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Li C, Margaryan D, Perka C, Trampuz A. The role of biopsy in diagnosing infection after hip and knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 2023; 143:1779-1792. [PMID: 35061082 PMCID: PMC10030426 DOI: 10.1007/s00402-021-04323-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 12/14/2021] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Early diagnosis of periprosthetic hip and knee infection still represents a major challenge, as no single test can achieve ideal results. Currently, multiple preoperative indicators were performed to diagnose periprosthetic joint infection (PJI) to confirm or exclude infection in the early stage. However, the diagnostic value of biopsy-related tests in diagnosing periprosthetic hip and knee infection remains unclear. MATERIALS AND METHODS Publications in PubMed, Embase, and the Web of Science databases were searched systematically until October 2020. Inclusion and exclusion criteria were used for screening biopsy-related studies of the diagnosis of periprosthetic hip and knee infection. RESULTS Three biopsy-related tests were identified in 14 articles and further analyzed in the present meta-analysis. The combined method had the highest value for the area under the curve (0.9805), followed by histology (0.9425) and microbiological tests (0.9292). In the subgroup, statistical differences were identified in sensitivity and specificity for PJI diagnosis between the synovial fluid culture and biopsy culture group, as well as in the biopsy-related combined method and serum C-reactive protein. CONCLUSIONS Biopsy culture does not appear to be advantageous compared to synovial fluid culture in the preoperative diagnosis of periprosthetic hip and knee infection. In contrast, combined biopsy microbial culture with histology analysis shows great potential in improving the preoperative diagnosis of PJI. The standard procedure of biopsy needs to be further explored. Further research is required to verify our results.
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Affiliation(s)
- Cheng Li
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, People's Republic of China.
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany.
| | - Donara Margaryan
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Carsten Perka
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
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Tang H, Xu J, Yuan W, Wang Y, Yue B, Qu X. Reliable Diagnostic Tests and Thresholds for Preoperative Diagnosis of Non-Inflammatory Arthritis Periprosthetic Joint Infection: A Meta-analysis and Systematic Review. Orthop Surg 2022; 14:2822-2836. [PMID: 36181336 PMCID: PMC9627080 DOI: 10.1111/os.13500] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 02/06/2023] Open
Abstract
Objective The current diagnostic criteria for periprosthetic joint infection (PJI) are diverse and controversial, leading to delayed diagnosis. This study aimed to evaluate and unify their diagnostic accuracy and the threshold selection of serum and synovial routine tests for PJI at an early stage. Methods We searched the MEDLINE and Embase databases for retrospective or prospective studies which reported preoperative‐available assays (serum, synovial, or culture tests) for the diagnosis of chronic PJI among inflammatory arthritis (IA) or non‐IA populations from January 1, 2000 to June 30, 2022. Threshold effective analysis was performed on synovial polymorphonuclear neutrophils (PMN%), synovial white blood cell (WBC), serum C‐reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to find the relevant cut‐offs. Results Two hundred and sixteen studies and information from 45,316 individuals were included in the final analysis. Synovial laboratory‐based α‐defensin and calprotectin had the best comprehensive sensitivity (0.91 [0.86–0.94], 0.95 [0.88–0.98]) and specificity (0.96 [0.94‐0.97], 0.95 [0.89–0.98]) values. According to the threshold effect analysis, the recommended cut‐offs are 70% (sensitivity 0.89 [0.85–0.92], specificity 0.90 [0.87–0.93]), 4100/μL (sensitivity 0.90 [0.87–0.93], specificity 0.97 [0.93–0.98]), 13.5 mg/L (sensitivity 0.84 [0.78–0.89], specificity 0.83 [0.73–0.89]), and 30 mm/h (sensitivity 0.79 [0.74–0.83], specificity 0.78 [0.72–0.83]) for synovial PMN%, synovial WBC, serum CRP, and ESR, respectively, and tests seem to be more reliable among non‐IA patients. Conclusions The laboratory‐based synovial α‐defensin and synovial calprotectin are the two best independent preoperative diagnostic tests for PJI. A cut off of 70% for synovial PMN% and tighter cut‐offs for synovial WBC and serum CRP could have a better diagnostic accuracy for non‐IA patients with chronic PJI.
