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Mazzella FM, Zhang Y, Bauer TW. Update on the role of pathology and laboratory medicine in diagnosing periprosthetic infection. Hum Pathol 2024; 147:5-14. [PMID: 38280657 DOI: 10.1016/j.humpath.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 01/22/2024] [Indexed: 01/29/2024]
Abstract
Technological and implant design advances have helped reduce the frequency of aseptic total joint arthroplasty failure, but periprosthetic joint infections (PJI) remain a clinical important problem with high patient morbidity. Misinterpreting PJI as aseptic mechanical loosening commonly leads to unsatisfactory revision arthroplasty, persistent infection, and poor long-term results. While there is no single "gold standard" diagnostic test for PJI, recent collaborative efforts by Orthopaedic and Infectious Disease Societies have developed algorithms for diagnosing PJI. However, the efficacy of individual tests as well as diagnostic thresholds are controversial. We review the recommended thresholds for commonly used screening tests as well as tissue histopathology and confirmatory tests to diagnose periprosthetic infection. We also update lesser-known laboratory tests, and we briefly summarize rapidly evolving molecular tests to diagnose periprosthetic infection. Pathologists hold a critical role in assisting with PJI diagnosis, maintaining laboratory test quality and interpreting test results. Collaboration between clinicians and pathologists is essential to provide optimal patient care and reduce the burden of PJI.
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Affiliation(s)
- Fermina M Mazzella
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, USA
| | - Yaxia Zhang
- Department of Pathology and Laboratory Medicine, Hospital for Sprecial Surgery, Weill Cornell College of Medicine, USA
| | - Thomas W Bauer
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th St, New York, NY, 10021, USA.
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Tsantes AG, Papadopoulos DV, Goumenos S, Trikoupis IG, Tsante KA, Koutserimpas C, Koulouvaris P, Petrakis V, Vaiopoulos AG, Piovani D, Nikolopoulos GK, Mavrogenis AF, Papagelopoulos PJ, Bonovas S, Tsantes AE. Rotational Thromboelastometry as a Diagnostic Tool for Persistent Infection in Two-Stage Exchange Arthroplasty. J Clin Med 2024; 13:1942. [PMID: 38610707 PMCID: PMC11012334 DOI: 10.3390/jcm13071942] [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: 03/12/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Background/Objectives: There is a lack of reliable biomarkers for diagnosis of infection eradication prior to second-stage reimplantation in two-stage exchange arthroplasty for periprosthetic joint infections (PJIs). The aim of this study was to assess the diagnostic accuracy of rotational thromboelastometry (ROTEM) for persistent infection in two-stage exchange arthroplasties. Methods: A pilot, retrospective analysis was performed including 70 patients who underwent a two-stage exchange arthroplasty for PJI. They were categorized as patients without (n = 64) or patients with persistent infection (n = 6) prior to reimplantation. Definition of persistent infection prior to reimplantation was based on the 2018 ICM criteria. Conventional coagulation biomarkers and ROTEM parameters were compared between groups. Results: Higher FIBTEM MCF values were associated with persistent infection (odds ratio [OR], 1.30, 95% confidence interval [CI], 1.04-1.63; p = 0.020), and FIBTEM MCF had the highest diagnostic accuracy for persistent infection prior to second-stage reimplantation (AUC, 0.907; 95% CI, 0.812-1.000). A cut-off value ≥ 18 mm for FIBTEM MCF was found to have 100.0% sensitivity and 73.4% specificity for diagnosing persistent infection prior to second-stage reimplantation. Moreover, the diagnostic accuracy of FIBTEM MCF was higher than that of fibrinogen levels (p = 0.036) and D-dimer (p = 0.006). Conclusions: Our findings indicate that ROTEM parameters have the potential to identify persistent infections before reimplantation in two-stage exchange arthroplasties for PJI. Such coagulation biomarkers could provide guidance regarding the optimal timing for reimplantation. Further studies in larger populations are warranted to validate the diagnostic accuracy of ROTEM parameters for persistent PJI.
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Affiliation(s)
- Andreas G. Tsantes
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (K.A.T.); (A.G.V.); (A.E.T.)
- Microbiology Department, “Saint Savvas” Oncology Hospital, 11522 Athens, Greece
| | - Dimitrios V. Papadopoulos
- Second Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Stavros Goumenos
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (S.G.); (I.G.T.); (P.K.); (A.F.M.); (P.J.P.)
| | - Ioannis G. Trikoupis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (S.G.); (I.G.T.); (P.K.); (A.F.M.); (P.J.P.)
| | - Konstantina A. Tsante
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (K.A.T.); (A.G.V.); (A.E.T.)
| | - Christos Koutserimpas
- Orthopaedic Surgery and Sports Medicine Department, Croix-Rousse Hospital, 69004 Lyon, France;
- Department of Anatomy, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Panagiotis Koulouvaris
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (S.G.); (I.G.T.); (P.K.); (A.F.M.); (P.J.P.)
| | - Vasileios Petrakis
- 2nd University Department of Internal Medicine, University General Hospital of Alexandroupolis, Democritus University of Thrace, 68132 Alexandroupolis, Greece;
- HIV Unit, Department of Infectious Diseases, University General Hospital of Alexandroupolis, Democritus University of Thrace, 68132 Alexandroupolis, Greece
| | - Aristeidis G. Vaiopoulos
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (K.A.T.); (A.G.V.); (A.E.T.)
