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Jardon M, Fritz J, Samim M. Imaging approach to prosthetic joint infection. Skeletal Radiol 2024; 53:2023-2037. [PMID: 38133670 DOI: 10.1007/s00256-023-04546-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/08/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Abstract
The diagnosis of prosthetic joint infection (PJI) remains challenging, despite multiple available laboratory tests for both serum and synovial fluid analysis. The clinical symptoms of PJI are not always characteristic, particularly in the chronic phase, and there is often significant overlap in symptoms with non-infectious forms of arthroplasty failure. Further exacerbating this challenge is lack of a universally accepted definition for PJI, with publications from multiple professional societies citing different diagnostic criteria. While not included in many of the major societies' guidelines for diagnosis of PJI, diagnostic imaging can play an important role in the workup of suspected PJI. In this article, we will review an approach to diagnostic imaging modalities (radiography, ultrasound, CT, MRI) in the workup of suspected PJI, with special attention to the limitations and benefits of each modality. We will also discuss the role that image-guided interventions play in the workup of these patients, through ultrasound and fluoroscopically guided joint aspirations. While there is no standard imaging algorithm that can universally applied to all patients with suspected PJI, we will discuss a general approach to diagnostic imaging and image-guided intervention in this clinical scenario.
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Affiliation(s)
- Meghan Jardon
- Department of Radiology, NYU Langone Medical Center, New York, NY, USA.
| | - Jan Fritz
- Department of Radiology, NYU Langone Medical Center, New York, NY, USA
| | - Mohammad Samim
- Department of Radiology, NYU Langone Medical Center, New York, NY, USA
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2
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Thejeel B, Coles Z, Li Q, Nguyen JT, Carli AV, Miller TT. When to lavage in the absence of a sonographically visible joint effusion in painful total knee arthroplasty: a retrospective longitudinal study. Skeletal Radiol 2024; 53:2279-2284. [PMID: 38514473 DOI: 10.1007/s00256-024-04657-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/10/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVE To determine if knee arthroplasty without sonographically visible effusion needs to undergo lavage to rule out infection. METHODS Patients were accrued by a retrospective search of a longitudinally maintained radiology database looking for patients referred for ultrasound guided aspiration of suspected TKA infection. Clinical presentations, laboratory tests, intraoperative findings, and follow-up were reviewed. RESULTS Four hundred sixty-nine patients were included (mean age of 67 years (range, 36-91)) including 251 females. Four hundred three patients had effusions, of which 57 were infected based on ultrasound-guided and surgical aspirates. Sixty-four patients lacked effusions, of which 47 underwent lavage at the clinicians' request, with 6/47 infected. Nineteen patients without effusion were not lavaged at the clinicians' request due to low suspicion, and none were infected. Patients with positive lavage cultures all had clinical risk factors. Infection rates were significantly higher in patients with joint effusion and clinical suspicion for infection compared to absent joint effusion and absent clinical suspicion. A significantly higher proportion of patients with hyperemia or moderate-severe synovial thickening on ultrasound were symptomatic and had joint effusion and positive joint cultures. Aspiration of native fluid had 85% sensitivity and 100% specificity while lavage had a sensitivity of 57% and specificity of 100%. Negative predictive value for native aspirates was 94% compared to 86% for lavage. CONCLUSION A TKA with low clinical suspicion of infection does not need to undergo lavage in the absence of a sonographically visible effusion.
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Affiliation(s)
- Bashiar Thejeel
- Hospital for Special Surgery Department of Radiology and Imaging, 535 E 70Th Street, New York, NY, 10021, USA
| | - Zachary Coles
- Hospital for Special Surgery Department of Orthopedic Surgery, 535 E 70Th Street, New York, NY, 10021, USA
| | - Qian Li
- Hospital for Special Surgery Biostatistics Core, 535 E 70Th Street, New York, NY, 10021, USA
| | - Joesph T Nguyen
- Hospital for Special Surgery Biostatistics Core, 535 E 70Th Street, New York, NY, 10021, USA
| | - Alberto V Carli
- Hospital for Special Surgery Department of Orthopedic Surgery, 535 E 70Th Street, New York, NY, 10021, USA
| | - Theodore T Miller
- Hospital for Special Surgery Department of Radiology and Imaging, 535 E 70Th Street, New York, NY, 10021, USA.
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Gordon AM, Ng MK, Magruder ML, Schwartz JM, Jason Wong CH, Mont MA. The Association of Dental Caries or Dental Implant Placement Within One Year of Primary Total Hip Arthroplasty on Medical and Implant Complications. J Arthroplasty 2024; 39:2295-2302. [PMID: 38649065 DOI: 10.1016/j.arth.2024.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/13/2024] [Accepted: 04/16/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) adverse events among patients who have dental diagnoses remain unclear. We sought to determine if dental caries or dental implant placements increased (1) 90-day medical complications, (2) 90-day readmissions, and (3) 2-year implant-related complications, including periprosthetic joint infections (PJIs) after THA. METHODS A nationwide database for primary THAs from 2010 to 2021 was queried to compare 3 patient cohorts. Patients who had a history of dental implants or caries within 12 months prior to THA (n = 1,179) or 12 months after THA (n = 1,218) were case-matched to patients who did not have dental history (n = 6,090) by age and comorbidities. Outcomes included 90-day complications, 90-day readmissions, and 2-year implant-related complications. Logistic regression models computed the odds ratios (ORs) of complications and readmissions. P values less than .006 were significant. RESULTS Patients who had dental caries or implant placement 12 months before or after THA experienced 1.6-fold greater odds of 90-day medical complications compared to case-matched patients. Readmissions within 90 days increased for patients who had a dental history before (11.7% versus 8.3%; OR: 1.49, P < .0001) and after (14.2% versus 8.3%; OR: 1.84, P < .0001) THA compared to case-matched patients. A dental caries diagnosis or dental implant placement within 12 months following THA increased 2-year implant complications compared to case-matched patients (15.2% versus 9.3%; OR: 1.69, P < .0001), including PJIs (5.3% versus 2.8%; OR: 1.98, P < .0001), dislocations (4.4% versus 2.7%; OR: 1.63, P = .002), and THA revisions (3.9% versus 2.5%; OR: 1.61, P = .005). CONCLUSIONS Dental diagnoses within 12 months of THA are associated with increased medical complications. Dental diagnoses occurring 12 months after THA are associated with greater implant-related complications, including PJIs. Delaying invasive dental procedures for 12 months after THA may be advisable.
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Affiliation(s)
- Adam M Gordon
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York; Questrom School of Business, Boston University, Boston, Massachusetts
| | - Mitchell K Ng
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Matthew L Magruder
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Jake M Schwartz
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Che Hang Jason Wong
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, New York
| | - Michael A Mont
- Rubin Institute of Orthopaedic Surgery, Department of Orthopaedic Surgery, Baltimore, Maryland
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Plesniar J, Breit HC, Clauss M, Donners R. Diagnosing periprosthetic hip joint infection with new-generation 0.55T MRI. Eur J Radiol 2024; 176:111524. [PMID: 38851014 DOI: 10.1016/j.ejrad.2024.111524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/06/2024] [Accepted: 05/21/2024] [Indexed: 06/10/2024]
Abstract
PURPOSE To assess the accuracy of 0.55 T MRI in diagnosing periprosthetic joint infection (PJI) in patients with symptomatic total hip arthroplasty (THA). MATERIAL AND METHODS 0.55 T MRI of patients with THA PJI (Group A) and noninfected THA (Group B), including aseptic loosening (Group C, subgroup of B) performed between May 2021 and July 2023 were analysed retrospectively. Two musculoskeletal fellowship-trained radiologists independently identified MRI bone and soft tissue changes including: marrow oedema, periosteal reaction, osteolysis, joint effusion, capsule oedema and thickening, fluid collections, muscle oedema, bursitis, inguinal adenopathy, and muscle tears. The diagnostic performance of MRI discriminators of PJI was evaluated using Fisher's exact test (p < 0.05) and interrater reliability was determined. 61 MRI scans from 60 THA patients (34 female, median age 68, range 41-93 years) in Group A (n = 9; female 4; median age 69, range 56-82 years), B (n = 51; 30; 67.5, 41-93 years), and C (10; 6; 67; 41-82 years) were included. RESULTS Capsule oedema (sensitivity 89 %, specificity 92 %,), intramuscular oedema (89 %, 82 %) and joint effusion (89 %, 73 %) were the best performing discriminators for PJI diagnosis (p ≤ 0.001), when viewed individually and had combined 70 % sensitivity and 100 % specificity for PJI diagnosis in parallel testing. For the differentiation between PJI and aseptic loosening, intramuscular oedema (89 %, 80 %) and capsule oedema (89 %, 80 %) were significant discriminators (p ≤ 0.001) with combined 64 % sensitivity and 96 % specificity for PJI. CONCLUSIONS New generation 0.55 T MRI may aid in the detection of PJI in symptomatic patients. Oedema of the joint capsule, adjacent muscles as well as joint effusion were indicative of the presence of PJI.
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Affiliation(s)
- Jan Plesniar
- Department of Radiology, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | | | - Martin Clauss
- Department for Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland; Center For Muskuloskeletal Infections (ZMSI), University Hospital Basel, Basel, Switzerland
| | - Ricardo Donners
- Department of Radiology, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
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Li M, Shao Z, Zhu H, Zhang Y. The diagnosis and treatment of septic hip with osteonecrosis of the femoral head. J Orthop Surg Res 2024; 19:46. [PMID: 38195515 PMCID: PMC10775663 DOI: 10.1186/s13018-023-04518-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 12/29/2023] [Indexed: 01/11/2024] Open
Abstract
This article aims to provide clinical doctors with references for the diagnosis and treatment of osteonecrosis of the femoral head (ONFH) accompanied with septic hip by summarizing and analyzing clinical data and postoperative follow-up information of patients treated with two-stage arthroplasty. We retrospectively analyzed ten patients who underwent two-stage arthroplasty in our hospital due to ONFH accompanied with septic hip. The diagnosis of septic hip includes erythrocyte sedimentation rate (ESR) > 30 mm/h, C-reactive protein (CRP) > 10 mg/L, pus-like synovial fluid, positive microbiological culture, and the findings of septic arthritis on magnetic resonance imaging (MRI) scan. Patient's information was evaluated based on the review of medical records, including gender, age, symptoms, risk factor of ONFH and septic arthritis, blood test, radiograph, MRI scan, microbiological culture, treatment, follow-up period and outcome. A total of ten patients were diagnosed with ONFH accompanied with septic hip. The average follow-up period was 43.5 months. None of the patients experienced failure during the follow-up period. The risk factor of ONFH was alcohol-related (60%), steroid-related (20%) and idiopathic (20%). Nine patients (90%) have no risk factor of septic arthritis and one patient (10%) has nephrotic syndrome. All patients did not experience any fever symptoms before surgery, but all showed worsening symptoms of pain. There were three patients (30%) with abnormal WBC count > 10 × 109/L. All patients had elevated ESR and/or CPR. Nine patients (90%) had positive MRI findings, and seven patients (70%) had positive microbiological culture. When patients with ONFH experience worsening hip joint pain accompanied by unexplained elevated CRP and/or ESR, it should be suspected whether ONFH is accompanied with septic hip. In these cases, MRI scans should be performed to exclude septic hip. Patients with ONFH accompanied with septic hip showed satisfactory results after two-stage arthroplasty.
