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Dong M, Wang Y, Fan H, Yang D, Wang R, Feng Y. The Albumin to Globulin Ratio Performs Well for Diagnosing Periprosthetic Joint Infection: A Single-Center Retrospective Study. J Arthroplasty 2024; 39:229-235.e4. [PMID: 37557968 DOI: 10.1016/j.arth.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Accurate diagnosis of the periprosthetic joint infection (PJI) remains a challenge for surgeons. The purpose of this study was to assess the value of albumin to globulin ratio (AGR) and globulin (GLB) for diagnosing PJI. METHODS A total of 182 patients undergoing revision after arthroplasty were included and divided into 2 groups, 61 in knee group (PJI: 38; non-PJI: 23) and 121 in hip group (PJI: 26; non-PJI: 95). We used receiver operating characteristic curves to determine the diagnostic value of AGR, GLB, inflammatory markers (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]). RESULTS The receiver operating characteristic curves showed the areas under the curve of AGR, GLB, ESR, and CRP in the knee group were 0.940, 0.928, 0.867, and 0.848, respectively, and they were 0.855, 0.831, 0.886, and 0.912 in the hip group. The optimal predictive cut-off values for AGR in knee and hip groups were 1.375 and 1.295, respectively. The sensitivity and specificity of AGR, respectively, were 94.7% and 87.0% (knee group) and 84.6% and 75.8% (hip group) for diagnosing PJI. The sensitivity of "AGR or ESR" and specificity of "AGR and GLB" in the knee group were 99.6% and 98.9%, respectively. CONCLUSION For knee or hip groups, the AGR exhibits good value for the diagnosis of PJI comparable with ESR and CRP. The AGR and GLB, together with CRP and ESR, should be used as the preferred indicators for diagnosing PJI. The "AGR or ESR" and "AGR and GLB" in the knee group have an excellent diagnostic value in sensitivity and specificity, respectively.
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Affiliation(s)
- Mingjie Dong
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Yushan Wang
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Hao Fan
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Dinglong Yang
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Renwei Wang
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Yi Feng
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, TaiYuan, China
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Scharf M, Schraag AD, Ehrnsperger M, Grifka J. [Structured approach for infected prosthesis]. Z Rheumatol 2023; 82:859-866. [PMID: 37851164 DOI: 10.1007/s00393-023-01421-7] [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] [Accepted: 07/18/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Endoprosthesis infections represent a major challenge for doctors and patients. Due to the increase in endoprosthesis implantation because of the increasing life expectancy, an increase in endoprosthesis infections is to be expected. In addition to infection prophylaxis, methods of infection control become highly relevant, especially in the group of geriatric and multimorbid patients. The aim is to reduce the high 1‑year mortality from prosthesis infections through a structured algorithm. ALGORITHM FOR PROSTHESIS INFECTIONS Prosthesis infections can basically be divided into early and late infections. According to the criteria of the International Consensus Meeting, a late infection is defined as the occurrence more than 30 days after implantation. With respect to the planned approach, the (p)TNM classification offers an orientation. In the early postoperative interval the clinical appearance is crucial as in this phase neither laboratory parameters nor an analysis of synovial fluid show a high sensitivity. It is fundamental that, apart from patients with sepsis, environment diagnostics should be initiated. If a late infection is suspected, in addition to radiological diagnostics (X-ray, skeletal scintigraphy and if necessary, computed tomography, CT), laboratory (C-reactive protein, CRP, leukocytes, blood sedimentation, and if necessary, interleukin‑6, procalcitonin) and microbiological diagnostics (arthrocentesis with synovial analysis and microbiology) are indicated; however, in addition to the arthrocentesis result, the clinical appearance is crucial in cases where an exclusion cannot be confirmed by laboratory parameters. If an infection is confirmed, the treatment depends on the spectrum of pathogens, the soft tissue situation and the comorbidities, including a multistage procedure with temporary explantation and, if necessary, implantation of an antibiotic-containing spacer is necessary. A prosthesis preservation using the debridement, antibiotics and implant retention (DAIR) regimen is only appropriate in an acute infection situation. Basically, radical surgical debridement should be carried out to reduce the pathogen load and treatment of a possible biofilm formation for both early and late infections. The subsequent antibiotic treatment (short or long interval) should be coordinated with the infectious disease specialists. CONCLUSION A structured approach for prosthesis infections oriented to an evidence-based algorithm provides a sufficient possibility of healing. An interdisciplinary approach involving cooperation between orthopedic and infectious disease specialists has proven to be beneficial. Surgical treatment with the aim of reducing the bacterial load by removing the biofilm with subsequent antibiotic treatment is of intrinsic importance.
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Affiliation(s)
- Markus Scharf
- Orthopädische Klinik für die Universität Regensburg im Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - Amadeus Dominik Schraag
- Orthopädische Klinik für die Universität Regensburg im Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Marianne Ehrnsperger
- Orthopädische Klinik für die Universität Regensburg im Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Joachim Grifka
- Orthopädische Klinik für die Universität Regensburg im Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
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Wang R, Shi G, Zhang H, Wang T, Ren W, Jiao Q. Globulin and Albumin/Globulin Ratios as Potential Biomarkers for the Diagnosis of Acute and Chronic Peri-Prosthetic Joint Infections: A Retrospective Study. Surg Infect (Larchmt) 2023; 24:58-65. [PMID: 36706257 DOI: 10.1089/sur.2022.215] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background: Peri-prosthetic joint infection (PJI) is the most serious complication after prosthetic joint replacement. However, the diagnosis of PJI remains challenging for clinicians because of the lack of a gold standard. The purpose of this study was to investigate the diagnostic significance of serum globulin, albumin/globulin, and other biomarkers in acute and chronic periprosthetic infections. Patients and Methods: A retrospective study of 162 patients with PJI and aseptic loosening between January 2016 and March 2021 at our institution was performed in three groups. There were 20 patients with acute infection in group A, 36 patients with chronic infection in group B, and 106 patients with aseptic loosening in group C. Globulin, albumin/globulin, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), platelet count (PLT), mean platelet volume (MPV), d-dimer, and platelet count/mean platelet volume ratio (PMR) levels were recorded. The area under the curve (AUC) was used to measure the diagnostic value of globulin and albumin/globulin with other biomarkers for PJI. Results: Compared with the aseptic loosening group, the acute and chronic PJI group had higher levels of CRP, ESR, d-dimer, globulin, PLT, and PMR (p < 0.01) and lower levels of albumin/globulin and MPV (p < 0.01). The optimal cutoff, AUC, sensitivity, and specificity of CRP, albumin/globulin, ESR, and globulin were: CRP, 8.3 mg/L, 0.903, 78.57%, and 88.68%; albumin/globulin, 1.31, 0.899, 91.07%, and 73.58%; ESR, 32 mm/h, 0.888, 75.%, and 85.85%; globulin, 29.5 g/L, 0.880, 91.07%, and 72.64%. Conclusions: Globulin and albumin/globulin have excellent diagnostic value for acute and chronic PJI and are promising potential biomarkers for the diagnosis of PJI. The diagnostic performance of albumin/globulin is superior to that of ESR and similar to that of CRP.
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Affiliation(s)
- Renwei Wang
- Department of Orthopedic, Linfen Central Hospital, Linfen, Shanxi Province, China.,Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Guang Shi
- Department of Orthopedic, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong Province, P.R. China
| | - Hui Zhang
- Department of Orthopedic, Xi'an International Medical Center Hospital, Xi'an, Shaanxi Province, China
| | - Tao Wang
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Weiping Ren
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Qiang Jiao
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
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Rajput V, Meek RMD, Haddad FS. Periprosthetic joint infection: what next? Bone Joint J 2022; 104-B:1193-1195. [DOI: 10.1302/0301-620x.104b11.bjj-2022-0944] [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] [Indexed: 11/05/2022]
Abstract
Periprosthetic joint infection (PJI) remains an extremely challenging complication. We have focused on this issue more over the last decade than previously, but there are still many unanswered questions. We now have a workable definition that everyone should align to, but we need to continue to focus on identifying the organisms involved. Surgical strategies are evolving and care is becoming more patient-centred. There are some good studies under way. There are, however, still numerous problems to resolve, and the challenge of PJI remains a major one for the orthopaedic community. This annotation provides some up-to-date thoughts about where we are, and the way forward. There is still scope for plenty of research in this area. Cite this article: Bone Joint J 2022;104-B(11):1193–1195.
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Affiliation(s)
- Vishal Rajput
- University College London Hospital, London, UK
- The Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | | | - Fares S. Haddad
- University College London Hospital, London, UK
- The Bone & Joint Journal, London, UK
- The Princess Grace Hospital, London, UK
- The NIHR Biomedical Research Centre, University College London Hospitals, London, UK
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Huang Z, Zhang Z, Li M, Li W, Fang X, Zhang W. Synovial Fluid Neutrophil Gelatinase-Associated Lipocalin Can be Used to Accurately Diagnose Prosthetic Joint Infection. Int J Infect Dis 2022; 123:170-175. [PMID: 35987468 DOI: 10.1016/j.ijid.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 08/05/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Neutrophil gelatinase-associated lipocalin (NGAL)1 in synovial fluid (SF) may have potential diagnostic value for prosthetic joint infection (PJI). The purpose of this study was to study (1) the diagnostic performance of SF-NGAL level for diagnosing PJI and (2) the impact of prior antibiotic use on the SF-NGAL levels. METHODS Consecutive patients who needed hip or knee revision surgery were included prospectively from January 2017 to September 2018. The patients were divided into the PJI group and the aseptic failure (AF) group. An enzyme-linked immunosorbent assay was used to determine the SF-NGAL level. RESULTS Fifty of 78 included patients were diagnosed with PJI. The median SF-NGAL level was 3633 ng/ml (interquartile range (IQR), 1332-10737) in the PJI group and 26.8 ng/ml (IQR, 12.4-52.5) in the AF group (p < 0.0001). When the SF-NGAL threshold was 263 ng/ml, the AUC was 0.98, the sensitivity was 92.9%, and the specificity was 98%. The median level was 5779 ng/ml (IQR, 1425-13072) in the antibiotic group and 2590 ng/ml (IQR, 932-8970) in the nonantibiotic group (p = 0.1). CONCLUSION SF-NGAL level can be used as a diagnostic indicator of PJI. The use of antibiotics prior to sampling does not affect the SF-NGAL level.
