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Sak B, Gottliebová P, Nyčová E, Holubová N, Fenclová J, Kicia M, Zajączkowska Ż, Kváč M. Microsporidia (Encephalitozoon cuniculi) in Patients with Degenerative Hip and Knee Disease, Czech Republic. Emerg Infect Dis 2024; 30:469-477. [PMID: 38289719 PMCID: PMC10902539 DOI: 10.3201/eid3003.231263] [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: 02/01/2024] Open
Abstract
Total joint arthroplasty is a commonly used surgical procedure in orthopedics. Revision surgeries are required in >10% of patients mainly because of prosthetic joint infection caused by bacteria or aseptic implant loosening caused by chronic inflammation. Encephalitozoon cuniculi is a microsporidium, an obligate intracellular parasite, capable of exploiting migrating proinflammatory immune cells for dissemination within the host. We used molecular detection methods to evaluate the incidence of E. cuniculi among patients who had total hip or knee arthroplasty revision. Out of 49 patients, E. cuniculi genotypes I, II, or III were confirmed in joint samples from 3 men and 2 women who had implant loosening. Understanding the risks associated with the presence of microsporidia in periprosthetic joint infections is essential for proper management of arthroplasty. Furthermore, E. cuniculi should be considered a potential contributing cause of joint inflammation and arthrosis.
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Lutro O, Mo S, Tjørhom MB, Fenstad AM, Leta TH, Bruun T, Hallan G, Furnes O, Dale H. How good are surgeons at disclosing periprosthetic joint infection at the time of revision, based on pre- and intra-operative assessment? A study on 16,922 primary total hip arthroplasties reported to the Norwegian Arthroplasty Register. Acta Orthop 2024; 95:67-72. [PMID: 38288989 PMCID: PMC10826841 DOI: 10.2340/17453674.2024.39914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/14/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND AND PURPOSE Revision due to infection, as reported to the Norwegian Arthroplasty Register (NAR), is a surrogate endpoint to periprosthetic joint infection (PJI). We aimed to find the accuracy of the reported causes of revision after primary total hip arthroplasty (THA) compared with PJI to see how good surgeons were at disclosing infection, based on pre- and intraoperative assessment. PATIENTS AND METHODS We investigated the reasons for revision potentially caused by PJI following primary THA: infection, aseptic loosening, prolonged wound drainage, and pain only, reported to the NAR from surgeons in the region of Western Norway during the period 2010-2020. The electronic patient charts were investigated for information on clinical assessment, treatment, biochemistry, and microbiological findings. PJI was defined in accordance with the Musculoskeletal Infection Society (MSIS) definition. Sensitivity, specificity, and accuracy were calculated. RESULTS 363 revisions in the NAR were eligible for analyses. Causes of revision were (reported/validated): infection (153/177), aseptic loosening (139/133), prolonged wound drainage (37/13), and pain only (34/40). The sensitivity for reported revision due to infection compared with PJI was 80%, specificity was 94%, and accuracy-the surgeons' ability to disclose PJI or non-septic revision at time of revision-was 87%. The accuracy for the specific revision causes was highest for revision due to aseptic loosening (95%) and pain only (95%), and lowest for revision due to prolonged wound drainage (86%). CONCLUSION The accuracy of surgeon-reported revisions due to infection as representing PJI was 87% in the NAR. Our study shows the importance of systematic correction of the reported cause of revision in arthroplasty registers, after results from adequately taken bacterial samples.
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Affiliation(s)
- Olav Lutro
- Department of Medicine, Stavanger University Hospital, Stavanger.
| | - Synnøve Mo
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
| | | | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
| | - Tesfaye Hordofa Leta
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; VID Specialized University, Bergen, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; Department of Medicine, Haukeland University Hospital, Bergen
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; Department of Clinical Medicine, University of Bergen, Bergen
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; Department of Clinical Medicine, University of Bergen, Bergen
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van Schaik T, Heesterbeek P, van Susante J, Rijnen W, Goosen J. Multiplex PCR test as an intra-operative diagnostic tool for periprosthetic joint infection in presumed aseptic revision hip and knee arthroplasty: a 1-year follow-up study of 200 cases. J Bone Jt Infect 2024; 9:9-16. [PMID: 38600999 PMCID: PMC11002914 DOI: 10.5194/jbji-9-9-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/06/2023] [Indexed: 04/12/2024] Open
Abstract
Automated custom-made multiplex PCR techniques (mPCR) have become commercially available and are designed for intra-operative screening of concurrent periprosthetic joint infections (PJIs). The purpose of this study was to evaluate the value of a positive mPCR test in presumed aseptic revision total hip (THA) and knee (TKA) arthroplasties after a 1-year follow-up. In an earlier study, such an automated mPCR technique (Unyvero ITI G2; Curetis, Holzgerlingen, Germany) was tested on intra-operatively obtained synovial fluid in 200 patients with a presumed aseptic TKA or THA revision. At the time of revision, no therapeutic consequences were attached to a positive test result since treating personnel were blinded for the test results. We retrospectively reviewed the outcome of cases with respect to the occurrence of PJIs using the European Bone and Joint Infection Society (EBJIS) criteria during a 1-year follow-up postoperatively. A total of 10 out of 200 patients had a positive mPCR test result at the time of revision. Of these 10 cases, none encountered outcome parameters fulfilling the criteria to diagnose PJIs in the first year after surgery, and one required re-revision surgery for reasons other than infection. Of the other 190 negative mPCR cases, none developed a PJI. A positive mPCR test at the time of presumed aseptic revision surgery did not correspond with intra-operatively obtained tissue cultures, and none of the encountered positive mPCR tests had developed a PJI at the 1-year follow-up. We recommend careful evaluation and monitoring of modern diagnostic tests before widespread use.
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Affiliation(s)
- Thomas J. A. van Schaik
- Department of Orthopaedic Surgery, Sint Maartenskliniek, Nijmegen, the Netherlands
- Department of Orthopaedic Surgery, Rijnstate Ziekenhuis, Arnhem, the Netherlands
- Department of Orthopaedic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | - Wim H. C. Rijnen
- Department of Orthopaedic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jon H. M. Goosen
- Department of Orthopaedic Surgery, Sint Maartenskliniek, Nijmegen, the Netherlands
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Pan B, Zhang Z, Wu X, Xian G, Hu X, Gu M, Zheng L, Li X, Long L, Chen W, Sheng P. Macrophages-derived exosomes modulates wear particle-induced osteolysis via miR-3470b targeting TAB3/NF-κB signaling. Bioact Mater 2023; 26:181-193. [PMID: 36911207 PMCID: PMC9999169 DOI: 10.1016/j.bioactmat.2023.02.028] [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: 12/06/2022] [Revised: 02/25/2023] [Accepted: 02/25/2023] [Indexed: 03/07/2023] Open
Abstract
Image 1.
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Key Words
- APL, Aseptic prothesis loosening
- Aseptic prothesis loosening
- Bglap, Osteocalcin
- CTSK, Cathepsin K
- Exosome
- Inflammatory osteolysis
- Macrophage
- NF-κB, nuclear factor kappa-light-chain-enhancer of activated B cells
- NFATc-1, Nuclear factor of activated T-cells, cytoplasmic 1
- Non-coding RNA
- OB, Osteoblast
- OC, Osteoclast
- P-P65, phospho-P65
- P65, NF-κB signaling
- Runx2, Runt-related transcription factor 2
- TAB3, TGF-β-activated kinase 1 (MAP3K7) binding protein 3
- ncRNA, non-coding RNA
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Affiliation(s)
- Baiqi Pan
- Department of Joint Surgery, The First Affiliated Hospital of Sun Yat-sen University, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, The First Affiliated Hospital of Sun Yat-Sen University, China
| | - Ziji Zhang
- Department of Joint Surgery, The First Affiliated Hospital of Sun Yat-sen University, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, The First Affiliated Hospital of Sun Yat-Sen University, China
| | - Xiaoyu Wu
- Department of Joint Surgery, The First Affiliated Hospital of Sun Yat-sen University, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, The First Affiliated Hospital of Sun Yat-Sen University, China
| | - Guoyan Xian
- Department of Joint Surgery, The First Affiliated Hospital of Sun Yat-sen University, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, The First Affiliated Hospital of Sun Yat-Sen University, China.,Université de Paris, CNRS, INSERM, B3OA, Paris, France
| | - Xuantao Hu
- Department of Joint Surgery, The First Affiliated Hospital of Sun Yat-sen University, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, The First Affiliated Hospital of Sun Yat-Sen University, China
| | - Minghui Gu
- Department of Joint Surgery, The First Affiliated Hospital of Sun Yat-sen University, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, The First Affiliated Hospital of Sun Yat-Sen University, China
| | - Linli Zheng
- Department of Joint Surgery, The First Affiliated Hospital of Sun Yat-sen University, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, The First Affiliated Hospital of Sun Yat-Sen University, China
| | - Xiang Li
- Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, The First Affiliated Hospital of Sun Yat-Sen University, China.,Department of Spine Surgery, The first affiliated hospital of Sun Yat-sen University, China
| | - Lingli Long
- Research Center of Translational Medicine, The First Affiliated Hospital of Sun Yat-sen University, China
| | - Weishen Chen
- Department of Joint Surgery, The First Affiliated Hospital of Sun Yat-sen University, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, The First Affiliated Hospital of Sun Yat-Sen University, China
| | - Puyi Sheng
- Department of Joint Surgery, The First Affiliated Hospital of Sun Yat-sen University, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, The First Affiliated Hospital of Sun Yat-Sen University, China
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Schwarze J, Moellenbeck B, Gosheger G, Puetzler J, Deventer N, Kalisch T, Schneider KN, Klingebiel S, Theil C. The Role of Single Positive Cultures in Presumed Aseptic Total Hip and Knee Revision Surgery-A Systematic Review of the Literature. Diagnostics (Basel) 2023; 13:diagnostics13091655. [PMID: 37175046 PMCID: PMC10178370 DOI: 10.3390/diagnostics13091655] [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: 01/30/2023] [Revised: 04/22/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
(1) Background: Prior to revision hip (THA) or knee arthroplasty (TKA), periprosthetic low-grade infection (PJI) should be ruled out. Despite advances in preoperative diagnosis, unsuspected positive cultures (UPCs) may occur in initially planned aseptic revisions. Particularly, single UPCs pose a diagnostic and therapeutic dilemma, as their impact on outcome is unclear and recommendations are heterogeneous. This review investigates the frequency of single UPCs and their impact on implant survivorship. (2) Methods: In July 2022, a comprehensive literature search was performed using PubMed and Cochrane Library search. In total, 197 articles were screened. Seven retrospective studies with a total of 5821 cases were able to be included in this review. (3) Results: Based on the cases included, UPCs were found in 794/5821 cases (14%). In 530/794 cases (67%), the majority of the UPCs were single positive. The most commonly isolated pathogens were coagulase negative Staphylococci and Cutibacterium acnes. Five of seven studies reported no influence on revision- or infection-free survival following a single positive culture. In two studies, single UPCs following THA revision were correlated with subsequent re-revision for PJI. (4) Conclusions: Single UPCs of a non-virulent pathogen following presumed aseptic TKA revision may be interpreted as contaminants. A single UPC following THA revision may be a risk factor for subsequent PJI. The role of systemic antibiotic treatment remains unclear, but it should be considered if other risk factors for PJI are present.