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Affiliation(s)
- MingYang Li
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - ZhenShuai Shao
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - HaoXiang Zhu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - YongTao Zhang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.
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Nelson SB, Pinkney JA, Chen AF, Tande AJ. Periprosthetic Joint Infection: Current Clinical Challenges. Clin Infect Dis 2023; 77:e34-e45. [PMID: 37434369 PMCID: PMC11004930 DOI: 10.1093/cid/ciad360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Indexed: 07/13/2023] Open
Abstract
Over the last several decades, periprosthetic joint infection has been increasing in incidence and is occurring in more complex patients. While there have been advances in both surgical and medical treatment strategies, there remain important gaps in our understanding. Here, we share our current approaches to the diagnosis and management of periprosthetic joint infection, focusing on frequent clinical challenges and collaborative interdisciplinary care.
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Affiliation(s)
- Sandra B Nelson
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jodian A Pinkney
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antonia F Chen
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron J Tande
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Tsikopoulos K, Meroni G. Periprosthetic Joint Infection Diagnosis: A Narrative Review. Antibiotics (Basel) 2023; 12:1485. [PMID: 37887186 PMCID: PMC10604393 DOI: 10.3390/antibiotics12101485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/20/2023] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
Replacement of native joints aims to restore patients' quality of life by relieving pain and improving joint function. While periprosthetic joint infection (PJI) affects a small percentage of patients, with an estimated incidence of 1-9% following primary total joint replacement, this postoperative complication necessitates a lengthy hospitalisation, extended antibiotic treatment and further surgery. It is highlighted that establishing the correct diagnosis of periprosthetic infections is critical in order for clinicians to avoid unnecessary treatments in patients with aseptic failure. Of note, the PJI diagnosis could not purely rely upon clinical manifestations given the fact that heterogeneity in host factors (e.g., age and comorbidities), variability in infection period, difference in anatomical location of the involved joint and discrepancies in pathogenicity/virulence of the causative organisms may confound the clinical picture. Furthermore, intra-operative contamination is considered to be the main culprit that can result in early or delayed infection, with the hematogenous spread being the most prevalent mode. To elaborate, early and hematogenous infections often start suddenly, whereas chronic late infections are induced by less virulent bacteria and tend to manifest in a more quiescent manner. Last but not least, viruses and fungal microorganisms exert a role in PJI pathogenesis.
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Affiliation(s)
- Konstantinos Tsikopoulos
- 1st Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Gabriele Meroni
- One Health Unit, Department of Biomedical, Surgical and Dental Sciences, School of Medicine, University of Milan, 20133 Milan, Italy;
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Berger GK, Schwartz AK, Kent WT. Safe and Effective Aspirations and Nerve Blocks for the On-Call Orthopaedic Surgeon. J Am Acad Orthop Surg 2023; 31:957-967. [PMID: 37276580 DOI: 10.5435/jaaos-d-23-00223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/17/2023] [Indexed: 06/07/2023] Open
Abstract
The on-call orthopaedic surgeon is faced with a wide array of orthopaedic pathology for which intra-articular aspiration, injection, and/or nerve/hematoma block may be used. Efficient use of these diagnostic and therapeutic modalities affords better patient care and a more effective on-call period. Often, these interventions are the rate limiting factor in a reduction or diagnosis. In this review, we describe joint aspirations, saline load tests, hematoma blocks, and nerve blocks in detail to include their indications, techniques, related pharmacology, pearls, and pitfalls.
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Affiliation(s)
- Garrett K Berger
- From the Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA
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9
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Rızvanoglu İH, Sakarya B, Benlier N, Kökçü F. HMGB-1 Levels in Painful Knee Arthroplasty: Is it Possible to Distingue Periprosthetic Joint Infection and Aseptic Loosening? Indian J Orthop 2023; 57:1023-1031. [PMID: 37384002 PMCID: PMC10293519 DOI: 10.1007/s43465-023-00903-9] [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: 01/08/2023] [Accepted: 04/27/2023] [Indexed: 06/30/2023]
Abstract
Introduction We investigated the efficiency of high mobility group box-1 protein (HMGB-1) in differentiation of asymptomatic knee prosthesis, and periprosthetic joint infection and aseptic loosening causing painful knee prosthesis. Materials and Methods The data of patients who consulted our clinic for checking after total knee arthroplasty surgery were recorded prospectively. Blood levels of CRP, ESR, WBC, and HMGB-1 were recorded. Patients whose examination and routine tests were within normal limits comprised group I, asymptomatic total knee arthroplasty (ATKA). Painful patients with abnormal test results underwent three phase bone scintigraphy for further investigation Patients with periprosthetic joint infection (PJI) and aseptic loosening (AL) according to scintigraphy comprised group II and group III, respectively. The mean values of HMGB-1 and cut-off values according to the groups and their correlations with other inflammatory parameters were determined. Results Seventy-three patients were included in the study. Significant differences were observed in three groups, in terms of CRP, ESR, WBC, and HMGB-1. The cut-off value of HMGB-1 was determined as 15.16 ng/ml between ATKA and PJI, 16.92 ng/ml between ATKA and AL, and 27.87 ng/ml between PJI and AL, respectively. Accordingly, the sensitivity, and specificity of HMGB-1 in differentiation of ATKA and PJI were 91%, 88%, and in differentiation of ATKA and AL were 91%, 96%, and in differentiation of PJI and AL were 81%, 73%, respectively. Conclusion HMGB-1 may be utilized as an additional blood test in the differential diagnosis of problematic knee prosthesis patients.
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Affiliation(s)
- İbrahim Halil Rızvanoglu
- Department of Orthopedics and Traumatology, NCR International Hospital, Mücahitler Neighborhood, No: 56. Şehitkamil, 27090 Gaziantep, Turkey
| | - Bülent Sakarya
- Department of Orthopedics and Traumatology, Mersin Toros Government Hospital, Cemalpaşa Neighborhood. 5314 Street, Akdeniz, Mersin, Turkey
| | - Necla Benlier
- Department of Medical Pharmacology, Sanko University School of Medicine, Ali Fuat Cebesoy Boulevard. No: 45, Şehitkamil, Gaziantep, Turkey
| | - Füsun Kökçü
- Department of Nuclear Medicine, Medical Park Gaziantep Hospital, Mücahitler Neighborhood, 52063 St., Şehitkamil, 27584 Gaziantep, Turkey
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Simon MJK, Beyersdorff J, Strahl A, Rolvien T, Rüther W, Niemeier A. Diagnostic value of open incisional biopsies in suspected, difficult-to-diagnose periprosthetic hip joint infection prior to revision surgery. Arch Orthop Trauma Surg 2023; 143:1663-1670. [PMID: 35348871 PMCID: PMC9957879 DOI: 10.1007/s00402-022-04402-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/20/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Prior to revision of total hip arthroplasty (THA), low-grade chronic periprosthetic joint infection (PJI) is often difficult to diagnose. We aimed to determine the diagnostic accuracy of open incisional tissue biopsy for the prediction of PJI prior to THA revision in cases with culture-negative or dry tap joint aspirates. MATERIALS AND METHODS This retrospective single-center study includes 32 consecutive THA revision cases with high clinical suspicion of low-grade chronic PJI of the hip with culture-negative or dry tap joint aspirates and without systemic signs of infection. Open incisional biopsy (OIB) was performed prior to revision surgery. Periprosthetic tissue samples were analyzed by microbiology and histopathology for PJI. During definitive revision arthroplasty, identical diagnostics were repeated. Results from both procedures were compared and sensitivity, specificity, positive and negative predictive values of OIB for the final diagnosis were calculated. RESULTS Average age at revision was 69.3 ± 13.5 years. The sensitivity of the OIB procedure was 80% (microbiology), 69% (histology) and 82% for combined analyses (microbiology and histology). Specificity of OIB was 80% (microbiology), 94% (histology) and 60% for combined analyses. CONCLUSIONS Open tissue biopsy performed in cases with culture-negative or inconclusive synovial fluid aspirates prior to revision of THA has limited diagnostic accuracy for the prediction of PJI. The procedure does not reliably close the diagnostic gap in a substantial number of cases. In this difficult patient population, risk of an open procedure may outweigh benefits and alternative less invasive methods should be considered for the preoperative diagnosis of PJI.
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Affiliation(s)
- M. J. K. Simon
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany ,Department of Orthopaedics and Trauma Surgery, University Medical Center Schleswig-Holstein, Arnold-Heller-Str. 3, 24105 Kiel, Germany
| | - J. Beyersdorff
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - A. Strahl
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - T. Rolvien
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - W. Rüther
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Andreas Niemeier
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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11
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Soliman SB, Davis JJ, Muh SJ, Vohra ST, Patel A, van Holsbeeck MT. Ultrasound evaluations and guided procedures of the painful joint arthroplasty. Skeletal Radiol 2022; 51:2105-2120. [PMID: 35624311 DOI: 10.1007/s00256-022-04080-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/22/2022] [Accepted: 05/22/2022] [Indexed: 02/02/2023]
Abstract
The purpose of this article is to describe the use of ultrasound for the diagnosis and treatment of painful joint arthroplasty. Ultrasound plays a crucial role in the diagnosis of the painful joint arthroplasty, especially given its unique dynamic capabilities, convenience, and high resolution. Ultrasound guidance is also instrumental for procedures in both diagnosing and in select cases, treating the painful joint arthroplasty. Topics to be discussed in this article include trends in arthroplasty placement, benefits of the use of ultrasound overall, and ultrasound evaluation of periprosthetic joint infections. We will also review the sonographic findings with dissociated/displaced components and adverse reaction to metallic debris including metallosis, trunnionosis, and metal-on-metal pseudotumors. Additionally, we will discuss ultrasound evaluation of tendon pathologies with arthroplasties, including dynamic maneuvers to evaluate for tendon impingement/snapping. Finally, we will cover ultrasound-guided joint arthroplasty injection indications and precautions. KEY POINTS: • Ultrasound is preferred over MRI in patients with joint arthroplasty and plays a crucial role in diagnosis, especially given its unique dynamic capabilities, convenience and high resolution. • It is especially beneficial for US-guided aspiration in periprosthetic joint infections; effectively used to evaluate periprosthetic fluid collections, facilitating differentiation between abscesses and aseptic collections, and tracking sinus tracts. • Recently, the diagnosis of periprosthetic joint infections has shifted focus to biomarkers in the periprosthetic fluid, specifically α-defensin, which has a high sensitivity and specificity for diagnosing infection. • Cutibacterium acnes is a major pathogen responsible for shoulder arthroplasty infections, often presenting with normal laboratory values and since slow growing, must be kept for a minimum of 14 days.
