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Röhrl A, Klawonn F, Füchtmeier B, Wulbrand C, Gessner A, Zustin J, Ambrosch A. Results of a monocentric field study: value of histology compared to sonication method and conventional tissue culture in the diagnosis of periprosthetic joint infection (PJI). Infection 2024:10.1007/s15010-024-02278-x. [PMID: 38730201 DOI: 10.1007/s15010-024-02278-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/21/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND To confirm the diagnosis of periprosthetic joint infection (PJI), the Infectious Diseases Society of America (IDSA) and the International Consensus Meeting (ICM) have defined criteria that include histology as a minor criterion and the sonication method only as an additional criterion. The aim of this monocentric, retrospective study was to investigate the value of histology and whether sonication leads to a more accurate diagnosis. MATERIALS AND METHODS All revision surgeries for knee and hip arthroplasty between 2017 and 2020 were included. With regard to microbiological diagnostic, conventional culture of periprosthetic biopsies and sonication of explant material were performed. In addition, histology and non-specific inflammatory markers (CRP, leukocytes) were recorded. RESULTS A total of 78 patients with PJI and 62 aseptic controls were included. From both microbiological methods (conventional culture / sonication), Staphyloccus (S.) epidermidis and S. aureus were detected most frequently. However, compared to the conventional microbiology, a higher sensitivity was calculated for sonication, albeit with a lower specificity in relation to a PJI. In two logistic regression models for the significance of all diagnostic parameters in PJI, the AUC was 0.92 and 0.96 with histology in particular making the decisive contribution in both models (p < 0. 001, both models). CONCLUSION Since histology showed the highest accuracy in the current study, its importance in the PJI criteria should be reevaluated. Sonication shows a high sensitivity for germ detection with a lower specificity and should only be used in combination with the conventional culture for microbiolgical diagnostics.
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Affiliation(s)
- Alexander Röhrl
- Department of Trauma Surgery, Orthopaedics & Sports Medicine, Hospital of Brothers of Mercy, Regensburg, Germany
| | - Frank Klawonn
- Biostatistics, Helmholtz Centre for Infection Research, Brunswick, Germany
- Institute for Information Engineering, Ostfalia University, Wolfenbüttel, Germany
| | - Bernd Füchtmeier
- Department of Trauma Surgery, Orthopaedics & Sports Medicine, Hospital of Brothers of Mercy, Regensburg, Germany
| | - Christian Wulbrand
- Department of Trauma Surgery, Orthopaedics & Sports Medicine, Hospital of Brothers of Mercy, Regensburg, Germany
| | - Andre Gessner
- Institute of Clinical Microbiology and Infection Prevention, University Hospital, Regensburg, Germany
| | - Jozef Zustin
- Private Histopathology Service, Regensburg, Germany
- Gerhard Domagk Institute of Pathology, University Medical Center, Münster, Germany
| | - Andreas Ambrosch
- Institute of Laboratory Medicine, Microbiology and Infection Prevention, Hospital of Brothers of Mercy, Prüfeninger Straße 86, 93049, Regensburg, Germany.
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Karlidag T, Dasci MF, Steinhoff J, Gehrke T, Citak M. What is the diagnostic accuracy of neutrophil to lymphocyte ratio and monocyte to lymphocyte ratio in detecting acute periprosthetic joint infections? A gender-specific analysis. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-05162-9. [PMID: 38147079 DOI: 10.1007/s00402-023-05162-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/26/2023] [Indexed: 12/27/2023]
Abstract
PURPOSE The accurate and timely diagnosis of periprosthetic joint infection (PJI) is critical for guiding optimal treatment management and success, highlighting the requirement of readily available inexpensive serum biomarkers to increase the diagnostic accuracy for PJI. Many studies have investigated the diagnostic accuracy of neutrophil to lymphocyte ratio (NLR) and monocyte to lymphocyte ratio (MLR). However, there is a lack of existing literature regarding optimal thresholds for acute PJI. The purpose of this study was to reveal the most appropriate cut-off values for MLR and NLR in detecting acute PJI with a gender specific analysis. METHODS Patients were classified as having an acute PJI if they met the International Consensus Meeting (ICM) 2018 modified criteria. Patients who had a negative clinical and diagnostic workup for a PJI and the presence of erythema on the index surgical area were included in the erysipelas group (control group). Data obtained from all patients included age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), procedure type (THA or TKA), serum C-reactive protein (CRP), and blood studies at the admission and culture results were retrieved from the electronic medical record. RESULTS ROC curve analysis was used to determine the gender-specific optimal threshold values for CRP, NLR, and MLR. Comparing the sensitivities and specificities of NLR and MLR at the identified best thresholds in males and females, the study found similar sensitivities of NLR in males and females with 0.84 and 0.84, respectively. On the other hand, an MLR of 0.67 or more reported a notably higher specificity in male patients [0.90 (95% CI 0.75-0.96) versus 0.70 (95% CI 0.56-0.80)]. CONCLUSION NLR and MLR represent commonly ordered, low-cost, simple, and readily available complete cell count laboratory values and should be used as adjunct tests with reasonable diagnostic accuracy in detecting acute PJIs. Moreover, with its excellent specificity and PPV, MLR could provide valuable insight in diagnosing acute PJI, particularly in male patients. LEVEL OF EVIDENCE Level III Retrospective Cohort analysis.
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Affiliation(s)
- Taner Karlidag
- Department of Orthopedics and Traumatology, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
- Department of Orthopedics and Traumatology, Gaziantep City Hospital, Gaziantep, Turkey
| | - Mustafa Fatih Dasci
- Department of Orthopedics and Traumatology, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Julian Steinhoff
- Department of Orthopedics and Traumatology, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopedics and Traumatology, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopedics and Traumatology, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany.