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Affiliation(s)
- Jan Schwarze
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Burkhard Moellenbeck
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Georg Gosheger
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Jan Puetzler
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Niklas Deventer
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Tobias Kalisch
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Kristian Nikolaus Schneider
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Sebastian Klingebiel
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Christoph Theil
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
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Vargas-Reverón C, Font-Vizcarra L, Morata L, Fernández-Valencia JA, Soriano A, Muñoz-Mahamud E. Do Cultures Obtained During Primary THA Predict the Likelihood of Revision? Clin Orthop Relat Res 2023; 481:778-785. [PMID: 36278949 PMCID: PMC10013665 DOI: 10.1097/corr.0000000000002460] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/23/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND There can be unexpectedly positive culture results during elective hip arthroplasty, but the degree to which these are associated with an increased risk of subsequent premature revision is not known. QUESTION/PURPOSE Are unexpectedly positive culture results obtained during elective THA associated with an increased likelihood of revision within 5 years of the procedure? METHODS Between March 2007 and March 2011, the hip unit at our institution performed elective primary THA in 829 patients. We systematically collected three samples in 52% (428 of 829) of the interventions. Of those, 26 patients were excluded because of sampling errors; 94% (402 of 428) had samples that were collected systematically and were eligible for the study. We only considered one hip randomly in bilateral procedures (4% [15 of 428]); patients presenting with acute (< 3 months) periprosthetic joint infection undergoing open debridement (4% [16 of 402]) and patients who died before 5 years of follow-up (2% [seven of 402]) were excluded from the study, leaving 91% (364 of 402) eligible for analysis in this retrospective study of a previous prospective trial. No patient included in the final analysis was lost to follow-up within 5 years from the index surgery. The patient group consisted of 52% (188 of 364) women, with a mean ± SD age of 64.8 ± 13.9 years. RESULTS Positives culture results were associated with a higher risk of revision within 5 years of the index surgery. The proportion of revision surgery was higher in the group with positive culture results than in those with negative results (10% [eight of 77] versus 2% [seven of 290]; p = 0.01). The difference was mainly attributable to a higher proportion of aseptic loosening in those with positive culture results than in those with negative results (8% [six of 74] versus 1% [four of 290]; p = 0.01). After a multivariable analysis, the only independent variable associated with 5-year revision surgery was the presence of positive results during THA (odds ratio 4.9 [95% confidence interval 1.72 to 13.99]). CONCLUSION Our findings suggest that bacterial contamination during THA is associated with an increased likelihood of early revision. This higher risk of revision is mainly because of presumed aseptic loosening; thus, efforts should focus on the need to rule out infection. These results not only open new questions that should be answered in new prospective and well-designed studies, but also may help to better select patients to obtain a more favorable outcome after THA. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Caribay Vargas-Reverón
- Department of Orthopedics and Trauma Surgery, Bone and Joint Infection Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Lluís Font-Vizcarra
- Bone and Joint Infection Unit, Department of Orthopedics. Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | - Laura Morata
- Department of Infectious Diseases, Bone and Joint Infection Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jenaro A. Fernández-Valencia
- Department of Orthopedics and Trauma Surgery, Bone and Joint Infection Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Bone and Joint Infection Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Ernesto Muñoz-Mahamud
- Department of Orthopedics and Trauma Surgery, Bone and Joint Infection Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
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Peng G, Liu Q, Guan Z, Liu M, Sun X, Zhu X, Chen J, Feng W, Li J, Zeng J, Zhong Z, Zeng Y. Diagnostic accuracy of sonication fluid cultures from prosthetic components in periprosthetic joint infection: an updated diagnostic meta-analysis. J Orthop Surg Res 2023; 18:175. [PMID: 36890571 PMCID: PMC9996915 DOI: 10.1186/s13018-023-03662-3] [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: 02/11/2022] [Accepted: 02/27/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is the most serious complication following total joint arthroplasty (TJA) and has a significant impact on patients and the national healthcare system. To date, the diagnosis of PJI is still confronted with dilemmas. The present study investigated the validity of sonication fluid culture (SFC) for removing implants in the diagnosis of PJI after joint replacement. METHODS From database establishment to December 2020, relevant literature was retrieved from the PubMed, Web of Science, Embase and Cochrane Library databases. Two reviewers independently performed quality assessment and data extraction to calculate the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), area under the curve (AUC) and diagnostic odds ratio (DOR) to evaluate the diagnostic value of overall SFC for PJI. RESULTS A total of 38 eligible studies including 6302 patients were selected in this study. The pooled sensitivity, specificity, PLR, NLR, and DOR of SFC for PJI diagnosis were 0.77 (95% confidence interval [CI], 0.76-0.79), 0.96 (95% CI, 0.95-0.96), 18.68 (95% CI, 11.92-29.28), 0.24 (95% CI, 0.21-0.29), and 85.65 (95% CI, 56.46-129.94), respectively, while the AUC was 0.92. CONCLUSION This meta-analysis showed that SFC was of great value in PJI diagnosis, and the evidence of SFC on PJI was more favorable but not yet strong. Therefore, improvement of the diagnostic accuracy of SFC is still necessary, and the diagnosis of PJI continues to warrant a multiplex approach before and during a revision procedure.
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Affiliation(s)
- Guanrong Peng
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, People's Republic of China.,Yudu People's Hospital, Huancheng North Road 2#, District Yudu, Ganzhou, 342300, Jiangxi, People's Republic of China
| | - Qiang Liu
- Peking University People's Hospital, Arthritis Clinic and Research Center, Beijing, People's Republic of China
| | - Zhenhua Guan
- Yudu People's Hospital, Huancheng North Road 2#, District Yudu, Ganzhou, 342300, Jiangxi, People's Republic of China
| | - Min Liu
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, People's Republic of China
| | - Xiaobo Sun
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, People's Republic of China
| | - Xingyang Zhu
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, People's Republic of China
| | - Jinlun Chen
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Wenjun Feng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Jie Li
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Jianchun Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Zhangrong Zhong
- Yudu People's Hospital, Huancheng North Road 2#, District Yudu, Ganzhou, 342300, Jiangxi, People's Republic of China.
| | - Yirong Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China.
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Kloos J, Vander Linden K, Vermote S, Berger P, Vandenneucker H. Prevalence, interpretation, and management of unexpected positive cultures in revision TKA: a systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:3998-4009. [PMID: 35031821 DOI: 10.1007/s00167-021-06856-6] [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: 08/09/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Unexpected positive intraoperative cultures (UPIC) found in revision total knee arthroplasty (TKA) are difficult to interpret. Management goes along with risks for both over- and undertreating a potential periprosthetic joint infection (PJI). The objective of this systematic review was to determine the prevalence of UPIC in revision TKA surgery, evaluate the diagnostic workup process and the postoperative treatment, and assess outcome regarding re-revision rates. METHODS Evidence was gathered from Medline (PubMed) and Embase published from January 2000 until April 2021. Nine studies with data of UPIC in revision TKA and outcome after at least 2 years of follow-up were identified. RESULTS The calculated prevalence of UPIC in aseptic knee revision surgery was 8.32%. However, the diagnostical approach differs as well as the used criteria to confirm PJI in presumed aseptic revision surgery. The work-up generally consists of a serum C-reactive protein and Erythrocyte Sedimentation Rate, joint fluid aspiration for culture and white blood cell count and formula, and radiographic imaging. Collection of intraoperative cultures is widely used, but inconsistent in sample amount and incubation time. Once a single UPIC is found, surgeons tend to treat it in different ways. Regarding re-revision rates, the weighted arithmetic mean in the included studies was 18.45% in the unsuspected PJI group compared to 2.94% in the aseptic group. There also seems to be a trend towards higher re-revision rates when a higher number of intraoperative cultures are positive. CONCLUSION The interpretation of UPIC in revision TKA is of utmost importance since the decision whether to treat a UPIC as an unsuspected PJI has a major impact on implant survival and re-revision rate. Different criteria are used to differentiate between unsuspected PJI and contamination in true aseptic failure, and the heterogeneity amongst the included papers impedes to state a clear recommendation, integrating not only quantitative findings, but also qualitative data such as virulence of the identified microorganism. LEVEL OF EVIDENCE Systematic review, III.
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Affiliation(s)
- Johannes Kloos
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Koen Vander Linden
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Stijn Vermote
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter Berger
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Hilde Vandenneucker
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
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9
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Akcaalan S, Ozaslan HI, Caglar C, Şimşek ME, Citak M, Akkaya M. Role of Biomarkers in Periprosthetic Joint Infections. Diagnostics (Basel) 2022; 12:diagnostics12122958. [PMID: 36552965 PMCID: PMC9777153 DOI: 10.3390/diagnostics12122958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/10/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
Periprosthetic joint infection (PJI) is one of the most serious complications after joint arthroplasty. The incidence rate of PJI after total joint replacement is 1-3%. Although there are different guidelines and diagnostic criteria used to diagnose PJI, diagnosing PJI is a highly difficult process for orthopedists. The current Musculoskeletal Infection Society (MSIS) criteria are widely used for the diagnosis of PJI. These criteria include results from blood/synovial fluid tests, physical examination, and histological and microbiological analyses of intra-operative samples. However, there is currently no blood or synovial test that can definitively diagnose PJI. To make a more effective diagnosis of PJI, a large number of studies have explored and continue to investigate biomarkers. This review aims to provide general information about serum and synovial markers used for the diagnosis of PJI that may be used to create a database to guide researchers in new studies.