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Affiliation(s)
- Steven B Soliman
- Division of Musculoskeletal Radiology, Department of Radiology, Henry Ford Hospital, Detroit, MI, USA.
| | - Jason J Davis
- Division of Orthopedic Surgery, Department of Orthopedics, Henry Ford Hospital, Detroit, MI, USA
| | - Stephanie J Muh
- Division of Orthopedic Surgery, Department of Orthopedics, Henry Ford Hospital, Detroit, MI, USA
| | - Saifuddin T Vohra
- Division of Musculoskeletal Radiology, Department of Radiology, Henry Ford Hospital, Detroit, MI, USA
| | - Ashish Patel
- Division of Musculoskeletal Imaging, Department of Radiology, Vanderbilt University, Nashville, TN, USA
| | - Marnix T van Holsbeeck
- Division of Musculoskeletal Radiology, Department of Radiology, Henry Ford Hospital, Detroit, MI, USA
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12
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Serfaty A, Jacobs A, Gyftopoulos S, Samim M. Likelihood of hip infection with image-guided hip aspiration dry tap: a 10-year retrospective study. Skeletal Radiol 2022; 51:1947-1958. [PMID: 35359220 DOI: 10.1007/s00256-022-04046-0] [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] [Received: 12/13/2021] [Revised: 03/27/2022] [Accepted: 03/27/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the rate of infection in patients with suspected hip septic arthritis who underwent image-guided aspiration (IHA) resulting in dry-tap, diagnostic value of subsequent lavage and re-aspiration, and if pre-aspiration MRI can help prevent a dry tap. MATERIALS AND METHODS Retrospective review between 2010 to 2020 identified native hip (NH) and total hip arthroplasty (THA) patients who had a dry-tap following aspiration for suspected infection or periprosthetic joint infection (PJI). Serology tests, lavage/re-aspiration volumes, and aspirate cell-count/culture were assessed. On pre-aspiration MRI, presence/grade of joint effusion (JE), pseudocapsule dehiscence (PD), extraarticular fluid and sinus-tract were recorded. RESULTS Out of 215 included dry-taps, 185 (86.0%) were non-infected and 30 (13.9%) infected. In subgroup analysis, 64/71(90.1%) NH and 121/144(84.0%) THA dry-taps were non-infected. Pre-aspiration MRI of THA group with dry-tap showed significant findings; PD with extraarticular fluid (8/12, 66.7%) and sinus tract (7/12, 58.3%) were higher in the infected compared to non-infected group (5/42, 11.9% and 0/42, 0.0%) (both p < 0.001). Among THA group, polymorphonuclear-leukocytes > 80% was present in 8/9 (88.9%) of infected versus 4/28 (14.3%) non-infected group (p < 0.001). Multivariable regression showed PD (p = 0.005) and JE (p = 0.042) being significant independent predictors of PJI, similarly the elevated CRP (p = 0.044) and JE (p = 0.017). CONCLUSION Majority of patients suspected of hip joint infection with dry-tap were non-infected. Synovial PMN% following lavage maintains high sensitivity for detection of PJI. In patients with THA, PD and subsequent extraarticular collection can be associated with dry-tap therefore, pre-aspiration MRI can help determine their presence and plan the aspiration.
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Affiliation(s)
- Aline Serfaty
- Department of Radiology, Faculty of Medicine, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, RJ, Brazil. .,Medscanlagos Radiology, rua Manoel Francisco Valentim, 57, Cabo Frio, RJ, 28906220, Brazil.
| | - Adam Jacobs
- NYU Langone Medical Center, New York University, New York, NY, USA
| | | | - Mohammad Samim
- NYU Langone Medical Center, New York University, New York, NY, USA
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13
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Goh GS, Parvizi J. Diagnosis and Treatment of Culture-Negative Periprosthetic Joint Infection. J Arthroplasty 2022; 37:1488-1493. [PMID: 35101593 DOI: 10.1016/j.arth.2022.01.061] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/18/2022] [Indexed: 02/02/2023] Open
Abstract
Identification of the causative organism(s) in periprosthetic joint infection (PJI) is a challenging task. The shortcomings of traditional cultures have been emphasized in recent literature, culminating in a clinical entity known as "culture-negative PJI." Amidst the growing burden of biofilm infections that are inherently difficult to culture, the field of clinical microbiology has seen a paradigm shift from culture-based to molecular-based methods. These novel techniques hold much promise in the demystification of culture-negative PJI and revolutionization of the microbiology laboratory. This article outlines the clinical implications of culture-negative PJI, common causes of this diagnostic conundrum, established strategies to improve culture yield, and newer molecular techniques to detect infectious organisms.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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14
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Huang C, Chen Y, Ding H, Huang Z, Zhang C, Li W, Liu X, Tu Z, Zhang W, Fang X. Metal Artifact Reduction Sequences MRI: A Useful Reference for Preoperative Diagnosis and Debridement Planning of Periprosthetic Joint Infection. J Clin Med 2022; 11:jcm11154371. [PMID: 35955986 PMCID: PMC9369276 DOI: 10.3390/jcm11154371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/11/2022] [Accepted: 07/22/2022] [Indexed: 11/26/2022] Open
Abstract
The diagnosis and treatment of periprosthetic joint infection (PJI) is complex and the use of MRI in PJI is gaining attention from orthopedic surgeons as MR technology continues to advance. This study aimed to investigate whether metal artefact reduction sequence (MARS) MRI could be used as an adjunct in the preoperative diagnosis of PJI and to explore its role in PJI debridement planning. From January 2020 to November 2021, participants with metal joint prostheses that needed to be judged for infection were prospectively enrolled. According to Musculoskeletal Infection Society standards, 31 cases were classified as infection, and 20 as non-infection. The sensitivity and specificity of MARS MRI for the diagnosis of PJI were 80.65% and 75%, respectively. In MARS MRI, the incidence of bone destruction, lamellar synovitis, and extracapsular soft tissue oedema were significantly higher in PJI than in non-PJI. Fourteen suspicious occult lesions were found in the preoperative MARS MRI in 9 cases, and the location of 9 infection lesions was confirmed intraoperatively. In conclusion, MARS MRI is an effective diagnostic tool for PJIand can provide a visual reference for preoperative surgical planning.
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Affiliation(s)
- Changyu Huang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350000, China; (C.H.); (Y.C.); (H.D.); (Z.H.); (C.Z.); (W.L.)
| | - Yang Chen
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350000, China; (C.H.); (Y.C.); (H.D.); (Z.H.); (C.Z.); (W.L.)
| | - Haiqi Ding
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350000, China; (C.H.); (Y.C.); (H.D.); (Z.H.); (C.Z.); (W.L.)
| | - Zida Huang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350000, China; (C.H.); (Y.C.); (H.D.); (Z.H.); (C.Z.); (W.L.)
| | - Chaofan Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350000, China; (C.H.); (Y.C.); (H.D.); (Z.H.); (C.Z.); (W.L.)
| | - Wenbo Li
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350000, China; (C.H.); (Y.C.); (H.D.); (Z.H.); (C.Z.); (W.L.)
| | - Xi Liu
- Department of Radiology and Imaging, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350000, China; (X.L.); (Z.T.)
| | - Zhanhai Tu
- Department of Radiology and Imaging, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350000, China; (X.L.); (Z.T.)
| | - Wenming Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350000, China; (C.H.); (Y.C.); (H.D.); (Z.H.); (C.Z.); (W.L.)
- Correspondence: (W.Z.); (X.F.)
| | - Xinyu Fang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350000, China; (C.H.); (Y.C.); (H.D.); (Z.H.); (C.Z.); (W.L.)
- Correspondence: (W.Z.); (X.F.)
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15
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Bohard L, Patry I, Sergent P, Leclerc G, Leroy J, Chirouze C, Bouiller K. Factors associated with late microbiological documentation of prosthetic joint infection. Future Microbiol 2022; 17:1115-1124. [PMID: 35860979 DOI: 10.2217/fmb-2021-0310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Purpose: To describe the number of prosthetic joint infections (PJIs) with late documentation and to identify associated factors. Methods: Bacterial PJIs with surgical management between November 2015 and November 2019 in a French center were analyzed. Results of short (72 h) and late culture (at 14 days) were analyzed. Results: A total of 160 PJIs were reported with 215 bacteria. Twenty-nine patients had late documentation (18.1%). The bacteria most involved were coagulase-negative staphylococci and Cutibacterium spp. (60%). In multivariate analysis, late chronic PJI (odds ratio = 2.47) and antibiotic therapy before surgery (odds ratio = 3.13) were associated with late-documented infection. Conclusion: A better knowledge of the factors associated with late-documented infections is essential in order to simplify antibiotic treatment at the appropriate time.
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Affiliation(s)
- Louis Bohard
- Department of Infectious Diseases, CHU Besancon, Besancon, 25000, France
| | - Isabelle Patry
- Department of Bacteriology, CHU Besancon, Besancon, 25000, France
| | - Pauline Sergent
- Department of Orthopedic, Trauma, Plastic & Reconstructive Surgery & Hand Clinic, CHU Besancon, Besancon, 25000, France
| | - Grégoire Leclerc
- Department of Orthopedic, Trauma, Plastic & Reconstructive Surgery & Hand Clinic, CHU Besancon, Besancon, 25000, France
| | - Joël Leroy
- Department of Infectious Diseases, CHU Besancon, Besancon, 25000, France
| | - Catherine Chirouze
- Department of Infectious Diseases, CHU Besancon, Besancon, 25000, France.,UMR-CNRS 6249 Chrono-Environnement, Université Bourgogne Franche-Comté, Besancon, Besancon, 25000, France
| | - Kevin Bouiller
- Department of Infectious Diseases, CHU Besancon, Besancon, 25000, France.,UMR-CNRS 6249 Chrono-Environnement, Université Bourgogne Franche-Comté, Besancon, Besancon, 25000, France
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16
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Barretto JM, Campos ALS, Ooka NHM. Periprosthetic Knee Infection - Part 1: Risk Factors, Classification and Diagnosis. Rev Bras Ortop 2022; 57:185-192. [PMID: 35652026 PMCID: PMC9142234 DOI: 10.1055/s-0041-1729935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/17/2020] [Indexed: 11/19/2022] Open
Abstract
Infection is one of the most feared complications in the postoperative period of knee arthroplasties. With the progressive aging of the population and the increased incidence of degenerative joint diseases, there is an exponential increase in the number of arthroplasties performed and, consequently, in the number of postoperative infections. The diagnosis of these should follow a hierarchical protocol, with well-defined criteria, which lead to diagnostic conclusion, thus guiding the most appropriate treatment. The aim of the present update article is to present the main risk factors, classifications and, mainly, to guide diagnostic investigation in an organized manner.