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Affiliation(s)
- Haozheng Tang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jialian Xu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei'en Yuan
- Ministry of Education Engineering Research Center of Cell & Therapeutic Antibody, School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - You Wang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Yue
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Abdelbary H, Cheng W, Ahmadzai N, Carli AV, Shea BJ, Hutton B, Fergusson DA, Beaulé PE. Combination Tests in the Diagnosis of Chronic Periprosthetic Joint Infection: Systematic Review and Development of a Stepwise Clinical Decision-Making Tool. J Bone Joint Surg Am 2020; 102:114-124. [PMID: 32870618 DOI: 10.2106/jbjs.20.00097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Our objective was to identify combination tests used to diagnose chronic periprosthetic joint infection (PJI) and develop a stepwise decision-making tool to facilitate diagnosis. METHODS We conducted a systematic review of existing combinations of serum, synovial, and tissue-based tests for diagnosing chronic PJI after hip or knee replacement. This work is an extension of our systematic review of single tests, from which we chose eligible studies that also described the diagnostic performance of combination tests. RESULTS Thirty-seven eligible articles described the performance of 56 combination tests, of which 8 combinations had at least 2 studies informing both sensitivity and specificity. We also identified 5 types of combination tests: (1) a type-I Boolean combination, which uses Boolean logic (AND, OR) and usually increases specificity at the cost of sensitivity; (2) a type-II Boolean combination, which usually increases sensitivity at the cost of specificity; (3) a triage-conditional rule, in which the value of 1 test serves to triage the use of another test; (4) an arithmetic operation on the values of 2 tests; and (5) a model-based prediction rule based on a fitted model applied to biomarker values. CONCLUSIONS Clinicians can initiate their diagnostic process with a type-II Boolean combination of serum C-reactive protein (CRP) and interleukin-6 (IL-6). False negatives of the combination can be minimized when the threshold is chosen to reach 90% to 95% sensitivity for each test. Once a joint infection is suspected on the basis of serum testing, joint aspiration should be performed. If joint aspiration yields a wet tap, a leukocyte esterase (LER) strip is highly recommended for point-of-care testing, with a reading of ++ or greater indicating PJI; a reading below ++ should be followed by one of the laboratory-based synovial tests. If joint aspiration yields a dry tap, clinicians should rely on preoperative tissue culture and histological analysis for diagnosis. Combinations based on triage-conditional, arithmetic, and model-based prediction rules require further research. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hesham Abdelbary
- Division of Orthopaedic Surgery (H.A. and P.E.B.) and School of Epidemiology and Public Health (B.J.S. and B.H.), University of Ottawa, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nadera Ahmadzai
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Beverley J Shea
- Division of Orthopaedic Surgery (H.A. and P.E.B.) and School of Epidemiology and Public Health (B.J.S. and B.H.), University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Brian Hutton
- Division of Orthopaedic Surgery (H.A. and P.E.B.) and School of Epidemiology and Public Health (B.J.S. and B.H.), University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery (H.A. and P.E.B.) and School of Epidemiology and Public Health (B.J.S. and B.H.), University of Ottawa, Ottawa, Ontario, Canada
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Enz A, Becker J, Warnke P, Prall F, Lutter C, Mittelmeier W, Klinder A. Increased Diagnostic Certainty of Periprosthetic Joint Infections by Combining Microbiological Results with Histopathological Samples Gained via a Minimally Invasive Punching Technique. J Clin Med 2020; 9:jcm9103364. [PMID: 33092199 PMCID: PMC7594052 DOI: 10.3390/jcm9103364] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 12/14/2022] Open
Abstract
Background: The diagnosis of low-grade infections of endoprostheses is challenging. There are still no unified guidelines for standardised diagnostic approaches, recommendations are categorised into major and minor criteria. Additional histopathological samples might sustain the diagnosis. However, ambulatory preoperative biopsy collection is not widespread. Method: 102 patients with hip or knee endoprosthesis and suspected periprosthetic joint infection (PJI) were examined by arthrocentesis with microbiological sample and histopathological punch biopsy. The data were retrospectively analysed for diagnosis concordance. Results: Preoperative microbiology compared to intraoperative results was positive in 51.9% (sensitivity 51.9%, specificity 97.3%). In comparison of preoperative biopsy to intraoperative diagnostic results 51.9% cases were positive (sensitivity 51.9%, specificity 100.0%). The combination of preoperative biopsy and microbiology in comparison to intraoperative results was positive in 70.4% of the cases (sensitivity 70.4%, specificity 97.3%). Conclusion: The diagnosis of PJI is complex. One single method to reliably detect an infection is currently not available. With the present method histopathological samples might be obtained quickly, easily and safely for the preoperative detection of PJI. A combination of microbiological and histopathological sampling increases the sensitivity up to 18.5% to detect periprosthetic infection.