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Affiliation(s)
- Serhat Akcaalan
- Kırıkkale Yuksek Ihtısas Hospital, Kırıkkale 71300, Turkey
- Correspondence:
| | - Halil Ibrahim Ozaslan
- Department of Orthopedics and Traumatology, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara 06010, Turkey
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara 06800, Turkey
| | - Ceyhun Caglar
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara 06800, Turkey
| | - Mehmet Emin Şimşek
- Department of Orthopedics and Traumatology, Faculty of Medicine, Lokman Hekim University, Ankara 06230, Turkey
| | | | - Mustafa Akkaya
- Department of Orthopedics and Traumatology, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara 06010, Turkey
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara 06800, Turkey
- Helios ENDO-Klinik Hamburg, 22767 Hamburg, Germany
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10
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The Prevalence and Outcomes of Unexpected Positive Intraoperative Cultures in Presumed Aseptic Revision Knee Arthroplasty. J Arthroplasty 2022; 37:2262-2271. [PMID: 35598759 DOI: 10.1016/j.arth.2022.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/11/2022] [Accepted: 05/16/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The prevalence and outcomes of unexpected positive intraoperative cultures (UPC) in presumed aseptic revision total knee arthroplasty (TKA) are unclear. The purpose of this study was to determine the prevalence of UPC and infection-free implant survival in this patient population. Secondly, we aimed to compare the infection-free implant survival between cohorts based on number of UPCs and antibiotic treatment. METHODS We reviewed our institutional database from 2006 to 2019 for all TKA revisions (n = 1795) to identify all presumed aseptic TKA revisions with intraoperative culture(s). After exclusions, 775 revisions were eligible and those with UPC were included in the Kaplan-Meier analysis to determine infection-free implant survival for the cohorts. RESULTS The prevalence of UPC was 9.8%. The 2- and 5-year infection-free survival was 97.4% and 95.3%, respectively. The 5-year infection-free survival from the same microorganism as the UPC was 98.7%. Infection-free survival was similar for the 1 versus ≥2 UPC cohorts (P = .416), however was poorer for the cohort treated with antibiotics (P = .021). Only one of 3 subsequent PJI-related implant failures was caused by the same microorganism (polymicrobial) as the UPC. There were no subsequent infections in patients with a single UPC not treated with antibiotics. CONCLUSIONS The prevalence of UPC was 9.8% and the infection-free implant survival is excellent. Infection-free survivorship from PJI caused by the same UPC microorganism is outstanding. Comparisons between cohorts must be interpreted with caution due to study limitations. A single UPC in patents without other signs of infection does not require antibiotic treatment. LEVEL OF EVIDENCE IV.
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11
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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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12
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Schwarze J, Dieckmann R, Gosheger G, Bensmann M, Moellenbeck B, Theil C. Unsuspected Positive Cultures in Planned Aseptic Revision Knee or Hip Arthroplasty-Risk Factors and Impact on Survivorship. J Arthroplasty 2022; 37:1165-1172. [PMID: 35189293 DOI: 10.1016/j.arth.2022.02.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/03/2022] [Accepted: 02/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Unsuspected positive cultures (UPCs) may be found at the time of planned aseptic revision surgery and have previously been associated with decreased implant survival. However, reported rates vary greatly, and potential risk factors are widely unknown. This study investigates the rate of UPCs, implant survival, as well as potential risk factors for UPCs and revision. METHODS This is a retrospective, single-center study on 434 cases of total hip arthroplasty (THA 277) and knee revision arthroplasty (TKA 157) performed between 2010 and 2017. Microbiology culture results, revision-free survival (RFS) and infection-free (IFS) survival, and the potential impact of UPCs as well as patient- or procedure-related risk factors were investigated at a minimum follow-up of 24 months (median 41 months). RESULTS A total of 37% of patients had a positive culture (160/434). 27% (119/434) had a solitary positive culture, and 9% (41/434) had ≥2 positive cultures of the same species. Most commonly, coagulase-negative staphylococci were cultured. Overall, 32% (13/41) of patients with ≥2 positive cultures underwent revision for infection compared with 6% (17/274) of patients with negative cultures. RFS and IFS were reduced if ≥2 cultures were positive. Single positive cultures had no impact on RFS or IFS. Male sex, elevated serum C-reactive protein, and obesity were independently associated with finding ≥2 UPCs in revision THA. CONCLUSION Appearance of ≥2 UPCs in aseptic revision leads to reduced RFS and IFS. Males, obese patients, and patients with elevated serum C-reactive protein planned for THA revision should be considered for extended diagnostics to rule out periprosthetic joint infection.
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Affiliation(s)
- Jan Schwarze
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Ralf Dieckmann
- Department for Orthopaedics and Trauma Surgery, Krankenhaus der Barmherzigen Brueder Trier, Trier, Germany
| | - Georg Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Matthias Bensmann
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Burkhard Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Christoph Theil
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
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13
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Muñoz-Mahamud E, Tornero E, Estrada J, Fernández-Valencia J, Martínez-Pastor J, Soriano Á. Usefulness of serum D-dimer and platelet count to mean platelet volume ratio to rule out chronic periprosthetic joint infection. J Bone Jt Infect 2022; 7:109-115. [PMID: 35620591 PMCID: PMC9128364 DOI: 10.5194/jbji-7-109-2022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/04/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Diagnosing periprosthetic joint infection (PJI) is challenging and usually requires the evaluation of several biomarkers. Our main aim was to evaluate the usefulness of D-dimer levels as well as the platelet count (PC) to mean platelet volume (MPV) ratio serum as biomarkers to rule out chronic knee and hip infection. Methods: The study enrolled a prospective cohort of 93 patients undergoing hip or knee revision. D-dimer values, PC to MPV ratio, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were preoperatively determined and evaluated as a predictor of PJI. The definitive diagnosis of PJI was established according to the 2018 International Consensus Meeting criteria. Results: A total of 24 (25.8 %) cases were postoperatively diagnosed with PJI. The median D-dimer value was significantly higher ( p < 0.001) for patients with PJI (1950 ng mL- 1 ) than for patients with aseptic failure (700 ng mL- 1 ). The area under the receiver operating characteristic curves for D-dimer, CRP and ESR was 0.820, 0.793 and 0.791 respectively. D-dimer ≥ 950 ng mL- 1 (91 % sensitivity, 64 % specificity), CRP ≥ 1.95 mg dL- 1 (61 % sensitivity, 90 % specificity) and ESR > 20 (74 % sensitivity, 82 % specificity) were identified as the values with the best balance between sensitivity and specificity. The mean PC to MPV ratio was 37.0 for PJI patients and 29.8 for patients in the aseptic revision cohort ( p = 0 .067). Conclusions: Serum D-dimer levels appear very unlikely to remain normal in the presence of chronic PJI. The 91 % sensitivity when considering 950 ng mL- 1 as the threshold highlights D-dimer as the most accurate initial test to rule out chronic PJI. Conversely, the PC to MPV ratio may be of limited value for accurately diagnosing PJI.
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Affiliation(s)
- Ernesto Muñoz-Mahamud
- Department of Orthopedics and Trauma Surgery, Hospital Clinic of
Barcelona, University of Barcelona, Barcelona, Spain
| | - Eduard Tornero
- Department of Orthopedics and Trauma Surgery, Hospital Clinic of
Barcelona, University of Barcelona, Barcelona, Spain
| | - José A. Estrada
- Department of Orthopedics and Trauma Surgery, Hospital Clinic of
Barcelona, University of Barcelona, Barcelona, Spain
| | - Jenaro A. Fernández-Valencia
- Department of Orthopedics and Trauma Surgery, Hospital Clinic of
Barcelona, University of Barcelona, Barcelona, Spain
| | - Juan C. Martínez-Pastor
- Department of Orthopedics and Trauma Surgery, Hospital Clinic of
Barcelona, University of Barcelona, Barcelona, Spain
| | - Álex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona,
University of Barcelona, Barcelona, Spain
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14
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Mancheño-Losa M, Lora-Tamayo J, Fernández-Sampedro M, Rodríguez-Pardo D, Muñoz-Mahamud E, Soldevila L, Palou M, Barbero JM, Del Toro MD, Iribarren JA, Sobrino B, Rico-Nieto A, Guío-Carrión L, Gómez L, Escudero-Sánchez R, García-País MJ, Jover-Sáenz A, Praena J, Baraia-Etxaburu JM, Auñón Á, Múñez-Rubio E, Murillo O. Prognosis of unexpected positive intraoperative cultures in arthroplasty revision: A large multicenter cohort. J Infect 2021; 83:542-549. [PMID: 34509512 DOI: 10.1016/j.jinf.2021.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/14/2021] [Accepted: 09/03/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The positive-intraoperative-cultures-type prosthetic joint infection (PIOC-PJI) is considered when surgical cultures yield microorganisms in presumed aseptic arthroplasty revisions. Herein we assess the risk factors for failure in the largest cohort of PIOC-PJI patients reported to date. METHODS A retrospective, observational, multicenter study was performed during 2007-2017. Surgeries leading to diagnose PIOC-PJI included only one-stage procedures with either complete or partial prosthesis revision. Failure was defined as recurrence caused by the same microorganism. RESULTS 203 cases were included (age 72 years, 52% females). Coagulase-negative staphylococci (n = 125, 62%) was the main etiology, but some episodes were caused by virulent bacteria (n = 51, 25%). Prosthesis complete and partial revision was performed in 93 (46%) and 110 (54%) cases, respectively. After a median of 3.4 years, failure occurred in 17 episodes (8.4%, 95%CI 5.3-13.1). Partial revision was an independent predictor of failure (HR 3.63; 95%CI 1.03-12.8), adjusted for gram-negative bacilli (GNB) infection (HR 2.68; 95%CI 0.91-7.89) and chronic renal impairment (HR 2.40; 95%CI 0.90-6.44). Treatment with biofilm-active antibiotics (rifampin/fluoroquinolones) had a favorable impact on infections caused by staphylococci and GNB. CONCLUSION Overall prognosis of PIOC-PJI is good, but close follow-up is required in cases of partial revision and in infections caused by GNB.