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy; (D.P.); (S.B.)
- IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Georgios K. Nikolopoulos
- Laboratory of Medical Statistics, Epidemiology and Public Health, Medical School, University of Cyprus, Nicosia 1678, Cyprus
| | - Andreas F. Mavrogenis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (S.G.); (I.G.T.); (P.K.); (A.F.M.); (P.J.P.)
| | - Panayiotis J. Papagelopoulos
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (S.G.); (I.G.T.); (P.K.); (A.F.M.); (P.J.P.)
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy; (D.P.); (S.B.)
- IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Argirios E. Tsantes
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (K.A.T.); (A.G.V.); (A.E.T.)
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Tsantes AG, Papadopoulos DV, Goumenos S, Trikoupis IG, Tsante KA, Bellou V, Koulouvaris P, Houhoula D, Kriebardis A, Piovani D, Nikolopoulos GK, Mavrogenis AF, Papagelopoulos PJ, Bonovas S, Tsantes AE. A Pilot Observational Study Evaluating the Diagnostic Capacity of Rotational Thromboelastometry in Periprosthetic Joint Infections. J Bone Joint Surg Am 2023; 105:1980-1986. [PMID: 37903295 DOI: 10.2106/jbjs.23.00532] [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] [Indexed: 11/01/2023]
Abstract
BACKGROUND Periprosthetic joint infections (PJIs) are associated with altered hemostatic dynamics; therefore, coagulation laboratory methods such as rotational thromboelastometry (ROTEM) may be valuable in their diagnosis. The aim of this study was to evaluate the diagnostic role of ROTEM in PJI. METHODS A diagnostic study was conducted including 65 patients who underwent revision total hip arthroplasty or total knee arthroplasty due to PJI (30 patients) or aseptic loosening (35 patients). Preoperative laboratory evaluation included conventional coagulation studies, inflammatory markers, and ROTEM analysis. These parameters were compared between patients with PJI and patients with aseptic loosening. RESULTS Several ROTEM parameters differed in the patients with PJI, indicating a higher coagulation potential associated with PJI. Specifically, the development of PJI was associated with higher EXTEM maximum clot firmness (MCF) (odds ratio [OR], 1.12 [95% confidence interval (CI), 1.04 to 1.20]; p = 0.001). Among the ROTEM parameters, EXTEM MCF was found to have the highest diagnostic accuracy for PJI (area under the receiver operating characteristic curve, 0.850; sensitivity, 76.6%; specificity, 91.4%), which was comparable with C-reactive protein (CRP) (p = 0.22) and erythrocyte sedimentation rate (ESR) (p = 0.65), but higher than D-dimer (p = 0.037). Moreover, the combined diagnostic accuracy of elevated EXTEM MCF and CRP was improved compared with CRP alone (p = 0.019). CONCLUSIONS Our results indicate that ROTEM analysis might be helpful for the detection of the hemostatic derangements that are associated with the development of PJI. However, because of the small size of this pilot study, further research is needed to investigate the value of incorporating viscoelastic studies in diagnostic scores for PJI. LEVEL OF EVIDENCE Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andreas G Tsantes
- Laboratory of Haematology and Blood Bank Unit, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Microbiology Department, Saint Savvas Oncology Hospital, Athens, Greece
| | - Dimitrios V Papadopoulos
- Second Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavros Goumenos
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis G Trikoupis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantina A Tsante
- Laboratory of Reliability and Quality Control in Laboratory Hematology, Department of Biomedical Sciences, School of Health & Caring Sciences, University of West Attica, Egaleo, Greece
| | - Vanesa Bellou
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Ioannina, Greece
- Department of Respiratory Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Panagiotis Koulouvaris
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitra Houhoula
- Laboratory of Haematology and Blood Bank Unit, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasios Kriebardis
- Laboratory of Reliability and Quality Control in Laboratory Hematology, Department of Biomedical Sciences, School of Health & Caring Sciences, University of West Attica, Egaleo, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Georgios K Nikolopoulos
- Laboratory of Medical Statistics, Epidemiology and Public Health, Medical School, University of Cyprus, Nicosia, Cyprus, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Panayiotis J Papagelopoulos
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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