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Affiliation(s)
- Zida Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Zijie Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Mengqing Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Wenbo Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Xinyu Fang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Wenming Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China.
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Abstract
Accurate diagnosis of orthopedic infection is crucial in guiding both antimicrobial therapy and surgical management in order to optimize patient outcomes. A variety of microbiological and nonmicrobiological methods are used to establish the presence of a musculoskeletal infection. In this minireview, we examine traditional culture-based and newer molecular methodologies for pathogen detection, as well as systemic and localized assays to assess host response to maximize diagnostic yield.
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Huang J, Wang J, Qin L, Zhu B, Huang W, Hu N. Combination of Synovial Fluid IL-4 and Polymorphonuclear Cell Percentage Improves the Diagnostic Accuracy of Chronic Periprosthetic Joint Infection. Front Surg 2022; 9:843187. [PMID: 35356501 PMCID: PMC8959493 DOI: 10.3389/fsurg.2022.843187] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 02/03/2022] [Indexed: 11/21/2022] Open
Abstract
Background Synovial fluid biomarkers have been found to improve the diagnosis of chronic periprosthetic joint infection (PJI); however, no “gold standard” exists yet. Interleukin-4 (IL-4) and polymorphonuclear cell (neutrophil) count in the synovial fluid are crucial in mediating local inflammation during bacterial infections and could be valuable biomarkers for PJI. Methods This prospective study was conducted to investigate the diagnostic potential of synovial fluid IL-4 (SF-IL4) and polymorphonuclear cell percentage (SF-PMN%) for chronic PJI. A total of 110 patients who underwent revision arthroplasty between January 2019 and October 2020 were enrolled, and 11 patients were excluded. Of 99 patients, 43 were classified as having PJI and 56 as having aseptic failures according to the 2013 Musculoskeletal Infections Society criteria. In all patients, SF-IL4, SF-PMN%, serum C-reactive protein (CRP), and serum erythrocyte sedimentation rate (ESR) were quantified preoperatively. The diagnostic value for each biomarker was analyzed, and optimal cutoff values were calculated. Results The patient demographics did not significantly vary. The area under the curve of SF-IL4 and SF-PMN% was 0.97 and 0.89, respectively, higher than that for serum ESR (0.72) and serum CRP (0.83). The combination of SF-IL4 and SF-PMN% provided higher specificity (97.0%) and accuracy (96.0%) when the cut-off values were 1.7 pg/mL and 75%, respectively. Conclusion SF-IL4 is a valuable biomarker for chronic PJI detection, and the combination of SF-IL4 and SF-PMN% improved the diagnostic value of chronic PJI, and further studies are needed until its clinical application.
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Affiliation(s)
- Jiaxing Huang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Jiawei Wang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Leilei Qin
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Bo Zhu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Ning Hu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
- *Correspondence: Ning Hu
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Akgün D, Wiethölter M, Siegert P, Danzinger V, Minkus M, Braun KF, Moroder P. The role of serum C-reactive protein in the diagnosis of periprosthetic shoulder infection. Arch Orthop Trauma Surg 2022; 142:1715-1721. [PMID: 33515325 PMCID: PMC9296386 DOI: 10.1007/s00402-021-03779-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/06/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION There is a paucity of literature regarding serum C-reactive protein (CRP) in the evaluation of a shoulder periprosthetic joint infection (PJI). The purpose of the current study was to establish cutoff values for diagnosing shoulder PJI and evaluate the influence of the type of infecting microorganism and the classification subgroups according to last proposed International Consensus Meeting (ICM) criteria on the CRP level. MATERIALS AND METHODS A retrospective analysis of all 136 patients, who underwent septic or aseptic revision shoulder arthroplasty in our institution between January 2010 and December 2019, was performed. Shoulder PJI was defined according to the last proposed definition criteria of the ICM. Serum CRP levels were compared between infected and non-infected cases, between infection subgroups, as well as between different species of infecting microorganisms. A receiver-operating characteristic (ROC) analysis was performed to display sensitivity and specificity of serum CRP level for shoulder PJI. RESULTS A total of 52 patients (38%) were classified as infected, 18 meeting the criteria for definitive infection, 26 for probable infection and 8 for possible infection. According to the ROC curve, an optimized serum CRP threshold of 7.2 mg/l had a sensitivity of 69% and specificity of 74% (area under curve = 0.72). Patients with definitive infection group demonstrated significantly higher median serum CRP levels (24.3 mg/l), when compared to probable, possible infection groups and PJI unlikely group (8 mg/l, 8.3 mg/l, 3.6 mg/l, respectively, p < 0.05). The most common isolated microorganism was Cutibacterium acnes in 25 patients (48%) followed by coagulase-negative staphylococci (CNS) in 20 patients (39%). Patients with a PJI caused by high-virulent microorganisms had a significantly higher median serum CRP level compared to patients with PJI caused by low-virulent microorganisms (48 mg/l vs. 11.3 mg/l, p = 0.04). CONCLUSIONS Serum CRP showed a low sensitivity and specificity for the diagnosis of shoulder PJI, even applying cutoffs optimized by receiver-operating curve analysis. Low-virulent microorganisms and patients with probable and possible infections are associated with lower CRP levels compared to patients with definitive infection and infections caused by high-virulent microorganisms. LEVEL OF EVIDENCE Diagnostic Level III.
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Affiliation(s)
- Doruk Akgün
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Mats Wiethölter
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Paul Siegert
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Victor Danzinger
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Marvin Minkus
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Karl Friedrich Braun
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Philipp Moroder
- Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité–University Medicine Berlin, Corporate Member of Freie Universität Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
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Maimaiti Z, Xu C, Fu J, Chai W, Zhou Y, Chen J. The Potential Value of Monocyte to Lymphocyte Ratio, Platelet to Mean Platelet Volume Ratio in the Diagnosis of Periprosthetic Joint Infections. Orthop Surg 2021; 14:306-314. [PMID: 34939337 PMCID: PMC8867408 DOI: 10.1111/os.12992] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/16/2021] [Accepted: 02/21/2021] [Indexed: 11/30/2022] Open
Abstract
Objective To explore the possibility of obtaining more accurate information from routine blood tests for the diagnosis of periprosthetic joint infection (PJI). Methods This is a retrospective study. Between 2017 and 2018, a total of 246 patients who underwent total hip or knee revision surgery were included in this study. There were 146 females and 100 males, and the mean age of the patients was 62.1 ± 12.75 years. Laboratory parameters erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP), D‐dimer, plasma fibrinogen, serum white blood cell (WBC), and calculable ratio markers were collected. Based on leukocytes (monocyte count, neutrophil count, lymphocyte count), platelet count, and mean platelet volume Inflammation‐related ratio markers were calculated, which including monocyte to lymphocyte ratio (MLR), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and platelet to mean platelet volume ratio (PMR). Follow‐up of all studied cases for at least 1 year. The diagnostic value of the markers based on the receiver operating characteristic (ROC) analysis. The most optimal combinations of blood markers were selected by the prediction models. Statistical analyses and prediction models were performed using R software. Results Of the 246 patients, 125 were diagnosed with PJI and 121 with aseptic loosening. A higher rate of patients underwent revision surgery due to hip prosthesis loosening in the aseptic loosening group (74.4%) compared to the PJI group (45.6%, P < 0.001). ROC curves showed that the area under the curve (AUC) for classical markers, fibrinogen was 0.853 (95% confidence interval [CI], 0.805–0.901), ESR was 0.836 (95% CI, 0.785–0.887) and CRP was 0.825 (95% CI, 0.773–0.878). Followed by the PMR, PLR, NLR and MLR, which showed promising diagnostic performance with AUCs of 0.791, 0.785, 0.736, and 0.733. The AUCs of the ratio markers were higher than those of D‐dimer (0.691;95% CI, 0.6243–0.7584) and serum WBC (0.622; 95% CI, 0.552–0.691). After the predictive model calculation, AUC was up to 0.923 (95% CI, 0.891–0.951) when plasma fibrinogen combined with MLR and PMR and interpreted excellent discriminatory capacity with a sensitivity of 86.40% and a specificity of 84.17%. The new combination significantly increases the accuracy and reliability of the diagnosis of PJI (P < 0.001). The AUC increased to 0.899 (95% CI, 0.861–0.931; P = 0.007) and 0.916 (95% CI, 0.880–0.946; P < 0.001), followed by CRP and ESR, respectively. All plasma fibrinogen, ESR, and CRP combined with both PMR and MLR achieved the highest specificity (89.17%) and PPV (85.34%). Conclusion The diagnostic performance greatly improved when plasma fibrinogen, ESR, and CRP combined with ratio markers.