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Affiliation(s)
- Mikel Mancheño-Losa
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica "imas12" Hospital 12 de Octubre, Av. de Córdoba s/n, Madrid, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Jaime Lora-Tamayo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica "imas12" Hospital 12 de Octubre, Av. de Córdoba s/n, Madrid, Spain; Spanish Network for the Study of Infectious Diseases / Red Española de Investigación en Patología Infecciosa (REIPI), Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; CIBER de Enfermedades Infecciosas, Instuto de Salud Carlos III, Madrid.
| | - Marta Fernández-Sampedro
- Department of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, Santander, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Dolors Rodríguez-Pardo
- Department of Infectious Diseases, Vall d'Hebron Hospital Universitari, Barcelona, Spain; Spanish Network for the Study of Infectious Diseases / Red Española de Investigación en Patología Infecciosa (REIPI), Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Ernesto Muñoz-Mahamud
- Department of Orthopedics and Trauma Surgery, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Laura Soldevila
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Mariona Palou
- Department of Infectious Diseases, Hospital Universitari Parc Taulí, Sabadell, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - José María Barbero
- Department of Internal Medicine, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - María Dolores Del Toro
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena, University of Seville, Institute of Biomedicine of Seville (IBiS), Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - José Antonio Iribarren
- Department of Infectious Diseases, Hospital Universitario Donostia, IIS BioDonostia, San Sebastián, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Beatriz Sobrino
- Department of Infectious Diseases, Hospital Regional Universitario de Málaga, Málaga, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Alicia Rico-Nieto
- Department of Infectious Diseases, Hospital Universitario La Paz, Madrid, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Laura Guío-Carrión
- Department of Infectious Diseases, Hospital Universitario Cruces, Barakaldo, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Lucía Gómez
- Department of Infectious Diseases, Hospital Universitari Mútua Terrassa, Terrassa, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Rosa Escudero-Sánchez
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Madrid, Spain; Spanish Network for the Study of Infectious Diseases / Red Española de Investigación en Patología Infecciosa (REIPI), Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - María José García-País
- Department of Infectious Diseases, Hospital Universitario Lucus Augusti, Lugo, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Alfredo Jover-Sáenz
- Department of Infectious Diseases, Hospital Universitari Arnau de Vilanova, Lleida, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Julia Praena
- Department of Infectious Diseases, Hospital Universitario Virgen del Rocío, Sevilla, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Josu Miren Baraia-Etxaburu
- Department of Infectious Diseases, Hospital Universitario de Basurto, Bilbao, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Álvaro Auñón
- Department of Orthopedics and Trauma Surgery, Hospital Universitario Fundación Jiménez-Díaz, Madrid, Spain; CIBER de Enfermedades Infecciosas, Instuto de Salud Carlos III, Madrid
| | - Elena Múñez-Rubio
- Department of Infectious Diseases, Hospital Universitario Puerta de Hierro, Madrid, Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - Oscar Murillo
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain; Spanish Network for the Study of Infectious Diseases / Red Española de Investigación en Patología Infecciosa (REIPI), Spain; Bone and Joint Infection Study Group of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; CIBER de Enfermedades Infecciosas, Instuto de Salud Carlos III, Madrid
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15
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Neufeld ME, Lanting BA, Shehata M, Howard JL, MacDonald SJ, Teeter MG, Vasarhelyi EM. Prevalence and Outcomes of Unexpected Positive Intraoperative Cultures in Presumed Aseptic Revision Hip Arthroplasty. J Bone Joint Surg Am 2021; 103:1392-1401. [PMID: 33974575 DOI: 10.2106/jbjs.20.01559] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The prevalence and outcomes of unexpected positive cultures (UPCs) of specimens taken during presumed aseptic revision total hip arthroplasty (THA) are unclear. The purpose of this study was to determine the prevalence of UPC and infection-free implant survival in this patient population. Secondary aims included identifying factors associated with subsequent infection-related failure in patients with UPC. METHODS We reviewed all THA revisions (n = 2,288) performed at our institution from 2006 to 2019. Presumed aseptic revision THAs with intraoperative culture(s) were eligible (n = 1,196), and those with UPC were included in a Kaplan-Meier analysis to determine the infection-free implant survival and in Cox regression analysis to identify factors associated with infection-related failure. RESULTS UPC(s) were documented for 9.2% (110) of 1,196 aseptic THA revisions. The 2- and 5-year infection-free implant survival in the entire UPC cohort was 93.1% (95% confidence interval [CI] = 90.5% to 95.7%) and 86.8% (95% CI = 82.9% to 90.7%), respectively. The 2- and 5-year infection-free survival with failure due to infection with the same microorganism as identified in the UPC as the end point was 95.8% (95% CI = 93.7% to 97.9%) and 94.3% (95% CI = 91.7% to 96.9%), respectively. Subsequent infection-related failures caused by the same microorganism as identified in the UPC were more likely to occur after revisions with ≥2 UPCs than after those with 1 UPC (p = 0.024). Revision due to adverse metal reaction was a risk factor for subsequent infection-related failure (hazard ratio [HR] = 14.49, 95% CI = 2.69 to 78.04). Patients with a single UPC who were not treated with antibiotics had no subsequent periprosthetic joint infections (PJIs) caused by the same microorganism as identified in the UPC. CONCLUSIONS The prevalence of UPC was 9.2%, and the infection-free implant survival in patients with UPC is encouraging. Implant survival free of PJI caused by the same microorganism as identified in the UPC was excellent. Aseptic revision for adverse metal reaction was a risk factor for subsequent PJI in patients with UPC. No patient with a single UPC who was not treated with antibiotics developed PJI caused by the UPC-identified microorganism, suggesting that in the absence of other signs of infection a single UPC does not warrant antibiotic treatment. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael E Neufeld
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada
| | - Brent A Lanting
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Michael Shehata
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada
| | - James L Howard
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Steven J MacDonald
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Matthew G Teeter
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Edward M Vasarhelyi
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada
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16
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Outcomes of patients with unexpected diagnosis of infection at total hip or total knee arthroplasty revisions. INTERNATIONAL ORTHOPAEDICS 2021; 45:2791-2796. [PMID: 34292384 DOI: 10.1007/s00264-021-05137-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/03/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE The pre-operative differential diagnosis between periprosthetic joint infections (PJIs) and aseptic failure is challenging particularly in low virulence and biofilm-related infections. This study aimed to assess the incidence and survival of patients with unexpected PJIs in a presumed aseptic revision of total hip (THA) and knee (TKA) arthroplasties. METHODS A retrospective analysis of a prospective cohort of patients was performed with 295 patients undergoing THA (n = 241) or TKA (n = 54) revision for presumed aseptic causes. Patients were diagnosed with unexpected PJI taking into account leukocyte count in the synovial fluid, sonicate, synovial culture, and tissue cultures of samples collected during surgery. The primary endpoint was the infection-free implant survival rate at theone year follow-up. RESULTS The unexpected PJIs were 60 out of 295 (20.3%), whereas 235 (79.7%) were aseptic revisions. In the unexpected PJI group, 6 (11.1%) patients underwent knee revision and 54 (22.4%) hip revision. At the one year follow-up, one patient (1.6%) in the unexpected PJI group and 3 (1.3%) in the aseptic group (p = 1.0) failed for infection. The infection-free implant survival rate at the one year follow-up was 98.3% (C.I. 95%, 94.9-99.9%) for the unexpected PJI group and 98.7% (C.I. 95%, 97.3-99.9%) (p = 0.82) for the aseptic group. CONCLUSION The incidence of unexpected PJIs in a presumed aseptic revision of THAs and TKAs has been previously underestimated. The infection-free implant survival rate at the one year follow-up in patients with unexpected PJIs was not significantly lower compared with patients undergoing aseptic revision.
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17
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Staphorst F, Jutte PC, Boerboom AL, Kampinga GA, Ploegmakers JJW, Wouthuyzen-Bakker M. Should all hip and knee prosthetic joints be aspirated prior to revision surgery? Arch Orthop Trauma Surg 2021; 141:461-468. [PMID: 33559723 PMCID: PMC7900020 DOI: 10.1007/s00402-021-03791-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 01/11/2021] [Indexed: 10/27/2022]
Abstract
AIMS It is essential to exclude a periprosthetic joint infection (PJI) prior to revision surgery. It is recommended to routinely aspirate the joint before surgery. However, this may not be necessary in a subgroup of patients. The aim of our study was to investigate if specific clinical and implant characteristics could be identified to rule out a PJI prior to revision surgery. METHODS We retrospectively evaluated clinical and implant characteristics of patients who underwent a hip or knee revision surgery between October 2015 and October 2018. Patients were diagnosed with a PJI according to the MSIS diagnostic criteria. RESULTS A total of 156 patients were analyzed, including 107 implants that were revised because of prosthetic loosening and 49 because of mechanical failure (i.e. instability, malalignment or malpositioning). No PJI was diagnosed in the group with mechanical failure. In the prosthetic loosening group, 20 of 107 were diagnosed with a PJI (19%). Although there was a significantly lower chance of having a PJI with an implant age of > 5 years combined with a CRP < 5 mg/L, an infection was still present in 3 out of 39 cases (8%). CONCLUSION Implants with solely mechanical failure without signs of loosening and low inflammatory parameters probably do not require a synovial fluid aspiration. These results need to be confirmed in a larger cohort of patients. In case of prosthetic loosening, all joints need to be aspirated before surgery as no specific characteristic could be identified to rule out an infection.
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Affiliation(s)
- Femke Staphorst
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Alexander L Boerboom
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Greetje A Kampinga
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Joris J W Ploegmakers
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
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18
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Trebse R, Roskar S. Evaluation and interpretation of prosthetic joint infection diagnostic investigations. INTERNATIONAL ORTHOPAEDICS 2021; 45:847-855. [PMID: 33555351 DOI: 10.1007/s00264-021-04958-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/29/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Total joint arthroplasty (TJA) is considered one of the most successful surgical procedures ever developed. It can successfully provide pain relief, restore joint function, and improve mobility and quality of life. Prosthetic joint infection (PJI) presents with a wide variety and severity of signs and symptoms. It remains a major threat to the outcome of TJA procedures and usually necessitates surgical intervention and prolonged courses of antibiotics. Inappropriate treatment of an unrecognized PJI usually ends with unacceptable and sometimes catastrophic results. THE AIM The understanding and evaluation of diagnostic investigations are extremely important to properly diagnose PJI, including frequently unrecognized low-grade infections, and to provide healthcare professionals with needed information for the care of patients affected by this condition. This article aims to review most of the methods available in PJI diagnostics, to emphasize the strengths and the weaknesses of each of them, and to provide a guideline on how to select the surgical treatment strategy based on the level of diagnostic certainty during the evaluation period. To safely accomplish this, it is crucial to be aware of the limitations of each diagnostic modality. THE FOCUS The emphasis will be on the use and interpretation of the core criteria for PJI diagnosis, including the pathognomonic sinus tract communicating with the implant, purulent synovial fluid, inflammation in the periprosthetic tissue, cell count with differential, microbial growth in the synovial fluid culture, tissue sample cultures, and sonication samples.