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Affiliation(s)
| | - André Luiz Siqueira Campos
- Departamento de Ortopedia e Traumatologista, Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brasil
| | - Nelson Hiroyuki Miyabe Ooka
- Departamento de Ortopedia e Traumatologista, Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ, Brasil.,Departamento de Ortopedia e Traumatologista, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, RJ, Brasil
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17
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Mondanelli N, Troiano E, Facchini A, Ghezzi R, Di Meglio M, Nuvoli N, Peri G, Aiuto P, Colasanti GB, Giannotti S. Treatment Algorithm of Periprosthetic Femoral Fracturens. Geriatr Orthop Surg Rehabil 2022; 13:21514593221097608. [PMID: 35573905 PMCID: PMC9096211 DOI: 10.1177/21514593221097608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction. The ever-expanding indications for total hip arthroplasty are leading to more implants being placed in younger as well as in older patients with high functional demand. Also, prolonged life expectancy is contributing to an overall increment of periprosthetic femoral fractures. The Vancouver classification has been the most used for guiding the surgeon choice since its proposal in 1995. Fractures occurring over a hip femoral implant can be divided into intra-operative and post-operative PFFs, and their treatment depends on factors that may severely affect the outcome: level of fracture, implant stability, quality of bone stock, patients' functional demand, age and comorbidities, and surgeon expertise. There are many different treatment techniques available which include osteosynthesis and revision surgery or a combination of both. The goals of surgical treatment are patients' early mobilization, restoration of anatomical alignment and length with a stable prosthesis and maintenance of bone stock. Significance. The aim of this review is to describe the state-of-the-art treatment and outcomes in the management of PFFs. We performed a systematic literature review of studies reporting on the management of PFFs around hip stems and inter-prosthetic fractures identifying 45 manuscripts eligible for the analysis. Conclusions. PFFs present peculiar characteristic that must be considered and special features that must be addressed. Their management is complex due to the extreme variability of stem designs, the possibility of having cemented or uncemented stems, the difficulty in identifying the "real" level of the fracture and the actual stability of the stem. As a result, the definition of a standardized treatment is unlikely, thereby high expertise is fundamental for the surgical management of PPFs, so this kind of fractures should be treated only in specialized centres with both high volume of revision joint arthroplasty and trauma surgery.
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Affiliation(s)
- Nicola Mondanelli
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
- Section of Orthopedics, Policlinico Santa Maria alle Scotte, Azienda Ospedaliero-Universitaria Senese, Italy
| | - Elisa Troiano
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
- Section of Orthopedics, Policlinico Santa Maria alle Scotte, Azienda Ospedaliero-Universitaria Senese, Italy
| | - Andrea Facchini
- Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia, Italy
| | - Roberta Ghezzi
- Ospedale Santa Maria degli Angeli, Azienda Sanitaria Friuli Occidentale, Italy
| | - Martina Di Meglio
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
- Section of Orthopedics, Policlinico Santa Maria alle Scotte, Azienda Ospedaliero-Universitaria Senese, Italy
| | - Nicolò Nuvoli
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
- Section of Orthopedics, Policlinico Santa Maria alle Scotte, Azienda Ospedaliero-Universitaria Senese, Italy
| | - Giacomo Peri
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
- Section of Orthopedics, Policlinico Santa Maria alle Scotte, Azienda Ospedaliero-Universitaria Senese, Italy
| | - Pietro Aiuto
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
- Section of Orthopedics, Policlinico Santa Maria alle Scotte, Azienda Ospedaliero-Universitaria Senese, Italy
| | - Giovanni Battista Colasanti
- Section of Orthopedics, Policlinico Santa Maria alle Scotte, Azienda Ospedaliero-Universitaria Senese, Italy
- Ospedale Santa Maria delle Croci, Azienda USL della Romagna, Italy
| | - Stefano Giannotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
- Section of Orthopedics, Policlinico Santa Maria alle Scotte, Azienda Ospedaliero-Universitaria Senese, Italy
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18
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Christensen TH, Ong J, Lin D, Aggarwal VK, Schwarzkopf R, Rozell JC. How Does a "Dry Tap" Impact the Accuracy of Preoperative Aspiration Results in Predicting Chronic Periprosthetic Joint Infection? J Arthroplasty 2022; 37:925-929. [PMID: 35114320 DOI: 10.1016/j.arth.2022.01.066] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/13/2022] [Accepted: 01/25/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is challenging to diagnose. We aimed to evaluate the impact of dry taps requiring saline lavage during preoperative intra-articular hip aspiration on the accuracy of diagnosing PJI before revision surgery. METHODS A retrospective review was conducted for THA patients with suspected PJI who received an image-guided hip aspiration from May 2016 to February 2020. Musculoskeletal Infection Society (MSIS) diagnostic criteria for PJI were compared between patients who had dry tap (DT) vs successful tap (ST). Sensitivity and specificity of synovial markers were compared between the DT and ST groups. Concordance between preoperative and intraoperative cultures was determined for the 2 groups. RESULTS In total, 335 THA patients met inclusion criteria. A greater proportion of patients in the ST group met MSIS criteria preoperatively (30.2% vs 8.3%, P < .001). Patients in the ST group had higher rates of revision for PJI (28.4% vs 17.5%, P = .026) and for any indication (48.4% vs 36.7%, P = .039). MSIS synovial white blood cell count thresholds were more sensitive in the ST group (90.0% vs 66.7%). There was no difference in culture concordance (67.9% vs 65.9%, P = .709), though the DT group had a higher rate of negative preoperative cultures followed by positive intraoperative cultures (85.7% vs 41.1%, P = .047). CONCLUSION Our results indicate that approximately one third of patients have dry hip aspiration, and in these patients cultures are less predictive of intraoperative findings. This suggests that surgeons considering potential PJI after THA should apply extra scrutiny when interpreting negative results in patients who require saline lavage for hip joint aspiration.
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Affiliation(s)
| | - Justin Ong
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Dana Lin
- Department of Radiology, NYU Langone Health, New York, NY
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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19
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Zingg M, Kheir MM, Ziemba-Davis M, Meneghini RM. Reduced Infection Rate After Aseptic Revision Total Knee Arthroplasty With Extended Oral Antibiotic Protocol. J Arthroplasty 2022; 37:905-909. [PMID: 35077819 DOI: 10.1016/j.arth.2022.01.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The optimal postoperative antibiotic duration has not been determined for aseptic revision total knee arthroplasty (R-TKA) where the risk of periprosthetic joint infection (PJI) is 3%-7.5%. This study compared PJI rates in aseptic R-TKA performed with extended oral antibiotic prophylaxis (EOAP) to published rates. METHODS Aseptic R-TKAs consecutively performed between 2013 and 2017 at a tertiary care referral center in the American Midwest were retrospectively reviewed. All patients were administered intravenous antibiotics while hospitalized and discharged on 7-day oral antibiotic prophylaxis. Infection rates and antibiotic-related complications were assessed. RESULTS Sixty-seven percent of the 176 analysis patients were female, with an average age of 64 years and body mass index of 35 kg/m2. Instability and aseptic loosening comprised 86% of revision diagnoses. Overall, 87.5% of intraoperative cultures were negative, and the remainder were single positive cultures considered contaminants. PJI rates were 0% at 90 days, 1.8% (95% confidence interval 0.4%-5.3%) at 1 year, and 2.2% (95% confidence interval 0.6%-5.7%) at mean follow-up of approximately 3 years (range, 7-65 months). CONCLUSION EOAP after aseptic R-TKA resulted in a PJI rate equivalent to primary TKA, representing a 2- to-4-fold decrease compared with published aseptic R-TKA infection rates. Further study on the benefits and costs of EOAP after aseptic R-TKA is encouraged.
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Affiliation(s)
- Matthieu Zingg
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, University Hospitals of Geneva
| | - Michael M Kheir
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - R Michael Meneghini
- Indiana University Health Saxony Hip & Knee Center, Fishers, IN; Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
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20
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Troiano E, Giacché T, Facchini A, Orlandi NC, Cacioppo M, Saviori M, Bottai V, Muratori F, Mondanelli N, Giannotti S. Surgical and Pharmacological Management of Periprosthetic Atypical Femoral Fractures: A Narrative Literature Review. Geriatr Orthop Surg Rehabil 2022; 13:21514593221090392. [PMID: 35433102 PMCID: PMC9006379 DOI: 10.1177/21514593221090392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 12/09/2021] [Accepted: 01/08/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction An increasing number of patients is annually undergoing total hip arthroplasty (THA), and a significant proportion of these patients are elderly and consequently at a higher risk of complications because of age, osteoporosis, and medical comorbidities. Periprosthetic femoral fractures (PFFs) are one of the worst complications of THA associated with high rates of unfavorable prognosis. Besides, in the last decade, a new independent disease entity called “atypical femoral fracture” (AFF) has been identified and defined by the American Society for Bone and Mineral Research (ASBMR) task force. Some PFFs present clinical history and radiographic aspect consistent with an AFF, meeting the ASBMR criteria for the diagnosis of AFF except that PFFs by themselves are an exclusion criterion for AFF. However, there is an increasing number of published studies suggesting that periprosthetic atypical femoral fractures (PAFFs) exist and should not be excluded by definition. Significance Nowadays, although there is an increasing interest in PAFFs, there are still very few studies published on the topic and a lack of consensus regarding their treatment. This narrative literature review aims to introduce this new emerging topic to a wider readership describing the characteristics of PAFFs and the state-of-the-art in their management. Conclusions Many authors agree that PAFFs should be considered as a subgroup of PFFs that have atypical characteristics; they also show a significant correlation with prolonged bisphosphonate use. A correct diagnosis is paramount for proper treatment of the disease that requires both surgical and medical actions to be taken.