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Sigmund IK, Yeghiazaryan L, Luger M, Windhager R, Sulzbacher I, McNally MA. Three to six tissue specimens for histopathological analysis are most accurate for diagnosing periprosthetic joint infection. Bone Joint J 2023; 105-B:158-165. [PMID: 36722061 DOI: 10.1302/0301-620x.105b2.bjj-2022-0859.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIMS The aim of this study was to evaluate the optimal deep tissue specimen sample number for histopathological analysis in the diagnosis of periprosthetic joint infection (PJI). METHODS In this retrospective diagnostic study, patients undergoing revision surgery after total hip or knee arthroplasty (n = 119) between January 2015 and July 2018 were included. Multiple specimens of the periprosthetic membrane and pseudocapsule were obtained for histopathological analysis at revision arthroplasty. Based on the Infectious Diseases Society of America (IDSA) 2013 criteria, the International Consensus Meeting (ICM) 2018 criteria, and the European Bone and Joint Infection Society (EBJIS) 2021 criteria, PJI was defined. Using a mixed effects logistic regression model, the sensitivity and specificity of the histological diagnosis were calculated. The optimal number of periprosthetic tissue specimens for histopathological analysis was determined by applying the Youden index. RESULTS Based on the EBJIS criteria (excluding histology), 46 (39%) patients were classified as infected. Four to six specimens showed the highest Youden index (four specimens: 0.631; five: 0.634; six: 0.632). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of five tissue specimens were 76.5% (95% confidence interval (CI) 67.6 to 81.4), 86.8% (95% CI 81.3 to 93.5), 66.0% (95% CI 53.2 to 78.7), and 84.3% (95% CI 79.4 to 89.3), respectively. The area under the curve (AUC) was calculated with 0.81 (as a function of the number of tissue specimens). Applying the ICM and IDSA criteria (excluding histology), 40 (34%) and 32 (27%) patients were categorized as septic. Three to five specimens had the highest Youden index (ICM 3: 0.648; 4: 0.651; 5: 0.649) (IDSA 3: 0.627; 4: 0.629; 5: 0.625). CONCLUSION Three to six tissue specimens of the periprosthetic membrane and pseudocapsule should be collected at revision arthroplasty and analyzed by a pathologist experienced and skilled in interpreting periprosthetic tissue.Cite this article: Bone Joint J 2023;105-B(2):158-165.
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Affiliation(s)
- Irene K Sigmund
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Lusine Yeghiazaryan
- Medical University of Vienna, Centre for Medical Statistics, Informatics and Intelligent Systems, Institute of Medical Statistics, Vienna, Austria
| | - Markus Luger
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Irene Sulzbacher
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
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Lucero CM, García-Mansilla A, Albani Forneris A, Díaz Dilernia F, Slullitel P, Zanotti G, Comba F, Piccaluga F, Buttaro M. Secuenciación de próxima generación para la detección de patógenos en cirugía de cadera: experiencia y viabilidad diagnóstica en un centro de atención terciaria de la Argentina. REVISTA DE LA ASOCIACIÓN ARGENTINA DE ORTOPEDIA Y TRAUMATOLOGÍA 2022. [DOI: 10.15417/issn.1852-7434.2022.87.5.1571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Introducción: El diagnóstico rápido y definitivo con identificación del patógeno es fundamental cuando hay una infección periprotésica. La secuenciación de próxima generación permite identificar el ADN en un germen determinado en poco tiempo. Hasta donde sabemos, no hay reportes sobre su empleo para el manejo de la infección periprotésica en Sudamérica. Nuestro objetivo fue demostrar la viabilidad diagnóstica de las muestras obtenidas de una serie de pacientes operados en Buenos Aires, Argentina, y analizadas con la técnica de secuenciación de próxima generación.
Materiales y Métodos: Se analizó a una serie prospectiva de 20 pacientes sometidos a cirugía de revisión séptica y aséptica de cadera desde diciembre de 2019 hasta marzo de 2020. Se obtuvieron muestras intraoperatorias de líquido sinovial, tejido profundo y canal endomedular, que fueron enviadas para su análisis al laboratorio NexGen Microgen.
Resultados: Se seleccionaron 17 pacientes, porque tenían una muestra apta para analizar. Los resultados se recibieron dentro de las 72 h de la cirugía. En un caso, el resultado de la secuenciación de próxima generación informó un germen distinto del identificado en los cultivos posoperatorios de partes blandas, esto permitió corregir la antibioticoterapia. En otro, esta técnica identificó Parabacteroides gordonii en una revisión aséptica, en otro, Morganella morganii, a partir de cultivos negativos en una revisión en un tiempo.
Conclusión: Se demostró la viabilidad diagnóstica con la secuenciación de próxima generación, se pueden obtener resultados de microorganismos patógenos dentro de las 72 h posteriores a la cirugía en pacientes con infección periprotésica y cultivos negativos.
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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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Sigmund IK, Luger M, Windhager R, McNally MA. Diagnosing periprosthetic joint infections : a comparison of infection definitions: EBJIS 2021, ICM 2018, and IDSA 2013. Bone Joint Res 2022; 11:608-618. [PMID: 36047011 PMCID: PMC9533249 DOI: 10.1302/2046-3758.119.bjr-2022-0078.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS This study evaluated the definitions developed by the European Bone and Joint Infection Society (EBJIS) 2021, the International Consensus Meeting (ICM) 2018, and the Infectious Diseases Society of America (IDSA) 2013, for the diagnosis of periprosthetic joint infection (PJI). METHODS In this single-centre, retrospective analysis of prospectively collected data, patients with an indicated revision surgery after a total hip or knee arthroplasty were included between 2015 and 2020. A standardized diagnostic workup was performed, identifying the components of the EBJIS, ICM, and IDSA criteria in each patient. RESULTS Of 206 included patients, 101 (49%) were diagnosed with PJI with the EBJIS definition. IDSA and ICM diagnosed 99 (48%) and 86 (42%) as infected, respectively. A total of 84 cases (41%) had an infection based on all three criteria. In 15 cases (n = 15/206; 7%), PJI was present when applying only the IDSA and EBJIS criteria. No infection was detected by one definition alone. Inconclusive diagnoses occurred more frequently with the ICM criteria (n = 30/206; 15%) compared to EBJIS (likely infections: n = 16/206; 8%) (p = 0.029). A better preoperative performance of the EBJIS definition was seen compared with the ICM and IDSA definitions (p < 0.001). CONCLUSION The novel EBJIS definition identified all PJIs diagnosed by any other criteria. Use of the EBJIS definition significantly reduced the number of uncertain diagnoses, allowing easier clinical decision-making.Cite this article: Bone Joint Res 2022;11(9):608-618.
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Affiliation(s)
- Irene K Sigmund
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Markus Luger
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
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Gazendam A, Wood TJ, Tushinski D, Bali K. Diagnosing Periprosthetic Joint Infection: a Scoping Review. Curr Rev Musculoskelet Med 2022; 15:219-229. [PMID: 35368214 DOI: 10.1007/s12178-022-09751-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to provide an up to date understanding of the utility and limitations of the current tests utilized in the diagnosis of periprosthetic joint infection (PJI) in total knee and hip arthroplasty. RECENT FINDINGS Despite the growth in literature surrounding PJI diagnosis, there remains challenges in establishing a diagnosis of PJI. A combination of clinical, serum, and synovial tests and microbiologic and histologic examinations can yield a diagnosis in the majority of cases. Novel molecular and imaging studies may be beneficial for indeterminant cases. A number of emerging diagnostic tests have been proposed and may be incorporated into diagnostic algorithms in the future. Recently proposed stepwise diagnostic algorithms have shown high sensitivity and specificity. The diagnosis of PJI remains challenging due to a lack of tests that can definitively rule out infection. Diagnosis and investigations should occur in a stepwise fashion. There has been a plethora of new diagnostic tests introduced in attempts to improve the accuracy of diagnostic algorithms. The definition and algorithms for the diagnoses of PJI will continue to evolve as new techniques and tests are introduced.