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Affiliation(s)
- Andreas Enz
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057 Rostock, Germany; (J.B.); (C.L.); (W.M.); (A.K.)
- Correspondence: ; Tel.: +49-381-494-9315
| | - Johanna Becker
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057 Rostock, Germany; (J.B.); (C.L.); (W.M.); (A.K.)
| | - Philipp Warnke
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsmedizin Rostock, Schillingallee 70, 18057 Rostock, Germany;
| | - Friedrich Prall
- Institut für Pathologie, Universitätsmedizin Rostock, Strempelstraße 14, 18057 Rostock, Germany;
| | - Christoph Lutter
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057 Rostock, Germany; (J.B.); (C.L.); (W.M.); (A.K.)
| | - Wolfram Mittelmeier
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057 Rostock, Germany; (J.B.); (C.L.); (W.M.); (A.K.)
| | - Annett Klinder
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057 Rostock, Germany; (J.B.); (C.L.); (W.M.); (A.K.)
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Davis CM, Hakim M, Choi DD, Behrman DA, Israel H, McCain JP. Early Clinical Outcomes of Arthroscopic Management of the Failing Alloplastic Temporomandibular Joint Prosthesis. J Oral Maxillofac Surg 2020; 78:903-907. [DOI: 10.1016/j.joms.2020.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
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Abstract
The Diagnosis and Prevention of Periprosthetic Joint Infections Clinical Practice Guideline is based on a systematic review of current scientific and clinical research. Through analysis of the current best evidence, this guideline seeks to evaluate strategies to mitigate the risk of periprosthetic joint infection (PJI) in hip and knee arthroplasty and identify best practices in the diagnostic evaluation for these infections. Twenty-five recommendations related to prevention and diagnosis of PJI are presented. In addition, the work group highlighted areas for needed additional research when evidence proved lacking on the topic and carefully reviewed the rationale behind the recommendations while also noting potential harms or risks associated with implementation.
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Twenty common errors in the diagnosis and treatment of periprosthetic joint infection. INTERNATIONAL ORTHOPAEDICS 2019; 44:3-14. [PMID: 31641803 PMCID: PMC6938795 DOI: 10.1007/s00264-019-04426-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/23/2019] [Indexed: 12/23/2022]
Abstract
Background Misconceptions and errors in the management of periprosthetic joint infection (PJI) can compromise the treatment success. The goal of this paper is to systematically describe twenty common mistakes in the diagnosis and management of PJI, to help surgeons avoid these pitfalls. Materials and methods Common diagnostic and treatment errors are described, analyzed and interpreted. Results Diagnostic errors include the use of serum inflammatory biomarkers (such as C-reactive protein) to rule out PJI, incomplete evaluation of joint aspirate, and suboptimal microbiological procedures (such as using swabs or collection of insufficient number of periprosthetic samples). Further errors are missing possible sources of distant infection in hematogenous PJI or overreliance on suboptimal diagnostic criteria which can hinder or delay the diagnosis of PJI or mislabel infections as aseptic failure. Insufficient surgical treatment or inadequate antibiotic treatment are further reasons for treatment failure and emergence of antimicrobial resistance. Finally, wrong surgical indication, both underdebridement and overdebridement or failure to individualize treatment can jeopardize surgical results. Conclusion Multidisciplinary teamwork with infectious disease specialists and microbiologists in collaboration with orthopedic surgeons have a synergistic effect on the management of PJI. An awareness of the possible pitfalls can improve diagnosis and treatment results.
