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Azad MA, Patel R. Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections. Clin Microbiol Rev 2024; 37:e0010423. [PMID: 38506553 DOI: 10.1128/cmr.00104-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.
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Affiliation(s)
- Marisa Ann Azad
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robin Patel
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Sax FH, Hoyka M, Blersch BP, Fink B. Diagnostics in Late Periprosthetic Infections-Challenges and Solutions. Antibiotics (Basel) 2024; 13:351. [PMID: 38667027 PMCID: PMC11047502 DOI: 10.3390/antibiotics13040351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/29/2024] Open
Abstract
The rising number of arthroplasties is combined with a rising number of periprosthetic joint infections, which leads to life-concerning consequences for the patients, including extended antibiotic treatment, further surgery and increased mortality. The heterogeneity of the symptoms and inflammatory response of the patients due to, e.g., age and comorbidities and the absence of a single diagnostic test with 100% accuracy make it very challenging to choose the right parameters to confirm or deny a periprosthetic joint infection and to establish a standardized definition. In recent years, additional diagnostic possibilities have emerged primarily through the increasing availability of new diagnostic methods, such as genetic techniques. The aim of the review is to provide an overview of the current state of knowledge about the various tests, including the latest developments. The combination of different tests increases the accuracy of the diagnosis. Each physician or clinical department must select the tests from the available methods that can be best implemented for them in organizational and technical terms. Serological parameters and the cultivation of the samples from aspiration or biopsy should be combined with additional synovial tests to create an accurate figure for the failure of the prosthesis, while imaging procedures are used to obtain additional information for the planned therapeutic procedure.
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Affiliation(s)
- Florian Hubert Sax
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
| | - Marius Hoyka
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
| | - Benedikt Paul Blersch
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
| | - Bernd Fink
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
- Orthopaedic Department, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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Tarabichi S, Johnson RM, Quinlan ND, Dennis DA, Parvizi J, Jennings JM. Commercial Synovial Antigen Testing is Inferior to Traditional Culture for the Diagnosis of Periprosthetic Joint Infection in Patients Undergoing Revision Total Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00311-5. [PMID: 38599530 DOI: 10.1016/j.arth.2024.03.067] [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: 01/22/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Despite its limitations, a culture remains the "gold standard" for pathogen identification in patients who have periprosthetic joint infection (PJI). Recently, a synovial fluid antigen test has been introduced by a commercial entity. The purpose of this multicenter study was to determine the accuracy of the antigen test in the diagnosis of PJI. METHODS This retrospective study identified 613 patients undergoing revision total knee arthroplasty who had undergone preoperative synovial fluid analysis. A PJI was defined using the 2018 International Consensus Meeting (ICM) criteria. Patients who had an extended period (> 180 days) from aspiration to revision procedure (n = 62), those presenting within 90 days of their index arthroplasty procedure (n = 17), and patients who had an inconclusive ICM score (n = 8) were excluded. Using receiver operator characteristic curve analyses, we examined the utility of the microbial identification (MID) antigen test and any positive culture (either preoperative or intraoperative) in the diagnosis of PJI. RESULTS A total of 526 patients were included. Of these, 125 (23.8%) were ICM positive and 401 (76.2%) were ICM negative. Culture demonstrated an area under the curve (AUC) of 0.864, sensitivity of 75.2%, and specificity of 97.5%. On the other hand, the MID test exhibited an AUC of 0.802, sensitivity of 61.6%, and specificity of 98.8%. The AUC of culture was significantly higher than that of the MID test (P = .037). The MID test was positive in 41.9% of culture-negative PJI cases. We also observed a high rate of discordance (29.7%) when both culture and the MID test were positive in the ICM-positive group. CONCLUSIONS Synovial fluid antigen testing does not provide additional clinical benefit when compared to traditional cultures for the diagnosis of PJI. The antigen test had low sensitivity in the diagnosis of PJI and a relatively high rate of discordance with culture. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Roseann M Johnson
- Colorado Joint Replacement, Orthopedic Sugery, AdventHealth Porter, Denver, Colorado
| | - Nicole D Quinlan
- Colorado Joint Replacement, Orthopedic Sugery, AdventHealth Porter, Denver, Colorado
| | - Douglas A Dennis
- Colorado Joint Replacement, Orthopedic Sugery, AdventHealth Porter, Denver, Colorado
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
| | - Jason M Jennings
- Colorado Joint Replacement, Orthopedic Sugery, AdventHealth Porter, Denver, Colorado
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Williams JA, Khawar H, Middleton R. Periprosthetic femoral fractures. Br J Hosp Med (Lond) 2024; 85:1-9. [PMID: 38416520 DOI: 10.12968/hmed.2023.0378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
The incidence of periprosthetic femoral fractures is rising in the UK, because of an ageing population and an increasing number of hip arthroplasty operations being performed. They can occur intra- or postoperatively, and usually follow low energy trauma. They present with pain, swelling over the thigh, and an inability to weight bear. Periprosthetic femoral fractures are usually classified as per the unified classification system. Their management usually is dependent on their classification, with type A (fracture at level of greater or lesser trochanter) managed non-operatively with protected weight bearing, type B (fracture adjacent to implant) managed with either open reduction internal fixation or revision surgery, and type C (fracture distal to implant) managed with open reduction internal fixation. Owing to their complexity, these patients must be adequately optimised before surgery and appropriately rehabilitated.
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Affiliation(s)
- Jevan At Williams
- Department of Trauma and Orthopaedics, Royal Cornwall Hospital, Truro, UK
| | - Haseeb Khawar
- School of Medicine, University of Exeter Medical School, Exeter, UK
| | - Rory Middleton
- Department of Trauma and Orthopaedics, Royal Cornwall Hospital, Truro, UK
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Keating TC, Guntin J, Harkin WE, Weintraub MT, Karas V, Berger RA. Low Risk of Acute Iatrogenic Periprosthetic Joint Infection After Prosthetic Joint Aspiration. J Arthroplasty 2023; 38:1861-1863. [PMID: 36966892 DOI: 10.1016/j.arth.2023.03.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/14/2023] [Accepted: 03/19/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Synovial fluid analysis is an essential tool in diagnosing periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). However, concern exists that aspiration may introduce infection into a noninfected joint. Therefore, the purpose of this study was to evaluate the incidence of iatrogenic PJI following diagnostic knee aspiration done within 6 months of the primary TKA. METHODS Between 2017 and 2021, the senior surgeon performed over 4,000 primary TKAs and aspirated 155 knees in 137 patients for whom there was a suspicion for PJI within 6 months of their primary TKA. There were 22 knees diagnosed as infected from the initial aspiration and therefore were excluded from the study. The remaining 133 aspirates in 115 patients who were negative for infection were followed for 6 months for signs and symptoms of PJI to elucidate whether aspiration introduced infection into an initially noninfected joint. RESULTS There were 70 of 133 knees (52.6%) aspirated between 0 and 6 weeks after index TKA, 40 of 133 (30.1%) between 6 weeks and 3 months, and 23 of 133 (17.3%) between 3 and 6 months. At final follow-up, none of the 133 initially noninfected knees exhibited evidence of subsequent iatrogenic PJI or had subsequent surgery for infection. CONCLUSION While joint aspiration is a procedure with inherent risks, this study shows that the rate of iatrogenic PJI is extremely low (0%). Therefore, if infection is suspected, the surgeon should consider joint aspiration, even in the initial postoperative period, as the risk for introducing infection is far outweighed by the risk of missing an infection.
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Affiliation(s)
- Timothy C Keating
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jonathan Guntin
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - William E Harkin
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Matthew T Weintraub
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Vasili Karas
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Richard A Berger
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
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Mardani M, Mohammadshahi J, Teimourpour R. Prosthetic knee joint infection caused by α-hemolytic Streptococcus species: a case report. J Med Case Rep 2023; 17:339. [PMID: 37496037 PMCID: PMC10369681 DOI: 10.1186/s13256-023-03905-1] [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: 01/07/2023] [Accepted: 03/23/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Knee arthroplasty is an orthopedic surgical procedure in which a damaged joint is replaced with an artificial one. It is estimated that 1-2% of knee arthroplasties will encounter infection over their lifetime. Although α-hemolytic Streptococcus species play an important role in prosthetic joint infection, they are less common than staphylococcal species. CASE PRESENTATION In this report, a 50-year-old Iranian woman was diagnosed with prosthetic knee joint infection based on clinical, radiological, and laboratory findings. She was diabetic and had undergone a left total knee arthroplasty, which, 18 months after the surgery, presented pain, erythema, and edema in that knee. The primary culture of knee aspirate was positive for α-hemolytic Streptococcus species, but following antibiotic medication, culture was negative. The primary antibiotic regime was vancomycin and meropenem, which was changed to cefepime for the management of the infection based on the results of antimicrobial susceptibility testing. CONCLUSIONS This report indicated the clinical presentation and management of the patient with prosthetic joint infection in which the patient recovered without any severe complications or surgical intervention.
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Affiliation(s)
- Masoud Mardani
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jafar Mohammadshahi
- Department of Infectious Diseases, School of Medicine, Ardabil University of Medical Science, Ardabil, Iran.
| | - Roghayeh Teimourpour
- Department of Microbiology, school of medicine, Ardabil University of Medical Science, Ardabil, Iran
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Sousa R, Carvalho A, Soares D, Abreu MA. Interval between two-stage exchanges: what is optimal and how do you know? ARTHROPLASTY 2023; 5:33. [PMID: 37403130 DOI: 10.1186/s42836-023-00185-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/04/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Two-stage exchange arthroplasty remains the most popular option for the treatment of chronic periprosthetic joint infection (PJI). Determining infection eradication and optimal timing of reimplantation can be challenging. Information to allow for a truly informed evidence-based decision is scarce. METHODS We conducted a critical review of available evidence on the presently available tests to help determine timing of reimplantation. RESULTS Serology is traditionally used to follow up patients after the first stage. Despite tradition mandates waiting for normal inflammatory markers, there is actually no evidence that they correlate with persistent infection. The role of synovial fluid investigation between stages is also explored. Cultures lack sensitivity and neither differential leukocyte counts nor alternative biomarkers have proven to be accurate in identifying persistent infection with a spacer in situ. We also examined the evidence regarding the optimal time interval between resection and reimplantation and whether there is evidence to support the implementation of a two week "antibiotic holiday" prior to proceeding with reimplantation. Finally, wound healing and other important factors in this setting will be discussed. CONCLUSION Currently there are no accurate metrics to aid in the decision on the optimal timing for reimplantation. Decision must therefore rely on the resolution of clinical signs and down trending serological and synovial markers.
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Affiliation(s)
- Ricardo Sousa
- Department of Orthopedics, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal.