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Affiliation(s)
- Elisa Troiano
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Tiziano Giacché
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Andrea Facchini
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Nicholas Crippa Orlandi
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Matteo Cacioppo
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Marco Saviori
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Vanna Bottai
- Second Clinic of Orthopedic and Traumatology, University of Pisa, Pisa, Italy
| | - Francesco Muratori
- Section of Orthopedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Nicola Mondanelli
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Stefano Giannotti
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
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21
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[Microbiological diagnosis of implant-associated infections : Retrospective analysis of 133 patients in an arthroplasty center]. DER ORTHOPADE 2022; 51:531-539. [PMID: 35089368 DOI: 10.1007/s00132-022-04212-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Because standardized microbiological cultures of puncture fluids and tissue samples often do not provide pathogen detection in implant-associated infections, sonication and polymerase chain reaction (PCR) are used additionally today. OBJECTIVES Pathogen spectra and previous microbiological standards are examined for agreement of results using the new methods sonication and PCR. MATERIALS AND METHODS In this descriptive, retrospective observational study, we evaluated the data of 133 patients in whom a joint prosthesis, osteosynthesis material or a spacer was removed during revision surgery with suspected implant-associated infection and sent for sonication. RESULTS Pathogen detection was achieved by culture of peri-implant material in 40.1% and by sonication in 42.5%. In each case, coagulase-negative staphylococci were detected most frequently. Overall, the results were consistent in 71.7% of cases. In the discrepant cases, more anaerobes could be detected by sonication, especially for osteosynthesis material and knee prostheses. PCR analyses in 21 cases showed pathogen detection in 14.3% and agreement with the results of peri-implant tissue culture and sonication in 57.1% and 66.7%, respectively. CONCLUSIONS The present results indicate a gain in sensitivity of sonication, especially for anaerobes that are difficult to grow, and a gain in specificity through sonication. PCR analyses should be reserved for specific questions.
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22
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Ong J, Tang A, Rozell JC, Babb JS, Schwarzkopf R, Lin D. Factors predicting hip joint aspiration yield or “dry taps” in patients with total hip arthroplasty. J Orthop Surg Res 2022; 17:42. [PMID: 35065660 PMCID: PMC8783512 DOI: 10.1186/s13018-022-02942-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/24/2021] [Indexed: 11/29/2022] Open
Abstract
Background Image-guided joint aspirations used to assist the diagnosis of periprosthetic joint infection (PJI) may commonly result in a dry tap–or insufficient fluid for culture and cell count analysis. Dry tap aspirations are painful and invasive for patients and often utilize a subsequent saline lavage to obtain a microbiology sample. Currently, there is a paucity of the literature addressing predictors that could suggest whether a dry tap will occur. The purpose of this study was to examine the effects of various factors on “dry tap” occurrence in patients with suspected PJI following total hip arthroplasty (THA). Methods A retrospective review was performed among THA patients suspected for PJI who received image-guided joint aspiration procedures at our institution from May 2016 to February 2020. The procedural factors included the imaging modality used for aspiration, anatomic approach, needle gauge size used, and the presence of a trainee. The patient-specific factors included number of prior ipsilateral hip surgeries, femoral head size, ESR/CRP values, and BMI. Results In total, 336 patients met our inclusion criteria. One hundred and twenty hip aspirations resulted in a dry tap (35.7%) where the patients underwent a saline lavage. Among the procedural and patient-specific factors, none of the factors were found to be statistically different between the two cohorts nor conferred any greater odds of a dry tap occurring. Conclusion No associations with dry tap occurrence were found among the procedural and patient-specific factors studied. Further research is needed to identify additional factors that may be more predictive of dry taps.
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Do Not Postpone Revision of Worn Conventional Liners in Ceramic-on-Polyethylene Total Hip Arthroplasty: A New Dramatic Failure. Arthroplast Today 2021; 10:108-113. [PMID: 34345640 PMCID: PMC8319508 DOI: 10.1016/j.artd.2021.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 12/03/2022] Open
Abstract
Catastrophic failure of ceramic-on-polyethylene total hip arthroplasty is still occasionally described. We report on a new case of complete atraumatic penetration of an intact ceramic head through the titanium cup in a cementless total hip arthroplasty due to dramatic polyethylene and metal wear. We reviewed the literature for similar cases and analyzed potential risk factors. Most importantly, revision of radiologically worn liners should not be postponed, especially in young and active patients with conventional liners, because the time to dramatic failure could be shorter than expected.
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Ribeiro TC, Honda EK, Daniachi D, Cury RDPL, da Silva CB, Klautau GB, Salles MJ. The impact of sonication cultures when the diagnosis of prosthetic joint infection is inconclusive. PLoS One 2021; 16:e0252322. [PMID: 34255768 PMCID: PMC8277053 DOI: 10.1371/journal.pone.0252322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 05/13/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In the absence of a gold standard criterion for diagnosing prosthetic joint infections (PJI), sonication of the removed implant may provide superior microbiological identification to synovial fluid and peri-implant tissue cultures. The aim of this retrospective study was to assess the role of sonication culture compared to tissue cultures for diagnosing PJI, using different consensus and international guidelines for PJI definition. METHODS Data of 146 patients undergoing removal of hip or knee arthroplasties between 2010 and 2018 were retrospectively reviewed. The International Consensus Meeting (ICM-2018), Musculoskeletal Infection Society (MSIS), Infectious Diseases Society of America (IDSA), the European Bone and Joint Infection Society (EBJIS), and a modified clinical criterion, were used to compare the performance of microbiological tests. McNemar´s test and proportion comparison were employed to calculate p-value. RESULTS Overall, 56% (82/146) were diagnosed with PJI using the clinical criteria. Out of these cases, 57% (47/82) tested positive on tissue culture and 93% (76/82) on sonication culture. Applying this clinical criterion, the sensitivity of sonication fluid and tissue cultures was 92.7% (95% CI: 87.1%- 98.3%) and 57.3% (95% CI: 46.6%-68.0%) (p<0.001), respectively. When both methods were combined for diagnosis (sonication and tissue cultures) sensitivity reached 96.3% (95% CI: 91.5%-100%). Sonication culture and the combination of sonication with tissue cultures, showed higher sensitivity rates than tissue cultures alone for all diagnostic criteria (ICM-18, MSIS, IDSA and EBJIS) applied. Conversely, tissue culture provided greater specificity than sonication culture for all the criteria assessed, except for the EBJIS criteria, in which sonication and tissue cultures specificity was 100% and 95.3% (95% CI: 87.8-100%), respectively (p = 0.024). CONCLUSIONS In a context where diagnostic criteria available have shortcomings and tissue cultures remain the gold standard, sonication cultures can aid PJI diagnosis, especially when diagnostic criteria are inconclusive due to some important missing data (joint puncture, histology).
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Affiliation(s)
- Taiana Cunha Ribeiro
- Internal Medicine Department, Infectious Diseases Clinic, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Emerson Kiyoshi Honda
- Orthopedic and Traumatology Department, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Daniel Daniachi
- Orthopedic and Traumatology Department, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Ricardo de Paula Leite Cury
- Orthopedic and Traumatology Department, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Cely Barreto da Silva
- Department of Laboratory Medicine and Pathology, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Giselle Burlamaqui Klautau
- Internal Medicine Department, Infectious Diseases Clinic, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Mauro Jose Salles
- Internal Medicine Department, Infectious Diseases Clinic, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
- Escola Paulista de Medicina, Universidade Federal de São Paulo, Division of Infection Diseases, São Paulo, Brazil
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Biddle M, Kennedy JW, Wright PM, Ritchie ND, Meek RMD, Rooney BP. Improving outcomes in acute and chronic periprosthetic hip and knee joint infection with a multidisciplinary approach. Bone Jt Open 2021; 2:509-514. [PMID: 34247508 PMCID: PMC8325970 DOI: 10.1302/2633-1462.27.bjo-2021-0064.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIMS Periprosthetic hip and knee infection remains one of the most severe complications following arthroplasty, with an incidence between 0.5% to 1%. This study compares the outcomes of revision surgery for periprosthetic joint infection (PJI) following hip and knee arthroplasty prior to and after implementation of a specialist PJI multidisciplinary team (MDT). METHODS Data was retrospectively analyzed from a single centre. In all, 29 consecutive joints prior to the implementation of an infection MDT in November 2016 were compared with 29 consecutive joints subsequent to the MDT conception. All individuals who underwent a debridement antibiotics and implant retention (DAIR) procedure, a one-stage revision, or a two-stage revision for an acute or chronic PJI in this time period were included. The definition of successfully treated PJI was based on the Delphi international multidisciplinary consensus. RESULTS There were no statistically significant differences in patient demographics or comorbidities between the groups. There was also no significant difference in length of overall hospital stay (p = 0.530). The time taken for formal microbiology advice was significantly shorter in the post MDT group (p = 0.0001). There was a significant difference in failure rates between the two groups (p = 0.001), with 12 individuals (41.38%) pre-MDT requiring further revision surgery compared with one individual (6.67%) post-MDT inception. CONCLUSION Our standardized multidisciplinary approach for periprosthetic knee and hip joint infection shows a significant reduction in failure rates following revision surgery. Following implementation of our MDT, our success rate in treating PJI is 96.55%, higher than what current literature suggests. We advocate the role of a specialist infection MDT in the management of patients with a PJI to allow an individualized patient-centred approach and care plan, thereby reducing postoperative complications and failure rates. Cite this article: Bone Jt Open 2021;2(7):509-514.