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Carli AV, Abdelbary H, Ahmadzai N, Cheng W, Shea B, Hutton B, Sniderman J, Philip Sanders BS, Esmaeilisaraji L, Skidmore B, Gauthier-Kwan OY, Bunting AC, Gauthier P, Crnic A, Logishetty K, Moher D, Fergusson D, Beaulé PE. Diagnostic Accuracy of Serum, Synovial, and Tissue Testing for Chronic Periprosthetic Joint Infection After Hip and Knee Replacements: A Systematic Review. J Bone Joint Surg Am 2019; 101:635-649. [PMID: 30946198 DOI: 10.2106/jbjs.18.00632] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint replacement. Patients with chronic PJI report a substantially lower quality of life and face a higher risk of short-term mortality. Establishing a diagnosis of chronic PJI is challenging because of conflicting guidelines, numerous tests, and limited evidence. Delays in diagnosing PJI are associated with poorer outcomes and morbid revision surgery. The purpose of this systematic review was to compare the diagnostic accuracy of serum, synovial, and tissue-based tests for chronic PJI. METHODS This review adheres to the Cochrane Collaboration's diagnostic test accuracy methods for evidence searching and syntheses. A detailed search of MEDLINE, Embase, the Cochrane Library, and the grey literature was performed to identify studies involving the diagnosis of chronic PJI in patients with hip or knee replacement. Eligible studies were assessed for quality and bias using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Meta-analyses were performed on tests with sufficient data points. Summary estimates and hierarchical summary receiver operating characteristic (HSROC) curves were obtained using a bivariate model. RESULTS A total of 12,616 citations were identified, and 203 studies met the inclusion criteria. Of these 203 studies, 170 had a high risk of bias. Eighty-three unique PJI diagnostic tests were identified, and 17 underwent meta-analyses. Laboratory-based synovial alpha-defensin tests and leukocyte esterase reagent (LER) strips (2+) had the best performance, followed by white blood-cell (WBC) count, measurement of synovial C-reactive protein (CRP) level, measurement of the polymorphonuclear neutrophil percentage (PMN%), and the alpha-defensin lateral flow test kit (Youden index ranging from 0.78 to 0.94). Tissue-based tests and 3 serum tests (measurement of interleukin-6 [IL-6] level, CRP level, and erythrocyte sedimentation rate [ESR]) had a Youden index between 0.61 to 0.75 but exhibited poorer performance compared with the synovial tests mentioned above. CONCLUSIONS The quality of the literature pertaining to chronic PJI diagnostic tests is heterogeneous, and the studies are at a high risk for bias. We believe that greater transparency and more complete reporting in studies of diagnostic test results should be mandated by peer-reviewed journals. The available literature suggests that several synovial fluid-based tests perform well for diagnosing chronic PJI and their use is recommended in the work-up of any suspected case of chronic PJI. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alberto V Carli
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Nadera Ahmadzai
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Beverley Shea
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jhase Sniderman
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Leila Esmaeilisaraji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Becky Skidmore
- Independent Information Specialist, Ottawa, Ontario, Canada
| | | | | | - Paul Gauthier
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Agnes Crnic
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Abstract
The most frequent indications for arthroscopy in patients with total knee arthroplasty (TKA) are soft-tissue impingement, arthrofibrosis (knee stiffness), periprosthetic infection and removal of free bodies or cement fragments. When performing a knee arthroscopy in a patient with a symptomatic TKA, look for possible free/retained bone or cement fragments, which can be anywhere in the joint. Patellar tracking should be evaluated and soft-tissue impingement under the patella or between the femoral and tibial prosthetic components should be ruled out. Current data suggest that knee arthroscopy is an effective procedure for the treatment of some patients with symptomatic TKA. The approximate rates of therapeutic success vary according to the problem in question: 85% in soft-tissue impingement; 90% in arthrofibrosis; and 55% in periprosthetic infections. More clinical studies are needed to determine which patients with symptomatic TKA can be the best candidates for knee arthroscopy.