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal.
| | - André Carvalho
- Department of Orthopedics, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal
| | - Daniel Soares
- Department of Orthopedics, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal
| | - Miguel Araújo Abreu
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal
- Department of Infectious Diseases, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
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Klaber I, Scholz F, Citak M, Zahar A, Gehrke T, Haasper C, Hawi N, Lausmann C. Diagnostic utility of open biopsy in patients with two culture-negative aspirations in the diagnostic work-up of periprosthetic joint infection. Arch Orthop Trauma Surg 2023; 143:749-754. [PMID: 34487240 DOI: 10.1007/s00402-021-04142-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/22/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Different approaches have been proposed for bacterial identification in patients with a suspected periprosthetic joint infection (PJI). If a one-stage procedure is considered, a higher rate of preoperative bacterial identification can be achieved if biopsy is included in the diagnostic work-up. The performance of open biopsy (OB) in the context of PJI has not been clearly determined yet. The purpose of this study was to determine the value of an OB added to two consecutive culture-negative joint aspirations during PJI workup. MATERIALS AND METHODS We retrospectively analyzed the OB data from a single institution. Patients under PJI work-up of the hip or knee with two culture-negative periprosthetic aspirations who underwent OB were included. Sensitivity and specificity were calculated using the musculoskeletal infection society (MSIS) criteria as gold standard. Patients undergoing urgent irrigation and debridement and patients with history of surgery to the affected joint in the prior 6 weeks were excluded. RESULTS 126 patients were included in this study. 62 (49.2%) patients had prior revisions, 48 of them due to PJI. The sensitivity and specificity of OB was 69.4% and 89.1%, respectively. The OB procedure led to the identification of the causative germ in 50 out of 126 (40%) cases so they could undergo one-stage (septic) exchange. CONCLUSION The OB is a valuable resource if preoperative synovial fluid cultures are negative, a high suspicion of infection persists and a one-stage procedure is preferred. It intends bacteria identification and allows surgeons to evaluate prosthetic complications for further surgical procedures.
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Affiliation(s)
- Ianiv Klaber
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany.,Department of Orthopedic Surgery, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Fabian Scholz
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
| | - Akos Zahar
- Department of Orthopaedic Surgery and Traumatology, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
| | - Carl Haasper
- Department of Orthopaedic Surgery, AMEOS Klinikum Seepark, Geestland, Germany
| | - Nael Hawi
- Department of Trauma Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Lausmann
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany.
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Diniz SE, Ribau A, Vinha A, Oliveira J, Abreu M, Sousa R. Simple and inexpensive synovial fluid biomarkers for the diagnosis of prosthetic joint infection according to the new EBJIS definition. J Bone Jt Infect 2023; 8:109-118. [PMID: 37032977 PMCID: PMC10077577 DOI: 10.5194/jbji-8-109-2023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/10/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction: diagnosis of periprosthetic joint infection (PJI) is challenging, as no single test has absolute accuracy. The purpose of this study was to assess the utility of different simple synovial biomarkers in the diagnosis of PJI as defined by the European Bone and Joint Infection Society (EBJIS). Methods: we retrospectively identified all patients undergoing revision hip or knee arthroplasty from 2013 to 2019 on our prospectively maintained database. Only patients with minimum required infection diagnostic workup were included in the study. Patients with comorbidities that may influence the accuracy of synovial biomarkers were excluded. Receiver operator characteristic (ROC) curves were utilised to assess the diagnostic utility of synovial fluid white blood cell (WBC) count, polymorphonuclear leukocyte percentage (PMN %), C-reactive protein (CRP), adenosine deaminase (ADA), and alpha-2-microglobulin (A2M). Results: in total, 102 patients met the inclusion criteria. Of these, 58 were classified as infection unlikely, 8 as infection likely, and 36 as infection confirmed. Synovial WBC count (area under the curve (AUC) 0.94) demonstrated the best utility for the diagnosis of PJI, followed by PMN % (AUC 0.91), synovial CRP (AUC 0.90), ADA (AUC 0.82), and A2M (AUC 0.76). We found added value in the combined interpretation of different biomarkers. We calculated high sensitivity and negative predictive value if at least two of them are negative and high specificity and positive predictive value if at least two are elevated. Conclusion: current results show that synovial fluid investigation is a useful tool for the diagnosis of PJI, and the combined interpretation of simple and inexpensive biomarkers demonstrated improved diagnostic accuracy.
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Affiliation(s)
- Sara Elisa Diniz
- Orthopedics Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Ana Ribau
- Orthopedics Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - André Vinha
- Orthopedics Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - José Carlos Oliveira
- Department of Laboratory Pathology, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Miguel Araújo Abreu
- Department of Infectious Diseases, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- part of the Porto Bone and Joint Infection Group (GRIP), Porto, Portugal
| | - Ricardo Sousa
- Orthopedics Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- part of the Porto Bone and Joint Infection Group (GRIP), Porto, Portugal
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Clinical Use of a 16S Ribosomal RNA Gene-Based Sanger and/or Next Generation Sequencing Assay to Test Preoperative Synovial Fluid for Periprosthetic Joint Infection Diagnosis. mBio 2022; 13:e0132222. [PMID: 36354331 PMCID: PMC9765659 DOI: 10.1128/mbio.01322-22] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Preoperative pathogen identification in patients with periprosthetic joint infection (PJI) is typically limited to synovial fluid culture. Whether sequencing-based approaches are of potential use in identification of pathogens in PJI, and if so which approach is ideal, is incompletely defined. The objective of the study was to analyze the accuracy of a 16S rRNA (rRNA) gene-based PCR followed by Sanger sequencing and/or targeted metagenomic sequencing approach (tMGS) performed on synovial fluid for PJI diagnosis. A retrospective study was conducted, analyzing synovial fluids tested between August 2020 and May 2021 at a single center. Subjects with hip, knee, shoulder, and elbow arthroplasties who had synovial fluid aspirated and clinically subjected to sequence-based testing and conventional culture were studied. A total of 154 subjects were included in the study; 118 had noninfectious arthroplasty failure (NIAF), while 36 had PJI. Clinical sensitivity and specificity for diagnosis of PJI were 69% and 100%, respectively, for the sequencing-based approach and 72% and 100%, respectively, for conventional culture (P = 0.74). The combination of both tests was more sensitive (83%) than culture alone (P = 0.04). Results of sequencing-based testing led to changes in treatment in four of 36 (11%) PJI subjects. Microbial identification was achieved using Sanger and next generation sequencing in 19 and 6 subjects, respectively. When combined with culture, the described 16S rRNA gene sequencing-based approach increased sensitivity compared to culture alone, suggesting its potential use in the diagnosis of PJI when synovial fluid culture is negative. IMPORTANCE Periprosthetic joint infection (PJI) is a dreadful complication of joint replacement. Noninvasive identification of infectious pathogens has been traditionnally limited to culture-based testing of synovial fluid which has poor sensitivity. Sanger and Next-generation sequencing (NGS) may be used for synovial fluid testing in PJI, but experience in routine practice is sparse. We used a targeted metagenomic sequencing approach for routine testing of synovial fluid involving NGS when Sanger sequencing had failed or was likely to fail. The objective of this study was to analyze the approach's performance for diagnosis of PJI in comparison to culture for testing synovial fluid. Overall, the sequencing-based approach was not superior to culture for diagnosis of PJI, but yielded positive results in some culture-negative samples.
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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: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 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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Treatment outcomes of patients with Cutibacterium acnes-positive cultures during total joint replacement revision surgery: a minimum 2-year follow-up. Arch Orthop Trauma Surg 2022; 143:2951-2958. [PMID: 35759014 DOI: 10.1007/s00402-022-04489-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/16/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is a devastating complication following total joint replacement (TJR). Cutibacterium acnes (C. acnes) is a low virulent skin commensal, commonly found during TJR revision surgery for "aseptic" causes. The purpose of the present study was to report the treatment outcomes of patients with C. acnes contamination or infection in the presence of a TJR treated with a revision surgery ± implant exchange ± prolonged (≥ 8 weeks) postoperative antibiotics. METHODS Medical records of patients with at least one positive C. acnes culture in intraoperative tissue samples or sonication fluid from a TJR revision surgery between January 2005 and December 2014 were retrospectively evaluated. The primary endpoint was infection eradication according to Delphi criteria. The diagnostic accuracy of preoperative TJR aspiration regarding the diagnosis of C. acnes PJI was also investigated. RESULTS A total of 52 TJR (28 shoulders, 17 hips, 7 knees) in 52 patients (35 males, 17 females) with an average age of 63 ± 11 (33-86) years were included. At an average follow-up of 67 ± 33 (24-127) months, the infection eradication of C. acnes PJI was 97% regardless of the surgical treatment or administration of prolonged postoperative antibiotics. The incidence of unsuspected C. acnes PJI was 28.8%. The sensitivity and specificity of preoperative joint aspiration in detecting C. acnes PJI were 59% and 88%, whereas the PPV and NNV were 83% and 67%, respectively. CONCLUSION Infection eradication of C. acnes PJI was very high at a minimum follow-up of 24 months, suggesting that C. acnes PJI could be adequately treated with a combination of revision surgery and prolonged postoperative antibiotics. The preoperative diagnosis of C. acnes PJI might be challenging with more than one-quarter of patients presenting without suspicion of C. acnes PJI. The appropriate treatment of patients with a single positive culture remains still unclear. A negative TJR aspiration should not rule out a C. acnes PJI, especially in the presence of clinical correlates of infection. LEVEL OF EVIDENCE Retrospective case-control study, Level III. IRB APPROVAL Kantonale Ethikkommission Zürich, BASEC Nr.:2017-00567.
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A protocol for periprosthetic joint infections from the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands. ARTHROPLASTY 2022; 4:19. [PMID: 35410299 PMCID: PMC8996586 DOI: 10.1186/s42836-022-00116-9] [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: 10/27/2021] [Accepted: 01/25/2022] [Indexed: 11/23/2022] Open
Abstract
Periprosthetic joint infection (PJI) is a devastating complication of joint arthroplasty surgery. Treatment success depends on accurate diagnostics, adequate surgical experience and interdisciplinary consultation between orthopedic surgeons, plastic surgeons, infectious disease specialists and medical microbiologists. For this purpose, we initiated the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands in 2014. The establishment of a mutual diagnostic and treatment protocol for PJI in our region has enabled mutual understanding, has supported agreement on how to treat specific patients, and has led to clarity for smaller hospitals in our region for when to refer patients without jeopardizing important initial treatment locally. Furthermore, a mutual PJI patient database has enabled the improvement of our protocol, based on medicine-based evidence from our scientific data. In this paper we describe our NINJA protocol. Level of evidence: III
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Abstract
Accurate diagnosis of orthopedic infection is crucial in guiding both antimicrobial therapy and surgical management in order to optimize patient outcomes. A variety of microbiological and nonmicrobiological methods are used to establish the presence of a musculoskeletal infection. In this minireview, we examine traditional culture-based and newer molecular methodologies for pathogen detection, as well as systemic and localized assays to assess host response to maximize diagnostic yield.
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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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Li C, Li H, Yang X, Zhu FZ, Xu C, Trampuz A. Meta-analysis of synovial fluid polymerase chain reaction for diagnosing periprosthetic hip and knee infection. J Orthop Surg Res 2022; 17:3. [PMID: 34983589 PMCID: PMC8725348 DOI: 10.1186/s13018-021-02813-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 10/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background and objective The purpose of this study was to estimate the diagnostic performance of synovial fluid polymerase chain reaction (PCR) in periprosthetic hip and knee infection, and whether synovial fluid PCR has greater diagnostic significance than conventional methods. Methods The literature databases PubMed, Scopus, and the Web of Science were searched for English articles describing periprosthetic joint infection (PJI) diagnosis by synovial fluid PCR. Articles were limited to the period between January 1990 and December 2019. Subsequently, conventional methods that were used on at least two occasions were included for further analysis. Data analysis was performed using the Meta-DiSc and Stata software. Results Eleven studies with 1360 cases were included in the meta-analysis. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) of synovial fluid PCR were 0.70 (95% CI 0.66–0.74), 0.92 (95% CI 0.90–0.93), and 37.4 (95% CI 17.77–78.74), respectively. Conclusions Synovial fluid PCR provides an effective tool for rapid diagnosis of PJI, and also in the early stages of culture-negative bacterial infections.