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Affiliation(s)
- Zulipikaer Maimaiti
- Department of Orthopaedics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Chi Xu
- Department of Orthopaedics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jun Fu
- Department of Orthopaedics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Wei Chai
- Department of Orthopaedics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yonggang Zhou
- Department of Orthopaedics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jiying Chen
- Department of Orthopaedics, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
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Salib CG, Reina N, van Wijnen AJ, Hanssen AD, Berry DJ, Abdel MP. Absence of signature inflammatory markers in synovial fluid for total knee arthroplasties revised for arthrofibrosis. Orthop Traumatol Surg Res 2021; 107:102870. [PMID: 33639288 PMCID: PMC8087631 DOI: 10.1016/j.otsr.2021.102870] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/17/2020] [Accepted: 11/26/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Current diagnostic criteria for arthrofibrosis are limited. Since many patients will be aspirated during their clinical course, synovial fluid analysis may supplement current diagnostic criteria for arthrofibrosis. The goal of this study was to determine a unique synovial fluid and inflammatory marker profile for diagnosing arthrofibrosis. HYPOTHESIS Patients with arthrofibrosis following total knee arthroplasty will have a unique synovial fluid aspirate profile compared to control patients to aid in diagnosis. MATERIALS AND METHODS Between 2013 and 2017, 32 patients (32 total knee arthroplasties [TKAs]) underwent revision TKAs for arthrofibrosis. Fourteen patients had pre-revision aspirations. They were 2:1 matched based on age, sex, body mass index (BMI), and year of revision to 28 patients who underwent aseptic revision TKAs for reasons other than arthrofibrosis (control group). Mean age at revision was 66years, with 64% males. RESULTS In TKAs revised for arthrofibrosis, mean total cell count was 828cells/uL. These aspirates contained a mean distribution of 46% macrophages (range: 4-76%), 31% lymphocytes (range: 11-68%), 21% neutrophils (range: 0-75%), 1% other cells (mainly synovial cells; range: 0-11%), and 1% eosinophils (range: 0-7%). There was no significant difference in mean total cell count (p=0.8) or mean distribution of macrophages (p=0.6), lymphocytes (p=0.1), neutrophils (p=0.2), eosinophils (p>0.9), or serum inflammatory markers (p>0.7) when compared to controls. All aspirations were culture negative for infection. DISCUSSION The profile of arthrofibrotic synovial fluid aspirates and serum inflammatory marker values were similar to patients revised for non-arthrofibrotic aseptic etiologies. This suggests synovial fluid and serum inflammatory markers in non-infected knees with arthrofibrosis should expect to have characteristics similar to synovial fluid and inflammatory marker profiles in other aseptic diagnoses. LEVEL OF EVIDENCE III; retrospective case-control study.
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Sayan A, Kopiec A, Shahi A, Chowdhry M, Bullock M, Oliashirazi A. The Expanding Role of Biomarkers in Diagnosing Infection in Total Joint Arthroplasty: A Review of Current Literature. THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:33-43. [PMID: 33778113 DOI: 10.22038/abjs.2020.42989.2169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Consistent diagnosis of periprosthetic infection in total joint arthroplasty continues to elude the orthopedic surgeon because no gold standard test exists. Therefore clinicians must rely on a combination of tests to help aid the diagnosis. The expanding role of biomarkers has shown promising results to more accurately diagnose an infection when combined with clinical suspicion and bacterial culture testing. This paper reviews the diagnostic capabilities of the most current serum and synovial biomarkers as well as next generation sequencing in the setting of periprosthetic joint infection. Future research and high-powered studies will be necessary to determine sensitivity and specificity of each biomarker.
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Affiliation(s)
- Ardalan Sayan
- Department of Orthopaedics, Marshall University - Joan C. Edwards School of Medicine, Huntington, WV, USA
| | - Adam Kopiec
- Department of Orthopaedics, Marshall University - Joan C. Edwards School of Medicine, Huntington, WV, USA
| | - Alisina Shahi
- Department of Orthopaedics, Marshall University - Joan C. Edwards School of Medicine, Huntington, WV, USA
| | - Madhav Chowdhry
- Department of Orthopaedics, Marshall University - Joan C. Edwards School of Medicine, Huntington, WV, USA
| | - Matthew Bullock
- Department of Orthopaedics, Marshall University - Joan C. Edwards School of Medicine, Huntington, WV, USA
| | - Ali Oliashirazi
- Department of Orthopaedics, Marshall University - Joan C. Edwards School of Medicine, Huntington, WV, USA
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[Diagnosis of periprosthetic joint infection : Development of an evidence-based algorithm by the work group of implant-associated infection of the AE-(German Society for Arthroplasty)]. DER ORTHOPADE 2021; 50:312-325. [PMID: 32666142 PMCID: PMC7990870 DOI: 10.1007/s00132-020-03940-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hintergrund Die Behandlung periprothetischer Infektionen (PPI) ist eine der größten Herausforderungen im Bereich der Endoprothetik. Der möglichst sichere Ausschluss oder die Bestätigung einer periprothetischen Infektion ist die Voraussetzung für jede Revisionsoperation und kann für den behandelnden Orthopäden und Unfallchirurgen eine große Herausforderung darstellen. Eine sichere evidenzbasierte präoperative Diagnostik ist im Sinne des Patienten notwendig, um einerseits eine periprothetische Infektion zu erkennen sowie die entsprechende chirurgische und antibiotische Therapie zu planen und andererseits unnötige zweizeitige Wechsel zu vermeiden. Ziel der Arbeit Ziel ist es, ein evidenzbasiertes problem- und prioritätenbasiertes Vorgehen zu entwickeln und dies in einem transparenten und standardisierten Algorithmus zusammenzufassen. Methode Durch systematische Literaturrecherche wurden relevante Arbeiten identifiziert und im Rahmen von Expertenrunden bewertet. Nach Extraktion der Daten erfolgte die Berechnung von Sensitivität, Spezifität, positiver und negativer Likelihood-Ratio sowie positiver und negativer prädiktiver Werte. Im Rahmen von 4 Treffen wurden die entsprechenden Studien der Arbeitsgruppe für implantatassoziierte Infektionen präsentiert und analog zu Standard-Delphi-Runden durch die einzelnen Experten bearbeitet und bewertet. Gemäß der Prioritätenliste der Expertenrunde erfolgte die Entwicklung eines zur ISO (International Organization for Standardisation) konformen Algorithmus. Ergebnisse Der entwickelte Algorithmus ist eine Abfolge von evidenzbasierten Prozessen gemäß der verwendeten ISO-Norm. Gemäß der durch die Expertenrunde priorisierten Haupt- und Nebenkriterien erfolgte die Entwicklung logisch strukturiert und problemorientiert. Schlussfolgerung Der Ausschluss einer periprothetischen Infektion ist von enormer Bedeutung vor einer Revisionsoperation und entscheidet in vielen Fällen über den Erfolg und die Invasivität der Operation. Die Diagnose „periprothetische Infektion“ erfordert eine substanzielle Veränderung der therapeutischen Strategie. Der durch die Arbeitsgruppe entwickelte Algorithmus fasst Positionen aus der aktuellen Literatur und spezielle Expertenmeinungen zusammen, dies ermöglicht einen transparenten diagnostischen Ansatz im Sinne einer Standard Operation Procedure.
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Kim SJ, Cho YJ. Current Guideline for Diagnosis of Periprosthetic Joint Infection: A Review Article. Hip Pelvis 2021; 33:11-17. [PMID: 33748021 PMCID: PMC7952269 DOI: 10.5371/hp.2021.33.1.11] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/24/2020] [Accepted: 10/05/2020] [Indexed: 11/24/2022] Open
Abstract
The nature of implant-related infections is complex. Currently, there is no definitive test for periprosthetic joint infection (PJI) and diagnosis remains challenging despite recent developments. Failure to diagnose and investigate pathologies of the hip appropriately results in delayed management and prolonged patient morbidity. A systematic approach to establishing clear diagnostic criteria for PJI is needed to improve our ability to avoid devastating outcomes associated with these infections. In the current review, we describe an algorithmic approach to the diagnosis of PJI and current controversies surrounding novel diagnostic methods.