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Affiliation(s)
- Aaron Gazendam
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Thomas J Wood
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Tushinski
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kamal Bali
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada. .,Juravinski Hospital, 711 Concession St, Hamilton, Ontario, L8V 1C3, Canada.
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Luyckx L, Somers JFA, Cokelaere K, Deloose S, Delrue G, Hermans L. Intraoperative frozen section histopathology for the diagnosis of periprosthetic joint infection in hip revision surgery: the influence of recent dislocation and/or periprosthetic fracture. Hip Int 2022; 32:87-93. [PMID: 32538176 DOI: 10.1177/1120700020933993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIMS To evaluate the accuracy of intraoperative frozen section histopathology for diagnosing periprosthetic joint infection (PJI) during hip revision surgery, both for patients with and without recent trauma to the hip. PATIENTS AND METHODS The study included all revision total hip replacement procedures where intraoperative frozen section histopathology had been used for the evaluation of infection in a single institution between 2008 and 2015. Musculoskeletal Infection Society criteria were used to define infection. 210 hips were included for evaluation. Prior to revision surgery, 36 hips had a dislocation or a periprosthetic fracture (group A), and 174 did not (group B). RESULTS The prevalence of infection was 14.3% (5.6% in group A and 16.1% in group B). Using Feldman criteria, the sensitivity of histopathology was 50.0%, specificity 47.1%, positive predictive value 5.3% and negative predictive value 94.1% in group A. The sensitivity of frozen section histopathology was 75.0%, specificity 96.5%, positive predictive value 85% and negative predictive value 95.3% in group B. CONCLUSIONS Intraoperative frozen section histopathology is reliable for the diagnosis of PJI if no dislocation or periprosthetic fracture has occurred prior to hip revision surgery.
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Affiliation(s)
- Lucas Luyckx
- Department of Orthopaedic Surgery, AZ Jan Portaels, Vilvoorde, Belgium
| | - Jan F A Somers
- Department of Orthopaedic Surgery, Jan Yperman Hospital, Ypres, Belgium
| | | | - Stijn Deloose
- Department of Pathology, Jan Yperman Hospital, Ypres, Belgium
| | - Gaétan Delrue
- Department of Orthopaedic Surgery, Jan Yperman Hospital, Ypres, Belgium
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Sigmund IK, McNally MA, Luger M, Böhler C, Windhager R, Sulzbacher I. Diagnostic accuracy of neutrophil counts in histopathological tissue analysis in periprosthetic joint infection using the ICM, IDSA, and EBJIS criteria. Bone Joint Res 2021; 10:536-547. [PMID: 34409845 PMCID: PMC8414440 DOI: 10.1302/2046-3758.108.bjr-2021-0058.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Aims Histology is an established tool in diagnosing periprosthetic joint infections (PJIs). Different thresholds, using various infection definitions and histopathological criteria, have been described. This study determined the performance of different thresholds of polymorphonuclear neutrophils (≥ 5 PMN/HPF, ≥ 10 PMN/HPF, ≥ 23 PMN/10 HPF) , when using the European Bone and Joint Infection Society (EBJIS), Infectious Diseases Society of America (IDSA), and the International Consensus Meeting (ICM) 2018 criteria for PJI. Methods A total of 119 patients undergoing revision total hip (rTHA) or knee arthroplasty (rTKA) were included. Permanent histology sections of periprosthetic tissue were evaluated under high power (400× magnification) and neutrophils were counted per HPF. The mean neutrophil count in ten HPFs was calculated (PMN/HPF). Based on receiver operating characteristic (ROC) curve analysis and the z-test, thresholds were compared. Results Using the EBJIS criteria, a cut-off of ≥ five PMN/HPF showed a sensitivity of 93% (95% confidence interval (CI) 81 to 98) and specificity of 84% (95% CI 74 to 91). The optimal threshold when applying the IDSA and ICM criteria was ≥ ten PMN/HPF with sensitivities of 94% (95% CI 79 to 99) and 90% (95% CI 76 to 97), and specificities of 86% (95% CI 77 to 92) and 92% (95% CI 84 to 97), respectively. In rTKA, a better performance of histopathological analysis was observed in comparison with rTHA when using the IDSA criteria (p < 0.001). Conclusion With high accuracy, histopathological analysis can be supported as a confirmatory criterion in diagnosing periprosthetic joint infections. A threshold of ≥ five PMN/HPF can be recommended to distinguish between septic and aseptic loosening, with an increased possibility of detecting more infections caused by low-virulence organisms. However, neutrophil counts between one and five should be considered suggestive of infection and interpreted carefully in conjunction with other diagnostic test methods. Cite this article: Bone Joint Res 2021;10(8):536–547.
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Affiliation(s)
- Irene K Sigmund
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Markus Luger
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Böhler
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Irene Sulzbacher
- Department of Pathology, Medical University of Vienna, Vienna, Austria
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Praz C, Gubbiotti L, Buia G, Chapus V, Dunet J, Grandhomme F, Michon J, Rochcongar G, Hulet C. Value of the synovial C-reactive protein test in the diagnosis of total hip and knee periprosthetic joint infections: A case-control study. Orthop Traumatol Surg Res 2021; 107:102903. [PMID: 33775885 DOI: 10.1016/j.otsr.2021.102903] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/20/2020] [Accepted: 10/27/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The diagnosis of periprosthetic joint infection (PJI) can be challenging and rests on several principles. The use of diagnostic biomarkers, such as the synovial C-Reactive Protein (CRP), seems promising. The purpose of this study was to determine whether synovial CRP was a more discriminating test than serum CRP for the diagnosis of hip and knee PJI. MATERIALS AND METHODS In total, 194 patients were included in this single center prospective study: 42 primary arthroplasties (control group [CG]), 111 revisions for aseptic prosthesis (aseptic revision group [ARG]), and 41 revisions for septic prosthesis (septic revision group [SRG]) based on the Musculoskeletal Infection Society (MSIS) criteria. RESULTS The serum and synovial CRP levels were significantly higher in the SRG than the other two groups (SRG serum CRP=75.6mg/L vs. ARG serum CRP=6mg/L and CG serum CRP=2.7mg/L, p<0.001; SRG synovial CRP=31.5mg/L vs. CG synovial CRP=2.6mg/L and ARG synovial CRP=1.7mg/L, p<0.001). The positive likelihood ratios (LR+) were very similar for both the synovial CRP cut-off value of 4.4mg/L (LR+=7.04; sensitivity [Se] 82.5%, specificity [Sp] 88.3%) and the serum CRP cut-off value of 9mg/L (LR+=6.3; Se 87.5%, Sp 86.1%). CONCLUSION This study showed that synovial CRP testing was not more discriminating than serum CRP in the diagnosis of hip and knee PJI. A serum CRP level greater than 9mg/L was a sign of PJI. LEVEL OF EVIDENCE III; case-control study.