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Affiliation(s)
- Cheng Li
- Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Beijing, China. .,Center for Musculoskeletal Surgery (CMSC), Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Hao Li
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, China
| | - Xue Yang
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, China
| | - Fang-Zheng Zhu
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, China
| | - Chi Xu
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, China
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery (CMSC), Charité-Universitätsmedizin Berlin, Berlin, Germany
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Clarke MJH, Salar O, Evans JP, Bayley MGR, Waterson BH, Toms AD, Phillips JRA. Prosthetic joint infection of the knee - arthroscopic biopsy identifies more and different organisms than aspiration alone. Knee 2021; 32:183-191. [PMID: 34500431 DOI: 10.1016/j.knee.2021.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/08/2021] [Accepted: 08/13/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Prosthetic joint infection (PJI) causes significant morbidity and mortality following knee replacement surgery. Identifying causative organisms and antibiotic sensitivities is critical in increasing the chance of infection eradication. This study investigated whether biopsy alone was superior to aspiration alone for serological diagnosis in PJI following knee replacement. Secondly, we investigated whether biopsy identifies the same or new/different microbiological flora as aspiration. METHODS Since December 2014, the Exeter Knee Reconstruction Unit (EKRU) has prospectively collated data regarding all PJIs referred from our local/regional network which have been reviewed via our Multi-Disciplinary Team (MDT). We identified and included consecutive patients from this MDT from Dec.2014-Mar.2020 and analysed their electronic records. Statistical analysis was performed using Stata. RESULTS 65/100 patients studied had both pre-operative aspiration and biopsy. 31/65 (48%) had positive aspiration and biopsies. No aspirate samples were positive with corresponding biopsies negative. In 19/65 (29%) of infection positive patients, biopsy identified new (7) or additional (12) organisms not identified by aspiration. Aspiration had a sensitivity of 70%, specificity of 88%, positive predictive value of 90.3% and negative predictive value of 64.7%. Biopsy had a sensitivity of 97.5%, specificity of 88%, positive predictive value of 92.9% and negative predictive value of 95.7%. CONCLUSION In 29% of confirmed PJI cases, arthroscopic biopsy identified either additional organisms in a polymicrobial PJI when compared to aspiration, or new positive results when aspiration alone was negative. This study demonstrates the benefits of arthroscopic biopsy for serological diagnosis in cases of knee PJI and aids treatment planning.
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Affiliation(s)
- Michael J H Clarke
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK.
| | - Omer Salar
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - Jonathan P Evans
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - Morgan G R Bayley
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - Ben H Waterson
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - Andrew D Toms
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
| | - Jonathan R A Phillips
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
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Ogawa S, Chikumi H, Tanishima S, Hayashi I, Mihara T, Nagashima H. Evaluation of infections in orthopedic patients using next-generation sequencing. J Infect Chemother 2021; 27:1626-1633. [PMID: 34391624 DOI: 10.1016/j.jiac.2021.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/15/2021] [Accepted: 07/23/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Culture tests are used to diagnose infections, but there are various problems such as low sensitivity in detecting infections in orthopedic cases. To address this problem, next generation sequencing (NGS) analysis, which can comprehensively search for bacterial genes, is being applied clinically. In this study, we examined whether NGS analysis was useful in evaluating infections in orthopedic cases. METHODS The participants were 23 patients suspected of having an infection between 2016 and 2017. Samples were collected from tissues suspected of being infected and were subjected to culture tests and NGS analysis, and the positive rates from the culture tests and from the NGS analysis were compared. We also attempted to determine cutoff value for the NGS analysis. RESULTS A total of 20 cases were ultimately diagnosed as infections and 3 cases were diagnosed as non-infections. The sensitivity of the culture tests was 70%, and the sensitivity of the NGS analysis was 55%. When the NGS analysis was performed with the diversity index set to the cut-off value, the sensitivity was 75% for the Simpson index. In this study, the sensitivity was 90% when the analysis was performed using the NGS index, which is a combination of the diversity index and the OTUs (operational taxonomic units) value. CONCLUSION NGS analysis using the NGS index showed excellent sensitivity and specificity compared to culture tests. NGS analysis is therefore a useful modality for assessing infections in orthopedic cases.
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Affiliation(s)
- Shinya Ogawa
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Yonago, Japan.
| | - Hiroki Chikumi
- Division of Infectious Diseases, Tottori University, Yonago, Japan
| | - Shinji Tanishima
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Ikuta Hayashi
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Tokumitsu Mihara
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Hideki Nagashima
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
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Sconfienza LM, Albano D, Messina C, D'Apolito R, De Vecchi E, Zagra L. Ultrasound-Guided Periprosthetic Biopsy in Failed Total Hip Arthroplasty: A Novel Approach to Test Infection in Patients With Dry Joints. J Arthroplasty 2021; 36:2962-2967. [PMID: 33814266 DOI: 10.1016/j.arth.2021.03.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To diagnose periprosthetic joint infection (PJI) preoperatively, ultrasound-guided joint aspiration (US-JA) may not be performed when effusion is minimal or absent. We aimed to report and investigate the diagnostic performance of ultrasound-guided periprosthetic biopsy (US-PB) of synovial tissue to obtain joint samples in patients without fluid around the implants. METHODS One-hundred nine patients (55 men; mean age: 68 ± 13 years) with failed total hip arthroplasty (THA) who underwent revision surgery performed preoperative US-JA or US-PB to rule out PJI. RESULTS Sixty-nine of 109 patients had joint effusion and underwent US-JA, while the remaining 40 with dry joint required US-PB. Thirty-five of 109 patients (32.1%) had PJI, while 74/109 (67.9%) had aseptic THA failure. No immediate complications were observed in both groups. Technical success of US-PB was 100%, as the procedure was carried on as planned in all cases. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of US-JA were 52.2%, 97.8%, 92.3%, 80.3%, and 82.6%, while for US-PB, they were 41.7%, 100%, 100%, 80%, and 82.5%, respectively, with no significant difference (P = .779). Using the final diagnosis as reference standard, we observed a moderate agreement with both US-JA (k = 0.56) and US-PB (k = 0.50). CONCLUSION We present a novel US-guided technique to biopsy periprosthetic synovial tissue of failed THA to rule out PJI. We found similar diagnostic performance as compared with traditional US-JA. This supports future larger studies on this procedure that might be applied in patients without joint effusion.
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Affiliation(s)
- Luca M Sconfienza
- Unità Operativa di Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Domenico Albano
- Unità Operativa di Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; Dipartimento di Biomedicina, Sezione di Scienze Radiologiche, Neuroscienze e Diagnostica Avanzata, Università degli Studi di Palermo, Palermo, Italy
| | - Carmelo Messina
- Unità Operativa di Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Rocco D'Apolito
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Elena De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Luigi Zagra
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Sousa R, Carvalho A, Santos AC, Abreu MA. Optimal microbiological sampling for the diagnosis of osteoarticular infection. EFORT Open Rev 2021; 6:390-398. [PMID: 34267930 PMCID: PMC8246105 DOI: 10.1302/2058-5241.6.210011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Infection is a dire complication afflicting every field of orthopaedics and traumatology. If specific clinical, laboratory and imaging parameters are present, infection is often assumed even in the absence of microbiological confirmation. However, apart from confirming infection, knowing the exact infecting pathogen(s) and their antimicrobial susceptibility patterns is paramount to help guide treatment. Every effort should therefore be undertaken with that goal in mind.Not all microbiological findings carry the same relevance, and knowing exactly how and where a sample was collected is key. Several different sampling techniques are available, and one must be aware of both advantages and limitations. Microbiological sampling alternatives in some of the most common clinical scenarios such as native and prosthetic joint infections, osteomyelitis and fracture-related infections, spinal and diabetic foot infections will be discussed.Orthopaedic surgeons should also be aware of basic laboratory sample processing techniques as they have a direct impact on the way specimens should be dealt with and transported to the laboratory. Only by knowing these basic principles will surgeons be able to participate in the multidisciplinary discussion and decision making around how to interpret microbiological findings in each specific patient. Cite this article: EFORT Open Rev 2021;6:390-398. DOI: 10.1302/2058-5241.6.210011.
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Affiliation(s)
- Ricardo Sousa
- Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal
| | - André Carvalho
- Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Cláudia Santos
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal.,Department of Microbiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Miguel Araújo Abreu
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal.,Department of Microbiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
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21
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Salar O, Phillips J, Porter R. Diagnosis of knee prosthetic joint infection; aspiration and biopsy. Knee 2021; 30:249-253. [PMID: 33964686 DOI: 10.1016/j.knee.2020.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/04/2020] [Accepted: 12/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Prosthetic joint infection (PJI) is a significant cause of morbidity and mortality following knee replacement surgery. The diagnosis can be challenging and is based on a combination of clinical suspicion, radiographic findings and also biochemical/ microbiological investigations. Our Aim was to review the role of aspiration and biopsy in the diagnosis of PJI in Total Knee Arthroplasty (TKA). METHOD/RESULTS Aspirated synovial fluid should be analysed by direct culture, via blood culture bottles, EDTA bottles for cell count and 'point of care' testing such as leucocyte esterase or alpha defensin. Synovial WCC and PMN cell percentage are important steps in diagnosis of both acute and chronic PJI. A minimum of 5 deep samples using a 5 clean instrument technique should be obtained and sent for tissue culture done either blind or arthroscopic. Formal fluoroscopic guided interface biopsy has also been described with excellent results. In a recent series of 86 TKRs preoperative arthroscopic biopsy group had a sensitivity of 100%, specificity of 94.7%, positive predictive value of 87.4% and a negative predictive value of 100%. CONCLUSION In the presence of clinical suspicion with raised biomarkers, it is recommended that aspiration +/- biopsy with synovial fluid testing is performed. Direct culture and cell count are recommended. 'Point of care tests' such as Leucocyte Esterase testing should be considered. Duration of culture, including pathogen and host factors, should be discussed with a local microbiology/ID department in the context of a formal multi-disciplinary team.
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Affiliation(s)
- Omer Salar
- Department of Trauma and Orthopaedics, Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospitals, Barrack Road, EX2 5DW, United Kingdom.
| | - Jonathan Phillips
- Department of Trauma and Orthopaedics, Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospitals, Barrack Road, EX2 5DW, United Kingdom
| | - Robert Porter
- Department of Microbiology, Royal Devon and Exeter Hospitals, Barrack Road, United Kingdom
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McNally M, Sousa R, Wouthuyzen-Bakker M, Chen AF, Soriano A, Vogely HC, Clauss M, Higuera CA, Trebše R. The EBJIS definition of periprosthetic joint infection. Bone Joint J 2021; 103-B:18-25. [PMID: 33380199 PMCID: PMC7954183 DOI: 10.1302/0301-620x.103b1.bjj-2020-1381.r1] [Citation(s) in RCA: 254] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition. Methods This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance. Results This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI. Conclusion The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice. Cite this article: Bone Joint J 2021;103-B(1):18–25.