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Zheng QY, Li R, Ni M, Ren P, Ji QB, Sun JY, Li JC, Chen JY, Zhang GQ. What Is the Optimal Timing for Reading the Leukocyte Esterase Strip for the Diagnosis of Periprosthetic Joint Infection? Clin Orthop Relat Res 2021; 479:1323-1330. [PMID: 33492869 PMCID: PMC8133206 DOI: 10.1097/corr.0000000000001609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/24/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The leucocyte esterase (LE) strip test often is used to diagnose periprosthetic joint infection (PJI). In accordance with the manufacturer's directions, the LE strip test result is read 3 minutes after exposing it to joint fluid, but this has not been supported by robust research. Moreover, we have noted that the results of the LE strip test might change over time, and our previous studies have found that centrifugation causes the results of the LE strip test to degrade. Still, there is no evidence-based recommendation as to when to read the LE strip test to maximize diagnostic accuracy, in general, and the best reading times for the LE strip test before and after centrifugation need to be determined separately, in particular. QUESTIONS/PURPOSES (1) What is the optimal timing for reading LE strip test results before centrifugation to diagnose PJI? (2) What is the optimal timing for reading LE strip test results after centrifugation to diagnose PJI? METHODS This study was a prospective diagnostic trial. In all, 120 patients who were scheduled for revision arthroplasty and had signs of infection underwent joint aspiration in the outpatient operating room between July 2018 and July 2019 and were enrolled in this single-center study. For inclusion, patients must have had a diagnosis of PJI or nonPJI, valid synovial fluid samples, and must not have received antibiotics within 2 weeks before arthrocentesis. As such, 36 patients were excluded; 84 patients were included for analysis, and all 84 patients agreed to participate. The 2018 International Consensus Meeting Criteria (ICM 2018) was used for the classification of 49 patients with PJI (score ≥ 6) and 35 without PJI (score ≤ 2). The classification was used as the standard against which the different timings for reading LE strips were compared. All patients without PJI were followed for more than 1 year, during which they did not report the occurrence of PJI. All patients were graded against the diagnostic criteria regardless of their LE strip test results. In 83 patients, one drop of synovial fluid (50 μL) was applied to LE strips before and after centrifugation, and in one patient (without PJI), the sample was not centrifuged because the sample volume was less than 1.5 mL. The results of the strip test were read on an automated colorimeter. Starting from 1 minute after centrifugation, these strips were automatically read once every minute, 15 times (over a period of 16 minutes), and the results were independently recorded by two observers. Results were rated as negative, ±, 1+, and 2+ upon the machine reading. Grade 2+ (dark purple) was used as the threshold for a positive result. An investigator who was blinded to the study performed the statistics. Optimal timing for reading the LE strip before and after centrifugation was determined by using receiver operative characteristic (ROC) analysis. The specificity, sensitivity, and positive predictive and negative predictive values were calculated for key timepoints. RESULTS Before centrifugation, the area under the curve was the highest when the results were read at 5 minutes (0.90 [95% CI 0.83 to 0.98]; sensitivity 0.88 [95% CI 0.75 to 0.95]; specificity 0.89 [95% CI 0.72 to 0.96]). After centrifugation, the area under the curve was the highest when the results were read at 10 minutes (0.92 [95% CI 0.86 to 0.98]; sensitivity 0.65 [95% CI 0.50 to 0.78]; specificity 0.97 [95% CI 0.83 to 1.00]). CONCLUSION The LE strip test results are affected by time and centrifugation. For samples without centrifugation, we found that 5 minutes after application was the best time to read LE strips. We cannot deny the use of centrifuges because this is an effective way to solve the sample-mingling problem at present. We recommend 10 minutes postapplication as the most appropriate time to read LE strips after centrifugation. Multicenter and large-sample size studies are warranted to further verify our conclusion. LEVEL OF EVIDENCE Level II, diagnostic study.
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Affiliation(s)
- Qing-yuan Zheng
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Rui Li
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Ming Ni
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Peng Ren
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Quan-bo Ji
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Jing-yang Sun
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Jun-cheng Li
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Ji-ying Chen
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Guo-qiang Zhang
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
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Goh GS, Parvizi J. Think Twice before Prescribing Antibiotics for That Swollen Knee: The Influence of Antibiotics on the Diagnosis of Periprosthetic Joint Infection. Antibiotics (Basel) 2021; 10:antibiotics10020114. [PMID: 33530305 PMCID: PMC7911292 DOI: 10.3390/antibiotics10020114] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 12/23/2022] Open
Abstract
Periprosthetic joint infection (PJI) is a rare but devastating complication after total joint arthroplasty. An estimated 7-12% of patients have negative cultures despite clear clinical evidence of infection. One oft-cited reason for this occurrence is the administration of antibiotics in the weeks prior to obtaining cultures. This article reviews the influence of antibiotics on the diagnosis of PJI. Specifically, we examine the effect of prophylactic and therapeutic antibiotic administration on the diagnostic accuracy of microbiological cultures as well as serum and synovial biomarkers. We also explore the potential of molecular techniques in overcoming these limitations in patients who have received antibiotics before specimen collection and propose areas for future research.
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Baldan R, Sendi P. Precision Medicine in the Diagnosis and Management of Orthopedic Biofilm Infections. Front Med (Lausanne) 2020; 7:580671. [PMID: 33240905 PMCID: PMC7683765 DOI: 10.3389/fmed.2020.580671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/22/2020] [Indexed: 01/02/2023] Open
Abstract
Orthopedic biofilm infections are difficult to treat and require a multidisciplinary approach to diagnostics and management. Recent advances in the field include methods to disrupt biofilm, sequencing tools, and antibiotic susceptibility tests for bacteria residing in biofilm. The observation of interclonal differences in biofilm properties of the causative microorganisms, together with considerations of comorbidities and polypharmacy in a growing aging population, calls for a personalized approach to treat these infections. In this article, we highlight aspects of precision medicine that may open new perspectives in the diagnosis and management of orthopedic biofilm infections.
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Affiliation(s)
- Rossella Baldan
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland.,Centre for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
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Zheng QY, Zhang GQ. Application of leukocyte esterase strip test in the screening of periprosthetic joint infections and prospects of high-precision strips. ARTHROPLASTY 2020; 2:34. [PMID: 35236471 PMCID: PMC8796411 DOI: 10.1186/s42836-020-00053-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/12/2020] [Indexed: 12/19/2022] Open
Abstract
Periprosthetic joint infection (PJI) represents one of the most challenging complications after total joint arthroplasty (TJA). Despite the availability of a variety of diagnostic techniques, the diagnosis of PJI remains a challenge due to the lack of well-established diagnostic criteria. The leucocyte esterase (LE) strips test has been proved to be a valuable diagnostic tool for PJI, and its weight in PJI diagnostic criteria has gradually increased. Characterized by its convenience, speed and immediacy, leucocyte esterase strips test has a prospect of broad application in PJI diagnosis. Admittedly, the leucocyte esterase strips test has some limitations, such as imprecision and liability to interference. Thanks to the application of new technologies, such as machine reading, quantitative detection and artificial intelligence, the LE strips test is expected to overcome the limitations and improve its accuracy.
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Diagnostic accuracy of MRI with metal artifact reduction for the detection of periprosthetic joint infection and aseptic loosening of total hip arthroplasty. Eur J Radiol 2020; 131:109253. [DOI: 10.1016/j.ejrad.2020.109253] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/22/2020] [Accepted: 08/19/2020] [Indexed: 11/20/2022]
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Oenning S, Moellenbeck B, Gosheger G, Schmidt-Bräkling T, Schwarze J, Ackmann T, Schneider KN, Theil C. Fungal Periprosthetic Knee Joint Infection in a Patient with Metamizole-Induced Agranulocytosis. Arthroplast Today 2020; 6:726-730. [PMID: 32923558 PMCID: PMC7475080 DOI: 10.1016/j.artd.2020.07.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/17/2020] [Accepted: 07/25/2020] [Indexed: 12/25/2022] Open
Abstract
We present the case of a 55-year-old female patient with metamizole-induced agranulocytosis after total knee arthroplasty, leading to septic periprosthetic joint infections (PJIs). Owing to metamizole-induced agranulocytosis, the synovial leukocyte count was negative. Here, we discuss the diagnostic challenges evolving from sepsis and neutropenia in patients with suspected PJIs. We suggest an urgent surgical approach, mainly focusing on the clinical presentation preoperatively. Later, our patient developed candidemia and periprosthetic tissue samples were positive for Candida albicans. For fungal PJIs, long-term follow-up studies are lacking and therapeutic recommendations differ. Here, we present our therapeutic approach, including staged revision and 12 weeks of systemic antifungal therapy, and discuss recent findings regarding the therapy of fungal PJIs.
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Affiliation(s)
- Sebastian Oenning
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Burkhard Moellenbeck
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Georg Gosheger
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Tom Schmidt-Bräkling
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Jan Schwarze
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Thomas Ackmann
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Kristian Nikolaus Schneider
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Christoph Theil
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
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Albano D, Messina C, Zagra L, Andreata M, De Vecchi E, Gitto S, Sconfienza LM. Failed Total Hip Arthroplasty: Diagnostic Performance of Conventional
MRI
Features and Locoregional Lymphadenopathy to Identify Infected Implants. J Magn Reson Imaging 2020; 53:201-210. [DOI: 10.1002/jmri.27314] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
- Domenico Albano
- IRCCS Istituto Ortopedico Galeazzi, Unità Operativa di Radiologia Diagnostica ed Interventistica Milan Italy
- Sezione di Scienze Radiologiche, Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata Università degli Studi di Palermo Palermo Italy
| | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, Unità Operativa di Radiologia Diagnostica ed Interventistica Milan Italy
- Dipartimento di Scienze Biomediche per la Salute Università degli Studi di Milano Milan Italy
| | - Luigi Zagra
- IRCCS Istituto Ortopedico Galeazzi, Hip Department Milan Italy
| | - Mauro Andreata
- IRCCS Istituto Ortopedico Galeazzi, Hip Department Milan Italy
| | - Elena De Vecchi
- IRCCS Istituto Ortopedico Galeazzi Laboratory of Clinical Chemistry and Microbiology Milan Italy
| | - Salvatore Gitto
- Dipartimento di Scienze Biomediche per la Salute Università degli Studi di Milano Milan Italy
| | - Luca M. Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Unità Operativa di Radiologia Diagnostica ed Interventistica Milan Italy
- Dipartimento di Scienze Biomediche per la Salute Università degli Studi di Milano Milan Italy
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Septic Arthritis: An Evidence-Based Review of Diagnosis and Image-Guided Aspiration. AJR Am J Roentgenol 2020; 215:568-581. [PMID: 32783556 DOI: 10.2214/ajr.20.22773] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE. The purpose of this evidence-based review is to equip radiologists to discuss and interpret findings obtained with various imaging modalities, guide patient selection for percutaneous aspiration, and safely perform arthrocentesis to assess for infection in both native and prosthetic joints. CONCLUSION. Septic arthritis is an emergency that can lead to rapidly progressive, irreversible joint damage. Despite the urgency associated with this diagnosis, there remains a lack of consensus regarding many aspects of the management of native and periprosthetic joint infections.