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Affiliation(s)
- Rihard Trebse
- Valdoltra Orthopaedic Hospital, Jadranska cesta 31, SI-6280, Ankaran, Slovenia.
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, SI, 1000, Ljubljana, Slovenia.
| | - Samo Roskar
- Valdoltra Orthopaedic Hospital, Jadranska cesta 31, SI-6280, Ankaran, Slovenia
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Ruling out underlying infection in 200 presumed aseptic knee and hip revision arthroplasties using a multiplex PCR system. Eur J Clin Microbiol Infect Dis 2021; 40:1283-1290. [PMID: 33479882 DOI: 10.1007/s10096-021-04155-z] [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: 09/06/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022]
Abstract
Ruling out an infection in one-stage knee and hip revisions for presumed aseptic failure by conventional tissue cultures takes up to 14 days. Multiplex polymerase chain reaction (mPCR) is a quick test (4-5 h) for detecting pathogens. The purpose of this study was to evaluate the diagnostic accuracy of an automated mPCR of synovial fluid obtained intraoperatively in unsuspected knee and hip revisions. A prospective study was conducted with 200 patients undergoing a one-stage knee or hip revision. Synovial fluid was analyzed with the mPCR Unyvero implant and tissue infection G2 cartridge (U-ITI G2) system and compared to intraoperative tissue cultures. The primary outcome measure was the diagnostic accuracy, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), of the mPCR U-ITI G2 system compared to conventional cultures. In the knee revision group, there were no patients with a positive mPCR in combination with positive cultures. This resulted in a non-calculable sensitivity and PPV. The specificity and NPV in the knee revision group of the mPCR compared to tissue cultures was 96.8% and 96.8%, respectively. In the hip revision group, the sensitivity, specificity, PPV, and NPV of the mPCR compared to tissue cultures was 36.4%, 96.6%, 57.1%, and 92.5%, respectively. Sixteen mismatches occurred between the mPCR and tissue cultures. The mPCR U-ITI G2 system is a quick and reliable synovium fluid test for ruling out infection in presumed aseptic knee and hip revisions with a high NPV compared with tissue cultures, although some mismatches were observed. Periprosthetic tissue cultures are still advised as back-up for false negative and positive mPCR test results.
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Bin G, Xinxin Y, Fan L, Shenghong W, Yayi X. Serum Fibrinogen Test Performs Well for the Diagnosis of Periprosthetic Joint Infection. J Arthroplasty 2020; 35:2607-2612. [PMID: 32446625 DOI: 10.1016/j.arth.2020.04.081] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/14/2020] [Accepted: 04/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Serum fibrinogen (FIB) is an acute-phase glycoprotein in the infection response that may stop excessive bleeding. The purposes of this study are to determine the value of FIB that can be used to differentiate between periprosthetic joint infection (PJI) and aseptic loosening of the prosthesis, and to determine the clinical significance of FIB for analyzing infection outcomes after first-stage surgery. METHODS This retrospective study included 90 patients undergoing total knee arthroplasty or total hip arthroplasty revision from January 2015 to August 2019. PJI was confirmed in 53 patients (group A), and the other 37 patients were diagnosed with aseptic loosening of the prosthesis (group B). Only 21 patients in group A documented the results for serum FIB, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) after spacer insertion, so the postoperative serological marker levels of the these patients were also assessed. RESULTS The FIB, CRP, and ESR levels were significantly higher in group A than in group B (P < .001). The area under the receiver operating characteristic curve was highest for FIB at 0.928. Analyses of FIB levels revealed a sensitivity of 79.25% and a specificity of 94.59%. FIB levels were significantly lower in patients with PJI after spacer insertion (P < .001). CONCLUSION FIB is an adequate test to aid in diagnosing PJI, and it is not inferior to CRP and ESR in distinguishing between PJI and aseptic loosening of the prosthesis. It is an especially useful tool in assessing infection outcomes after first-stage surgery.
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Affiliation(s)
- Geng Bin
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, People's Republic of China
| | - Yang Xinxin
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, People's Republic of China
| | - Lu Fan
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, People's Republic of China
| | - Wang Shenghong
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, People's Republic of China
| | - Xia Yayi
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, People's Republic of China
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Prevalence and Impact of Positive Intraoperative Cultures in Partial Hip or Knee Revision. J Arthroplasty 2020; 35:1912-1916. [PMID: 32147341 DOI: 10.1016/j.arth.2020.02.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/16/2020] [Accepted: 02/12/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Our aim is to investigate the impact of unexpected positive cultures on the outcome of partial prosthetic revisions. METHODS Data regarding patients who underwent a partial hip or knee revision from 2003 and 2012 with the preoperative diagnosis of aseptic loosening was retrospectively reviewed. The protocol of revision included at least 3 intraoperative cultures. Failure was defined as the need for re-revision due to aseptic or septic loosening at 5 years. RESULTS A total of 99 hip and 46 knee partial revisions were included. All cases had at least 5 years of follow-up. Ninety-seven cases (66.9%) had all cultures negative, 35 (24.1%) a single positive culture and 13 (9.0%) ≥2 positive cultures for the same microorganism. The median time from primary arthroplasty to partial revision was significantly shorter for patients with ≥2 positive cultures (26 months) than in those with all cultures negative (48 months) or with a single positive culture (51 months). Partial revisions performed within the first 5 years of implantation had a higher 5-year re-revision rate. The presence of a single positive culture during the partial exchange was not associated with a higher re-revision rate (2 of 35, 5.7%) than in those with negative cultures (3 of 97, 3.1%). On the contrary, re-revision rate was significantly higher in cases with ≥2 positive cultures (3 of 13, 23.1%) than in those with negative cultures (P = .02). CONCLUSION Partial revisions performed within the first 5 years from implantation and ≥2 intraoperative positive cultures were associated with a higher re-revision risk at 5 years.
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Khalid V, Schønheyder HC, Larsen LH, Nielsen PT, Kappel A, Thomsen TR, Aleksyniene R, Lorenzen J, Ørsted I, Simonsen O, Jordal PL, Rasmussen S. Multidisciplinary Diagnostic Algorithm for Evaluation of Patients Presenting with a Prosthetic Problem in the Hip or Knee: A Prospective Study. Diagnostics (Basel) 2020; 10:diagnostics10020098. [PMID: 32053936 PMCID: PMC7168188 DOI: 10.3390/diagnostics10020098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/28/2020] [Accepted: 02/04/2020] [Indexed: 12/17/2022] Open
Abstract
The predominant indications for revision surgery after total hip (THA) or knee arthroplasty (TKA) are an aseptic failure (AF) and prosthetic joint infection (PJI). Accurate diagnosis is crucial. Therefore, we evaluated prospectively a multidisciplinary diagnostic algorithm including multi-modal radionucleid imaging (RNI) and extended microbiological diagnostics. If the surgeon suspected PJI or AF, revision surgery was performed with multiple samples obtained in parallel for special culture procedures and later molecular analyses. Alternatively, if the underlying cause was not evident, RNI was scheduled comprising 99Tc—HDP SPECT/CT, 111In-labeled white blood cells combined with 99Tc-nanocoll bone marrow SPECT/CT, and 18F-FDG PET/CT. A multidisciplinary clinical team made a recommendation on the indication for a diagnostic procedure guided by RNI images or revision surgery. A total of 156 patients with 163 arthroplasties were included. Fifty-five patients underwent RNI. In all, 118 revision surgeries were performed in 112 patients: 71 on the indication of AF and 41 revision of PJI. Thirty-four patients were concluded with chronic pain, and revision surgery refrained. The effective median follow-up period was 13 months. A structured approach offered by the algorithm was useful for the clinician in the evaluation of patients with a failing TKA or THA. Surgical revision was possibly obviated in approximately 20% of patients where an explanation or cause of failure was not found. The algorithm served as an effective tool.
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Affiliation(s)
- Vesal Khalid
- Orthopaedic Research Unit, Aalborg University Hospital, 9000 Aalborg, Denmark (A.K.); (O.S.); (S.R.)
- Department of Orthopaedic Surgery, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark;
- Correspondence: ; Tel.: +45-31336988
| | - Henrik Carl Schønheyder
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark;
- Department of Clinical Microbiology, Aalborg University Hospital, 9000 Aalborg, Denmark;
| | - Lone Heimann Larsen
- Department of Clinical Microbiology, Aalborg University Hospital, 9000 Aalborg, Denmark;
- Center for Microbial Communities, Department of Biotechnology, Chemistry and Environmental Engineering, Aalborg University, 9000 Aalborg, Denmark;
| | - Poul Torben Nielsen
- Orthopaedic Research Unit, Aalborg University Hospital, 9000 Aalborg, Denmark (A.K.); (O.S.); (S.R.)
- Department of Orthopaedic Surgery, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark;
| | - Andreas Kappel
- Orthopaedic Research Unit, Aalborg University Hospital, 9000 Aalborg, Denmark (A.K.); (O.S.); (S.R.)
- Department of Orthopaedic Surgery, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark;
| | - Trine Rolighed Thomsen
- Center for Microbial Communities, Department of Biotechnology, Chemistry and Environmental Engineering, Aalborg University, 9000 Aalborg, Denmark;
- Danish Technological Institute, Medical Biotechnology, 8000 Aarhus C, Denmark; (J.L.); (P.L.J.)
| | - Ramune Aleksyniene
- Department of Nuclear Medicine, Aalborg University Hospital, 9000 Aalborg, Denmark;
| | - Jan Lorenzen
- Danish Technological Institute, Medical Biotechnology, 8000 Aarhus C, Denmark; (J.L.); (P.L.J.)
| | - Iben Ørsted
- Department of Infectious Disease, Aalborg University Hospital, 9000 Aalborg, Denmark;
| | - Ole Simonsen
- Orthopaedic Research Unit, Aalborg University Hospital, 9000 Aalborg, Denmark (A.K.); (O.S.); (S.R.)