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Affiliation(s)
- Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Ricardo Sousa
- Porto Bone Infection Group (GRIP), Orthopaedic Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Antonia F Chen
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - H Charles Vogely
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martin Clauss
- Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic, Florida, USA
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Li R, Li X, Ni M, Zheng QY, Zhang GQ, Chen JY. Anatomic Landmark-Guided Hip Aspiration in the Diagnosis of Periprosthetic Joint Infection. Orthopedics 2021; 44:e85-e90. [PMID: 33089335 DOI: 10.3928/01477447-20201007-04] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/20/2019] [Indexed: 02/03/2023]
Abstract
Hip aspirations used to detect a periprosthetic joint infection (PJI) are usually performed under fluoroscopy or ultrasound. The aim of this study was to evaluate the results of simply using anatomic landmarks for aspiration and detecting PJI without the use of any complicated technologies. The authors retrospectively reviewed a total of 186 consecutive hip aspirations performed between April 2015 and December 2018. All patients were suspected to have infections after total hip arthroplasty. The procedures were performed with the patients in the supine position. The authors aimed to aspirate at the neck of the prosthesis. They located the y-axis of the puncture point approximately 2 to 3 cm lateral to the pulse of the femoral artery in the region of the inguinal ligament. The x-axis was estimated by using the pubic symphysis or greater trochanter according to an anteroposterior radiograph of the hip joint. The aspiration failure rate, incidence of complications, and culture results were recorded. The overall aspiration failure rate was 3.8% (7 of 186). No obvious complications related to aspiration were observed. The saline lavage and reaspiration rate was 45.3% (81 of 179) due to "dry taps." The sensitivity, specificity, positive predictive value, and negative predictive value of the remaining 169 patients with definite diagnoses were 0.781 (95% CI, 0.678-0.860), 0.939 (95% CI, 0.857-0.977), 0.931 (95% CI, 0.841-0.975), and 0.802 (95% CI, 0.706-0.874), respectively. Anatomic landmark-guided hip aspiration was a convenient method that could provide satisfactory detection of PJI. [Orthopedics. 2021;44(1):e85-e90.].
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Mihalič R, Zdovc J, Brumat P, Trebše R. Synovial fluid interleukin-6 is not superior to cell count and differential in the detection of periprosthetic joint infection. Bone Jt Open 2020; 1:737-742. [PMID: 33367280 PMCID: PMC7750741 DOI: 10.1302/2633-1462.112.bjo-2020-0166.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Aims Synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells (%PMN) are elevated at periprosthetic joint infection (PJI). Leucocytes produce different interleukins (IL), including IL-6, so we hypothesized that synovial fluid IL-6 could be a more accurate predictor of PJI than synovial fluid WBC count and %PMN. The main aim of our study was to compare the predictive performance of all three diagnostic tests in the detection of PJI. Methods Patients undergoing total hip or knee revision surgery were included. In the perioperative assessment phase, synovial fluid WBC count, %PMN, and IL-6 concentration were measured. Patients were labeled as positive or negative according to the predefined cut-off values for IL-6 and WBC count with %PMN. Intraoperative samples for microbiological and histopathological analysis were obtained. PJI was defined as the presence of sinus tract, inflammation in histopathological samples, and growth of the same microorganism in a minimum of two or more samples out of at least four taken. Results In total, 49 joints in 48 patients (mean age 68 years (SD 10; 26 females (54%), 25 knees (51%)) were included. Of these 11 joints (22%) were infected. The synovial fluid WBC count and %PMN predicted PJI with sensitivity, specificity, accuracy, PPV, and NPV of 82%, 97%, 94%, 90%, and 95%, respectively. Synovial fluid IL-6 predicted PJI with sensitivity, specificity, accuracy, PPV, and NPV of 73%, 95%, 90%, 80%, and 92%, respectively. A comparison of predictive performance indicated a strong agreement between tests. Conclusions Synovial fluid IL-6 is not superior to synovial fluid WBC count and %PMN in detecting PJI. Level of Evidence: Therapeutic Level II Cite this article: Bone Jt Open 2020;1-12:737–742.
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Affiliation(s)
- René Mihalič
- Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
| | - Jurij Zdovc
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Brumat
- Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
| | - Rihard Trebše
- Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Measurement of Serum Anti-staphylococcal Antibodies Increases Positive Predictive Value of Preoperative Aspiration for Hip Prosthetic Joint Infection. Clin Orthop Relat Res 2020; 478:2786-2797. [PMID: 32667753 PMCID: PMC7899396 DOI: 10.1097/corr.0000000000001392] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preoperative synovial fluid culture is pivotal in the early diagnosis of prosthetic joint infection (PJI) but may yield false-positive and false-negative results. We evaluated the predictive value of synovial fluid culture results combined with the measurement of serum anti-staphylococcal antibodies (SASA). QUESTIONS/PURPOSES (1) For hip and knee PJI, does combining positive SASA results with preoperative synovial culture results improve the positive predictive value (PPV) of preoperative synovial fluid culture alone? (2) Does combining preoperative synovial fluid culture results with a positive cell count and differential result increase the PPV of preoperative synovial fluid culture alone? (3) What proportion of isolated organisms exhibit concordance in antibiotic susceptibility: preoperative aspiration versus intraoperative isolates? METHODS A prospective study was conducted at two French reference centers that manage bone and joint infections and included 481 adult patients who had a revision or resection arthroplasty between June 25, 2012 and June 23, 2014. Exclusion criteria including no serum sample available for immunoassay, the lack of microbiological documentation, and the absence of preoperative aspiration reduced the patient number to 353. Seven patients with an undetermined SASA result were excluded from the analysis. We also excluded patients with PJI involving more than one Staphylococcus species (polystaphylococcal infection) and those in whom more than one Staphylococcus species was recovered from the preoperative synovial fluid culture (polystaphylococcal synovial fluid culture). In total, 340 patients were included in the analysis (no infection, 67% [226 of 340]; staphylococcal infection, 21% [71 of 340]; other infection, 13% [43 of 340]). The preoperative synovial fluid analysis included a cell count and differential and bacterial culture. SASAs were measured using a multiplex immunoassay. The diagnosis of PJI was determined using the Infectious Diseases Society of America (IDSA) criteria [] and intraoperative tissue culture at the time of revision surgery was used as the gold standard (at least one positive intraoperative sample for a "virulent" organism (such as S. aureus) or two positive samples for a "non-virulent" (for example S. epidermidis). RESULTS SASA increased the PPV compared with synovial fluid culture alone (92% [95% CI 82 to 97] versus 79% [95% CI 68 to 87]; p = 0.04); when stratified by site, an increase in PPV was seen in hip infections (100% [95% CI 89 to 100] versus 77% [95% CI 63 to 88]; p = 0.01) but not in knee infections (84% [95% CI 66 to 95] versus 80% [95% CI 64 to 91]; p = 0.75). A positive cell count and differential result increased the PPV of staphylococcal synovial fluid cultures compared with synovial fluid culture alone (86% [95% CI 70 to 95] versus 79% [95% CI 68 to 87]; p = 0.36); when stratified by site, no difference in hip and knee infections was observed (86% [95% CI 67 to 96] versus 77% [95% CI 63 to 88]; p = 0.42) and 86% [95% CI 70 to 95] versus 80% [95% CI 64 to 91]; p = 0.74). CONCLUSION SASA measurement improves the predictive value of synovial fluid cultures of the hip for all staphylococcal organisms, including coagulase-negative staphylococci, but the PPV of SASA plus synovial fluid culture it is not superior to the PPV of synovial fluid cell count/differential plus synovial culture for the knee. LEVEL OF EVIDENCE Level III, diagnostic study.
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Schulz P, Dlaska CE, Perka C, Trampuz A, Renz N. Preoperative synovial fluid culture poorly predicts the pathogen causing periprosthetic joint infection. Infection 2020; 49:427-436. [PMID: 33141393 PMCID: PMC8159841 DOI: 10.1007/s15010-020-01540-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/12/2020] [Indexed: 11/09/2022]
Abstract
Purpose We investigated the value of preoperative pathogen detection and evaluated its concordance with intraoperative cultures in patients with culture-positive periprosthetic joint infection (PJI). Methods Culture-positive PJI episodes with available preoperative (synovial fluid) and intraoperative cultures (periprosthetic tissue, synovial or sonication fluid) were analyzed. The pathogen detection rate in preoperative and intraoperative cultures was compared using Fisher’s exact test and their concordance was calculated. Results Among 167 included PJI episodes, 150 were monomicrobial with coagulase-negative staphylococci (n = 55, 37%), S. aureus (n = 34, 23%), and streptococci (n = 21, 14%) being the most common pathogens. Seventeen episodes (10%) were polymicrobial infections. The pathogen(s) grew in preoperative culture in 110 and in intraoperative cultures in 153 episodes (66% vs. 92%, p < 0.001). The pathogen detection rate was lower in preoperative compared to intraoperative cultures for low-virulent pathogens (40% vs. 94%, p < 0.001), polymicrobial infections (59% vs. 100%, p = 0.007), and in delayed and late PJI (63% vs. 94%, and 66% vs. 91%, respectively, p < 0.001). Full concordance of preoperative and intraoperative cultures was found in 87 episodes (52%). The pathogen was detected solely preoperatively in 14 episodes (8%) and solely intraoperatively in 57 cases (34%); an additional pathogen was found in 3 episodes (2%) preoperatively and in 6 episodes (4%) intraoperatively. Conclusion The concordance of preoperative and intraoperative cultures was poor (52%). The sole or an additional pathogen was found exclusively in intraoperative cultures in 38% of PJI episodes, hence preoperative synovial fluid cultures are considered unreliable for pathogen detection in PJI.
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Affiliation(s)
- Philipp Schulz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Constantin E Dlaska
- Orthopaedic Research Institute of Queensland, 7 Turner Street, Pimlico, Townsville, QLD, 4812, Australia
| | - Carsten Perka
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Nora Renz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany.
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Rockov ZA, Clarke HD, Grys TE, Chang YHH, Schwartz AJ. Is There an Optimal Cutoff for Aspiration Fluid Volume in the Diagnosis of Periprosthetic Joint Infection? J Arthroplasty 2020; 35:2217-2222. [PMID: 32269007 DOI: 10.1016/j.arth.2020.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 02/11/2020] [Accepted: 03/05/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The diagnosis of periprosthetic joint infection is often challenging in the setting of low aspiration volumes, or in the presence of infection with a slow-growing organism. We sought to determine if an optimal threshold of aspiration fluid volume exists when cultures from the preoperative aspiration are compared to intraoperative cultures. METHODS All revision total hip and knee arthroplasty procedures over 5 years at our institution were reviewed. Cases were excluded if they underwent joint lavage during aspiration, had an antibiotic spacer in place, were suspected of adverse local tissue reaction to metal debris, did not have an accurate aspiration volume recorded, or if there were no aspiration or operative cultures available. Receiver operating characteristic curves were used to evaluate aspiration volume for identifying cases with identical aspiration and culture results. RESULTS A total of 857 revision cases were reviewed, among which 294 met inclusion criteria. There were 45 cases (15.3%) with discordant aspiration and operative cultures. The mean aspiration volume for identical cases was significantly higher than for discordant cases (19.1 vs 10.2 mL, P = .02). The proportion of slow-growing organisms was significantly greater among discordant compared to identical operative cultures (52.4% for discordant cases vs 8.2% for identical cases, P < .001). The optimal cutoff value for predicting identical cultures was 3.5 mL for typical organisms and 12.5 mL for slow-growing organisms. CONCLUSION Aspiration cultures are more likely to correlate with intraoperative cultures with higher aspiration volumes, and the optimal aspiration volume is higher for slow-growing organisms.