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Boyle KK, Kapadia M, Landy DC, Henry MW, Miller AO, Westrich GH. Utilization of Debridement, Antibiotics, and Implant Retention for Infection After Total Joint Arthroplasty Over a Decade in the United States. J Arthroplasty 2020; 35:2210-2216. [PMID: 32279946 DOI: 10.1016/j.arth.2020.03.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 02/28/2020] [Accepted: 03/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Reported clinical outcomes have varied for debridement, antibiotics, and implant retention (DAIR) and little is known regarding trends in utilization. We sought to evaluate the rate of DAIR utilization for total knee arthroplasty (TKA) and total hip arthroplasty (THA) periprosthetic joint infection (PJI) over a decade and clinical factors associated with these trends. METHODS A retrospective study of primary TKAs and THAs was performed using Medicare data from 2005 to 2014 using the PearlDiver database platform. Current Procedural Technology and International Classification of Diseases Ninth Edition codes identified patients who underwent a surgical revision for PJI, whether revision was a DAIR, as well as associated clinical factors including timing from index arthroplasty. RESULTS The proportion of revision TKAs and THAs performed using DAIR was 27% and 12% across all years, respectively. This proportion varied by year for TKAs and THAs with a linear trend toward increasing relative use of DAIR estimated at 1.4% and 0.9% per year (P < .001; P < .001). DAIR for TKA and THA performed within 90 days increased at a faster rate, 3.4% and 2.1% per year (P < .001; P < .001). Trends over time in TKA DAIRs showed an association with Elixhauser Comorbidity Index (ECI), 0-5 group increasing at 2.0% per year (P = .03) and patients >85 years (P = .04). CONCLUSION The proportion of revision arthroplasty cases for PJI managed with DAIR has been increasing over time in the United States, with the most substantial increase seen <90 days from index arthroplasty. Age, gender, and ECI had a minimal association with this trend, except in the TKA population >85 years and in those with a very low ECI score.
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Affiliation(s)
- K Keely Boyle
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Milan Kapadia
- Department of Medicine, Division of Infectious Disease, Hospital for Special Surgery, New York, NY
| | - David C Landy
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Michael W Henry
- Department of Medicine, Division of Infectious Disease, Hospital for Special Surgery, New York, NY
| | - Andy O Miller
- Department of Medicine, Division of Infectious Disease, Hospital for Special Surgery, New York, NY
| | - Geoffrey H Westrich
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
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CORR Insights®: Synovial Fluid Aspirates Diluted with Saline or Blood Reduce the Sensitivity of Traditional and Contemporary Synovial Fluid Biomarkers. Clin Orthop Relat Res 2020; 478:1814-1816. [PMID: 32749830 PMCID: PMC7371082 DOI: 10.1097/corr.0000000000001247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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36
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Synovial Fluid Aspirates Diluted with Saline or Blood Reduce the Sensitivity of Traditional and Contemporary Synovial Fluid Biomarkers. Clin Orthop Relat Res 2020; 478:1805-1813. [PMID: 32191417 PMCID: PMC7371050 DOI: 10.1097/corr.0000000000001188] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent criteria-based diagnostic tools to diagnose periprosthetic infection (PJI), such as the International Consensus Meeting (ICM) definition of PJI, are heavily reliant on synovial fluid laboratory results. Despite the importance of synovial fluid in PJI diagnosis, the effect of the quality of synovial fluid aspirate on testing results has not been studied. Our laboratory has established quality control parameters to identify synovial fluid aspirates that are highly diluted by saline or blood, which appear to degrade the diagnostic performance of synovial fluid laboratory tests. QUESTIONS/PURPOSES (1) What proportion of synovial fluid aspirates analyzed at one laboratory are of poor quality (defined as having a red blood count > 1M cells/uL or an optical density at 280 nm < 0.324 or > 1.19)? (2) Does a poor-quality aspirate decrease the sensitivities of International Consensus Meeting-based scores and other synovial fluid biomarker tests in terms of their ability to anticipate a positive culture? METHODS From January 2016 to July 2019, a total of 123,549 synovial fluid samples were submitted to one laboratory for the purpose of diagnostic testing. Of these, 14% (16,773 of 123,549) samples were excluded because they were from a site other than a hip, knee, or shoulder arthroplasty, and an additional 33% (35,660 of 106,776) were excluded due to insufficient requested tests, resulting in 58% (71,116 of 123,549) samples included in this study. Specimens diluted with extreme levels of saline or blood were identified (defined as having a red blood count >1 M cells/uL or an optical density at 280 nm < 0.324 or > 1.19) as poor-quality aspirates. The sensitivities of synovial fluid C-reactive protein, alpha defensin, neutrophil elastase, white blood cell count, polymorphonuclear cell percentage, and the 2018 ICM-based tool were assessed in good-quality versus poor-quality synovial fluid samples. To avoid bias from using these evaluated tests within the reference definition of PJI in this study, a positive culture resulting from the synovial fluid served as the reference diagnosis defining a control cohort of PJI-positive samples. Although the low false-positive rate of synovial fluid culture allows for the valid estimation of synovial fluid test sensitivity, the high false-negative rate of synovial fluid culture prevents the valid estimation of test specificity, which was not evaluated in this study. RESULTS Of the samples analyzed, 8% (6025 of 71,116) were found to have poor quality, in that they were substantially compromised by saline and/or blood. The sensitivity of all tests to detect culture-positive synovial fluid was lower in poor-quality than in good-quality samples: 2018 International Consensus Meeting-based tool (83% [95% CI 80 to 86] versus 97% [95% CI 96 to 97]), synovial fluid C-reactive protein (65% [95% CI 61 to 69] versus 88% [95% CI 87 to 89]), alpha defensin (70% [95% CI 66 to 73] versus 93% [95% CI 93 to 94]), neutrophil elastase (80% [95% CI 77 to 83] versus 96% [95% CI 96 to 97]), synovial fluid white blood cell count (69% [95% CI 65 to 73] versus 93% [95% CI 93 to 94]), and the polymorphonuclear cell percentage (88% [95% CI 85 to 91] versus 95% [95% CI 94 to 95]), with all p < 0.001. CONCLUSIONS When synovial fluid is substantially diluted with saline or blood, the biomarkers and cells being measured are also diluted, decreasing the sensitivity of laboratory testing. We recommend that future diagnostic studies exclude these samples because an artificial reduction in test sensitivity will be observed. CLINICAL RELEVANCE Clinicians should avoid relying on negative synovial fluid testing to rule out PJI when the fluid submitted is substantially constituted of saline or blood. Further studies are necessary to understand the diagnostic utility, if any, of these diluted aspirate samples.
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Prosthetic joint infections: diagnosis, management, and complications of the two-stage replacement arthroplasty. Skeletal Radiol 2020; 49:847-859. [PMID: 32040604 DOI: 10.1007/s00256-020-03389-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 02/06/2023]
Abstract
Despite improved strategies to prevent prosthetic joint infection, as the total number of joint replacements increases, so does the absolute number of infections. Radiography serves as the first-line imaging modality for the assessment of a suspected prosthetic joint infection. Additionally, serial radiographs acquired after a surgery to eradicate a prosthetic joint infection are an important clinical tool. Prosthetic joint infections are often treated with a 2-stage replacement arthroplasty utilizing a prosthesis with antibiotic-loaded acrylic cement. While complications are uncommon with this procedure, imaging may demonstrate periprosthetic fractures, as well as spacer migration, joint dislocation, and spacer fracture. We describe the classification of prosthetic joint infections, the clinical and imaging diagnosis, and treatment strategies. Familiarity with the hardware utilized in the management of the prosthetic joint infection, and its potential complications is fundamental to accurate imaging interpretation.
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Thiesen DM, Mumin-Gündüz S, Gehrke T, Klaber I, Salber J, Suero E, Citak M. Synchronous Periprosthetic Joint Infections: The Need for All Artificial Joints to Be Aspirated Routinely. J Bone Joint Surg Am 2020; 102:283-291. [PMID: 31855870 DOI: 10.2106/jbjs.19.00835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a severe complication with increasing incidence. However, we are not aware of any robust data on patients having PJI at the same time in ≥2 joints that had undergone total joint arthroplasty, referred to as synchronous PJI throughout this article. The aims of this study were to investigate the probability of the development of synchronous PJI of another prosthetic joint and to identify possible clinical risk factors for the development of synchronous PJI. In addition, we aimed to determine whether routine aspiration of all other prosthetic joints was warranted after a diagnosis of PJI in a single joint. METHODS A total of 2,532 septic revision procedures were performed during the study period. In the final analysis, 644 patients (26 with synchronous PJI and 618 with non-synchronous PJI) with 1,508 prosthetic joints were included. The mean age (and standard deviation) was 71 ± 9.6 years. Using bivariate analyses, we calculated the odds of synchronous PJI as a function of various demographic and clinical variables. RESULTS A suspicious clinical presentation of the non-primary joint had the strongest association with synchronous PJI (odds ratio [OR], 58.5 [95% confidence interval (CI), 22.4 to 152.8]). Additional associations with synchronous PJI were detected for a history of neoplasia (OR, 12 [95% CI, 3.9 to 37.2]), the use of immune-modulating therapy (OR, 9.5 [95% CI, 3.4 to 26.2]), the presence of systemic inflammatory response syndrome or sepsis (OR, 8.4 [95% CI, 2.8 to 25]), and having ≥3 prosthetic joints (OR, 3.0 [95% CI, 1.37 to 6.64]). CONCLUSIONS Synchronous PJI is a rare but very serious complication and every prosthetic joint should be investigated meticulously. Suspicious clinical presentation, a history of neoplasia, sepsis, immune-modulating therapy, and ≥3 prosthetic joints were identified as risk factors and should increase the physician's vigilance. In the case of PJI, aspiration of each joint that had undergone total joint arthroplasty should be considered. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Darius M Thiesen
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany.,Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Seval Mumin-Gündüz
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany.,Department of Surgery, Ruhr-University Bochum, Bochum, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Ianiv Klaber
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Jochen Salber
- Department of Surgery, Ruhr-University Bochum, Bochum, Germany
| | - Eduardo Suero
- Department of General, Trauma and Reconstructive Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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Goodman SB, Gallo J, Gibon E, Takagi M. Diagnosis and management of implant debris-associated inflammation. Expert Rev Med Devices 2020; 17:41-56. [PMID: 31810395 PMCID: PMC7254884 DOI: 10.1080/17434440.2020.1702024] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/04/2019] [Indexed: 02/07/2023]
Abstract
Introduction: Total joint replacement is one of the most common, safe, and efficacious operations in all of surgery. However, one major long-standing and unresolved issue is the adverse biological reaction to byproducts of wear from the bearing surfaces and modular articulations. These inflammatory reactions are mediated by the innate and adaptive immune systems.Areas covered: We review the etiology and pathophysiology of implant debris-associated inflammation, the clinical presentation and detailed work-up of these cases, and the principles and outcomes of non-operative and operative management. Furthermore, we suggest future strategies for prevention and novel treatments of implant-related adverse biological reactions.Expert opinion: The generation of byproducts from joint replacements is inevitable, due to repetitive loading of the implants. A clear understanding of the relevant biological principles, clinical presentations, investigative measures and treatments for implant-associated inflammatory reactions and periprosthetic osteolysis will help identify and treat patients with this issue earlier and more effectively. Although progressive implant-associated osteolysis is currently a condition that is treated surgically, with further research, it is hoped that non-operative biological interventions could prolong the lifetime of joint replacements that are otherwise functional and still salvageable.