- Department of Orthopaedic Surgery, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark;
| | - Peter Lüttge Jordal
- Danish Technological Institute, Medical Biotechnology, 8000 Aarhus C, Denmark; (J.L.); (P.L.J.)
| | - Sten Rasmussen
- Orthopaedic Research Unit, Aalborg University Hospital, 9000 Aalborg, Denmark (A.K.); (O.S.); (S.R.)
- Department of Orthopaedic Surgery, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark;
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Khalid V, Schønheyder HC, Nielsen PT, Kappel A, Thomsen TR, Aleksyniene R, Lorenzen J, Rasmussen S. 72 revision surgeries for aseptic failure after hip or knee arthroplasty: a prospective study with an extended diagnostic algorithm. BMC Musculoskelet Disord 2019; 20:600. [PMID: 31830947 PMCID: PMC6909479 DOI: 10.1186/s12891-019-2944-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 11/13/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Unrecognized periprosthetic joint infections are a concern in revision surgery for aseptic failure (AF) after total hip (THA) or knee (TKA) arthroplasties. A gold diagnostic standard does not exist. The aim of the current study was to determine the prevalence of unrecognized periprosthetic joint infection (PJI) in a cohort of revision for AF, using an experimental diagnostic algorithm. METHODS The surgeons' suspicion of AF was based primarily on patient history and clinical evaluation. X-ray imaging was used to reveal mechanical problems. To rule out an infectious aetiology standard blood biochemical tests were ordered in most patients. Evaluation followed the existing practice in the institute. Cases were included if revision surgery was planned for suspected AF. Intraoperatively, five synovial tissue biopsies were obtained routinely. PJI was defined as ≥3 positive cultures with the same microorganism(s). Patients were followed for 1 year postoperatively. Protocol samples included joint fluid, additional synovial tissue biopsies, bone biopsy, swabs from the implant surface, and sonication of retrieved components. Routine and protocol samples were cultured with extended incubation (14 days) and preserved for batchwise 16S rRNA gene amplification. Patients were stratified based on culture results and a clinical status was obtained at study end. RESULTS A total of 72 revisions were performed on 71 patients (35 THA and 37 TKA). We found five of 72 cases of unrecognized PJI. Extended culture and protocol samples accounted for two of these. One patient diagnosed with AF was treated for a PJI during follow-up. The remaining patients did not change status from AF during follow-up. CONCLUSIONS We found a low prevalence of unrecognized periprosthetic joint infections in patients with an AF diagnosis. The algorithm strengthens the surgeons' preoperative diagnosis of a non-infective condition. Evaluation for a failing TKA or THA is complex. Distinguishing between AF and PJI pre-operatively was a clinical decision. Our data did not support additional testing in routine revision surgery for AF.
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Affiliation(s)
- Vesal Khalid
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark. .,Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Henrik Carl Schønheyder
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark
| | - Poul Torben Nielsen
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Andreas Kappel
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Trine Rolighed Thomsen
- Center for Microbial Communities, Department of Biotechnology, Chemistry and Environmental Engineering, Aalborg University, Aalborg, Denmark.,Danish Technological Institute, Medical Biotechnology, Aarhus, Denmark
| | - Ramune Aleksyniene
- Department of Nuclear Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Jan Lorenzen
- Danish Technological Institute, Medical Biotechnology, Aarhus, Denmark
| | - Sten Rasmussen
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Unexpected positive intraoperative cultures (UPIC) in revision Hip and knee arthroplasty- A review of the literature. J Orthop 2019; 17:1-6. [PMID: 31879464 DOI: 10.1016/j.jor.2019.06.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 06/30/2019] [Indexed: 11/21/2022] Open
Abstract
Unexpected positive intraoperative culture (UPIC) in revision hip and knee arthroplasty has a prevalence of 10.5%, there is no consensus in the literature on how to interpret them and how to treat them. Our literature review showed that most authors would consider two or more positive cultures as significant and usually treat them with culture specific antibiotics for 4-6 weeks. A single positive intraoperative culture can or cannot be significant depending on the virulence of the organism, hence taking multiple tissue samples in and around the joint is recommended. All failed arthroplasty cases must be evaluated preoperatively according to musculoskeletal infection society criteria (MSIS) to rule out the possibility of infection as an etiology for failure of the arthroplasty. Most authors reported that large majority of these UPIC were from a low virulence organism. Our review showed that the implant survival is more than 85% with 4-6 weeks of antibiotic treatment.
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Milandt NR, Gundtoft PH, Overgaard S. A Single Positive Tissue Culture Increases the Risk of Rerevision of Clinically Aseptic THA: A National Register Study. Clin Orthop Relat Res 2019; 477:1372-1381. [PMID: 31136437 PMCID: PMC6554107 DOI: 10.1097/corr.0000000000000609] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 11/26/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The diagnostic and prognostic value of unexpected positive intraoperative cultures remains unclear in diagnosing prosthetic joint infection (PJI) in THA revisions. QUESTIONS/PURPOSES Therefore, we asked: (1) What is the clinical importance of bacterial growth in intraoperative tissue cultures taken during first-time revision of a clinically aseptic THA in terms of all-cause rerevision and rerevision for PJI specifically? (2) Is there a difference in outpatient antibiotic treatment patterns that is dependent on the number of positive intraoperative cultures? METHODS This register-based study included all procedures reported to the Danish Hip Arthroplasty Register (DHR) as first-time aseptic loosening revisions performed during January 2010 to May 2016. DHR data were merged with that of the Danish Microbiology Database, which contains data from all intraoperatively obtained cultures in Denmark. Both registers have been validated and have a very high degree of completeness and very few patients are missing as a result of emigration. Revisions were grouped based on the number of unexpected positive cultures growing the same bacterial genus: zero, one, or two or more cultures. We defined a positive culture as "unexpected" if it was observed after a revision THA that had been reported to the DHR as aseptic. In Denmark, cultures are routinely obtained even in revisions coded as aseptic, and in this report, 91% (2090 of 2305) of the revision THAs coded as aseptic had cultures taken. The revisions were followed until rerevision, death, or end of the 1-year followup period. The relative risk for rerevision resulting from all causes and PJI was estimated. The Danish National Prescription Registry was reviewed for outpatient antibiotic prescription within 6 weeks of revision. We included 2305 first-time aseptic revisions. Unexpected growth was found in 282 THAs (12%), of which 170 (60%) had growth in only one culture or mixed microbial growth. Coagulase-negative Staphylococcus was the dominating bacteria in 121 revisions (71%). Rerevision was performed on 163 THAs (7%) with PJI being the indication for rerevision in 43 THAs (26%). RESULTS The risk of all-cause rerevision was greater among first-time revisions with one positive culture (relative risk [RR], 1.73; 95% confidence interval [CI], 1.07-2.80; p = 0.020), but not in the two or more positive group (RR, 1.52; 95% CI, 0.82-2.80; p = 0.180) when compared with the culture-negative THAs. First-time revisions with one positive culture also had a higher risk of rerevision for PJI specifically (RR, 2.63; 95% CI, 1.16-5.96; p = 0.020), but this was not the case in the two or more positive group (RR, 2.28; 95% CI, 0.81-6.43; p = 0.120). Outpatient antibiotic prescription was more frequent after revisions with two or more positive cultures compared with culture-negative revision (50 of 112 [45%] versus 353 of 2023 [17%]; p < 0.001). This was not the case in revisions with one positive culture (36 of 170 [21%] versus 353 of 2023 [17%]; p = 0.220). CONCLUSIONS First-time clinically aseptic THA revisions with unexpected growth in one biopsy culture had an increased risk for rerevision, both in terms of all-cause revision and revision for PJI. The predominant bacteria in revisions with later rerevision was coagulase-negative Staphylococcus. This emphasizes that unexpected bacterial growth with common bacteria may be clinically important, even if only one of five biopsy cultures is positive. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Nikolaj R Milandt
- N. R. Milandt, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark P. H. Gundtoft, Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, Kolding, Denmark S. Overgaard, Department of Clinical Research, University of Southern Denmark, Odense, Denmark and Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
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Schwarz EM, Parvizi J, Gehrke T, Aiyer A, Battenberg A, Brown SA, Callaghan JJ, Citak M, Egol K, Garrigues GE, Ghert M, Goswami K, Green A, Hammound S, Kates SL, McLaren AC, Mont MA, Namdari S, Obremskey WT, O'Toole R, Raikin S, Restrepo C, Ricciardi B, Saeed K, Sanchez-Sotelo J, Shohat N, Tan T, Thirukumaran CP, Winters B. 2018 International Consensus Meeting on Musculoskeletal Infection: Research Priorities from the General Assembly Questions. J Orthop Res 2019; 37:997-1006. [PMID: 30977537 DOI: 10.1002/jor.24293] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 02/22/2019] [Accepted: 03/19/2019] [Indexed: 02/04/2023]
Abstract
Musculoskeletal infections (MSKI) remain the bane of orthopedic surgery, and result in grievous illness and inordinate costs that threaten healthcare systems. As prevention, diagnosis, and treatment has remained largely unchanged over the last 50 years, a 2nd International Consensus Meeting on Musculoskeletal Infection (ICM 2018, https://icmphilly.com) was completed. Questions pertaining to all areas of MSKI were extensively researched to prepare recommendations, which were discussed and voted on by the delegates using the Delphi methodology. The questions, including the General Assembly (GA) results, have been published (GA questions). However, as critical outcomes include: (i) incidence and cost data that substantiate the problems, and (ii) establishment of research priorities; an ICM 2018 research workgroup (RW) was assembled to accomplish these tasks. Here, we present the result of the RW consensus on the current and projected incidence of infection, and the costs per patient, for all orthopedic subspecialties, which range from 0.1% to 30%, and $17,000 to $150,000. The RW also identified the most important research questions. The Delphi methodology was utilized to initially derive four objective criteria to define a subset of the 164 GA questions that are high priority for future research. Thirty-eight questions (23% of all GA questions) achieved the requisite > 70% agreement vote, and are highlighted in this Consensus article within six thematic categories: acute versus chronic infection, host immunity, antibiotics, diagnosis, research caveats, and modifiable factors. Finally, the RW emphasizes that without appropriate funding to address these high priority research questions, a 3rd ICM on MSKI to address similar issues at greater cost is inevitable.