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Affiliation(s)
- Zachary A Rockov
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Henry D Clarke
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Thomas E Grys
- Department of Microbiology, Mayo Clinic Arizona, Phoenix, AZ
| | - Yu-Hui H Chang
- Department of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ
| | - Adam J Schwartz
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ
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Detecting the presence of bacteria in low-volume preoperative aspirated synovial fluid by metagenomic next-generation sequencing. Int J Infect Dis 2020; 99:108-116. [PMID: 32721535 DOI: 10.1016/j.ijid.2020.07.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/14/2020] [Accepted: 07/21/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Preoperative diagnosis is important for patients who need revision surgery due to PJI. Microbial culture plays an important role in PJI diagnosis, but the sensitivity of cultures is low when the sample amount is limited or when a patient is treated with antibiotics before sample collection. In this study, metagenomic next-generation sequencing (mNGS) was used to detect bacteria in preoperative puncture synovial fluid samples from patients with suspected PJI, and the preoperative and intraoperative culture results were compared to estimate its diagnostic efficiency. METHODS From July 2016 to December 2018, patients with suspected PJI who underwent prosthetic joint revision surgery were included, and the results of those who had been tested by preoperative synovial fluid culture and mNGS were obtained. The demographic characteristics, medical history, laboratory test results, culture results, and mNGS results of each patient were recorded. Then, the efficiency of preoperative synovial fluid mNGS was compared to that of synovial fluid culture for diagnosing PJI. RESULTS A total of 37 patients were included, and 24 patients (25 joints) were diagnosed with PJI. The sensitivity, specificity, and accuracy of preoperative synovial fluid mNGS were 92%, 91.7%, and 83.7%, respectively. The sensitivity, specificity, and accuracy of preoperative synovial fluid culture were 52%, 91.7%, and 43.7%, respectively. CONCLUSIONS With a low volume of synovia (1 ml), mNGS can be performed with higher sensitivity and specificity compared to synovial culture. Thus, mNGS can be a useful supplemental method to improve diagnostic efficiency during the preoperative period.
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Li C, Ojeda-Thies C, Xu C, Trampuz A. Meta-analysis in periprosthetic joint infection: a global bibliometric analysis. J Orthop Surg Res 2020; 15:251. [PMID: 32650802 PMCID: PMC7350679 DOI: 10.1186/s13018-020-01757-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/16/2020] [Indexed: 02/07/2023] Open
Abstract
Background Periprosthetic joint infection (PJI) is the most serious complication of joint replacement surgery. Further comorbidities include bedsore, deep vein thrombosis, reinfection, or even death. An increasing number of researchers are focusing on this challenging complication. The aim of the present study was to estimate global PJI research based on bibliometrics from meta-analysis studies. Methods A database search was performed in PubMed, Scopus, and Web of Science. Relevant studies were assessed using the bibliometric analysis. Results A total of 117 articles were included. The most relevant literature on PJI was found on Scopus. China made the highest contributions to global research, followed by the USA and the UK. The institution with the most contributions was the University of Bristol. The journal with the highest number of publications was The Journal of Arthroplasty, whereas the Journal of Clinical Medicine had the shortest acceptance time. Furthermore, the top three frequently used databases were Embase, MEDLINE, and Cochrane. The most frequent number of authors in meta-analysis studies was four. Most studies focused on the periprosthetic hip and knee. The alpha-defensin diagnostic test, preventive measures on antibiotics use, and risk factors of intra-articular steroid injections were the most popular topic in recent years. Conclusion Based on the results of the present study, we found that there was no single database that covered all relevant articles; the optimal method for bibliometric analysis is a combination of databases. The most popular research topics on PJI focused on alpha-defensin, antibiotic use, risk factors of intra-articular steroid injections, and the location of prosthetic hip and knee infection.
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Affiliation(s)
- Cheng Li
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, D-10117, Berlin, Germany
| | | | - Chi Xu
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, People's Republic of China
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, D-10117, Berlin, Germany.
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30
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Yang B, Fang X, Cai Y, Yu Z, Li W, Zhang C, Huang Z, Zhang W. Detecting the presence of bacterial RNA by polymerase chain reaction in low volumes of preoperatively aspirated synovial fluid from prosthetic joint infections. Bone Joint Res 2020; 9:219-224. [PMID: 32566143 PMCID: PMC7284288 DOI: 10.1302/2046-3758.95.bjr-2019-0127.r2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Aims Preoperative diagnosis is important for revision surgery after prosthetic joint infection (PJI). The purpose of our study was to determine whether reverse transcription-quantitative polymerase chain reaction (RT-qPCR), which is used to detect bacterial ribosomal RNA (rRNA) preoperatively, can reveal PJI in low volumes of aspirated fluid. Methods We acquired joint fluid samples (JFSs) by preoperative aspiration from patients who were suspected of having a PJI and failed arthroplasty; patients with preoperative JFS volumes less than 5 ml were enrolled. RNA-based polymerase chain reaction (PCR) and bacterial culture were performed, and diagnostic efficiency was compared between the two methods.According to established Musculoskeletal Infection Society (MSIS) criteria, 21 of the 33 included patients were diagnosed with PJI. Results RNA-based PCR exhibited 57.1% sensitivity, 91.7% specificity, 69.7% accuracy, 92.3% positive predictive value, and 55.0% negative predictive value. The corresponding values for culture were 28.6%, 83.3%, 48.5%, 75.0%, and 40.0%, respectively. A significantly higher sensitivity was thus obtained with the PCR method versus the culture method. Conclusion In situations in which only a small JFS volume can be acquired, RNA-based PCR analysis increases the utility of preoperative puncture for patients who require revision surgery due to suspected PJI. Cite this article:Bone Joint Res. 2020;9(5):219–224.
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Affiliation(s)
- B Yang
- Department of Laboratory Medicine, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - X Fang
- Department of Orthopedic Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Y Cai
- Department of Orthopedic Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Z Yu
- Department of Orthopedic Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - W Li
- Department of Orthopedic Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - C Zhang
- Department of Orthopedic Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China; Department of Orthopedics & Traumatology, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Z Huang
- Department of Orthopedic Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - W Zhang
- Department of Orthopedic Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
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Suren C, Feihl S, Cabric S, Banke IJ, Haller B, Trampuz A, von Eisenhart-Rothe R, Prodinger PM. Improved pre-operative diagnostic accuracy for low-grade prosthetic joint infections using second-generation multiplex Polymerase chain reaction on joint fluid aspirate. INTERNATIONAL ORTHOPAEDICS 2020; 44:1629-1637. [PMID: 32296908 PMCID: PMC7452934 DOI: 10.1007/s00264-020-04552-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/26/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND A major obstacle for the treatment of prosthetic joint infection (PJI) is the identification of the underlying causative organism. While the diagnostic criteria ruling PJI in or out have become ever more accurate, the detection of the causative pathogen(s) still relies mostly on conventional and time-consuming microbial culture. The aim of this study was to evaluate the diagnostic potential of a second-generation multiplex PCR assay (Unyvero ITI G2, Curetis AG, Holzgerlingen, Germany) used on synovial fluid specimens. Our hypothesis was that the method would yield a higher diagnostic accuracy in the pre-operative workup than synovial fluid culture. Thus, a more precise classification of septic and aseptic prosthesis failure could be achieved before revision surgery. METHODS Prospectively collected frozen joint fluid specimens from 26 patients undergoing arthroplasty revision surgery of the hip or knee were tested as per the manufacturer's protocol. Sensitivities, specificities, positive and negative predictive values as well as positive and negative likelihood ratios with corresponding confidence intervals were estimated using the statistical software R. A combination of the serum C-reactive protein (CRP) level, leukocyte count, erythrocyte sedimentation rate, joint fluid culture, tissue biopsy culture, and tissue biopsy histology served as the gold standard. RESULTS Of the 26 patients included in the study, 15 were infected and 11 were aseptic. Conventional joint fluid culture showed a sensitivity of 0.67 and a specificity of 0.91. Joint fluid multiplex PCR yielded a sensitivity of 0.8 and a specificity of 1.0. CONCLUSIONS Using the second-generation Unyvero ITI cartridge on joint fluid aspirate for the detection of prosthetic joint infection, we were able to achieve a higher diagnostic accuracy than with conventional culture. We conclude that to improve pathogen detection before revision surgery, this method represents a valuable and practicable tool.
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Affiliation(s)
- Christian Suren
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Susanne Feihl
- Institut für Medizinische Mikrobiologie, Immunologie und Hygiene, Technische Universität München, Trogerstr. 30, 81675, Munich, Germany
| | - Sabrina Cabric
- Centrum für Muskuloskeletale Chirurgie (CMSC), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Ingo J Banke
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Haller
- Institut für medizinische Informatik, Statistik und Epidemiologie, Technische Universität München, Grillparzerstr. 18, 81675, Munich, Germany
| | - Andrej Trampuz
- Centrum für Muskuloskeletale Chirurgie (CMSC), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Rüdiger von Eisenhart-Rothe
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Peter M Prodinger
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
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Wang C, Wang Q, Li R, Qin J, Song L, Zhang Q, Liu M, Chen J, Wang C. LTF, PRTN3, and MNDA in Synovial Fluid as Promising Biomarkers for Periprosthetic Joint Infection: Identification by Quadrupole Orbital-Trap Mass Spectrometry. J Bone Joint Surg Am 2019; 101:2226-2234. [PMID: 31644522 DOI: 10.2106/jbjs.18.01483] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Diagnosing periprosthetic joint infection (PJI) requires various laboratory and clinical criteria. The purpose of this study was to explore novel biomarkers that could rapidly diagnose PJI with high accuracy. METHODS In this retrospective study of prospectively collected samples, 50 synovial fluid aspirates, 20 from the hip and 30 from the knee, were collected before surgery; 25 of the patients were diagnosed as having aseptic loosening (non-PJI) and 25, as having PJI according to the Musculoskeletal Infection Society criteria. A quadrupole orbital-trap mass spectrometry (MS) instrument was used to compare expression of proteins in patients with and without PJI. Proteins that were most efficacious for diagnosis of PJI were then determined using prediction analysis of microarray software and a random forest model. The most promising proteins were selected, and altered expression of these selected proteins was verified by ELISA (enzyme-linked immunosorbent assay) in an extended sample cohort. RESULTS A total of 256 proteins were significantly upregulated (≥3.0-fold) and 14 proteins were downregulated in synovial fluid of patients with PJI compared with patients without PJI. The 3 most promising proteins were lactoferrin (LTF), polymorphonuclear leukocyte serine protease 3 (PRTN3), and myeloid nuclear differentiation antigen (MNDA). When MS was used for diagnosis of PJI, the area under the curve was 0.9888 for LTF, 0.9488 for PRTN3, and 0.9632 for MNDA. ELISA results verified that LTF, MNDA, and PRTN3 were sensitive, while LTF and MNDA were specific, for diagnosis of PJI. CONCLUSIONS This proteomic study identified a previously noted protein and 2 novel candidate proteins as promising synovial fluid biomarkers for PJI diagnosis, and they should be further validated in future clinical trials. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Chi Wang
- Departments of Clinical Laboratory Medicine (Chi Wang, Q.W., Q.Z., and Chengbin Wang) and Orthopedics (Q.W., R.L., and J.C.), People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Qi Wang
- Departments of Clinical Laboratory Medicine (Chi Wang, Q.W., Q.Z., and Chengbin Wang) and Orthopedics (Q.W., R.L., and J.C.), People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Rui Li
- Departments of Clinical Laboratory Medicine (Chi Wang, Q.W., Q.Z., and Chengbin Wang) and Orthopedics (Q.W., R.L., and J.C.), People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Jun Qin
- State Key Laboratory of Proteomics, National Center for Protein Sciences (The PHOENIX Center), Beijing Proteome Research Center, Beijing, People's Republic of China
| | - Lei Song
- State Key Laboratory of Proteomics, National Center for Protein Sciences (The PHOENIX Center), Beijing Proteome Research Center, Beijing, People's Republic of China
| | - Qian Zhang
- Departments of Clinical Laboratory Medicine (Chi Wang, Q.W., Q.Z., and Chengbin Wang) and Orthopedics (Q.W., R.L., and J.C.), People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Mingwei Liu
- State Key Laboratory of Proteomics, National Center for Protein Sciences (The PHOENIX Center), Beijing Proteome Research Center, Beijing, People's Republic of China
| | - Jiying Chen
- Departments of Clinical Laboratory Medicine (Chi Wang, Q.W., Q.Z., and Chengbin Wang) and Orthopedics (Q.W., R.L., and J.C.), People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Chengbin Wang
- Departments of Clinical Laboratory Medicine (Chi Wang, Q.W., Q.Z., and Chengbin Wang) and Orthopedics (Q.W., R.L., and J.C.), People's Liberation Army General Hospital, Beijing, People's Republic of China
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Tsai TT, Huang TH, Ho NYJ, Chen YP, Chen CA, Chen CF. Development of a multiplex and sensitive lateral flow immunoassay for the diagnosis of periprosthetic joint infection. Sci Rep 2019; 9:15679. [PMID: 31666656 PMCID: PMC6821814 DOI: 10.1038/s41598-019-52051-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/10/2019] [Indexed: 02/07/2023] Open
Abstract
The diagnosis of periprosthetic joint infection (PJI) remains a challenge. However, recent studies showed that synovial fluid biomarkers have demonstrated greater diagnostic accuracy than the currently used PJI diagnostic tests. In many diagnostic tests, combining several biomarkers into panels is critical for improving diagnostic efficiency, enhancing the diagnostic precision for specific diseases, and reducing cost. In this study, we prove that combining alpha-defensin and C-reactive protein (CRP) as biomarkers possesses the potential to provide accurate PJI diagnosis. To further verify the result, we developed a multi-target lateral flow immunoassay strip (msLFIA) with staking pad design to obtain on-site rapid response for clinical diagnosis of PJI. A total of 10 synovial fluid samples were tested using the msLFIA, and the results showed that the combined measurements of synovial fluid alpha-defensin and CRP levels were consistent with those obtained from a commercial enzyme-linked immunosorbent assay kit. In addition, we developed a multi-target lateral flow immunoassay strip (msLFIA) with staking pad design to obtain on-site rapid response for clinical diagnosis of PJI, which the multi-target design is used to increase specificity and the stacking pad design is to enhance detection sensitivity. As a result, the turnaround time of the highly sensitive test can be limited from several hours to 20 min. We expect that the developed msLFIA possesses the potential for routine monitoring of PJI as a convenient, low-cost, rapid and easy to use detection device for PJI.