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Affiliation(s)
- César Praz
- Unit Inserm COMETE, UMR U1075, département de chirurgie orthopédique et traumatologique, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France.
| | - Laura Gubbiotti
- Unit Inserm COMETE, UMR U1075, département de chirurgie orthopédique et traumatologique, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France
| | - Geoffrey Buia
- Unit Inserm COMETE, UMR U1075, département de chirurgie orthopédique et traumatologique, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France
| | - Valentin Chapus
- Unit Inserm COMETE, UMR U1075, département de chirurgie orthopédique et traumatologique, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France
| | - Julien Dunet
- Unit Inserm COMETE, UMR U1075, département de chirurgie orthopédique et traumatologique, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France
| | - Frederique Grandhomme
- Secteurs biochimie et hormonologie, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France
| | - Jocelyn Michon
- Unit Inserm COMETE, UMR U1075, département de chirurgie orthopédique et traumatologique, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France
| | - Goulven Rochcongar
- Unit Inserm COMETE, UMR U1075, département de chirurgie orthopédique et traumatologique, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France
| | - Christophe Hulet
- Unit Inserm COMETE, UMR U1075, département de chirurgie orthopédique et traumatologique, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France
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11
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Kelly ME, Bahethi SR, King ME, Elstner BC, Turcotte JJ, King PJ. The Utility of Frozen Section Histology in Diagnosing Periprosthetic Joint Infection in Revision Total Joint Arthroplasty. J Arthroplasty 2021; 36:2137-2143. [PMID: 33579630 DOI: 10.1016/j.arth.2020.12.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/14/2020] [Accepted: 12/31/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Surgeons utilize a combination of preoperative tests and intraoperative findings to diagnose periprosthetic joint infection (PJI); however, there is currently no reliable diagnostic marker that can be used in isolation. The purpose of our study is to evaluate the utility of frozen section histology in diagnosis of PJI. METHODS Retrospective analysis of 614 patients undergoing revision total joint arthroplasty with frozen section histology from a single institution was performed. Discriminatory value of frozen section histology was assessed using univariate analysis and evaluation of area under the curve (AUC) of a receiver operating characteristic curve comparing frozen section histology results to the 2018 International Consensus Meeting (ICM) PJI criteria modified to exclude the histology component. RESULTS The sensitivity of the frozen section histology was 53.6% and the specificity was 95.2%. There was 99.2% concordance between the permanent section and frozen section results. The receiver operating characteristic curve for frozen section yielded an AUC of 0.744 (95% confidence interval 0.627-0.860) and the modified ICM score yielded an AUC of 0.912 (95% confidence interval 0.836-0.988) when compared to the full score. The addition of frozen section histology changed the decision to infected in 20% of "inconclusive" cases but less than 1% of total cases. CONCLUSION In comparison to the modified ICM criteria, intraoperative frozen section histology has poor sensitivity, strong specificity, and acceptable overall discrimination for diagnosing PJI. This test appears to be of particular value for patients deemed "inconclusive" for infection using the remaining ICM criteria.
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Slullitel PA, Oñativia JI, Cima I, Zanotti G, Comba F, Piccaluga F, Buttaro MA. Patients with no recurrence of infection five years after two-stage revision hip arthroplasty may be classified as periprosthetic infection 'in remission'. Bone Joint J 2021; 103-B:79-86. [PMID: 33380194 DOI: 10.1302/0301-620x.103b1.bjj-2020-0955.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIMS We aimed to report the mid- to long-term rates of septic and aseptic failure after two-stage revision surgery for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). METHODS We retrospectively reviewed 96 cases which met the Musculoskeletal Infection Society criteria for PJI. The mean follow-up was 90 months (SD 32). Septic failure was assessed using a Delphi-based consensus definition. Any further surgery undertaken for aseptic mechanical causes was considered as aseptic failure. The cumulative incidence with competing risk analysis was used to predict the risk of septic failure. A regression model was used to evaluate factors associated with septic failure. The cumulative incidence of aseptic failure was also analyzed. RESULTS There were 23 septic failures at final follow-up, with a cumulative incidence of 14% (95% confidence interval (CI) 8% to 22%) at one year, 18% (95% CI 11% to 27%) at two years, 22% (95% CI 14% to 31%) at five years, and 23% (95% CI 15% to 33%) at ten years. Having at least one positive culture (hazard ratio (HR) 2.38 (interquartile range (IQR) 1.19 to 4.74); p = 0.013), or a positive intraoperative frozen section (HR 2.55 (IQR 1.06 to 6.15); p = 0.037) was significantly associated with septic failure after reimplantation. With dislocation being the most common cause of aseptic revision (5.2%), the cumulative incidence of aseptic failure was 1% (95% CI 0% to 5%) at one year, 6% (95% CI 1% to 8%) at five years, and 8% (95%CI 3% to 17%) at ten years. CONCLUSION If there is no recurrent infection in the five years following reimplantation, the chances of further infection thereafter are remote. While the results of a frozen section may be a reliable guide to the timing of reimplantation, intraoperative culture has, currently, only prognostic value. Surgeons should be aware that instability remains a potential indication for further revision surgery. Cite this article: Bone Joint J 2021;103-B(1):79-86.
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Affiliation(s)
- Pablo A Slullitel
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - José I Oñativia
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Ignacio Cima
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Gerardo Zanotti
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Fernando Comba
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Piccaluga
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Martin A Buttaro
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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Tirumala V, Klemt C, Xiong L, Chen W, van den Kieboom J, Kwon YM. Diagnostic Utility of Platelet Count/Lymphocyte Count Ratio and Platelet Count/Mean Platelet Volume Ratio in Periprosthetic Joint Infection Following Total Knee Arthroplasty. J Arthroplasty 2021; 36:291-297. [PMID: 32773272 DOI: 10.1016/j.arth.2020.07.038] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Diagnosing a periprosthetic joint infection (PJI) can be challenging and often requires a combination of clinical and laboratory findings. Monocyte/lymphocyte ratio, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio (PLR), and platelet/mean platelet volume ratio (PVR) are simple predictors for inflammation that can be readily obtained from complete blood count. The aim of this study is to evaluate the diagnostic utility of these markers in predicting PJI in total knee arthroplasty (TKA) patients. METHODS A total of 538 patients who underwent revision TKA with calculable marker ratios prerevision in 2 groups were evaluated: (1) 206 patients with a preoperative diagnosis of PJI (group I) and (2) 332 patients treated for revision TKA for aseptic failures (group II). The diagnostic abilities of the markers were assessed via receiver operator characteristic curve analysis. RESULTS The optimal threshold of PVR at 30.82 had the highest sensitivity of 87.7%, while the optimal threshold of PLR at 234.13 had the highest specificity of 82.5%. Both PLR and PVR, when combined with Musculoskeletal Infection Society thresholds for erythrocyte sedimentation rate, C-reactive protein, synovial WBC, and PMN%, achieve significantly higher sensitivity and specificity rates for PJI at or above 97% (PLR: 99.03%; 98.80%; PVR: 98.54%;97.89%). CONCLUSION Our study demonstrates that PVR and PLR, which are readily available and inexpensive to obtain from complete blood counts, when combined with serum and synovial fluid markers have increased sensitivity and specificity comparable to that of alpha defensin. This suggests that PVR and PLR can be used together with other hematologic and aspirate markers to increase the accuracy of PJI diagnosis in TKA patients.