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Affiliation(s)
- Edward M Schwarz
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Javad Parvizi
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios Endo Klinik Hamburg, Hamburg, Germany
| | - Amiethab Aiyer
- Department of Orthopaedic Surgery, University of Miami/Miller School of Medicine, Miami, Florida
| | - Andrew Battenberg
- Department of Orthopaedics, Kaiser Permanente Vacaville Medical Center, Vacaville, California
| | - Scot A Brown
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - John J Callaghan
- Deparment of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios Endo Klinik Hamburg, Hamburg, Germany
| | - Kenneth Egol
- Department of Orthopedic Surgery, New York University, New York, New York
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michelle Ghert
- Department of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Karan Goswami
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Andrew Green
- Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
| | - Sommer Hammound
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Alex C McLaren
- Department of Orthopaedic Surgery, College of Medicine-Phoenix, University of Arizona, Phoenix, Arizona
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Surena Namdari
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - William T Obremskey
- Department of Orthopedic Surgery, Vanderbilt Medical Center, Nashville, Tennessee
| | - Robert O'Toole
- Department of Orthopaedics, University of Maryland, Baltimore, Maryland
| | - Steven Raikin
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Camilo Restrepo
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Benjamin Ricciardi
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Kordo Saeed
- Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, United Kingdom
- Department of Microbiology, School of Medicine, University of Southampton, Southampton, United Kingdom
| | | | - Noam Shohat
- Department of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Timothy Tan
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Caroline P Thirukumaran
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Brian Winters
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Ascione T, Barrack R, Benito N, Blevins K, Brause B, Cornu O, Frommelt L, Gant V, Goswami K, Hu R, Klement MR, Komnos G, Malhotra R, Mirza Y, Munhoz Lima AL, Nelson C, Noor SS, O'Malley M, Oussedik S, Portillo ME, Prieto H, Saxena A, Sessa G. General Assembly, Diagnosis, Pathogen Isolation - Culture Matters: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S197-S206. [PMID: 30360977 DOI: 10.1016/j.arth.2018.09.071] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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Abdel MP, Akgün D, Akin G, Akinola B, Alencar P, Amanatullah DF, Babazadeh S, Borens O, Vicente Cabral RM, Cichos KH, Deirmengian C, de Steiger R, Ghanem E, Radtke Gonçalves JR, Goodman S, Hamlin B, Hwang K, Klatt BA, Lee GC, Manrique J, Moon AS, Ogedegbe F, Salib CG, Tian S, Winkler T. Hip and Knee Section, Diagnosis, Pathogen Isolation, Culture: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S361-S367. [PMID: 30343972 DOI: 10.1016/j.arth.2018.09.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Amanatullah D, Dennis D, Oltra EG, Marcelino Gomes LS, Goodman SB, Hamlin B, Hansen E, Hashemi-Nejad A, Holst DC, Komnos G, Koutalos A, Malizos K, Martinez Pastor JC, McPherson E, Meermans G, Mooney JA, Mortazavi J, Parsa A, Pécora JR, Pereira GA, Martos MS, Shohat N, Shope AJ, Zullo SS. Hip and Knee Section, Diagnosis, Definitions: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S329-S337. [PMID: 30348576 DOI: 10.1016/j.arth.2018.09.044] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Liu TH, Cheng SS, You HL, Lee MS, Lee GB. Bacterial detection and identification from human synovial fluids on an integrated microfluidic system. Analyst 2019; 144:1210-1222. [DOI: 10.1039/c8an01764f] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
An integrated microfluidic system was developed for detecting and identifying four bacteria in human joint fluid with the limit of detection as low as 100 colony forming units (CFUs) per milliliter (or 20 CFUs per reaction).
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Affiliation(s)
- Ting-Hang Liu
- Department of Power Mechanical Engineering
- National Tsing Hua University
- Hsinchu
- Taiwan
| | - Shu-Shen Cheng
- Department of Laboratory Medicine
- Kaohsiung Chang Gung Memorial Hospital
- Kaohsiung
- Taiwan
| | - Huey-Ling You
- Department of Laboratory Medicine
- Kaohsiung Chang Gung Memorial Hospital
- Kaohsiung
- Taiwan
| | - Mel S. Lee
- Department of Orthopaedic Surgery
- Kaohsiung Chang Gung Memorial Hospital
- Kaohsiung
- Taiwan
| | - Gwo-Bin Lee
- Department of Power Mechanical Engineering
- National Tsing Hua University
- Hsinchu
- Taiwan
- Institute of Biomedical Engineering
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Schiffner E, Latz D, Thelen S, Grassmann JP, Karbowski A, Windolf J, Schneppendahl J, Jungbluth P. Normal CRP and WBC values in total hip arthroplasty (THA) with signs of loosening. Do we need a joint aspiration? J Clin Orthop Trauma 2019; 10:566-570. [PMID: 31061591 PMCID: PMC6492220 DOI: 10.1016/j.jcot.2018.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 09/18/2018] [Accepted: 09/25/2018] [Indexed: 01/24/2023] Open
Abstract
PURPOSE Overall Total hip arthroplasty (THA) is a very successful procedure. However, in case of complication dedicated management is required. Two major complications of THA failures are aseptic loosening (AL) and periprosthetic joint infection (PJI). The primary hypothesis of this study was that joint aspirations in patients with signs of loosening after THA are capable to detect PJI in suspected AL with negative serologic testing. METHODS In this study a total of 108 symptomatic patients with radiographic signs of prosthetic loosening and hip pain in THA were included. Based on a standardized algorithm all patients underwent serological testing followed by joint aspiration preoperatively. Intraoperatively harvested samples were subjected to microbiological testing and served as the gold standard in differential diagnosis. Demographics, as well as the results of serologic and microbiological testing were collected from the medical records. RESULTS Of the included patients 85 were finally diagnosed with an AL and 23 with PJI. Within the patients with PJI 13 (56%) patients demonstrated elevated CRP and WBC counts, as well as positive synovial cultures after joint aspiration. In ten patients (44%) diagnosed with PJI neither CRP nor WBC were abnormal. CONCLUSION The diagnosis of PJI can be difficult in THA with radiographic signs of loosening. Clinical features including pain, fever, and local sings of infection are uncommon especially a long period after index operation. First-line screening testing relies on serological evaluation of CRP and WBC. However, normal CRP and WBC values cannot rule out a PJI. These cases can be detected by joint aspiration and synovial cultures reliably.
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Affiliation(s)
- Erik Schiffner
- Department of Trauma and Handsurgery, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - David Latz
- Department of Trauma and Handsurgery, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany,Corresponding author.
| | - Simon Thelen
- Department of Trauma and Handsurgery, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Jan P. Grassmann
- Department of Trauma and Handsurgery, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Alfred Karbowski
- Department of Orthopaedic Surgery, Krankenhaus der Augustinerinnen, Jakobstraße 27-31, 50678, Cologne, Germany
| | - Joachim Windolf
- Department of Trauma and Handsurgery, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Johannes Schneppendahl
- Department of Trauma and Handsurgery, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Pascal Jungbluth
- Department of Trauma and Handsurgery, Heinrich Heine University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
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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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Histopathology in Periprosthetic Joint Infection: When Will the Morphomolecular Diagnosis Be a Reality? BIOMED RESEARCH INTERNATIONAL 2018; 2018:1412701. [PMID: 29862251 PMCID: PMC5971260 DOI: 10.1155/2018/1412701] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/07/2018] [Indexed: 02/07/2023]
Abstract
The presence of a polymorphonuclear neutrophil infiltrate in periprosthetic tissues has been shown to correlate closely with the diagnosis of septic implant failure. The histological criterion considered by the Musculoskeletal Infection Society to be diagnostic of periprosthetic joint infection is “greater than five neutrophils per high-power field in five high-power fields observed from histologic analysis of periprosthetic tissue at ×400 magnification.” Surgeons and pathologists should be aware of the qualifications introduced by different authors during the last years in the histological techniques, samples for histological study, cutoffs used for the diagnosis of infection, and types of patients studied. Recently, immunohistochemistry and histochemistry studies have appeared which suggest that the cutoff point of five polymorphonuclear neutrophils in five high-power fields is too high for the diagnosis of many periprosthetic joint infections. Therefore, morphomolecular techniques could help in the future to achieve a more reliable histological diagnosis of periprosthetic joint infection.
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Kicia M, Wesolowska M, Kopacz Z, Kváč M, Sak B, Sokulska M, Cebulski K, Hendrich AB, Pozowski A. Disseminated Infection of Encephalitozoon cuniculi Associated With Osteolysis of Hip Periprosthetic Tissue. Clin Infect Dis 2018; 67:1228-1234. [DOI: 10.1093/cid/ciy256] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 03/29/2018] [Indexed: 01/06/2023] Open
Affiliation(s)
- Marta Kicia
- Department of Biology and Medical Parasitology, Wroclaw Medical University, Poland
| | - Maria Wesolowska
- Department of Biology and Medical Parasitology, Wroclaw Medical University, Poland
| | - Zaneta Kopacz
- Department of Biology and Medical Parasitology, Wroclaw Medical University, Poland
| | - Martin Kváč
- Biology Centre, Institute of Parasitology, Czech Academy of Sciences, Czech Republic
- Faculty of Agriculture, University of South Bohemia, České Budějovice, Czech Republic
| | - Bohumil Sak
- Biology Centre, Institute of Parasitology, Czech Academy of Sciences, Czech Republic
| | - Magdalena Sokulska
- Department of Biology and Medical Parasitology, Wroclaw Medical University, Poland
| | - Kamil Cebulski
- Department of Biology and Medical Parasitology, Wroclaw Medical University, Poland
| | - Andrzej B Hendrich
- Department of Biology and Medical Parasitology, Wroclaw Medical University, Poland
| | - Andrzej Pozowski
- Department of Physiotherapy, Wroclaw Medical University, Wroclaw, Poland
- Nonresident Department of Traumatic-Orthopedic Surgery, Provincial Specialist Hospital, Wroclaw, Poland
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Jacobs AME, Bénard M, Meis JF, van Hellemondt G, Goosen JHM. The unsuspected prosthetic joint infection. Bone Joint J 2017; 99-B:1482-1489. [DOI: 10.1302/0301-620x.99b11.bjj-2016-0655.r2] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 06/23/2017] [Indexed: 02/01/2023]
Abstract
Aims Positive cultures are not uncommon in cases of revision total knee and hip arthroplasty (TKA and THA) for presumed aseptic causes. The purpose of this study was to assess the incidence of positive intra-operative cultures in presumed aseptic revision of TKA and THA, and to determine whether the presence of intra-operative positive cultures results in inferior survival in such cases. Patients and Methods A retrospective cohort study was assembled with 679 patients undergoing revision knee (340 cases) or hip arthroplasty (339 cases) for presumed aseptic causes. For all patients three or more separate intra-operative cultures were obtained. Patients were diagnosed with a previously unsuspected prosthetic joint infection (PJI) if two or more cultures were positive with the same organism. Records were reviewed for demographic details, pre-operative laboratory results and culture results. The primary outcome measure was infection-free implant survival at two years. Results The incidence of unsuspected PJI was 27 out of 340 (7.9%) in TKA and 41 out of 339 (12.1%) in THA. Following revision TKA, the rate of infection-free implant survival in patients with an unsuspected PJI was 88% (95% confidence intervals (CI) 60 to 97) at two years compared with 98% (95% CI 94 to 99) in patients without PJI (p = 0.001). After THA, the rate of survival was similar in those with unsuspected PJI (92% (95% CI 73 to 98) at two years) and those without (94% (95% CI 89 to 97), p = 0.31). Conclusion Following revision of TKA and THA for aseptic diagnoses, around 10% of cases were found to have positive cultures. In the knee, such cases had inferior infection-free survival at two years compared with those with negative cultures; there was no difference between the groups following THA. Cite this article: Bone Joint J 2017;99-B:1482–9.