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Affiliation(s)
- Seung-Ju Kim
- Department of Orthopaedic Surgery, Hanil General Hospital, Seoul, Korea
| | - Yun Jae Cho
- Department of Orthopaedic Surgery, Hanil General Hospital, Seoul, Korea
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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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Suren C, Lazic I, Stephan M, Lenze FW, Pohlig F, von Eisenhart-Rothe R. Diagnostic algorithm in septic total knee arthroplasty failure - What is evidence-based? J Orthop 2021; 23:208-215. [PMID: 33603316 DOI: 10.1016/j.jor.2020.12.020] [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: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 11/25/2022] Open
Abstract
Prosthetic joint infection (PJI) is among the most common differential diagnoses of total knee arthroplasty failure. It is a challenging complication, not least because of the difficulty of establishing the correct diagnosis. The fact that no single diagnostic parameter or test has been identified that can accurately rule in or out PJI has led to an evolution of similar but competing definitions of PJI on the grounds of an array of criteria. This development has had very positive effects on the scientific evaluation of various methods of PJI diagnostics and treatment because of an increased comparability. However, it can be challenging to stay abreast of the evidence these definitions are based on. Also, the definitions alone do not necessarily entail an algorithm to aid in evaluating the right criteria in a sound order to be able to use the definitions as a sensible tool. The aim of this overview is to state the most recent evidence on the diagnostic parameters included in the most established PJI definitions and to exhibit and compare the few algorithmic approaches published. Clinical symptoms of PJI are very rarely reported on in the literature, hence the evidence on their diagnostic value is poor. The only symptom that is part of the established PJI definitions is the presence of a fistula. Concerning serological markers, CRP and ESR are still the common denominator in the literature, most recently accompanied by D-Dimer as a potentially suitable marker that has been included in the most recent update of the International Consensus Meeting (ICM) criteria. Imaging plays a minor role in the diagnostic cascade because of inconsistent evidence, and no role whatsoever in the established definitions. The most important preoperative diagnostic measure is arthrocentesis and cultural and cytological analysis of the synovial fluid. The much acclaimed α-Defensin test has so far not been included in the established criteria due to inconsistent reports on its diagnostic accuracy, it is, however, in wide use and considered an optional diagnostic tool for inconclusive cases. The most diagnostic accuracy lies in the cultural and histological analysis of periprosthetic tissue biopsies, whether they are gathered in a small procedure or during arthroplasty revision. Published algorithmic approaches to PJI diagnosis are much rarer than the well-established definitions by various associations. With their PJI definition, the American Academy of Orthopedic Surgeons (AAOS) published a consensus based flowchart for PJI diagnosis. Another algorithm was proposed as part of the endeavor of the MSIS and the first consensus meeting, also based on a consensus among experts. There have been two more recent publications of flowcharts based on the current evidence, one introduced at our institution in 2013, one established in 2020 by the German Society for Arthroplasty (AE).
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Affiliation(s)
- Christian Suren
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Igor Lazic
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Maximilian Stephan
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Florian Walter Lenze
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Florian Pohlig
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
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van den Kieboom J, Tirumala V, Xiong L, Klemt C, Kwon YM. Concomitant Hip and Knee Periprosthetic Joint Infection in Periprosthetic Fracture: Diagnostic Utility of Serum and Synovial Fluid Markers. J Arthroplasty 2021; 36:722-727. [PMID: 32893059 DOI: 10.1016/j.arth.2020.08.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Diagnosing periprosthetic joint infection (PJI) in patients with a periprosthetic fracture can be challenging due to concerns regarding the reliability of commonly used serum and synovial fluid markers. This study aimed at determining the diagnostic performance of serum and synovial fluid markers for diagnosing PJI in patients with a periprosthetic fracture of a total joint arthroplasty. METHODS A total of 144 consecutive patients were included: (1) 41 patients with concomitant PJI and periprosthetic fracture and (2) 103 patients with periprosthetic fracture alone. Serum markers erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and synovial markers white blood cell (WBC) count and polymorphonuclear percentage were assessed. RESULTS ESR demonstrated 87% sensitivity and 48% specificity at the Musculoskeletal Infection Society threshold, area under the curve (AUC) of 0.74, and optimal threshold of 45.5 mm/h (76% sensitivity, 68% specificity). CRP showed 94% sensitivity and 40% specificity, AUC of 0.68 with optimal threshold of 16.7 mg/L (84% sensitivity, 51% specificity). Synovial WBC count demonstrated 87% sensitivity and 78% specificity, AUC of 0.90 with optimal threshold of 4552 cells/μL (86% sensitivity, 85% specificity). Polymorphonuclear percentage showed 79% sensitivity and 63% specificity, AUC of 0.70 with optimal threshold of 79.5% (74% sensitivity, 63% specificity). The AUC of all combined markers was 0.90 with 84% sensitivity and 79% specificity. CONCLUSION The diagnostic utility of the serum and synovial markers for diagnosing PJI was lower in the setting of concomitant periprosthetic fracture compared to PJI alone. Using the Musculoskeletal Infection Society thresholds, ESR, CRP, and WBC count showed high sensitivity, yet low specificity, thus higher thresholds and utilizing all serum and synovial markers in combination should be considered.
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Affiliation(s)
- Janna van den Kieboom
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Venkatsaiakhil Tirumala
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Liang Xiong
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christian Klemt
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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McNally M, Sousa R, Wouthuyzen-Bakker M, Chen AF, Soriano A, Vogely HC, Clauss M, Higuera CA, Trebše R. The EBJIS definition of periprosthetic joint infection. Bone Joint J 2021; 103-B:18-25. [PMID: 33380199 PMCID: PMC7954183 DOI: 10.1302/0301-620x.103b1.bjj-2020-1381.r1] [Citation(s) in RCA: 254] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition. Methods This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance. Results This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI. Conclusion The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice. Cite this article: Bone Joint J 2021;103-B(1):18–25.
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Affiliation(s)
- Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Ricardo Sousa
- Porto Bone Infection Group (GRIP), Orthopaedic Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Antonia F Chen
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - H Charles Vogely
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martin Clauss
- Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic, Florida, USA
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Xu Y, Wang L, Xu W. Risk factors affect success rate of debridement, antibiotics and implant retention (DAIR) in periprosthetic joint infection. ARTHROPLASTY 2020; 2:37. [PMID: 35236454 PMCID: PMC8796582 DOI: 10.1186/s42836-020-00056-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/27/2020] [Indexed: 12/23/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is the most devastating complication of joint replacement that seriously affects the quality of life and causes a heavy burden to the families and society. Due to shorter hospital stays, lower costs, improved joint function and less morbidity, a process of debridement, antibiotics and implant retention (DAIR) is recommended as the preferred treatment for acute periprosthetic joint infection. However, the factors that impact the success rate of DAIR remain controversial. This article evaluates the influential factors of DAIR and provides insights for orthopaedics surgeons to make optimal decisions to improve the success rate of DAIR. Conclusion The poor general condition of patients, high preoperative C-reactive protein (CRP) level, repeated joint surgeries, and Methicillin-resistant Staphylococcus aureus (MRSA) infections may be associated with lower DAIR success rate. To the contrary, early surgery, radical debridement, exchange of removable components, washing with iodine and vacuum sealing drainage (VSD) may improve the success rate of DAIR. A sinus tract may not be absolutely contraindicated, but surgeons should treat it with caution. As there is no consensus on many issues, more high-quality research is required.
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Alvand A, Morgan-Jones R. Diagnosis of knee periprosthetic joint infection. Knee 2020; 27:1671-1675. [PMID: 32847691 DOI: 10.1016/j.knee.2020.07.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Wang Y, Man Z, Yuan T, Cao H, Sun S. Reliability of d-Dimer Determination in Diagnosis of Peri-Prosthetic Joint Infection: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2020; 22:374-382. [PMID: 32897817 DOI: 10.1089/sur.2020.212] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Surgeons continue to seek indicators for the diagnosis of peri-prosthetic joint infection (PJI), which is a serious complication after total joint arthroplasty (TJA). Many recent studies have assessed the value of d-dimer in diagnosing PJI because of the close relation between the d-dimer value and inflammation. However, the conclusions from different studies are still disputed. Methods: We searched for studies published from 2011 to March 2020 using online databases and screened studies based on the inclusion criteria. Diagnostic parameters of d-dimer, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were calculated, including the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and the area under the curve (AUC). In addition, univariate meta-regression and subgroup analyses were performed to identify sources of heterogeneity. Results: A total of nine studies with 431 Patients with PJI were included. The pooled sensitivity, specificity, DOR, and AUC of d-dimer were 0.82 (95% confidence interval [CI], 0.73-0.89), 0.73 (95% CI, 0.58-0.83), 12 (95% CI, 5-30), and 0.85 (95% CI, 0.82-0.88), respectively. In addition, the sensitivity, specificity, and AUC of CRP were 0.78 (95% CI, 0.73-0.83), 0.80 (95% CI, 0.73-0.86) and 0.85 (95% CI, 0.81-0.87), respectively, whereas those of ESR were 0.68 (95% CI, 0.60-0.74), 0.83 (95% CI, 0.75-0.88), and 0.80 (95% CI, 0.76-0.83), respectively. Conclusions: d-dimer determination had similar performance to CRP and ESR in the diagnosis of PJI and may be a good addition to the current diagnostic criteria.
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Affiliation(s)
- Yi Wang
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Zhentao Man
- Department of Joint Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Tao Yuan
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Huan Cao
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Shui Sun
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Joint Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
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Wang Y, Li Y, Qiao L, Sun S. Comparison of a Comprehensive Set of Fibrinolytic Markers With C-Reactive Protein and Erythrocyte Sedimentation Rate for the Diagnosis of Periprosthetic Joint Infection. J Arthroplasty 2020; 35:2613-2618. [PMID: 32461024 DOI: 10.1016/j.arth.2020.04.096] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/12/2020] [Accepted: 04/28/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The diagnosis of periprosthetic joint infection (PJI), a serious complication after primary total joint arthroplasty, remains challenging. Recently, fibrinolytic activities have been shown to be closely related to infections and inflammation. However, data assessing the value of fibrinolytic markers for the diagnosis of PJI have been sparse until now. METHODS We retrospectively enrolled 157 patients undergoing revision for aseptic loosening (n = 106, group A) or revision for chronic PJI (n = 51, group B) from January 2014 to August 2019. PJI was defined using the Musculoskeletal Infection Society criteria. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), D-dimer, fibrin degradation product (FDP), and fibrinogen were measured preoperatively. The diagnostic values of each biomarker were analyzed and compared using receiver operating characteristic curves, sensitivity, and specificity. RESULTS Compared with group A, group B had significantly higher levels of CRP, ESR, D-dimer, FDP, and fibrinogen (P < .001). The area under the curve of fibrinogen was 0.914, which was slightly lower than that of CRP (0.924). FDP and D-dimer had area under the curve values of 0.808 and 0.784, respectively. The optimal threshold, sensitivity, and specificity were 3.56 g/L, 86.27%, and 83.96% for fibrinogen; 1.22 mg/L, 66.67%, and 85.85% for D-dimer; and 3.98 μg/mL, 72.55%, and 80.19% for FDP, respectively. CONCLUSION Fibrinolytic markers provided promising diagnostic support for PJI, especially fibrinogen, which had a diagnostic efficiency similar to that of CRP and ESR.
