perka C, Müller M, Hardt S. Two-Stage Revision Total Hip Arthroplasty Without Spacer Placement: A Viable Option to Manage Infection in Patients With Severe Bone Loss or Abductor Deficiency. J Arthroplasty 2021; 36:2575-2585. [PMID: 33750632 DOI: 10.1016/j.arth.2021.02.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/06/2021] [Accepted: 02/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND High rates of spacer-related complications in two-stage exchange total hip arthroplasty (THA) have been reported. Patients with advanced bone defects and abductor deficiency may benefit from a nonspacer two-stage revision. This study reports on the clinical course of a contemporary two-stage exchange for periprosthetic hip infection without spacer insertion. METHODS We reviewed 141 infected THAs with extensive bone loss or abductor damage who underwent two-stage exchange without spacer placement. The mean duration from resection arthroplasty to reimplantation was 9 weeks (2-29). Clinical outcomes included interim revision, reinfection, and aseptic revision rates. Restoration of leg-length and offset was assessed radiographically. Modified Harris hip scores were calculated. Mean follow-up was 5 years (3-7). Treatment success was defined using the modified Delphi consensus criteria. RESULTS Thirty-four patients (24%) had treatment failure, including 13 reinfections, 16 interim redebridements for persistent infection, 2 antibiotic suppressive therapies, and 3 prosthetic joint infection-related deaths. Aseptic rerevision after reimplantation was necessary in 14 patients (10%). Dislocation accounted for most aseptic complications, with 20 dislocations occurring in 15 patients (11%). Leg-length and offset were restored to preoperative measures. Mean modified Harris hip scores significantly improved from 35 points to 67 points. CONCLUSION A nonspacer two-stage exchange is a viable option for managing chronically infected THA with severe bone loss or abductor deficiency, showing comparable rates of interim revision and recurrence of infection. Cementless reimplantation demonstrates good midterm survivorship with comparable functional outcomes and leg-length restoration. However, dislocation continues to be a major concern.
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Affiliation(s)
- Christian Hipfl
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Teresa Carganico
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Vincent Leopold
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Carsten Perka
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Michael Müller
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Sebastian Hardt
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
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50
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Foster AL, Cutbush K, Ezure Y, Schuetz MA, Crawford R, Paterson DL. Cutibacterium acnes in shoulder surgery: a scoping review of strategies for prevention, diagnosis, and treatment. J Shoulder Elbow Surg 2021; 30:1410-1422. [PMID: 33373684 DOI: 10.1016/j.jse.2020.11.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/02/2020] [Accepted: 11/08/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cutibacterium acnes is a commensal, gram-positive, facultatively anaerobic bacillus that resides in the dermis. Historically thought to be a contaminant when identified on cultured specimens, recent advances in diagnostic technology have now implicated it as the most common organism responsible for postoperative shoulder infections. Despite a recognition of the role of this organism and a significant research interest in recent years, there is clear lack of consensus guideline on strategies to prevent, diagnose, and treat postoperative shoulder infection. METHOD The electronic databases PubMed, MEDLINE, CINAHL, Scopus, and Web of Science were searched in March 2020. All experimental and nonexperimental studies that investigate C acnes in shoulder surgery were included. Inclusion was limited to articles published after 2000 and written in English; reviews, gray literature, or abstracts were excluded. A total of 70 studies were included in this review. This scoping review was performed in accordance with the Extended Preferred Reporting Items of Systematic Reviews and Meta-Analyses Statement for Scoping Reviews (PRISMA-ScR). RESULTS Standard surgical prophylactic regimens such as intravenous antibiotics and topical chlorhexidine are ineffective at removing C acnes from the deep layer of the dermis, and there is a shift toward using topical benzoyl peroxide with significantly improved efficacy. An improved understanding of the bacteria has demonstrated that a prolonged culture time of up to 14 days is needed, especially in cases of established infection. Advances in diagnostics such as sonication and molecular-based testing are promising. Although usually thought to be susceptible to a broad range of antibiotics, resistance is emerging to clindamycin. An improved understanding of its ability to form a biofilm highlights the difficulty in treating an established infection. CONCLUSION The role of C acnes causing postoperative infection following shoulder surgery is being increasingly recognized. Strategies for prevention, diagnosis, and treatment have been outlined from both an antimicrobial and surgical perspective. A number of these strategies are emerging and require further research to demonstrate efficacy before implementation into clinical guidelines.
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Affiliation(s)
- Andrew L Foster
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Department of Surgery, School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Kenneth Cutbush
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Department of Surgery, School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Yukiko Ezure
- University of Queensland Centre for Clinical Research, RBWH Campus, Brisbane, QLD, Australia
| | - Michael A Schuetz
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Ross Crawford
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, RBWH Campus, Brisbane, QLD, Australia.
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