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Affiliation(s)
- Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan
| | - Tse-Hao Huang
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan
| | - Natalie Yi-Ju Ho
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan
| | - Yu-Pei Chen
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan
| | - Chung-An Chen
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan.,Institute of Applied Mechanics, National Taiwan University, Taipei, 106, Taiwan
| | - Chien-Fu Chen
- Institute of Applied Mechanics, National Taiwan University, Taipei, 106, Taiwan.
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Chen MF, Chang CH, Chiang-Ni C, Hsieh PH, Shih HN, Ueng SWN, Chang Y. Rapid analysis of bacterial composition in prosthetic joint infection by 16S rRNA metagenomic sequencing. Bone Joint Res 2019; 8:367-377. [PMID: 31537994 PMCID: PMC6719533 DOI: 10.1302/2046-3758.88.bjr-2019-0003.r2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objectives Prosthetic joint infection (PJI) is the most common cause of arthroplasty failure. However, infection is often difficult to detect by conventional bacterial cultures, for which false-negative rates are 23% to 35%. In contrast, 16S rRNA metagenomics has been shown to quantitatively detect unculturable, unsuspected, and unviable pathogens. In this study, we investigated the use of 16S rRNA metagenomics for detection of bacterial pathogens in synovial fluid (SF) from patients with hip or knee PJI. Methods We analyzed the bacterial composition of 22 SF samples collected from 11 patients with PJIs (first- and second-stage surgery). The V3 and V4 region of bacteria was assessed by comparing the taxonomic distribution of the 16S rDNA amplicons with microbiome sequencing analysis. We also compared the results of bacterial detection from different methods including 16S metagenomics, traditional cultures, and targeted Sanger sequencing. Results Polymicrobial infections were not only detected, but also characterized at different timepoints corresponding to first- and second-stage exchange arthroplasty. Similar taxonomic distributions were obtained by matching sequence data against SILVA, Greengenes, and The National Center for Biotechnology Information (NCBI). All bacteria isolated from the traditional culture could be further identified by 16S metagenomics and targeted Sanger sequencing. Conclusion The data highlight 16S rRNA metagenomics as a suitable and promising method to detect and identify infecting bacteria, most of which may be uncultivable. Importantly, the method dramatically reduces turnaround time to two days rather than approximately one week for conventional cultures. Cite this article: M-F. Chen, C-H. Chang, C. Chiang-Ni, P-H. Hsieh, H-N. Shih, S. W. N. Ueng, Y. Chang. Rapid analysis of bacterial composition in prosthetic joint infection by 16S rRNA metagenomic sequencing. Bone Joint Res 2019;8:367–377. DOI: 10.1302/2046-3758.88.BJR-2019-0003.R2.
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Affiliation(s)
- Mei-Feng Chen
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Bone and Joint Research Center, Chang Gung Memorial Hospital; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University. Taoyuan, Taiwan
| | - Chuan Chiang-Ni
- Department of Microbiology and Immunology, College of Medicine, Chang Gung University; Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital. Taoyuan, Taiwan
| | - Pang-Hsin Hsieh
- Bone and Joint Research Center, Chang Gung Memorial Hospital; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsin-Nung Shih
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Steve W N Ueng
- Bone and Joint Research Center, Chang Gung Memorial Hospital; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yuhan Chang
- Bone and Joint Research Center, Chang Gung Memorial Hospital; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Han X, Xie K, Jiang X, Wang L, Wu H, Qu X, Yan M. Synovial fluid α-defensin in the diagnosis of periprosthetic joint infection: the lateral flow test is an effective intraoperative detection method. J Orthop Surg Res 2019; 14:274. [PMID: 31455372 PMCID: PMC6712677 DOI: 10.1186/s13018-019-1320-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 08/16/2019] [Indexed: 12/29/2022] Open
Abstract
Background Synovial fluid α-defensin is a valuable biomarker for periprosthetic joint infection (PJI). Its diagnostic value for PJI has been widely evaluated recently, but results are inconsistent, especially for different test methods. The objective of this study was to evaluate the diagnostic value of laboratory-based immunoassay and lateral flow testing for the detection of α-defensin against hip and knee PJI. Methods We systematically searched MEDLINE and EMBASE for articles on the diagnostic accuracy of α-defensin for PJI published up to September 2018. The pooled sensitivity, specificity, area under the curve (AUC), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were calculated for the evaluation of the diagnostic value of α-defensin for PJI. Results Nineteen studies were included. Eleven evaluated laboratory-based immunoassay, and 10 evaluated the lateral flow test results. The pooled sensitivity, specificity, AUC, PLR, NLR, and DOR of laboratory-based immunoassays were 0.96 (95% confidence interval [CI] 0.90–0.98), 0.97 (95% CI 0.95–0.99), 0.99 (95% CI 0.98–1.00), 35.0 (95% CI 18.5–66.2), 0.04 (95% CI 0.02–0.11), and 811 (95% CI 220–2990), respectively. The pooled sensitivity, specificity, AUC, PLR, NLR, and DOR of the lateral flow test were 0.86 (95% CI 0.81–0.91), 0.96 (95% CI 0.93–0.98), 0.95 (95% CI 0.93–0.97), 21.2 (95% CI 11.7–38.5), 0.14 (95% CI 0.10–0.21), and 148 (95% CI 64–343), respectively. Conclusions Laboratory-based immunoassay of α-defensin is highly accurate for the diagnosis of hip and knee PJI. The lateral flow test is less sensitive but still a useful intraoperative detection tool for PJI.
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Affiliation(s)
- Xuequan Han
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Kai Xie
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Xu Jiang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Liao Wang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Haishan Wu
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, 145 Middle Shandong Road, Shanghai, China
| | - Mengning Yan
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China.
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Kleiss S, Jandl NM, Novo de Oliveira A, Rüther W, Niemeier A. Diagnostic accuracy of alpha-defensin enzyme-linked immunosorbent assay in the clinical evaluation of painful hip and knee arthroplasty with possible prosthetic joint infection. Bone Joint J 2019; 101-B:970-977. [DOI: 10.1302/0301-620x.101b8.bjj-2018-1390.r2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Aims The aim of this study was to evaluate the diagnostic accuracy of the synovial alpha-defensin enzyme-linked immunosorbent assay (ELISA) for the diagnosis of prosthetic joint infection (PJI) in the work-up prior to revision of total hip (THA) and knee arthroplasty (TKA). Patients and Methods Inclusion criteria for this prospective cohort study were acute or chronic symptoms of the index joint without specific exclusion criteria. Synovial fluid aspirates of 202 patients were analyzed and semiquantitative laboratory alpha-defensin ELISA was performed. Final diagnosis of PJI was established by examination of samples obtained during revision surgery. Results Sensitivity and specificity of the alpha-defensin ELISA for PJI were 78.2% (95% confidence interval (CI) 66.7 to 88.5) and 96.6% (95% CI 93.0 to 99.3). Positive and negative predictive values were 89.6% (95% CI 80.6 to 97.8) and 92.2% (95% CI 87.5 to 96.1). The test remained false-negative in 22% of septic revisions, most of which were due to coagulase-negative staphylococci all occurring in either late-chronic or early-postoperative PJI. Conclusion The routine use of synovial fluid alpha-defensin laboratory ELISA in the preoperative evaluation of symptomatic THAs and TKAs is insufficient to accurately diagnose PJI. Particularly in cases involving low-virulence organisms, such as coagulase-negative staphylococci, there remains a need for tests with a higher sensitivity. Cite this article: Bone Joint J 2019;101-B:970–977.