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Affiliation(s)
- Yi Wang
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, China
| | - Yi Li
- Department of Joint Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Li Qiao
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, China
| | - Shui Sun
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, China; Department of Joint Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
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Wasterlain AS, Goswami K, Ghasemi SA, Parvizi J. Diagnosis of Periprosthetic Infection: Recent Developments. J Bone Joint Surg Am 2020; 102:1366-1375. [PMID: 32769605 DOI: 10.2106/jbjs.19.00598] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ There is no absolute test for the preoperative diagnosis of periprosthetic joint infection (PJI); thus, clinical practice relies on a combination of supportive tests and criteria.➤ Novel serum and synovial tests have improved our ability to diagnose PJI. The 2018 evidence-based algorithm for PJI diagnosis provides weighted scores for serum markers, as well as synovial markers, to facilitate diagnosis when major criteria such as positive cultures or a sinus tract are not present.➤ Culture-independent technologies such as next-generation sequencing can facilitate pathogen identification, particularly in the setting of culture-negative PJI.➤ Despite recent developments, PJI diagnosis remains challenging and warrants further innovation.
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Affiliation(s)
- Amy S Wasterlain
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Doshi K, Daultani D, Kumar MA, Shetty S, Pai S. Reliability of intra-operative frozen section study in revision of infected hip arthroplasty. ARTHROPLASTY 2019; 1:15. [PMID: 35240761 PMCID: PMC8796485 DOI: 10.1186/s42836-019-0016-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 11/13/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Frozen sections are extensively used to help in the diagnosis of periprosthetic joint infection during revision hip arthroplasty, though there are insufficient data in relation to its usefulness. Methods Twenty-one patients with infected hip arthroplasties were operated in the form of one or two-staged revision hip arthroplasties. A frozen section was obtained intra-operatively and > 5 PMN’s/ HPF was considered as a positive indicator of infection. If the frozen section was reported negative (≤5 PMN’s/HPF), the revision prosthesis was implanted after a thorough debridement and a wash. If the frozen section was reported as positive, post the debridement; a non-articulating antibiotic-loaded cement spacer was implanted for 8 weeks, supplemented with 3 weeks of intravenous antibiotics and 3 weeks of oral antibiotics. This was followed by an antibiotic-free interval of 2 weeks. The patient was taken up for a revision surgery once the frozen section study was negative (≤5 PMN’s/HPF). The patients were followed up for a minimum of 1 year to a maximum of 2 years after the revision for any evidence of infection (assessed clinically, serologically, and radiologically). Results Frozen section analysis of PMNs per high power field had a 100% specificity in our patients in detecting periprosthetic joint infection. Conclusion Frozen section study is a safe, rapid, cheap and reliable intra-operative modality to diagnose periprosthetic joint infection.
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Affiliation(s)
- Karan Doshi
- Tejasvini Hospital & SSIOT, Kadri Temple road, Kadri, Mangalore, Karnataka, 575003, India.
| | - Deepesh Daultani
- Tejasvini Hospital & SSIOT, Kadri Temple road, Kadri, Mangalore, Karnataka, 575003, India
| | - M Ajith Kumar
- Tejasvini Hospital & SSIOT, Kadri Temple road, Kadri, Mangalore, Karnataka, 575003, India
| | - Shantharam Shetty
- Tejasvini Hospital & SSIOT, Kadri Temple road, Kadri, Mangalore, Karnataka, 575003, India
| | - Shailesh Pai
- Tejasvini Hospital & SSIOT, Kadri Temple road, Kadri, Mangalore, Karnataka, 575003, India
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Wang HY, Zhang Md R, Luo ZY, Wang Md PhD D, Pei FX, Tang X, Zhou ZK. One-Stage Arthroplasty or Revision for Seronegative Infections in Hip and Knee. Orthop Surg 2019; 12:38-49. [PMID: 31788965 PMCID: PMC7031574 DOI: 10.1111/os.12545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 02/05/2023] Open
Abstract
Objective To assess the safety and effectiveness of one‐stage total joint arthroplasty (TJA) or revision for seronegative infections after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods This retrospective study included a total of 495 patients who had undergone one‐stage total joint (hip or knee) arthroplasty or revision with a diagnosis of osteoarthritis secondary to sepsis, osteoarthritis or osteonecrosis of the femoral head (ONFH) secondary to internal fixation surgery of the hip joint, and one‐stage revision for prosthesis loosening after THA or TKA from January 2012 to December 2016. Bacterial cultures were taken from all patients (from joint fluid or articular cavity fluid and four to six different parts of soft tissues) during the operation. If the cultures were positive, patients received antibiotic treatment. Microbiology results from surgical samples, clinical evaluations, SF‐12 score (physical component summary [PCS] and mental component summary [MCS]), Harris hip score (HHS) or Hospital for Special Surgery (HSS) score, and patients' satisfaction was recorded at every follow‐up session. Results A total of 24 patients had a positive result for bacterial culture (4.85%). The bacterial culture results showed that there were 19 cases (79.16%) of gram‐positive cocci (Staphylococcus aureus), 4 cases (16.67%) of gram‐negative bacilli, and 1 case (4.17%) of fungi. For at least 24 months (mean 35 months) follow‐up, no reinfection was discovered. The mean HHS or HSS score improved significantly from 36.29 points preoperatively to 84.21 points postoperatively (P < 0.001). The mean PCS score improved from 10.15 preoperatively to 20.34 postoperatively, and the mean MCS from 13.22 preoperatively to 21.76 postoperatively, with significant differences. Most of the patients were satisfied. Conclusion One‐stage arthroplasty or revision with exhaustive debridement, adequate dosage, and duration of sensitive antibiotics is safe and effective for patients who have seronegative infection of hip or knee joints.
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Affiliation(s)
- Hao-Yang Wang
- Department of Orthopaedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Rui Zhang Md
- Department of Orthopaedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China.,Rehabilitation Medicine Center, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Ze-Yu Luo
- Department of Orthopaedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Duan Wang Md PhD
- Department of Orthopaedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Fu-Xing Pei
- Department of Orthopaedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Xin Tang
- Department of Orthopaedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Zong-Ke Zhou
- Department of Orthopaedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
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Xiong L, Li S, Dai M. Comparison of D-dimer with CRP and ESR for diagnosis of periprosthetic joint infection. J Orthop Surg Res 2019; 14:240. [PMID: 31358018 PMCID: PMC6664511 DOI: 10.1186/s13018-019-1282-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/16/2019] [Indexed: 12/25/2022] Open
Abstract
Background Despite the availability of several biomarkers, the diagnosis of periprosthetic joint infection (PJI) continues to be challenging. Serum D-dimer assessment is a widely available test that detects fibrinolytic activities and has been reported as an inflammatory biomarker. However, quite a few articles have reported the diagnostic efficiency of D-dimer for PJI. Methods This prospective study enrolled patients who had undergone total joint arthroplasty, were suspected of PJI, and also prepared for revision arthroplasty. PJI was defined using the Musculoskeletal Infection Society criteria. In all patients, serum D-dimer level, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) level were measured preoperatively. We then compared the diagnostic efficiency of these three biomarkers. Results The median D-dimer level was significantly higher (p < 0.001) for the patients with PJI than for the patients with aseptic failure. With a sensitivity of 80.77% (95% CI, 65.62 to 95.92%) and a specificity of 79.63% (95% CI, 68.89 to 90.37%), the diagnostic efficiency of D-dimer did not outperform serum CRP (with a sensitivity of 84.61% and specificity of 64.81%) and ESR (with a sensitivity of 73.08% and specificity of 90.47%). Conclusions Serum D-dimer as a marker for the diagnosis of PJI still requires more large-scale and detailed clinical trials.
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Affiliation(s)
- Longjiang Xiong
- Nanchang University, Nanchang, 330003, China.,Department of Orthopedics, Jiangxi Province Hospital of Integrated Chinese and Western Medicine, Nanchang, 330003, China
| | - Siyun Li
- Department of Orthopedics, Jiangxi Province Hospital of Integrated Chinese and Western Medicine, Nanchang, 330003, China
| | - Min Dai
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, NO.17, Yongwai Street, Nanchang, 330006, China.