Cite this article: EFORT Open Rev 2019;4:33-43. DOI: 10.1302/2058-5241.4.180035.
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Bauer TW, Bedair H, Creech JD, Deirmengian C, Eriksson H, Fillingham Y, Grigoryan G, Hickok N, Krenn V, Krenn V, Lazarinis S, Lidgren L, Lonner J, Odum S, Shah J, Shahi A, Shohat N, Tarabichi M, W-Dahl A, Wongworawat MD. Hip and Knee Section, Diagnosis, Laboratory Tests: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S351-S359. [PMID: 30343973 DOI: 10.1016/j.arth.2018.09.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Li ZL, Hou YF, Zhang BQ, Chen YF, Wang Q, Wang K, Chen ZY, Li XW, Lin JH. Identifying Common Pathogens in Periprosthetic Joint Infection and Testing Drug-resistance Rate for Different Antibiotics: A Prospective, Single Center Study in Beijing. Orthop Surg 2018; 10:235-240. [PMID: 30152610 DOI: 10.1111/os.12394] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 01/05/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The aim of this study is to identify the common microorganisms causing PJI as well as the drug-resistant spectrum for each microorganism, to help orthopaedic surgeons to choose appropriate antibiotics. METHOD One hundred and sixty patients who suffered from failure of primary or revision total hip or knee arthroplasty for different reasons were prospectively recruited. These patients underwent revision or re-revision total hip or knee arthroplasty in our institution between August 2013 to August 2016. The details of patients' medical history and comprehensive physical examination, as well as demographic data were recorded precisely. Routine blood test results, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), high sensitive C-reactive protein (hs-CRP), interleukin-6 (IL-6) levels, and synovial leukocyte counts were collected. Additionally, aspiration was conducted during surgery to avoid pollution unless when PJI was strongly suspected, in which case, joint puncture and aspiration were conducted before surgery. Intraoperatively, the implant-surrounding tissue and the prosthesis were collected under aseptic conditions. Postoperatively, the prosthesis, implant-surrounding tissue and synovium were sent to the laboratory immediately. The sonicate extraction (the prosthesis was sent for ultrasound sonication first), implant surrounding tissue and synovium were sent for microbiologic culture, and the implant-surrounding tissue was also sent for pathological examination. The isolated bacteria strains and drug-resistance rates for each pathogen for different antibiotics were presented. RESULTS There were 59 PJI cases in the infectious group and 101 cases in the non-infectious group (PJI is diagnosed according to the diagnosing criteria from the Workgroup of the Musculoskeletal Infection Society). Of 69 strains of pathogens isolated, Gram-positive bacterium is the most common pathogenic bacteria causing PJI (60, 86.96%). Staphylococcus epidermidis and Staphylococcus aureus played an important role as well, followed by Gram-negative bacteria (8, 11.59%) and fungus (1, 1.45%). Penicillin (78.57%), erythromycin (66.67%) and clindamycin (44.74%) showed high antibiotic resistance rate. In addition, the second-generation cephalosporin, usually as the prophylactic antibiotic, resistance rate was high (20%) as well. Fortunately, no vancomycin-resistant bacteria were discovered in the current study. CONCLUSION This study provides some information on the most common pathogens in our institution and the selection of antibiotics in the perioperative period in northern China. Cefuroxime and clindamycin might not be appropriate for use as prophylactic antibiotics in revision total knee or hip arthroplasty. Vancomycin is ideal for empiric antibiotic use in suspected PJI cases because of the low drug-resistance rate.