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Affiliation(s)
- Venkatsaiakhil Tirumala
- Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA
| | - Christian Klemt
- Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA
| | - Liang Xiong
- Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA
| | - Wenhao Chen
- Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA
| | - Janna van den Kieboom
- Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA
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Plate A, Anagnostopoulos A, Glanzmann J, Stadler L, Weigelt L, Sutter R, Kästli M, Zinkernagel AS, Zingg PO, Achermann Y. Synovial C-reactive protein features high negative predictive value but is not useful as a single diagnostic parameter in suspected periprosthetic joint infection (PJI). J Infect 2019; 78:439-444. [PMID: 30965066 DOI: 10.1016/j.jinf.2019.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 03/29/2019] [Accepted: 04/01/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Synovial fluid C-reactive protein (syCRP) has been recently described as a new biomarker in preoperative diagnostics to identify periprosthetic joint infections (PJI). The aim of this study was to evaluate syCRP in a large cohort of patients with suspected PJI and to calculate the optimal cut-off to diagnose PJI. METHODS Between September 2015 and June 2017, we prospectively included patients with suspected PJI, in which syCRP was additionally measured along with routine preoperative diagnostic serum and synovial biomarkers. We analysed the sensitivity and specificity of syCRP using receiver operating characteristic curves. RESULTS We included 192 cases (hip n = 80, knee n = 91, shoulder n = 21) with a final diagnosis of PJI in 26 cases (14.0%). Combined for all joints, the syCRP values were significantly higher in the PJI group than in the no PJI group (median: 13.8 vs. 0 mg/l; p < 0.001). The optimal cut-off (Youden Index: 0.71) for the PJI diagnosis combined for all joints was at a syCRP value of 2.9 mg/l with a sensitivity of 88%, a specificity of 82%, and a negative predictive value of 98%. CONCLUSIONS SyCRP features high negative predictive value but is not useful as a single diagnostic parameter in suspected periprosthetic joint infection (PJI).
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Affiliation(s)
- A Plate
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland.
| | - A Anagnostopoulos
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - J Glanzmann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - L Stadler
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - L Weigelt
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - R Sutter
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - M Kästli
- Zentrallabour Zurich, Zurich, Switzerland
| | - A S Zinkernagel
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - P O Zingg
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Y Achermann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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Zagra L, Villa F, Cappelletti L, Gallazzi E, Materazzi G, De Vecchi E. Can leucocyte esterase replace frozen sections in the intraoperative diagnosis of prosthetic hip infection? Bone Joint J 2019; 101-B:372-377. [PMID: 30929495 DOI: 10.1302/0301-620x.101b4.bjj-2018-0752.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Leucocyte esterase (LE) has been shown to be an accurate marker of prosthetic joint infection (PJI), and has been proposed as an alternative to frozen section (FS) histology for intraoperative diagnosis. In this study, the intraoperative assessment of LE was compared with FS histology for the diagnosis of prosthetic hip infection. PATIENTS AND METHODS A total of 119 patients undergoing revision total hip arthroplasty (THA) between June 2015 and December 2017 were included in the study. There were 56 men and 63 women with a mean age of 66.2 years (27 to 88). Synovial fluid was collected before arthrotomy for the assessment of LE using enzymatic colourimetric strips. Between five and six samples were stained with haematoxylin and eosin for FS histology, and considered suggestive of infection when at least five polymorphonuclear leucocytes were found in five high-power fields. RESULTS The sensitivity and specificity of the LE assay were 100% and 93.8%, respectively; the positive (PPV) and the negative (NPV) predictive values were 79.3% and 100%, respectively. The mean time between the collection of the sample and the result being known was 20.1 minutes (sd 4.4). The sensitivity and specificity of FS histology were 78.3% and 96.9%, respectively; the PPV and the NPV were 85.7% and 94.9%, respectively. The mean time between the collection of the sample and the result being known was 27.2 minutes (sd 6.9). CONCLUSION The sensitivity of LE assay was higher, with similar specificity and diagnostic accuracy, compared with FS histology. The faster turnaround time, its ease of use, and low costs make LE assay a valuable alternative to FS histology. We now use it routinely for the intraoperative diagnosis of PJI. Cite this article: Bone Joint J 2019;101-B:372-377.