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Affiliation(s)
- S. Kleiss
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - N. M. Jandl
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A. Novo de Oliveira
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - W. Rüther
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A. Niemeier
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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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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Li R, Lu Q, Chai W, Hao LB, Lu SB, Chen JY. Saline Solution Lavage and Reaspiration for Culture with a Blood Culture System Is a Feasible Method for Diagnosing Periprosthetic Joint Infection in Patients with Insufficient Synovial Fluid. J Bone Joint Surg Am 2019; 101:1004-1009. [PMID: 31169577 DOI: 10.2106/jbjs.18.01052] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Culture is a key step for detecting periprosthetic joint infection (PJI) before surgery. However, using saline solution lavage and reaspiration in patients with insufficient synovial fluid remains controversial. The objective of this study was to evaluate this technique. METHODS This study included 286 aspirations performed by 1 surgeon in patients after total joint arthroplasty during the period of April 2015 to August 2018. If >1.0 mL of synovial fluid was obtained, then we directly used the fluid for culture. For cases in which ≤1.0 mL of synovial fluid was aspirated, 10 mL of saline solution was injected and the joint was reaspirated for culture. The samples were injected into 2 blood culture bottles for anaerobic bacterial culture and aerobic bacterial and fungal culture, and were inoculated for 14 days in a BACT/ALERT 3D blood culture system unless microorganisms were detected. A PJI diagnosis was determined on the basis of the modified Musculoskeletal Infection Society criteria. RESULTS Saline solution lavage and reaspiration were used in 82 cases (47 PJI cases and 35 non-PJI cases), while direct aspiration was used in 204 cases (99 PJI cases and 105 non-PJI cases). The overall rate for the use of saline solution lavage was 28.7% (82 of 286). Among knee cases, the saline solution lavage rate was 15.0% (21 of 140), and among hip cases, the rate was 41.8% (61 of 146). The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of culture were 0.795 (95% confidence interval [CI], 0.720 to 0.857), 0.957 (95% CI, 0.909 to 0.984), 0.951 (95% CI, 0.896 to 0.982), and 0.817 (95% CI, 0.749 to 0.873); and for "dry tap" cases, they were 0.851 (95% CI, 0.717 to 0.938), 0.857 (95% CI, 0.697 to 0.952), 0.889 (95% CI, 0.760 to 0.963), and 0.811 (95% CI, 0.648 to 0.920), respectively. CONCLUSIONS Saline solution lavage and reaspiration for culture in patients with insufficient synovial fluid before surgery may be a sound practice. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Rui Li
- Department of Orthopedics (R.L., Q.L., W.C., L.-B.H., and J.-Y.C.) and Institute of Orthopedics, Beijing Key Laboratory of Regenerative Medicine in Orthopedics, and Key Laboratory of Musculoskeletal Trauma & War Injuries PLA (S.-B.L.), Chinese PLA General Hospital, Beijing, China
| | - Qiang Lu
- Department of Orthopedics (R.L., Q.L., W.C., L.-B.H., and J.-Y.C.) and Institute of Orthopedics, Beijing Key Laboratory of Regenerative Medicine in Orthopedics, and Key Laboratory of Musculoskeletal Trauma & War Injuries PLA (S.-B.L.), Chinese PLA General Hospital, Beijing, China
| | - Wei Chai
- Department of Orthopedics (R.L., Q.L., W.C., L.-B.H., and J.-Y.C.) and Institute of Orthopedics, Beijing Key Laboratory of Regenerative Medicine in Orthopedics, and Key Laboratory of Musculoskeletal Trauma & War Injuries PLA (S.-B.L.), Chinese PLA General Hospital, Beijing, China
| | - Li-Bo Hao
- Department of Orthopedics (R.L., Q.L., W.C., L.-B.H., and J.-Y.C.) and Institute of Orthopedics, Beijing Key Laboratory of Regenerative Medicine in Orthopedics, and Key Laboratory of Musculoskeletal Trauma & War Injuries PLA (S.-B.L.), Chinese PLA General Hospital, Beijing, China
| | - Shi-Bi Lu
- Department of Orthopedics (R.L., Q.L., W.C., L.-B.H., and J.-Y.C.) and Institute of Orthopedics, Beijing Key Laboratory of Regenerative Medicine in Orthopedics, and Key Laboratory of Musculoskeletal Trauma & War Injuries PLA (S.-B.L.), Chinese PLA General Hospital, Beijing, China
| | - Ji-Ying Chen
- Department of Orthopedics (R.L., Q.L., W.C., L.-B.H., and J.-Y.C.) and Institute of Orthopedics, Beijing Key Laboratory of Regenerative Medicine in Orthopedics, and Key Laboratory of Musculoskeletal Trauma & War Injuries PLA (S.-B.L.), Chinese PLA General Hospital, Beijing, China
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Ouyang Z, Tan T, Liu C, Duan J, Wang W, Guo X, Zhang Q, Li Z, Huang Q, Dou P, Liu T. Targeted delivery of hesperetin to cartilage attenuates osteoarthritis by bimodal imaging with Gd 2(CO 3) 3@PDA nanoparticles via TLR-2/NF-κB/Akt signaling. Biomaterials 2019; 205:50-63. [PMID: 30903825 DOI: 10.1016/j.biomaterials.2019.03.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/16/2019] [Accepted: 03/14/2019] [Indexed: 02/05/2023]
Abstract
The progressive degeneration of cartilage marks the advancement of osteoarthritis (OA), which requires specific targeted treatment for effective cartilage repair. However, there is still no efficient cartilage delivery system or novel magnetic resonance (MR) contrast agent (CA). Herein, we report the synthesis of a novel class of MR CA, Gd2(CO3)3-based nanoparticles (NPs), from a simpler and "greener" approach than previous ones. After the coating of polydopamine (PDA) onto the Gd2(CO3)3 core, we further anchored a cartilage-targeting peptide and loaded hesperetin (Hes) into NPs (Hes-Gd2(CO3)3@PDA-PEG-DWpeptide, HGdPDW), showing excellent cartilage affinity and MR suitability. Additionally, the synthesized HGdPDW exerted significant protective effects against IL-1β stimulation, as shown by the decreased apoptosis and inflammation and increased maturation of chondrocytes in vitro. More importantly, RNA-seq analyses showed the significant reduction of TLR-2 in IL-1β-treated chondrocytes, and this reduction was followed by the inactivation of NF-κB/Akt signaling, leading to the protective effect of HGdPDW. By the establishment of anterior cruciate ligament transection (ACLT) OA mice, the bimodal MRI/IVIS imaging demonstrated the effective cartilage-binding ability of HGdPDW in OA knees with low cytotoxicity, which alleviated the gradual degeneration of articular cartilage in vivo by inhibiting TLR-2 in chondrocytes. Taken together, these results suggest that HGdPDW could target cartilage effectively, thereby protecting chondrocytes from apoptosis and inflammation via TLR-2/NF-κB/Akt signaling. We hope this new class of MRI CA could be applied in not only other fields using MRI technology but also the treatment of general cartilage-related diseases; this application will undoubtedly extend the treatment of OA clinically.
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Affiliation(s)
- Zhengxiao Ouyang
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, PR China; State Key Laboratory of Powder Metallurgy, Central South University, Changsha, Hunan 410083, PR China
| | - Tingting Tan
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, PR China; Department of Metabolism & Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, PR China
| | - Chunfeng Liu
- Department of Orthopedics, Suzhou Kowloon Hospital Affiliated to School of Medicine, Shanghai Jiao Tong University, Suzhou, 215021, PR China
| | - Juan Duan
- Department of Geriatrics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, PR China
| | - Wanchun Wang
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, PR China
| | - Xiaoning Guo
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, PR China
| | - Qing Zhang
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, PR China
| | - Zhihong Li
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, PR China
| | - Qianli Huang
- State Key Laboratory of Powder Metallurgy, Central South University, Changsha, Hunan 410083, PR China
| | - Pengcheng Dou
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, PR China.
| | - Tang Liu
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, PR China; State Key Laboratory of Powder Metallurgy, Central South University, Changsha, Hunan 410083, PR China.
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Strahm C, Zdravkovic V, Egidy C, Jost B. Accuracy of Synovial Leukocyte and Polymorphonuclear Cell Count in Patients with Shoulder Prosthetic Joint Infection. J Bone Jt Infect 2018; 3:245-248. [PMID: 30533345 PMCID: PMC6284099 DOI: 10.7150/jbji.29289] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 09/14/2018] [Indexed: 11/13/2022] Open
Abstract
Joint aspiration in suspected infected implants is a validated diagnostic method in establishing the diagnosis of prosthetic joint infection (PJI). Cut-off values for synovial leukocyte counts and differentials are well described for patients with hip and knee PJI. In 19 failed shoulder implants, a leucocyte count of >12.2 G/L had a sensitivity and specificity of 92% and 100% respectively; A differential of >54% neutrophils had a sensitivity of 100 % and a specificity of 75%.
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Affiliation(s)
- Carol Strahm
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Vilijam Zdravkovic
- Department of Orthopaedics and Traumatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Claus Egidy
- Department of Orthopaedics and Traumatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Bernhard Jost
- Department of Orthopaedics and Traumatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
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Sebastian S, Malhotra R, Dhawan B. Prosthetic Joint Infection: A Major Threat to Successful Total Joint Arthroplasty. Indian J Med Microbiol 2018; 36:475-487. [DOI: 10.4103/ijmm.ijmm_19_11] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Bone and joint infections are potentially limb-threatening or even life-threatening diseases. Emergency physicians must consider infection when evaluating musculoskeletal complaints, as misdiagnosis can have significant consequences. Patients with bone and joint infections can have heterogeneous presentations with nonspecific signs and symptoms. Staphylococcus aureus is the most commonly implicated microorganism. Although diagnosis may be suggested by physical examination, laboratory testing, and imaging, tissue sampling for Gram stain and microbiologic culture is preferable, as pathogen identification and susceptibility testing help optimize long-term antibiotic therapy. A combination of medical and surgical interventions is often necessary to effectively manage these challenging infections.
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Affiliation(s)
- Daniel C Kolinsky
- Department of Emergency Medicine, Southeast Louisiana Veterans Health Care System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Stephen Y Liang
- Division of Emergency Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8072, St Louis, MO 63110, USA; Division of Infectious Diseases, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8051, St Louis, MO 63110, USA.
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Rodriguez-Merchan EC. Preoperative Aspiration Culture (PAC) for the Diagnosis of Infection in a Prosthetic Knee Joint. THE ARCHIVES OF BONE AND JOINT SURGERY 2018; 6:342-345. [PMID: 30320171 PMCID: PMC6168232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 08/31/2017] [Indexed: 06/08/2023]
Abstract
BACKGROUND Periprosthetic infection is the most serious joint replacement complication, occurring in 0.8-1.9% of total knee arthroplasties (TKAs).This review aims to define the role of preoperative aspiration culture (PAC) for diagnosis of TKA infection. METHODS A PubMed (MEDLINE) search related to TKA infection and PAC was analyzed. The main criteria for selection were that the articles were focused in the aforementioned question. RESULTS Twenty articles were found, but only fourteen were selected and reviewed because they were deeply focused on the topic. PAC has shown an average sensitivity of 67.6% (range, 28% to 100%) and an average specificity of 98.4% (range, 96% to 100%). CONCLUSION PAC has moderate to high sensitivity and very high specificity for diagnosing TKA infection.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Research performed at the Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain
- Department of Orthopaedic Surgery, La Paz University Hospital-IdiPaz, Paseo de la Castellana, Madrid, Spain
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Li R, Lu Q, Zhou YG, Chai W, Lu SB, Chen JY. Centrifugation May Change the Results of Leukocyte Esterase Strip Testing in the Diagnosis of Periprosthetic Joint Infection. J Arthroplasty 2018; 33:2981-2985. [PMID: 29752029 DOI: 10.1016/j.arth.2018.04.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/24/2018] [Accepted: 04/08/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Centrifugation is used to remove the color interference by erythrocytes in blood-synovial fluid samples before leukocyte esterase (LE) strip testing. However, the impact of centrifugation requires further study. METHODS From April 2016 to October 2017, 133 (53 infected and 80 noninfected) patients were included in this study. One drop of synovial fluid was applied to LE strips before and after centrifugation in 110 cases. The other 23 cases could not be read without centrifugation due to the color disturbance caused by blood contamination. The results were recorded after approximately 3 minutes according to different color grades on a color chart, including grade 3 (++), grade 2 (+), and grade 1 (others). RESULTS After centrifugation, almost every sample was lighter in color than before. Although most results changed inconspicuously and remained in the same grade, 18.6% (8/43) and 17.9% (12/67) of cases were downgraded in the periprosthetic joint infection and non-periprosthetic joint infection groups, respectively. Before centrifugation, when grade 3 (++) was used as the positive threshold, the sensitivity and specificity were 97.7% (86.2%-99.9%) and 100% (94.3%-100%), respectively. After centrifugation, when grades 2 and 3 (+ and ++, respectively) were used as the positive threshold, the sensitivity and specificity were 92.5% (80.9%-97.6%) and 100% (94.3%-100%), respectively. CONCLUSIONS The influence of centrifugation should be considered when interpreting the LE strip test results. For cases without centrifugation, we recommended using ++ as the positive threshold, while for cases using centrifugation, the threshold should be reduced to both ++ and +.