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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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Akgün D, Müller M, Perka C, Winkler T. High cure rate of periprosthetic hip joint infection with multidisciplinary team approach using standardized two-stage exchange. J Orthop Surg Res 2019; 14:78. [PMID: 30866970 PMCID: PMC6415338 DOI: 10.1186/s13018-019-1122-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/06/2019] [Indexed: 02/08/2023] Open
Abstract
Background Two-stage exchange arthroplasty is still the preferred treatment choice for chronic PJI. However, the results remain unpredictable. We analyzed the treatment success of patients with an infected hip prosthesis, who were treated according to a standardized algorithm with a multidisciplinary team approach and evaluated with a strict definition of failure. Methods In this single-center prospective cohort study, all hip PJI episodes from March 2013 to May 2015 were included. Treatment failure was assessed according to the Delphi-based consensus definition. The Kaplan-Meier survival method was used to estimate the probability of infection-free survival. Patients were dichotomized into two groups depending on the number of previous septic revisions, duration of prosthesis-free interval, positive culture with difficult-to-treat microorganisms, microbiology at explantation, and microbiology at reimplantation. Results Eighty-four patients with hip PJI were the subject of this study. The most common isolated microorganisms were coagulase-negative staphylococci (CNS) followed by Staphylococcus aureus and Propionibacterium. Almost half of the study cohort (46%) had at least one previous septic revision before admission. The Kaplan-Meier estimated infection-free survival after 3 years was 89.3% (95% CI, 80% to 94%) with 30 patients at risk. The mean follow-up was 33.1 months (range, 24–48 months) with successful treatment of PJI. There were no statistical differences in infect eradication rate among the dichotomized groups. Conclusions High infect eradication rates were achieved in a challenging cohort using a standardized two-stage exchange supported by a multidisciplinary approach.
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Affiliation(s)
- Doruk Akgün
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany. .,Charite Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Michael Müller
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Carsten Perka
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Tobias Winkler
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
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Bauer TW, Bedair H, Creech JD, Deirmengian C, Eriksson H, Fillingham Y, Grigoryan G, Hickok N, Krenn V, Krenn V, Lazarinis S, Lidgren L, Lonner J, Odum S, Shah J, Shahi A, Shohat N, Tarabichi M, W-Dahl A, Wongworawat MD. Hip and Knee Section, Diagnosis, Laboratory Tests: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S351-S359. [PMID: 30343973 DOI: 10.1016/j.arth.2018.09.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Barrack R, Bhimani S, Blevins JL, Blevins K, Demetres M, Figgie M, Fillingham Y, Goodman S, Huddleston J, Kahlenberg C, Lautenbach C, Lin J, Lonner J, Lynch M, Malkani A, Martin L, Mirza S, Rahim Najjad MK, Penna S, Richardson S, Sculco P, Shahi A, Szymonifka J, Wang Q. General Assembly, Diagnosis, Laboratory Test: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S187-S195. [PMID: 30348554 DOI: 10.1016/j.arth.2018.09.070] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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30
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General Assembly, Diagnosis, Pathogen Isolation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S207-S214. [PMID: 30348573 DOI: 10.1016/j.arth.2018.09.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Akgün D, Müller M, Perka C, Winkler T. The serum level of C-reactive protein alone cannot be used for the diagnosis of prosthetic joint infections, especially in those caused by organisms of low virulence. Bone Joint J 2018; 100-B:1482-1486. [PMID: 30418061 DOI: 10.1302/0301-620x.100b11.bjj-2018-0514.r1] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
AIMS The aim of this study was to determine the prevalence and characteristics of C-reactive protein (CRP)-negative prosthetic joint infection (PJI) and evaluate the influence of the type of infecting organism on the CRP level. PATIENTS AND METHODS A retrospective analysis of all PJIs affecting the hip or knee that were diagnosed in our institution between March 2013 and December 2016 was performed. A total of 215 patients were included. Their mean age was 71 years (sd 11) and there were 118 women (55%). The median serum CRP levels were calculated for various species of organism and for patients with acute postoperative, acute haematogenous, and chronic infections. These were compared using the Kruskal-Wallis test, adjusting for multiple comparisons with Dunn's test. The correlation between the number of positive cultures and serum CRP levels was estimated using Spearman correlation coefficient. RESULTS Preoperative CRP levels were normal (< 10 mg/l) in 77 patients (35.8%) with positive cultures. Low-virulent organisms were isolated in 66 PJIs (85.7%) with normal CRP levels. When grouping organisms by species, patients with an infection caused by Propionibacterium spp., coagulase-negative staphylococci (CNS), and Enterococcus faecalis had significantly lower median serum CRP levels (5.4 mg/l, 12.2 mg/l, and 23.7 mg/l, respectively), compared with those with infections caused by Staphylococcus aureus and Streptococcus spp. (194 mg/l and 89.3 mg/l, respectively; p < 0.001). Those with a chronic PJI had statistically lower median serum CRP levels (10.6 mg/l) than those with acute postoperative and acute haematogenous infections (83.7 mg/l and 149.4 mg/l, respectively; p < 0.001). There was a significant correlation between the number of positive cultures and serum CRP levels (Spearman correlation coefficient, 0.456; p < 0.001). CONCLUSION The CRP level alone is not accurate as a screening tool for PJI and may yield high false-negative rates, especially if the causative organism has low virulence. Aspiration of the joint should be used for the diagnosis of PJI in patients with a chronic painful arthroplasty, irrespective of CRP level. Cite this article: Bone Joint J 2018;100-B:1482-86.
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Affiliation(s)
- D Akgün
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Berlin, Germany
| | - M Müller
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Berlin, Germany
| | - C Perka
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Berlin, Germany
| | - T Winkler
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Berlin, Germany
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Intra-operative diagnosis of periprosthetic joint infection can rely on frozen sections in patients without synovial fluid analyses. INTERNATIONAL ORTHOPAEDICS 2018; 43:1303-1308. [DOI: 10.1007/s00264-018-4227-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
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Significant increase of pathogen detection rate by dry arthroscopic biopsies at suspected low-grade infection following total knee arthroplasty: a prospective observational study. Arch Orthop Trauma Surg 2018; 138:1583-1590. [PMID: 30182141 DOI: 10.1007/s00402-018-3032-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The differentiation between stiff-knee and low-grade periprosthetic joint infection (PJI) is the current diagnostic challenge in total knee (TKA) revision arthroplasty. The aim of this study was to investigate the additional value of dry biopsies, compared to wet biopsies, in patients presenting with knee stiffness following primary TKA. MATERIALS AND METHODS Single center, prospective observational study. Consecutive patients with joint stiffness of unknown origin following primary TKA were enrolled. Patient assessment followed the diagnostic standard algorithm. During diagnostic arthroscopy, synovial fluid (synovial WBC, PMN%) and five dry biopsies (dry) were collected. Then fluid was infused and another five microbiology (wet) and five histological biopsies gathered, all from identical locations. The primary outcome parameter was the difference between the pathogens in wet and dry biopsies. RESULTS 71 patients (61% females, 67 ± 10 years) were eligible. Preoperative blood serology mean CRP (0.7 ± 1.5 mg/dl; p = 0.852), WBC (6.6 ± 1.7 G/l; p = 0.056), and synovial fluid mean WBC (1639 ± 2111; p = 0.602), PMN% (38 ± 28; p = 0.738) did not differ between patients with negative, positive wet or dry biopsies. The histology was in 11% positive (p = 0.058). In 32% at least one pathogen was detected, 48% from wet, 44% from dry biopsies. An inhomogeneous distribution was found. Cutibacterium acnes (100%) was solely found in wet, Micrococcus luteus (75%), Staphylococcus capitis (67%), and Micrococcus lylae (100%) were predominantly found in dry biopsies. Additional dry biopsies increased the pathogen detection rate by 49%. CONCLUSION The addition of dry biopsies to the current standard diagnostic algorithm for PJI increased the pathogen detection rate by 49%.
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Sebastian S, Malhotra R, Dhawan B. Prosthetic Joint Infection: A Major Threat to Successful Total Joint Arthroplasty. Indian J Med Microbiol 2018; 36:475-487. [DOI: 10.4103/ijmm.ijmm_19_11] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Risitano S, Sabatini L, Atzori F, Massè A, Indelli PF. Static antibiotic spacers augmented by calcium sulphate impregnated beads in revision TKA: Surgical technique and review of literature. J Orthop 2018; 15:313-318. [PMID: 29556116 DOI: 10.1016/j.jor.2018.02.008] [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] [Received: 09/26/2017] [Revised: 01/16/2018] [Accepted: 02/18/2018] [Indexed: 01/20/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a serious complication in total knee arthroplasty (TKA) and represents one of the most common causes of revision. The challenge for surgeons treating an infected TKA is to quickly obtain an infection-free joint in order to re-implant, when possible, a new TKA. Recent literature confirms the role of local antibiotic-loaded beads as a strong bactericidal, allowing higher antibiotic elution when compared with antibiotic loaded spacers only. Unfortunately, classical Polymethylmethacrylate (PMMA) beads might allow bacteria adhesion, secondary development of antibiotic resistance and eventually surgical removal once antibiotics have eluted. This article describes a novel surgical technique using static, custom-made antibiotic loaded spacers augmented by calcium sulphate antibiotic-impregnated beads to improve the success rate of revision TKA in a setting of PJI. The use of calcium sulphate beads has several potential benefits, including a longer sustained local antibiotic release when compared with classical PMMA beads and, being resorbable, not requiring accessory surgical interventions.