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Affiliation(s)
- L Zagra
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - F Villa
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - L Cappelletti
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - E Gallazzi
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - G Materazzi
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - E De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Carli AV, Abdelbary H, Ahmadzai N, Cheng W, Shea B, Hutton B, Sniderman J, Philip Sanders BS, Esmaeilisaraji L, Skidmore B, Gauthier-Kwan OY, Bunting AC, Gauthier P, Crnic A, Logishetty K, Moher D, Fergusson D, Beaulé PE. Diagnostic Accuracy of Serum, Synovial, and Tissue Testing for Chronic Periprosthetic Joint Infection After Hip and Knee Replacements: A Systematic Review. J Bone Joint Surg Am 2019; 101:635-649. [PMID: 30946198 DOI: 10.2106/jbjs.18.00632] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint replacement. Patients with chronic PJI report a substantially lower quality of life and face a higher risk of short-term mortality. Establishing a diagnosis of chronic PJI is challenging because of conflicting guidelines, numerous tests, and limited evidence. Delays in diagnosing PJI are associated with poorer outcomes and morbid revision surgery. The purpose of this systematic review was to compare the diagnostic accuracy of serum, synovial, and tissue-based tests for chronic PJI. METHODS This review adheres to the Cochrane Collaboration's diagnostic test accuracy methods for evidence searching and syntheses. A detailed search of MEDLINE, Embase, the Cochrane Library, and the grey literature was performed to identify studies involving the diagnosis of chronic PJI in patients with hip or knee replacement. Eligible studies were assessed for quality and bias using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Meta-analyses were performed on tests with sufficient data points. Summary estimates and hierarchical summary receiver operating characteristic (HSROC) curves were obtained using a bivariate model. RESULTS A total of 12,616 citations were identified, and 203 studies met the inclusion criteria. Of these 203 studies, 170 had a high risk of bias. Eighty-three unique PJI diagnostic tests were identified, and 17 underwent meta-analyses. Laboratory-based synovial alpha-defensin tests and leukocyte esterase reagent (LER) strips (2+) had the best performance, followed by white blood-cell (WBC) count, measurement of synovial C-reactive protein (CRP) level, measurement of the polymorphonuclear neutrophil percentage (PMN%), and the alpha-defensin lateral flow test kit (Youden index ranging from 0.78 to 0.94). Tissue-based tests and 3 serum tests (measurement of interleukin-6 [IL-6] level, CRP level, and erythrocyte sedimentation rate [ESR]) had a Youden index between 0.61 to 0.75 but exhibited poorer performance compared with the synovial tests mentioned above. CONCLUSIONS The quality of the literature pertaining to chronic PJI diagnostic tests is heterogeneous, and the studies are at a high risk for bias. We believe that greater transparency and more complete reporting in studies of diagnostic test results should be mandated by peer-reviewed journals. The available literature suggests that several synovial fluid-based tests perform well for diagnosing chronic PJI and their use is recommended in the work-up of any suspected case of chronic PJI. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alberto V Carli
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Nadera Ahmadzai
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Beverley Shea
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jhase Sniderman
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Leila Esmaeilisaraji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Becky Skidmore
- Independent Information Specialist, Ottawa, Ontario, Canada
| | | | | | - Paul Gauthier
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Agnes Crnic
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Al-Houraibi RK, Aalirezaie A, Adib F, Anoushiravani A, Bhashyam A, Binlaksar R, Blevins K, Bonanzinga T, Chih-Kuo F, Cordova M, Deirmengian GK, Fillingham Y, Frenkel T, Gomez J, Gundtoft P, Harris MA, Harris M, Heller S, Jennings JA, Jiménez-Garrido C, Karam JA, Khlopas A, Klement MR, Komnos G, Krebs V, Lachiewicz P, Miller AO, Mont MA, Montañez E, Romero CA, Schwarzkopf R, Shaffer A, Sharkey PF, Smith BM, Sodhi N, Thienpont E, Villanueva AO, Yazdi H. General Assembly, Prevention, Wound Management: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S157-S168. [PMID: 30360978 DOI: 10.1016/j.arth.2018.09.066] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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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18
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General Assembly, Treatment, Multidisciplinary Issues: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S239-S243. [PMID: 30348547 DOI: 10.1016/j.arth.2018.09.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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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19
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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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20
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A meta-analysis of synovial biomarkers in periprosthetic joint infection: Synovasure™ is less effective than the ELISA-based alpha-defensin test. Knee Surg Sports Traumatol Arthrosc 2018; 26:3039-3047. [PMID: 29557491 DOI: 10.1007/s00167-018-4904-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 03/16/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE (1) To determine the overall accuracy of synovial alpha-defensin, synovial C-reactive protein (sCRP), interleukin-6 (sIL-6), and leukocyte esterase (sLE) as diagnostic markers for periprosthetic joint infection (PJI) and (2) to independantly evaluate the accuracy of both the laboratory-based ELISA alpha-defensin test and the Synovasure™ alpha-defensin test kit. METHODS An EMBASE and MEDLINE (PubMed) database search was performed using a set of professionally set search terms. Two independent reviewers rated eligible articles. Sensitivity and specificity were meta-analysed using a bivariate random-effects model. RESULTS Accuracy values were extracted from 42 articles. Pooled sensitivity and specificity of the represented biomarkers were: alpha-defensin ELISA 0.97 (95% CI 0.91-0.99) and 0.97 (95% CI 0.94-0.98), respectively; Synovasure™ test kit assay 0.80 (95% CI 0.65-0.89) and 0.89 (95% CI 0.76-0.96), respectively; sLE 0.79 (95% CI 0.67-0.87) and 0.92 (95% CI 0.87-0.92), respectively; sIL-6 0.76 (95% CI 0.65-0.84) and 0.91 (95% CI 0.88-0.94), respectively; sCRP 0.86 (95% CI 0.81-0.91) and 0.90 (95% CI 0.86-0.93), respectively. CONCLUSION The labararory-based alpha-defensin ELISA test showed the highest ever reported accuracy for PJI diagnosis. However, this did not apply for the Synovasure™ alpha-defensin test, which was comparable in its overall diagnostic accuracy to sCRP, sIL-6 and sLE. The later biomarkers also did not yield an overall diagnostic accuracy higher than that previously reported for synovial white cell count (sWBC) or culture bacteriology. Based on current evidence, no synovial biomarker should be applied as a standalone diagnostic tool. Furthermore, the use of the laboratory-based alpha-defensin ELISA test should be encouraged, still, the Synovasure™ alpha-defensin test kit should be critically appreciated. LEVER OF EVIDENCE III.
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Slullitel PA, Oñativia JI, Buttaro MA, Sánchez ML, Comba F, Zanotti G, Piccaluga F. State-of-the-art diagnosis and surgical treatment of acute peri-prosthetic joint infection following primary total hip arthroplasty. EFORT Open Rev 2018; 3:434-441. [PMID: 30233819 PMCID: PMC6129958 DOI: 10.1302/2058-5241.3.170032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Acute peri-prosthetic joint infection (PJI) following total hip arthroplasty (THA) is a potentially devastating and undesired complication, with a prevalence of 0.3% to 2.9%. Its suspicion begins with a meticulous physical examination and anamnesis. Diagnosis should be made on the basis of the Musculoskeletal Infection Society criteria. Serum and synovial biomarkers are very useful tools when major criteria are absent.Although sometimes not possible due to medical conditions, surgery is usually the first line of treatment. Although its outcome is highly correlated with the isolated microorganism, irrigation and debridement with implant retention (DAIR) is the gold standard for treatment. Ideally, the prior approach should be proximally and distally extended to augment the field of view and remove all of the prosthetic modular components, that is, femoral head and acetabular insert.Given DAIR's unclear control of infection, with successful outcomes in the range of 30% to 95%, one- or two-stage revision protocols may play a role in certain cases of acute infections; nonetheless, further prospective, randomized studies are necessary to compare long-term outcomes between DAIR and revision surgeries.Following surgical treatment, length of antibiotherapy is in the range of six weeks to six months, without any difference in outcomes between short and long protocols. Treatment should be adjusted to the isolated bacteria and controlled further with post-operative serum biomarker levels. Cite this article: EFORT Open Rev 2018;3:434-441. DOI: 10.1302/2058-5241.3.170032.