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Affiliation(s)
- Rui Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Qiang Lu
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Yong-Gang Zhou
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Wei Chai
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Shi-Bi Lu
- Institute of Orthopedics, Chinese PLA General Hospital, Beijing, China; Beijing Key Laboratory of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China; Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Chinese PLA General Hospital, Beijing, China
| | - Ji-Ying Chen
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
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Ottink KD, Wouthuyzen-Bakker M, Kampinga GA, Jutte PC, Ploegmakers JJ. Puncture Protocol in the Diagnostic Work-Up of a Suspected Chronic Prosthetic Joint Infection of the Hip. J Arthroplasty 2018. [PMID: 29530521 DOI: 10.1016/j.arth.2018.01.072] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Diagnosing a chronic prosthetic joint infection (PJI) can be challenging. We hypothesized that obtaining preoperative tissue samples for culture in hip arthroplasty will increase the likelihood of diagnosing an infection before revision surgery. The aim of this cohort study was to determine the diagnostic accuracy of 2 tissue acquiring biopsy strategies to diagnose a PJI. METHODS Patients with a painful hip arthroplasty, in which a chronic PJI was suspected, were included. Tissue samples were obtained either by ultrasound guidance with a 16-Gauge needle (2012-2013) or in the operating room with a thick-bore needle (2013-2016). Revision surgery tissue biopsies were used as the gold standard. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were calculated. RESULTS A total of 16 patients in the ultrasound cohort and 29 patients in the surgical cohort were included. Thirty-one percent (n = 14) were finally diagnosed with a PJI. The addition of thick bore needle tissue biopsies resulted in 9% more diagnosed PJIs compared with synovial fluid alone. The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio was 33%, 85%, 33%, 85%, 2.2, and 0.8, respectively, for the ultrasound-guided biopsy cohort and 82%, 100%, 100%, 90%, infinite, and 0.2, respectively, for the surgical biopsy cohort. CONCLUSION Obtaining multiple good quality tissue biopsies in a sterile environment will contribute to the diagnosis of a chronic PJI of the hip, with a higher diagnostic accuracy compared with ultrasound-guided thin needle biopsies and compared with synovial fluid culture alone.
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Affiliation(s)
- Karsten D Ottink
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Greetje A Kampinga
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Joris J Ploegmakers
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
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46
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Gomez-Urena EO, Tande AJ, Osmon DR, Berbari EF. Diagnosis of Prosthetic Joint Infection: Cultures, Biomarker and Criteria. Infect Dis Clin North Am 2018; 31:219-235. [PMID: 28483043 DOI: 10.1016/j.idc.2017.01.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Prosthetic joint infections (PJIs) are devastating complications after joint arthroplasty that continue to pose a diagnostic challenge. Currently, a single, stand-alone test with the adequate accuracy and reliability for diagnosis of PJI is not available; therefore, physicians who care for patients with PJI must rely on a combination of diagnostic tests for the diagnosis of PJI. This article reviews conventional laboratory test modalities, diagnostic accuracy and limitations of current tests, and novel emerging tests for the diagnosis of PJI.
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Affiliation(s)
- Eric O Gomez-Urena
- Division of Infectious Diseases, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Aaron J Tande
- Division of Infectious Diseases, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Douglas R Osmon
- Division of Infectious Diseases, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Elie F Berbari
- Division of Infectious Diseases, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
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47
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Lee YS, Koo KH, Kim HJ, Tian S, Kim TY, Maltenfort MG, Chen AF. Synovial Fluid Biomarkers for the Diagnosis of Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2017; 99:2077-2084. [PMID: 29257013 DOI: 10.2106/jbjs.17.00123] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The search for a single standard reference test for determining periprosthetic joint infection (PJI) through analysis of synovial fluid has yielded numerous biomarkers as potential candidates. The purpose of the present systematic review and meta-analysis was to evaluate the diagnostic accuracy of synovial fluid biomarkers and to determine which test has the highest diagnostic odds ratio (DOR) for the diagnosis of PJI. METHODS An online literature search of the MEDLINE, Embase, and Cochrane databases identified 33 articles reporting a total of 13 major parameters for diagnosing PJI through analysis of synovial fluid. Each of the included articles was independently analyzed for risk of bias and for concerns regarding applicability utilizing the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool. The mada (meta-analysis of diagnostic accuracy) tool was used to generate forest plots for sensitivity, specificity, and the log of the DOR, as well as summary statistics. RESULTS In this analysis, 13 index tests (leukocyte count; measurement of the percentage of polymorphonucleocytes [PMN%] and the levels of C-reactive protein [CRP], α-defensin, leukocyte esterase [LE], interleukin [IL]-6, IL-8, IL-10, IL-1β, vascular endothelial growth factor [VEGF], and granulocyte-colony stimulating factor [G-CSF]; culture; and polymerase chain reaction [PCR] analysis) were evaluated on the basis of ≥2 articles. Of these tests, 8 (leukocyte count, PMN%, CRP, α-defensin, LE, IL-6, IL-8, and culture) were appropriate for pooled analysis. The overall sensitivity of these 8 markers was 0.85, and all but culture showed a sensitivity of ≥0.8. All markers showed a specificity of ≥0.9. Of the 8 tests, measurement of the α-defensin level showed the highest log DOR. CONCLUSIONS Synovial fluid leukocyte count, PMN%, CRP, α-defensin, LE, IL-6, and IL-8 all demonstrated high sensitivity for diagnosing PJI, with α-defensin being the best synovial marker based on the highest log DOR. However, other synovial fluid tests that demonstrate good diagnostic performance can also be used in combination for the diagnosis of PJI. LEVEL OF EVIDENCE Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Yong Seuk Lee
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Hyun Jung Kim
- Institute for Evidence-Based Medicine and Department of Preventive Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Shaoqi Tian
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Joint Surgery, the Affiliated Hospital of Medical College, Qingdao University, Qingdao, People's Republic of China
| | - Tae-Young Kim
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Mitchell G Maltenfort
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Antonia F Chen
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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48
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Berger P, Van Cauter M, Driesen R, Neyt J, Cornu O, Bellemans J. Diagnosis of prosthetic joint infection with alpha-defensin using a lateral flow device: a multicentre study. Bone Joint J 2017; 99-B:1176-1182. [PMID: 28860397 DOI: 10.1302/0301-620x.99b9.bjj-2016-1345.r2] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 05/11/2017] [Indexed: 12/12/2022]
Abstract
AIMS The purpose of this current multicentre study is to analyse the presence of alpha-defensin proteins in synovial fluid using the Synovasure lateral flow device and to determine its diagnostic reliability and accuracy compared with the prosthetic joint infection (PJI) criteria produced by the Musculoskeletal Infection Society (MSIS). PATIENTS AND METHODS A cohort of 121 patients comprising 85 total knee arthroplasties and 36 total hip arthroplasties was prospectively evaluated between May 2015 and June 2016 in three different orthopaedic centres. The tests were performed on patients with a chronically painful prosthesis undergoing a joint aspiration in a diagnostic pathway or during revision surgery. RESULTS Based on the MSIS criteria, 34 patients (28%) would have had a PJI, and 87 patients had no PJI. Testing with the lateral flow device had a sensitivity of 97.1% (95% confidence intervals (CI) 84.5 to 99.9) and a specificity of 96.6% (95% CI 90.3 to 99.2). The positive predictive value was 91.7% (95% CI 77.7% to 98.3), and the negative predictive value was 98.8% (95% CI 93.6 to 99.9). Receiver operator characteristics analysis demonstrated an area under the curve for the Synovasure test of 0.97 (95% CI 0.93 to 1.00). CONCLUSION Our findings suggest that the Synovasure test has an excellent diagnostic performance to confirm or reject the diagnosis of a PJI. The results are promising for the care of the painful or problematic knee and hip joint arthroplasty and the test should be considered as part of the diagnostic toolbox for PJIs. Cite this article: Bone Joint J 2017;99-B:1176-82.
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Affiliation(s)
- P Berger
- University Hospitals Leuven, Weligerveld 1, 3212 Pellenberg, Belgium
| | - M Van Cauter
- University Hospital Saint Luc, Hippocrateslaan 10, 1200 Sint-Lambrechts-Woluwe, Belgium
| | - R Driesen
- Ziekenhuis Oost-Limburg, Genk, Schiepse Bos 6, 3600 Genk, Belgium
| | - J Neyt
- University Hospitals Leuven, Weligerveld 1, 3212 Pellenberg, Belgium
| | - O Cornu
- University Hospital Saint Luc, Hippocrateslaan 10, 1200 Sint-Lambrechts-Woluwe, Belgium
| | - J Bellemans
- Ziekenhuis Oost-Limburg, Genk, Schiepse Bos 6, 3600 Genk, Belgium
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49
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Wouthuyzen-Bakker M, Benito N, Soriano A. The Effect of Preoperative Antimicrobial Prophylaxis on Intraoperative Culture Results in Patients with a Suspected or Confirmed Prosthetic Joint Infection: a Systematic Review. J Clin Microbiol 2017; 55:2765-2774. [PMID: 28659322 PMCID: PMC5648712 DOI: 10.1128/jcm.00640-17] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 06/23/2017] [Indexed: 02/08/2023] Open
Abstract
Obtaining reliable cultures during revision arthroplasty is important to adequately diagnose and treat a prosthetic joint infection (PJI). The influence of antimicrobial prophylaxis on culture results remains unclear. Since withholding prophylaxis increases the risk for surgical site infections, clarification on this topic is critical. A systematic review was performed with the following research question: in patients who undergo revision surgery of a prosthetic joint, does preoperative antimicrobial prophylaxis affect the culture yield of intraoperative samples in comparison with nonpreoperative antimicrobial prophylaxis? Seven articles were included in the final analysis. In most studies, standard diagnostic culture techniques were used. In patients with a PJI, pooled analysis showed a culture yield of 88% (145/165) in the prophylaxis group versus 95% (344/362) in the nonprophylaxis group (P = 0.004). Subanalysis of patients with chronic PJIs showed positive cultures in 88% (78/89) versus 91% (52/57), respectively (P = 0.59). In patients with a suspected chronic infection, a maximum difference of 4% in culture yield between the prophylaxis and nonprophylaxis groups was observed. With the use of standard culture techniques, antimicrobial prophylaxis seems to affect cultures in a minority of patients. Along with the known risk of surgical site infections due to inadequate timing of antimicrobial prophylaxis, we discourage the postponement of prophylaxis until tissue samples are obtained in revision surgery. Future studies are necessary to conclude whether the small percentage of false-negative cultures after prophylaxis can be further reduced with the use of more-sensitive culture techniques, like sonication.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Natividad Benito
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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50
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Preoperative joint aspiration in the diagnosis of non-acute hip and knee prosthetic joint infections. Med Mal Infect 2017; 47:364-369. [DOI: 10.1016/j.medmal.2017.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/06/2016] [Accepted: 04/10/2017] [Indexed: 11/23/2022]
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