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Affiliation(s)
- Salvatore Risitano
- Department of Orthopaedic Surgery and Traumatology, University of Turin, "Città della salute e della scienza"-CTO Hospital of Turin, Turin, ITA, Italy.,Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System (PAVAHCS), Palo Alto, CA, USA
| | - Luigi Sabatini
- Department of Orthopaedic Surgery and Traumatology, University of Turin, "Città della salute e della scienza"-CTO Hospital of Turin, Turin, ITA, Italy
| | - Francesco Atzori
- Department of Orthopaedic Surgery, Cottolengo Hospital, Turin, Italy
| | - Alessandro Massè
- Department of Orthopaedic Surgery and Traumatology, University of Turin, "Città della salute e della scienza"-CTO Hospital of Turin, Turin, ITA, Italy
| | - Pier Francesco Indelli
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System (PAVAHCS), Palo Alto, CA, USA
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Lee YS, Lee YK, Han SB, Nam CH, Parvizi J, Koo KH. Natural progress of D-dimer following total joint arthroplasty: a baseline for the diagnosis of the early postoperative infection. J Orthop Surg Res 2018; 13:36. [PMID: 29439725 PMCID: PMC5811971 DOI: 10.1186/s13018-018-0730-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 01/23/2018] [Indexed: 12/13/2022] Open
Abstract
Background Early detection followed by prompt intervention is essential for the treatment of periprosthetic joint infection (PJI). D-dimer, a fibrin degradation product, characteristically changes rapidly during early postoperative period and has a short half-life. The aim of this prospective study was to measure postoperative change of D-dimer level after joint arthroplasty in conjunction with ESR and CRP. Methods ESR, CRP, and D-dimer levels were measured on the day before surgery, postoperative days 1, 2, 3, and 5 and weeks 2 and 6 in 65 patients who underwent elective primary total hip arthroplasty (38 hips in 38 patients) or total knee arthroplasty (27 knees in 27 patients). We compared perioperative changes of the three biomarkers. Results ESR level was elevated from postoperative day 1 and reached a peak level of 45 mm/h at postoperative day 5. The elevation persisted until postoperative week 6. CRP level was elevated from postoperative day 1 and reached a peak level of 10 mg/dl between postoperative day 2 and day 3. The CRP level was decreased to the normal level around postoperative week 2. D-dimer level was sharply elevated and peaked to 4.5 μg/dl at postoperative day 1. At postoperative day 2, it decreased to baseline level. After then, it slowly elevated again and reached a second peak at postoperative week 2. Conclusion D-dimer showed a more rapid rise and fall than ESR and CRP in very early postoperative period. The D-dimer test might be effective in early detection of PJI, if combined with levels of ESR and CRP. The postoperative change of D-dimer in our study can serve as a baseline for early diagnosis of PJI.
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Affiliation(s)
- Yong Seuk Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 463-707, South Korea
| | - Young-Kyun Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 463-707, South Korea.
| | - Seung Bum Han
- Department of Orthopedic Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Chang Hyun Nam
- Department of Orthopedic Surgery, Mokdong Himchan Hospital, Seoul, South Korea
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 463-707, South Korea
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Gomez-Urena EO, Tande AJ, Osmon DR, Berbari EF. Diagnosis of Prosthetic Joint Infection: Cultures, Biomarker and Criteria. Infect Dis Clin North Am 2018; 31:219-235. [PMID: 28483043 DOI: 10.1016/j.idc.2017.01.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Prosthetic joint infections (PJIs) are devastating complications after joint arthroplasty that continue to pose a diagnostic challenge. Currently, a single, stand-alone test with the adequate accuracy and reliability for diagnosis of PJI is not available; therefore, physicians who care for patients with PJI must rely on a combination of diagnostic tests for the diagnosis of PJI. This article reviews conventional laboratory test modalities, diagnostic accuracy and limitations of current tests, and novel emerging tests for the diagnosis of PJI.
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Affiliation(s)
- Eric O Gomez-Urena
- Division of Infectious Diseases, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Aaron J Tande
- Division of Infectious Diseases, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Douglas R Osmon
- Division of Infectious Diseases, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Elie F Berbari
- Division of Infectious Diseases, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
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Abstract
OBJECTIVES The diagnosis of periprosthetic joint infection (PJI) is difficult and requires a battery of tests and clinical findings. The purpose of this review is to summarize all current evidence for common and new serum biomarkers utilized in the diagnosis of PJI. METHODS We searched two literature databases, using terms that encompass all hip and knee arthroplasty procedures, as well as PJI and statistical terms reflecting diagnostic parameters. The findings are summarized as a narrative review. RESULTS Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were the two most commonly published serum biomarkers. Most evidence did not identify other serum biomarkers that are clearly superior to ESR and CRP. Other serum biomarkers have not demonstrated superior sensitivity and have failed to replace CRP and ESR as first-line screening tests. D-dimer appears to be a promising biomarker, but more research is necessary. Factors that influence serum biomarkers include temporal trends, stage of revision, and implant-related factors (metallosis). CONCLUSION Our review helped to identify factors that can influence serum biomarkers' level changes; the recognition of such factors can help improve their diagnostic utility. As such, we cannot rely on ESR and CRP alone for the diagnosis of PJI prior to second-stage reimplantation, or in metal-on-metal or corrosion cases. The future of serum biomarkers will likely shift towards using genomics and proteomics to identify proteins transcribed via messenger RNA in response to infection and sepsis.Cite this article:Bone Joint Res 2018;7:85-93.
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Affiliation(s)
- A Saleh
- Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA
| | - J George
- Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA
| | - M Faour
- Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA
| | - A K Klika
- Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA
| | - C A Higuera
- Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA
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Park KH, Patel R. Diagnostic Methods for Prosthetic Joint Infection in Korea. Infect Chemother 2018; 50:199-209. [PMID: 30270579 PMCID: PMC6167515 DOI: 10.3947/ic.2018.50.3.199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Indexed: 01/29/2023] Open
Abstract
Prosthetic joint infection (PJI) poses a burden on patients and health care resources. PJI diagnosis can be challenging, owing to imperfect definition, alongside inadequate diagnostic techniques. In this review, we describe consensus definitions of PJI, approaches to diagnosis using methods available in Korea, and novel diagnostic methods.
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Affiliation(s)
- Kyung Hwa Park
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, Korea.
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.,Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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40
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Liang H, Xin M, Zhao L, Wang L, Sun M, Wang J. Serum creatinine level and ESR values associated to clinical pathology types and prognosis of patients with renal injury caused by ANCA-associated vasculitis. Exp Ther Med 2017; 14:6059-6063. [PMID: 29285157 PMCID: PMC5740565 DOI: 10.3892/etm.2017.5306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 10/05/2017] [Indexed: 01/16/2023] Open
Abstract
The correlation between serum creatinine and erythrocyte sedimentation rate (ESR) values and clinical pathology and prognosis in patients with renal injury caused by anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis were analyzed. Eighty-six patients with ANCA-associated vasculitis (AAV) treated in the Affiliated Hospital of Qingdao University were enrolled in the study. Patients were assigned into an elderly group (n=45) or a non-elderly group (n=41) according to age. The serum creatinine (Scr) level was measured via the sarcosine oxidase method, and the erythrocyte sedimentation rate (ESR) was measured using the full-automatic ESR analyzer; the relationship between Scr and ESR values and the pathology type of patients was statistically analyzed. The mean levels of Scr and ESR in the 86 patients were 406.87±12.37 µmol/l and 83.83±7.64 mm/1 h, respectively. Importantly, the levels of Scr and the ESR in the elderly group were significantly higher than those in the non-elderly group (P<0.05). In addition, patients with high levels of Scr and accelerated ESR presented mainly the crescentic and sclerotic pathological types, while in the same patients the numbers of focal and mixed types were lower (P<0.05). Kaplan-Meier analysis showed that the survival rate in the elderly group was significantly lower than that in the non-elderly group, and likewise patients with high levels of Scr and accelerated ESR had significantly lower survival rates than those with low levels of Scr and normal ESR (P<0.05). The AUC of the Scr level was 0.901, the sensitivity 90.2%, the specificity 89.5% and the cut-off value was 392.5 µmol/l; while the AUC of the ESR level was 0.864, the sensitivity 89.2%, the specificity 88.5% and the cut-off value 72.8 mm/1 h. Logistic regression analysis showed that the levels of Scr (OR=2.315, P<0.01) and ESR (OR=1.847, P<0.01) were independent factors affecting the prognosis of patients. Based on our findings, the seric Scr level and the ESR are closely related to the clinicopathological features of the disease in patients with renal injury caused by ANCA-associated vasculitis, and they can be used as prognosis and treatment evaluation markers.
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Affiliation(s)
- Hongda Liang
- Department of Rheumatology and Clinical Immunology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266005, P.R. China
| | - Miaomiao Xin
- Department of Rheumatology and Clinical Immunology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266005, P.R. China
| | - Lei Zhao
- Department of Rheumatology and Clinical Immunology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266005, P.R. China
| | - Liqin Wang
- Department of Rheumatology and Clinical Immunology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266005, P.R. China
| | - Mingshu Sun
- Department of Rheumatology and Clinical Immunology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266005, P.R. China
| | - Jibo Wang
- Department of Rheumatology and Clinical Immunology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266005, P.R. China
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Tsang STJ, Ting J, Simpson AHRW, Gaston P. Outcomes following debridement, antibiotics and implant retention in the management of periprosthetic infections of the hip: a review of cohort studies. Bone Joint J 2017; 99-B:1458-1466. [PMID: 29092984 DOI: 10.1302/0301-620x.99b11.bjj-2017-0088.r1] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 07/05/2017] [Indexed: 02/07/2023]
Abstract
AIMS The aims of the study were to review and analyse the reported series of debridement, antibiotics and implant retention (DAIR) in the management of infected total hip arthroplasties (THAs) to establish the overall success and the influencing factors. PATIENTS AND METHODS Using a standardised recognised study protocol, meta-analysis of observational studies in epidemiology guidelines, a comprehensive review and analysis of the literature was performed. The primary outcome measure was the success of treatment. The search strategy and inclusion criteria which involved an assessment of quality yielded 39 articles for analysis, which included 1296 patients. RESULTS The proportion of success following DAIR in the management of an infected THA appeared to improve after 2004 with a pooled mean proportion of success of 72.2%. For all reported series, from 1977 onwards, there was improved success with early debridement (< 7 days; 75.7%) and exchange of modular components (77.5%). There was a statistically non-significant improvement if debridement was performed within four weeks of the initial procedure (73.0%). CONCLUSION The reported success following DAIR has improved since 2004. The only determinants of outcome which we found were the timing of debridement after the onset of symptoms of infection and the exchange of modular components. Cite this article: Bone Joint J 2017;99-B:1488-66.