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Affiliation(s)
| | | | | | | | - Fernando Comba
- Hip Surgery Unit, Italian Hospital of Buenos Aires, Argentina
| | - Gerardo Zanotti
- Hip Surgery Unit, Italian Hospital of Buenos Aires, Argentina
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Histopathology in Periprosthetic Joint Infection: When Will the Morphomolecular Diagnosis Be a Reality? BIOMED RESEARCH INTERNATIONAL 2018; 2018:1412701. [PMID: 29862251 PMCID: PMC5971260 DOI: 10.1155/2018/1412701] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/07/2018] [Indexed: 02/07/2023]
Abstract
The presence of a polymorphonuclear neutrophil infiltrate in periprosthetic tissues has been shown to correlate closely with the diagnosis of septic implant failure. The histological criterion considered by the Musculoskeletal Infection Society to be diagnostic of periprosthetic joint infection is “greater than five neutrophils per high-power field in five high-power fields observed from histologic analysis of periprosthetic tissue at ×400 magnification.” Surgeons and pathologists should be aware of the qualifications introduced by different authors during the last years in the histological techniques, samples for histological study, cutoffs used for the diagnosis of infection, and types of patients studied. Recently, immunohistochemistry and histochemistry studies have appeared which suggest that the cutoff point of five polymorphonuclear neutrophils in five high-power fields is too high for the diagnosis of many periprosthetic joint infections. Therefore, morphomolecular techniques could help in the future to achieve a more reliable histological diagnosis of periprosthetic joint infection.
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Lee YS, Koo KH, Kim HJ, Tian S, Kim TY, Maltenfort MG, Chen AF. Synovial Fluid Biomarkers for the Diagnosis of Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2017; 99:2077-2084. [PMID: 29257013 DOI: 10.2106/jbjs.17.00123] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The search for a single standard reference test for determining periprosthetic joint infection (PJI) through analysis of synovial fluid has yielded numerous biomarkers as potential candidates. The purpose of the present systematic review and meta-analysis was to evaluate the diagnostic accuracy of synovial fluid biomarkers and to determine which test has the highest diagnostic odds ratio (DOR) for the diagnosis of PJI. METHODS An online literature search of the MEDLINE, Embase, and Cochrane databases identified 33 articles reporting a total of 13 major parameters for diagnosing PJI through analysis of synovial fluid. Each of the included articles was independently analyzed for risk of bias and for concerns regarding applicability utilizing the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool. The mada (meta-analysis of diagnostic accuracy) tool was used to generate forest plots for sensitivity, specificity, and the log of the DOR, as well as summary statistics. RESULTS In this analysis, 13 index tests (leukocyte count; measurement of the percentage of polymorphonucleocytes [PMN%] and the levels of C-reactive protein [CRP], α-defensin, leukocyte esterase [LE], interleukin [IL]-6, IL-8, IL-10, IL-1β, vascular endothelial growth factor [VEGF], and granulocyte-colony stimulating factor [G-CSF]; culture; and polymerase chain reaction [PCR] analysis) were evaluated on the basis of ≥2 articles. Of these tests, 8 (leukocyte count, PMN%, CRP, α-defensin, LE, IL-6, IL-8, and culture) were appropriate for pooled analysis. The overall sensitivity of these 8 markers was 0.85, and all but culture showed a sensitivity of ≥0.8. All markers showed a specificity of ≥0.9. Of the 8 tests, measurement of the α-defensin level showed the highest log DOR. CONCLUSIONS Synovial fluid leukocyte count, PMN%, CRP, α-defensin, LE, IL-6, and IL-8 all demonstrated high sensitivity for diagnosing PJI, with α-defensin being the best synovial marker based on the highest log DOR. However, other synovial fluid tests that demonstrate good diagnostic performance can also be used in combination for the diagnosis of PJI. LEVEL OF EVIDENCE Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Yong Seuk Lee
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Hyun Jung Kim
- Institute for Evidence-Based Medicine and Department of Preventive Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Shaoqi Tian
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Joint Surgery, the Affiliated Hospital of Medical College, Qingdao University, Qingdao, People's Republic of China
| | - Tae-Young Kim
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Mitchell G Maltenfort
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Antonia F Chen
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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The Diagnostic Utility of Synovial Fluid Markers in Periprosthetic Joint Infection: A Systematic Review and Meta-analysis. J Am Acad Orthop Surg 2017; 25:763-772. [PMID: 29059113 DOI: 10.5435/jaaos-d-16-00548] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION This study is a systematic review of all reported synovial fluid markers for the diagnosis of periprosthetic joint infection and a meta-analysis of the most frequently reported markers to identify those of greatest diagnostic utility. METHODS A search of six databases was conducted to identify all studies evaluating the utility of synovial fluid markers in the diagnosis of periprosthetic joint infection. Two observers assessed methodologic quality and extracted data independently. A meta-analysis of the most frequently reported markers was performed. RESULTS Twenty-three studies were included in the meta-analysis. The most common markers (and their respective area under the curve) were interleukin-17 (0.974), leukocyte esterase (0.968), α-defensin (0.958), interleukin-6 (0.956), interleukin-1β (0.948), and C-reactive protein (0.927). Among these markers, α-defensin had the highest diagnostic odds ratio but did not achieve statistically significant superiority. CONCLUSION The most frequently studied synovial fluid markers for the diagnosis of periprosthetic joint infection are C-reactive protein, leukocyte esterase, interleukin-6, interleukin-1β, α-defensin, and interleukin-17, all of which have high diagnostic utility. LEVEL OF EVIDENCE Level II.
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Li R, Li X, Yu B, Li X, Song X, Li H, Xu C, Chen J. Comparison of Leukocyte Esterase Testing of Synovial Fluid with Synovial Histology for the Diagnosis of Periprosthetic Joint Infection. Med Sci Monit 2017; 23:4440-4446. [PMID: 28912417 PMCID: PMC5612200 DOI: 10.12659/msm.906705] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is a complication of total joint arthroplasty (TJA). The leukocyte esterase (LE) strip test and histology are diagnostic methods for PJI. The aims of this study were to determine the sensitivity and specificity of the LE strip test and to compare it with histology in the diagnosis of PJI. Material/Methods Between January and December 2015, 93 patients who underwent TJA with PJI were enrolled in the study. Synovial fluid samples were tested with an LE strip, and three synovial tissue samples from each patient underwent frozen section and formalin-fixed histology. Recent criteria from the Musculoskeletal Infection Society (MSIS) were used for the diagnosis of PJI. Results Ninety-three patients studied included 38 cases of PJI and 55 non-infected cases. Sensitivity and specificity of the LE strip test were 92.1% (95% CI, 77.5–97.9%) and 96.4% (95% CI, 86.4–99.4%), respectively. There was no significant difference in sensitivity (p=0.249) or specificity (p=0.480) between frozen and paraffin sections for histology; the two methods were strongly correlated (ϕ=0.892). Comparison of the LE test results with histology showed a strong correlation (ϕ=0.758, and ϕ=0.840). Conclusions The findings of this preliminary study have shown that the LE strip test on synovial fluid showed similar sensitivity and specificity as histology for the diagnosis of PJI, indicating that that further controlled clinical studies should be performed to investigate the role of the LE strip test for the early diagnosis of PJI.