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Affiliation(s)
- A. M. E. Jacobs
- Sint Maartenskliniek Research, Sint
Maartenskliniek, PO box 9011, 6500
GM Nijmegen, The Netherlands
| | - M. Bénard
- Sint Maartenskliniek Research, Sint
Maartenskliniek, PO box 9011, 6500
GM Nijmegen, The Netherlands
| | - J. F. Meis
- Radboud University Medical Center, Nijmegen, The
Netherlands
| | - G. van Hellemondt
- Prosthetic Joint Infection Unit , Sint
Maartenskliniek, PO box 9011, 6500
GM Nijmegen, The Netherlands
| | - J. H. M. Goosen
- Prosthetic Joint Infection Unit , Sint
Maartenskliniek, PO box 9011, 6500
GM Nijmegen, The Netherlands
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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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Wouthuyzen-Bakker M, Tornero E, Claret G, Bosch J, Martinez-Pastor JC, Combalia A, Soriano A. Withholding Preoperative Antibiotic Prophylaxis in Knee Prosthesis Revision: A Retrospective Analysis on Culture Results and Risk of Infection. J Arthroplasty 2017; 32:2829-2833. [PMID: 28456562 DOI: 10.1016/j.arth.2017.03.064] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/08/2017] [Accepted: 03/28/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A significant amount of patients undergoing revision surgery of a prosthetic joint turn out to have an infection. Withholding preoperative antibiotic prophylaxis in these patients to optimize culture yield during revision surgery remains a matter of debate. The aim of our study was to determine (1) the rate of positive intraoperative cultures with or without preoperative antibiotic prophylaxis and (2) the incidence of a prosthetic joint infection (PJI) during the follow-up in the 2 groups. METHODS Medical files of patients in whom preoperative antibiotic prophylaxis was withheld until culture samples were taken (2007-2010, n = 284) and in whom antibiotic prophylaxis was given during the induction of anesthesia (2010-2013, n = 141) were retrospectively reviewed. RESULTS The percentage of ≥1 positive cultures was the same in the group without (26%) and with preoperative prophylaxis (27%; P value, .7). PJI was diagnosed during revision surgery according to the Musculoskeletal Infection Society criteria in 6.7% patients not receiving preoperative prophylaxis and in 7.0% receiving it (P value, .79). We found no important differences in the type of microorganisms that were isolated in both groups. During a 3-month follow-up, an early PJI developed in patients undergoing total revision surgery in 6.4% of the nonpreoperative prophylaxis group vs 1.6% in the preoperative prophylaxis group (P value, .1). CONCLUSION Preoperative antibiotic prophylaxis does not reduce culture yield in patients undergoing knee revision surgery. Our data show a trend toward a higher PJI rate in the postoperative period of total revision surgery when preoperative prophylaxis is withheld.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Internal Medicine/Infectious diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eduard Tornero
- Department of Orthopedic Surgery and Traumatology, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Guillem Claret
- Department of Orthopedic Surgery and Traumatology, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jordi Bosch
- Department of Microbiology, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), ISGlobal, Barcelona, Spain
| | - Juan Carlos Martinez-Pastor
- Department of Orthopedic Surgery and Traumatology, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Andreu Combalia
- Department of Orthopedic Surgery and Traumatology, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alex Soriano
- Infectious Diseases Service, Department of Internal Medicine, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Fernández-Sampedro M, Fariñas-Alvarez C, Garces-Zarzalejo C, Alonso-Aguirre MA, Salas-Venero C, Martínez-Martínez L, Fariñas MC. Accuracy of different diagnostic tests for early, delayed and late prosthetic joint infection. BMC Infect Dis 2017; 17:592. [PMID: 28841913 PMCID: PMC6389211 DOI: 10.1186/s12879-017-2693-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 08/17/2017] [Indexed: 01/16/2023] Open
Abstract
Background A combination of laboratory, histopathological and microbiological tests for diagnosis of prosthetic joint infection (PJI) have been strongly recommended. This study aims to characterize the accuracy of individual or group tests, such as culture of sonicate fluid, synovial fluid and peri-implant tissue, C-reactive protein (CRP) and histopathology for detection of early, delayed and late PJI. Methods A prospective study of patients undergoing hip or knee arthroplasty from February 2009 to February 2014 was performed in a Spanish tertiary health care hospital. The diagnostic accuracy of the different methods was evaluated constructing receiver-operating-characteristic (ROC) curve areas. Results One hundred thirty consecutive patients were included: 18 (13.8%) early PJI, 35 (27%) delayed PJI and 77 (59.2%) late PJI. For individual parameters, the area under the ROC curve for peri-implant tissue culture was larger for early (0.917) than for delayed (0.829) and late PJI (0.778), p = 0.033. There was a significantly larger difference for ROC area in the synovial fluid culture for delayed (0.803) than for early (0.781) and late infections (0.679), p = 0.039. The comparison of the areas under the ROC curves for the two microbiological tests showed that sonicate fluid was significantly different from peri-implant tissue in delayed (0.951 vs 0.829, p = 0.005) and late PJI (0.901 vs 0.778, p = 0.000). The conjunction of preoperative parameters, synovial fluid culture and CRP, improved the accuracy for late PJI (p = 0.01). The conjunction of histopathology and sonicate fluid culture increased the area under ROC curve of sonication in early (0.917 vs 1.000); p = 0.06 and late cases (0.901 vs 0.999); p < 0.001. Conclusion For early PJI, sonicate fluid and peri-implant tissue cultures achieve the same best sensitivity. For delayed and late PJI, sonicate fluid culture is the most sensitive individual diagnostic method. By combining histopathology and peri-implant tissue, all early, 97% of delayed and 94.8% of late cases are diagnosed. The conjunction of histopathology and sonicate fluid culture yields a sensitivity of 100% for all types of infection.
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Affiliation(s)
- M Fernández-Sampedro
- Infectious Diseases Unit, Department of Medicine, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain.
| | - C Fariñas-Alvarez
- Division of Health Care Quality Hospital, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - C Garces-Zarzalejo
- Department of Orthopaedic Surgery, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - M A Alonso-Aguirre
- Department of Orthopaedic Surgery, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - C Salas-Venero
- Service of Microbiology, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - L Martínez-Martínez
- Service of Microbiology, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - M C Fariñas
- Infectious Diseases Unit, Department of Medicine, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain.
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Identification of Asymptomatic Prosthetic Joint Infection: Microbiologic and Operative Treatment Outcomes. Surg Infect (Larchmt) 2017; 18:582-587. [DOI: 10.1089/sur.2016.253] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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40
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Serum and Synovial Fluid Interleukin-6 for the Diagnosis of Periprosthetic Joint Infection. Sci Rep 2017; 7:1496. [PMID: 28473693 PMCID: PMC5431429 DOI: 10.1038/s41598-017-01713-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 03/31/2017] [Indexed: 01/29/2023] Open
Abstract
A gold standard for diagnosis of periprosthetic joint infection (PJI) has not yet been established. The objective of this study was to evaluate the diagnostic value of serum and synovial fluid interleukin (IL)-6 levels for PJI. The MEDLINE and EMBASE databases were searched for studies describing PJI diagnosis using serum and synovial fluid IL-6 and published between January 1990 and October 2016. Seventeen studies were included in the analysis. The pooled sensitivities of serum and synovial fluid IL-6 were 0.72 (95% confidence interval [CI]: 0.63–0.80) and 0.91 (95% CI: 0.82–0.96), respectively. The pooled specificities of serum and synovial fluid IL-6 were 0.89 (95% CI: 0.77–0.95) and 0.90 (95% CI: 0.84–0.95), respectively. The pooled diagnostic odds ratios (DORs) of serum and synovial fluid IL-6 were 20 (95% CI: 7–58) and 101 (95% CI: 28–358), respectively, and the pooled areas under the curve (AUCs) were 0.83 (95% CI: 0.79–0.86) and 0.96 (95% CI: 0.94–0.98), respectively. Synovial fluid IL-6 had high diagnostic value for PJI. Although serum IL-6 test was less sensitive than synovial fluid IL-6 test, it may be regularly prescribed for patients with prosthetic failure owing to its high specificity.
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Saeed K, Dryden M, Bassetti M, Bonnet E, Bouza E, Chan M, Cortes N, Davis JS, Esposito S, Giordano G, Gould I, Hartwright D, Lye D, Marin M, Morgan-Jones R, Lajara-Marco F, Righi E, Romano CL, Segreti J, Unal S, Williams RL, Yalcin AN. Prosthetic joints: shining lights on challenging blind spots. Int J Antimicrob Agents 2017; 49:153-161. [DOI: 10.1016/j.ijantimicag.2016.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/23/2016] [Accepted: 10/01/2016] [Indexed: 12/12/2022]
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