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Affiliation(s)
- Stuart B. Goodman
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Jiri Gallo
- Department of Orthopaedics, Palacký University Olomouc, Olomouc, Czech Republic
| | - Emmanuel Gibon
- Department of Orthopaedic Surgery, University of Florida, Gainesville, FL, USA
| | - Michiaki Takagi
- Department of Orthopaedic Surgery, Yamagata University, Yamagata, Japan
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Bistolfi A, Ferracini R, Albanese C, Vernè E, Miola M. PMMA-Based Bone Cements and the Problem of Joint Arthroplasty Infections: Status and New Perspectives. MATERIALS (BASEL, SWITZERLAND) 2019; 12:E4002. [PMID: 31810305 PMCID: PMC6926619 DOI: 10.3390/ma12234002] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 02/07/2023]
Abstract
Polymethyl methacrylate (PMMA)-based bone cement is a biomaterial that has been used over the last 50 years to stabilize hip and knee implants or as a bone filler. Although PMMA-based bone cement is widely used and allows a fast-primary fixation to the bone, it does not guarantee a mechanically and biologically stable interface with bone, and most of all it is prone to bacteria adhesion and infection development. In the 1970s, antibiotic-loaded bone cements were introduced to reduce the infection rate in arthroplasty; however, the efficiency of antibiotic-containing bone cement is still a debated issue. For these reasons, in recent years, the scientific community has investigated new approaches to impart antibacterial properties to PMMA bone cement. The aim of this review is to summarize the current status regarding antibiotic-loaded PMMA-based bone cements, fill the gap regarding the lack of data on antibacterial bone cement, and explore the progress of antibacterial bone cement formulations, focusing attention on the new perspectives. In particular, this review highlights the innovative study of composite bone cements containing inorganic antibacterial and bioactive phases, which are a fascinating alternative that can impart both osteointegration and antibacterial properties to PMMA-based bone cement.
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Affiliation(s)
- Alessandro Bistolfi
- AO Citta’ della Salute e della Scienza. CTO Hospital, Department of Orthopedics. Via Zuretti 29, 10126 Turin, Italy; (A.B.); (C.A.)
| | - Riccardo Ferracini
- IRCCS Ospedale Policlinico San Martino, Department of Surgical Sciences and Integrated Diagnostics, University of Genova, Largo R. Benzi 10, 16132 Genova, Italy;
| | - Carlo Albanese
- AO Citta’ della Salute e della Scienza. CTO Hospital, Department of Orthopedics. Via Zuretti 29, 10126 Turin, Italy; (A.B.); (C.A.)
| | - Enrica Vernè
- Department of Applied Science and Technology, PolitoBIOMed Lab, Politecnico di Torino, C.so Duca Degli Abruzzi 24, 10129 Torino, Italy;
| | - Marta Miola
- Department of Applied Science and Technology, PolitoBIOMed Lab, Politecnico di Torino, C.so Duca Degli Abruzzi 24, 10129 Torino, Italy;
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Ahmed SS, Begum F, Kayani B, Haddad FS. Risk factors, diagnosis and management of prosthetic joint infection after total hip arthroplasty. Expert Rev Med Devices 2019; 16:1063-1070. [PMID: 31752561 DOI: 10.1080/17434440.2019.1696673] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Although a relatively rare complication, the incidence and prevalence of prosthetic joint infection (PJI) is certainly rising. This is mainly due to the number of arthroplasties performed each year and our ability to capture more cases. There is currently no consensus in the optimal diagnosis and management of the infected total hip arthroplasty. Various management techniques have been described in literature.Areas covered: We discuss and summarize the literature in diagnosing prosthetic joint infection (PJI) including next-generation sequencing. An in-depth critical analysis of the biomarkers and the novel tests available in the market is reviewed including the evolving nature of the diagnostic criteria for PJI. The key issues in managing infected THA are identified.Expert commentary: The senior authors' expert opinion on diagnostic criteria is discussed. We also stress the importance of tissue/fluid analysis of microbiology and histology being key to diagnosis of PJI. The indications of one-stage versus two-stage revision arthroplasty is examined, including techniques for successful one-stage revision.
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Affiliation(s)
- Syed S Ahmed
- Trauma & Orthopaedics, University College Hospital, London, UK.,Trauma & Orthopaedics, Princess Grace Hospital, London, UK
| | - Fahima Begum
- Trauma & Orthopaedics, University College Hospital, London, UK.,Trauma & Orthopaedics, Princess Grace Hospital, London, UK
| | - Babar Kayani
- Trauma & Orthopaedics, University College Hospital, London, UK.,Trauma & Orthopaedics, Princess Grace Hospital, London, UK
| | - Fares S Haddad
- Trauma & Orthopaedics, University College Hospital, London, UK.,Trauma & Orthopaedics, Princess Grace Hospital, London, UK
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Xu C, Tan TL, Kuo FC, Goswami K, Wang Q, Parvizi J. Reevaluating Current Cutoffs for Acute Periprosthetic Joint Infection: Current Thresholds Are Insensitive. J Arthroplasty 2019; 34:2744-2748. [PMID: 31307871 DOI: 10.1016/j.arth.2019.06.048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/12/2019] [Accepted: 06/21/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Diagnosing acute periprosthetic joint infection remains a challenge. Several studies have proposed different acute cutoffs resulting in the International Consensus Meeting recommending a cutoff of 100 mg/L, 10,000 cell/μL and 90% for serum C-reactive protein (CRP), synovial white blood cell count (WBC), and polymorphonuclear percentage (PMN%), respectively. However, establishing cutoffs are difficult as the control group is limited to rare early aseptic revisions, and performing aspiration in asymptomatic patients is difficult because of a fear of seeding a well-functioning joint arthroplasty. This study (1) assessed the sensitivity of current thresholds for acute periprosthetic joint infection (PJI) and (2) identified associated factors for false negatives. METHODS We retrospectively reviewed patients with acute PJIs (n = 218), defined as less than 6 weeks from index arthroplasty, treated between 2000 and 2017. Diagnosis of PJI was based on 2 positive cultures of the same pathogen from the periprosthetic tissue or synovial fluid samples. Sensitivities of International Consensus Meeting cutoff values of CRP, synovial WBC, and PMN% were evaluated according to organism type. Multiple logistic regression analysis was performed to determine associated factors for false negatives. RESULTS Overall, the sensitivity of CRP, synovial WBC, and PMN% for acute PJI was 55.3%, 59.6%, and 50.5%, respectively. Coagulase-negative Staphylococcus (CNS) demonstrated the lowest sensitivity for both CRP (37.5%) and WBC (55.6%). CNS infection was identified as an independent risk factor for false-negative CRP. CONCLUSIONS Current thresholds for acute PJI may be missing approximately half of PJIs. Low virulent organisms, such as CNS, may be responsible for these false negatives. Current thresholds for acute PJI must be reexamined.
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Affiliation(s)
- Chi Xu
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, China
| | - Timothy L Tan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Feng-Chih Kuo
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Qiaojie Wang
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiaotong University, Shanghai, China
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Affiliation(s)
- Mengnai Li
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Andrew Glassman
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, Ohio
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Middleton R, Khan T, Alvand A. Update on the diagnosis and management of prosthetic joint infection in hip and knee arthroplasty. ACTA ACUST UNITED AC 2019. [DOI: 10.1302/2048-0105.84.360701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- R. Middleton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - T. Khan
- Department of Academic Orthopaedics & Trauma Surgery, Queen’s Medical Centre, Nottingham, UK
| | - A. Alvand
- Nuffield Orthopaedic Centre, Oxford, UK; University of Oxford, Oxford UK
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Performance of Sequencing Assays in Diagnosis of Prosthetic Joint Infection: A Systematic Review and Meta-Analysis. J Arthroplasty 2019; 34:1514-1522.e4. [PMID: 31005434 DOI: 10.1016/j.arth.2019.02.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/08/2019] [Accepted: 02/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND A prompt, accurate diagnosis of prosthetic joint infection (PJI) allows early treatment, and with identification of the causative organism, sensitive antibiotics could be applied. However, routine methods cannot identify the causative organism under certain circumstances. Gene sequencing assays have unique superiority in promptness and broad coverage of pathogens, but evidence of its accuracy is quite limited. METHODS Of 247 citations identified for screening, 12 studies with 1965 patients in total were included. The diagnostic value of sequencing assays in PJI was systematically reviewed. Subgroup analysis was conducted to explore the source of heterogeneity. RESULTS Pooled sensitivity was 0.81 (95% confidence interval [CI], 0.73-0.87); pooled specificity was 0.94 (95% CI, 0.91-0.97); positive likelihood ratio was 14.2 (95% CI, 8.7-23.4); negative likelihood ratio was 0.20 (95% CI, 0.14-0.29); and the area under the curve was 0.94 (95% CI, 0.18-1.00). The results of subgroup analysis revealed that antibiotics reduced the sensitivity of sequencing-based diagnosis compared with withholding antibiotics before sampling (0.71 vs 0.94). In another subgroup analysis, sequencing by synthesis (Illumina sequencing) had better specificity than other next-generation sequencing methods (0.963 vs 0.829) and specificity similar to time-consuming and laborious Sanger sequencing (0.963 vs 0.967). CONCLUSION Sequencing assays had favorable diagnostic accuracy of PJI. When sequencing assays were applied to diagnosing PJI, an antibiotic-free interval before sampling may enhance the ability to detect the causative organism and, among next-generation sequencing methods, sequencing by synthesis seemed to have advantages over other methods in specificity.
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46
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Sukeik M, Haddad FS. Periprosthetic joint infections after total hip replacement: an algorithmic approach. SICOT J 2019; 5:5. [PMID: 30816089 PMCID: PMC6394232 DOI: 10.1051/sicotj/2019004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 01/28/2019] [Indexed: 12/25/2022] Open
Abstract
An algorithm for managing periprosthetic joint infections (PJIs) after total hip replacement (THR) surgery using a multidisciplinary approach and a clearly defined protocol may improve infection eradication rates. In this article, we present an algorithm for the management of different types of PJIs including the acutely infected cemented and cementless THRs where the components are well-fixed postoperatively and when the infection is secondary to haematogenous spread in previously well-functioning and well-fixed implants. For chronic PJIs where the components are often loose, the standard treatment includes a two-stage revision procedure. However, in a highly selected subset of patients, a single-stage approach has been utilised with high rates of eradicating infections.
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Affiliation(s)
- Mohamed Sukeik
- Foothills Medical Centre, 1403 29 St NW Calgary, AB T2N 2T9, Canada
| | - Fares Sami Haddad
- University College London Hospital, 235 Euston Road, London NW1 2BU, UK
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