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Affiliation(s)
- Rui Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China (mainland)
| | - Xiang Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China (mainland)
| | - Baozhan Yu
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China (mainland)
| | - Xin Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China (mainland)
| | - Xinggui Song
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China (mainland)
| | - Heng Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China (mainland)
| | - Chi Xu
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China (mainland)
| | - Jiying Chen
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China (mainland)
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Definition of periprosthetic joint infection of the hip and new tools for diagnosis. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wang C, Wang Q, Li R, Duan JY, Wang CB. Synovial Fluid C-reactive Protein as a Diagnostic Marker for Periprosthetic Joint Infection: A Systematic Review and Meta-analysis. Chin Med J (Engl) 2017; 129:1987-93. [PMID: 27503025 PMCID: PMC4989431 DOI: 10.4103/0366-6999.187857] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Periprosthetic joint infection (PJI) is the main cause of failure following total joint arthroplasty. Until now, the diagnosis of PJI is still confronted with technical limitations, and the question of whether synovial fluid biomarker, C-reactive protein (CRP), can provide high value in the diagnosis of PJI remains unanswered and, therefore, was the aim of the study. Methods: First, we conducted a systematic review on CRP in the diagnosis of PJI by searching online databases using keywords such as “periprosthetic joint infection”, “synovial fluid”, and “C-reactive protein”. Eligible studies providing sufficient data to construct 2 × 2 contingency tables were then selected based on the list of criteria and the quality of included studies was assessed subsequently. Finally, the reported sensitivity, specificity, diagnostic odds ratio (DOR), summary receiver operating characteristic (SROC) curve, and the area under the SROC (AUSROC) were pooled together and used to evaluate overall diagnostic performance. Results: Seven studies were included in our review, six of which comprising a total of 456 participants were further investigated in our meta-analysis. The pooled sensitivity, specificity, and DOR were 0.92 (95% confidence interval [CI]: 0.86–0.96), 0.90 (95% CI: 0.87–0.93), and 101.40 (95% CI: 48.07–213.93), respectively. The AUSROC was 0.9663 (standard error, 0.0113). Conclusions: Synovial fluid CRP is a good biomarker for the diagnosis of PJI with high sensitivity and specificity.
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Affiliation(s)
- Chi Wang
- Department of Clinical Laboratory, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Qi Wang
- Outpatient Department of Chinese People's Liberation Army, Beijing, 101123, China
| | - Rui Li
- Department of Orthopedics, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Jin-Yan Duan
- Department of Clinical Laboratory, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Cheng-Bin Wang
- Department of Clinical Laboratory, Chinese People's Liberation Army General Hospital, Beijing 100853, China
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George J, Kwiecien G, Klika AK, Ramanathan D, Bauer TW, Barsoum WK, Higuera CA. Are Frozen Sections and MSIS Criteria Reliable at the Time of Reimplantation of Two-stage Revision Arthroplasty? Clin Orthop Relat Res 2016; 474:1619-26. [PMID: 26689583 PMCID: PMC4887348 DOI: 10.1007/s11999-015-4673-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Frozen section histology is widely used to aid in the diagnosis of periprosthetic joint infection at the second stage of revision arthroplasty, although there are limited data regarding its utility. Moreover, there is no definitive method to assess control of infection at the time of reimplantation. Because failure of a two-stage revision can have serious consequences, it is important to identify the cases that might fail and defer reimplantation if necessary. Thus, a reliable test providing information about the control of infection and risk of subsequent failure is necessary. QUESTIONS/PURPOSES (1) At second-stage reimplantation surgery, what is the diagnostic accuracy of frozen sections as compared with the Musculoskeletal Infection Society (MSIS) as the gold standard? (2) What are the diagnostic accuracy parameters for the MSIS criteria and frozen sections in predicting failure of reimplantation? (3) Do positive MSIS criteria or frozen section at the time of reimplantation increase the risk of subsequent failure? METHODS A total of 97 patients undergoing the second stage of revision total hip arthroplasty or total knee arthroplasty in 2013 for a diagnosis of periprosthetic joint infection (PJI) were considered eligible for the study. Of these, 11 had incomplete MSIS criteria and seven lacked 1-year followup, leaving 79 patients (38 knees and 41 hips) available for analysis. At the time of reimplantation, frozen section results were compared with modified MSIS criteria as the gold standard in detecting infection. Subsequently, success or failure of reimplantation was defined by (1) control of infection, as characterized by a healed wound without fistula, drainage, or pain; (2) no subsequent surgical intervention for infection after reimplantation surgery; and (3) no occurrence of PJI-related mortality; and diagnostic parameters in predicting treatment failure were calculated for both the modified MSIS criteria and frozen sections. RESULTS At the time of second-stage reimplantation surgery, frozen section is useful in ruling in infection, where the specificity is 94% (95% confidence interval [CI], 89%-99%); however, there is less utility in ruling out infection, because sensitivity is only 50% (CI, 13%-88%). Both the MSIS criteria and frozen sections have high specificity for ruling in failure of reimplantation (MSIS criteria specificity: 96% [CI, 91%-100%]; frozen section: 95% [CI, 88%-100%]), but screening capabilities are limited (MSIS sensitivity: 26% [CI, 9%-44%]; frozen section: 22% [CI, 9%-29%]). Positive MSIS criteria at the time of reimplantation were a risk factor for subsequent failure (hazard ratio [HR], 5.22 [1.64-16.62], p = 0.005), whereas positive frozen section was not (HR, 1.16 [0.15-8.86], p = 0.883). CONCLUSIONS On the basis of our results, both frozen section and MSIS are recommended at the time of the second stage of revision arthroplasty. Both frozen section and modified MSIS criteria had limited screening capabilities to identify failure, although both demonstrated high specificity. MSIS criteria should be evaluated at the second stage of revision arthroplasty because performing reimplantation in a joint that is positive for infection significantly increases the risk for subsequent failure. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Jaiben George
- Department of Orthopaedic Surgery, Cleveland Clinic, Mail Code: A-41, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Grzegorz Kwiecien
- Department of Orthopaedic Surgery, Cleveland Clinic, Mail Code: A-41, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Alison K. Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Mail Code: A-41, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Deepak Ramanathan
- Department of Orthopaedic Surgery, Cleveland Clinic, Mail Code: A-41, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Thomas W. Bauer
- Department of Pathology, Cleveland Clinic, Cleveland, OH USA
| | - Wael K. Barsoum
- Department of Orthopaedic Surgery, Cleveland Clinic, Mail Code: A-41, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Carlos A. Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic, Mail Code: A-41, 9500 Euclid Avenue, Cleveland, OH 44195 USA
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