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Affiliation(s)
- Zhang-Lai Li
- Department of Orthopedics, Fuzhou Second Hospital of Xiamen University, Fuzhou, China.,Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Yun-Fei Hou
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Bao-Qing Zhang
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China.,Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, China
| | - Yi-Fan Chen
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Qi Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Kai Wang
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Zhao-Yu Chen
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Xiao-Wei Li
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Jian-Hao Lin
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
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Significant increase of pathogen detection rate by dry arthroscopic biopsies at suspected low-grade infection following total knee arthroplasty: a prospective observational study. Arch Orthop Trauma Surg 2018; 138:1583-1590. [PMID: 30182141 DOI: 10.1007/s00402-018-3032-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The differentiation between stiff-knee and low-grade periprosthetic joint infection (PJI) is the current diagnostic challenge in total knee (TKA) revision arthroplasty. The aim of this study was to investigate the additional value of dry biopsies, compared to wet biopsies, in patients presenting with knee stiffness following primary TKA. MATERIALS AND METHODS Single center, prospective observational study. Consecutive patients with joint stiffness of unknown origin following primary TKA were enrolled. Patient assessment followed the diagnostic standard algorithm. During diagnostic arthroscopy, synovial fluid (synovial WBC, PMN%) and five dry biopsies (dry) were collected. Then fluid was infused and another five microbiology (wet) and five histological biopsies gathered, all from identical locations. The primary outcome parameter was the difference between the pathogens in wet and dry biopsies. RESULTS 71 patients (61% females, 67 ± 10 years) were eligible. Preoperative blood serology mean CRP (0.7 ± 1.5 mg/dl; p = 0.852), WBC (6.6 ± 1.7 G/l; p = 0.056), and synovial fluid mean WBC (1639 ± 2111; p = 0.602), PMN% (38 ± 28; p = 0.738) did not differ between patients with negative, positive wet or dry biopsies. The histology was in 11% positive (p = 0.058). In 32% at least one pathogen was detected, 48% from wet, 44% from dry biopsies. An inhomogeneous distribution was found. Cutibacterium acnes (100%) was solely found in wet, Micrococcus luteus (75%), Staphylococcus capitis (67%), and Micrococcus lylae (100%) were predominantly found in dry biopsies. Additional dry biopsies increased the pathogen detection rate by 49%. CONCLUSION The addition of dry biopsies to the current standard diagnostic algorithm for PJI increased the pathogen detection rate by 49%.
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Akgün D, Müller M, Perka C, Winkler T. An often-unrecognized entity as cause of recurrent infection after successfully treated two-stage exchange arthroplasty: hematogenous infection. Arch Orthop Trauma Surg 2018; 138:1199-1206. [PMID: 29868943 DOI: 10.1007/s00402-018-2972-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Reinfection after two-stage exchange arthroplasty is a difficult clinical scenario with limited data on adequate treatment algorithms. Beside the possibility of treatment failure and a new intraoperative infection at the time of reimplantation, hematogenous seeding could play an up to date underestimated crucial role as another cause of an infection after two-stage exchange. The aim of this study was to evaluate its incidence and treatment possibilities in a prospectively followed case series. METHODS All consecutive hip and knee periprosthetic joint infection cases (93 hips and 89 knees) treated according to a standardized diagnostic and therapeutic algorithm at our institution with a two-stage exchange arthroplasty from 2013 to 2015 were included and followed prospectively to identify recurrent infections due to hematogenous seeding. RESULTS Six percent from our septic revision hip and knee arthroplasties (11 of 182, including 5 hips and 6 knees) were identified with a hematogenous reinfection after a mean follow-up of 31.8 months (range 14-48 months). The mean time to reinfection after reimplantation was 12.2 months (range 3.1-35.1). In all but two cases was the causative microorganism different than isolated at the time of initial two-stage exchange. In 5 of 11 patients, the primary focus of infection was identified. CONCLUSION Hematogenous infection after a successful two-stage exchange arthroplasty is a rare but very important cause of a reinfection. With our work, we aim at raising the awareness for this entity and recommend consideration of irrigation and debridement with implant retention in these cases, as well as possibly the identification of a primary infection source.
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Affiliation(s)
- Doruk Akgün
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, Berlin, 13353, Germany.
| | - Michael Müller
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Tobias Winkler
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, Berlin, 13353, Germany
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Claassen L, Wirries N, Ettinger S, Pastor MF, Windhagen H, Flörkemeier T. Diagnosing periprosthetic hip joint low-grade infection via arthroscopic neo synovium biopsies. Technol Health Care 2018; 26:973-982. [PMID: 29991149 DOI: 10.3233/thc-181265] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is currently a lack of consensus regarding the most effective diagnostic algorithm for cases of supposed low-grade infection after total hip arthoplasty (THA). OBJECTIVE The aim of this study was to assess reliability in the use of biopsies, obtained by hip arthroscopy, to detect a periprosthetic hip joint infection (PJI). METHODS From 2012 to 2016, diagnostic arthroscopy of the hip joint was performed in 20 patients with a supposed PJI following THA. In 10 of these patients, the THA was revised for various reasons after diagnostic arthroscopy. The microbiological and histological findings of the biopsies obtained by arthroscopy were compared to findings from intraoperative samples of the revision arthroplasty. RESULTS For arthroscopic biopsies, we detected a sensitivity of 1.00 (95% confidence interval [CI] 0.40-1.00), a specificity of 0.83 (95% CI 0.36-1.00), a positive predictive value of 0.80 (95% CI 0.28-1.00), and a negative predictive value of 1.00 (95% CI 0.48-1.00). The accuracy was 0.90. CONCLUSIONS The analysis of arthroscopic biopsies represents a helpful tool to verify or rule out a PJI in selected patients. Nevertheless, minimally invasive diagnostic tools (e.g., laboratory analysis and aspiration) should be utilized beforehand.
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Ottink KD, Wouthuyzen-Bakker M, Kampinga GA, Jutte PC, Ploegmakers JJ. Puncture Protocol in the Diagnostic Work-Up of a Suspected Chronic Prosthetic Joint Infection of the Hip. J Arthroplasty 2018. [PMID: 29530521 DOI: 10.1016/j.arth.2018.01.072] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Diagnosing a chronic prosthetic joint infection (PJI) can be challenging. We hypothesized that obtaining preoperative tissue samples for culture in hip arthroplasty will increase the likelihood of diagnosing an infection before revision surgery. The aim of this cohort study was to determine the diagnostic accuracy of 2 tissue acquiring biopsy strategies to diagnose a PJI. METHODS Patients with a painful hip arthroplasty, in which a chronic PJI was suspected, were included. Tissue samples were obtained either by ultrasound guidance with a 16-Gauge needle (2012-2013) or in the operating room with a thick-bore needle (2013-2016). Revision surgery tissue biopsies were used as the gold standard. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were calculated. RESULTS A total of 16 patients in the ultrasound cohort and 29 patients in the surgical cohort were included. Thirty-one percent (n = 14) were finally diagnosed with a PJI. The addition of thick bore needle tissue biopsies resulted in 9% more diagnosed PJIs compared with synovial fluid alone. The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio was 33%, 85%, 33%, 85%, 2.2, and 0.8, respectively, for the ultrasound-guided biopsy cohort and 82%, 100%, 100%, 90%, infinite, and 0.2, respectively, for the surgical biopsy cohort. CONCLUSION Obtaining multiple good quality tissue biopsies in a sterile environment will contribute to the diagnosis of a chronic PJI of the hip, with a higher diagnostic accuracy compared with ultrasound-guided thin needle biopsies and compared with synovial fluid culture alone.
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Affiliation(s)
- Karsten D Ottink
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Greetje A Kampinga
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Joris J Ploegmakers
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
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