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Affiliation(s)
- S-T J Tsang
- University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - J Ting
- University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - A H R W Simpson
- University of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - P Gaston
- University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
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42
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Lausmann C, Zahar A, Citak M, Brañes J, Schmidl S, Frommelt L, Gehrke T, Gebauer M. Are There Benefits In Early Diagnosis Of Prosthetic Joint Infection With Multiplex Polymerase Chain Reaction? J Bone Jt Infect 2017; 2:175-183. [PMID: 29119076 PMCID: PMC5671930 DOI: 10.7150/jbji.22062] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/30/2017] [Indexed: 12/27/2022] Open
Abstract
Purpose Identification of bacteria and susceptibility are fundamental in periprosthetic joint infection (PJI). Especially in the case of systemic inflammatory response syndrome (SIRS) rapid detection of pathogens is essential for proper therapy. Bacterial cultures are time consuming. The polymerase chain reaction (PCR) is a non-culture molecular method and is able to rapidly identify pathogens and their resistance genes. Multiplex PCR (mPCR) can amplify several different DNA sequences simultaneously. The aim of this study was to show the value of mPCR for early diagnosis of PJI. Methods 60 patients undergoing total hip or knee revisions were recruited in this prospective single-centre-study. Three groups were created: 26 patients with aseptic loosening (negative control), 26 patients with chronic PJI, and 8 patients with acute PJI/SIRS. We compared the results of joint aspirates obtained intraoperatively investigated by mPCR with the microbiology results of tissue specimens. Results The overall sensitivity of mPCR was 78.8% (95% CI, 61.1 - 91.0%), the specificity was 100% (95% CI, 87.2 - 100%), the negative predictive value was 79.4% (95% CI, 62.1 - 91.3%), the positive predictive value was 100% (95% CI, 86.8 - 100%), and the overall accuracy was 88.3% (95% CI, 77.4 - 95.2%). The overall accuracy in acute infections/SIRS (87.5%) was greater than in late chronic PJI (76.9%). In PJI the mPCR was able to provide the results within 5 hours whereas the mean time for cultures was 6.4 days. Conclusions Multiplex PCR is a reliable diagnostic tool in PJI management, especially in acute cases complicated with SIRS. Early diagnosis within several hours is possible, targeted antibiotic treatment can be started promptly.
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Affiliation(s)
- Christian Lausmann
- Helios ENDO-Klinik Hamburg, Department of Orthopedic Surgery, Hamburg, Germany
| | - Akos Zahar
- Helios ENDO-Klinik Hamburg, Department of Orthopedic Surgery, Hamburg, Germany
| | - Mustafa Citak
- Helios ENDO-Klinik Hamburg, Department of Orthopedic Surgery, Hamburg, Germany
| | - Julian Brañes
- Hospital San José, University of Santiago de Chile, Santiago, Chile
| | - Stefan Schmidl
- Helios ENDO-Klinik Hamburg, Department of Orthopedic Surgery, Hamburg, Germany
| | - Lars Frommelt
- Helios ENDO-Klinik Hamburg, Department of Orthopedic Surgery, Hamburg, Germany
| | - Thorsten Gehrke
- Helios ENDO-Klinik Hamburg, Department of Orthopedic Surgery, Hamburg, Germany
| | - Matthias Gebauer
- Helios ENDO-Klinik Hamburg, Department of Orthopedic Surgery, Hamburg, Germany
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43
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Alvand A, Rezapoor M, Parvizi J. The Role of Biomarkers for the Diagnosis of Implant-Related Infections in Orthopaedics and Trauma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 971:69-79. [PMID: 28243953 DOI: 10.1007/5584_2017_11] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Diagnosis of implant-related (periprosthetic joint) infections poses a major challenge to infection disease physicians and orthopaedic surgeons. Conventional diagnostic tests continue to suffer from issues of accuracy and feasibility. Biomarkers are used throughout medicine for diagnostic and prognostic purposes, as they are able to objectively determine the presence of a disease or a biological state. There is increasing evidence to support the measurement of specific biomarkers in serum and/or synovial fluid of patients with suspected periprosthetic joint infections. Promising serum biomarkers include interleukin (IL)-4, IL-6, tumour necrosis factor (TNF)-α, procalcitonin, soluble intercellular adhesion molecule 1 (sICAM-1), and D-dimer. In addition to c-reactive protein and leucocyte esterase, promising biomarkers that can be measured in synovial fluid include antimicrobial proteins such as human β-defensin (HBD)-2 and human β-defensin (HBD)-3, and cathelicidin LL-37, as well as several interleukins such as IL-1β, IL-6, IL-8, IL-17, TNF- α, interferon-δ, and vascular endothelial growth factor.
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Affiliation(s)
- Abtin Alvand
- The Rothman Institute, 925 Chestnut Street, Philadelphia, PA, 19107, USA.
| | - Maryam Rezapoor
- The Rothman Institute, 925 Chestnut Street, Philadelphia, PA, 19107, USA
| | - Javad Parvizi
- The Rothman Institute, 925 Chestnut Street, Philadelphia, PA, 19107, USA
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Honkanen M, Jämsen E, Karppelin M, Huttunen R, Lyytikäinen O, Syrjänen J. Concordance between the old and new diagnostic criteria for periprosthetic joint infection. Infection 2017; 45:637-643. [PMID: 28608224 DOI: 10.1007/s15010-017-1038-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 06/06/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE There is no uniform definition for periprosthetic joint infection (PJI). New diagnostic criteria were formulated in an international consensus meeting in 2013 and adopted by Centers for Disease Control (CDC) in 2016. The purpose of this study is to compare the new diagnostic criteria with the old CDC criteria from the year 1992. METHODS Patients, who had been treated for PJI of hip or knee from 2002 to 2014, in a tertiary care hospital, were identified. Patient records were reviewed by a physician to identify PJI cases fulfilling the old or new CDC criteria and to record data concerning the diagnostic criteria. PJI frequencies were calculated for the two diagnostic criteria sets. Cross tables were formed to compare the concordance between the two sets of criteria in the whole material and in different clinical subgroups. RESULTS Overall 405 cases fulfilling either or both sets of criteria for PJI were identified. 73 (18%) of the patients fulfilled only the old criteria, whereas only one (0.2%) fulfilled only the new criteria. Of the patients who did not fulfil the new criteria, in 39 (53%) the diagnosis was based solely on the clinician's opinion. CONCLUSIONS The number of PJIs is notably lower when using the new, more objective, diagnostic criteria. A large portion of the cases diagnosed as infection by the treating clinician, did not fulfil the new diagnostic criteria.
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Affiliation(s)
- Meeri Honkanen
- Department of Internal Medicine, University Hospital of Tampere, PL 2000, 33521, Tampere, Finland.
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.
| | - Esa Jämsen
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Coxa, Hospital for Joint Replacement, Tampere, Finland
| | - Matti Karppelin
- Department of Internal Medicine, University Hospital of Tampere, PL 2000, 33521, Tampere, Finland
| | - Reetta Huttunen
- Department of Internal Medicine, University Hospital of Tampere, PL 2000, 33521, Tampere, Finland
| | - Outi Lyytikäinen
- Department of Infectious Diseases, National Institute for Health and Welfare, Helsinki, Finland
| | - Jaana Syrjänen
- Department of Internal Medicine, University Hospital of Tampere, PL 2000, 33521, Tampere, Finland
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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Alrashidi Y, Galhoum AE, Wiewiorski M, Herrera-Pérez M, Hsu RY, Barg A, Valderrabano V. How To Diagnose and Treat Infection in Total Ankle Arthroplasty. Foot Ankle Clin 2017; 22:405-423. [PMID: 28502355 DOI: 10.1016/j.fcl.2017.01.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Periprosthetic infection after total ankle arthroplasty (TAA) is a serious complication, often requiring revision surgery, including revision arthroplasty, conversion to ankle arthrodesis, or even amputation. Risk factors for periprosthetic ankle infection include prior surgery at the site of infection, low functional preoperative score, diabetes, and wound healing problems. The clinical presentation of patients with periprosthetic ankle joint infection can be variable and dependent on infection manifestation: acute versus chronic. The initial evaluation in patients with suspected periprosthetic joint infections should include blood tests: C-reactive protein and erythrocyte sedimentation rate. Joint aspiration and synovial fluid analysis can help confirm suspected periprosthetic ankle infection.
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Affiliation(s)
- Yousef Alrashidi
- Orthopaedic Department, College of Medicine, Taibah University, P.O. Box 30001, Almadinah Almunawwarah 41411, Kingdom of Saudi Arabia
| | - Ahmed E Galhoum
- Nasser Institute for Research and Treatment, Cairo, Egypt; Department of Orthopaedics and Traumatology, Swiss Ortho Center, Schmerzklinik Basel, Hirschgässlein 15, Basel 4010, Switzerland
| | - Martin Wiewiorski
- Orthopaedic and Trauma Department, Kantonsspital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Mario Herrera-Pérez
- Orthopaedic Department, University Hospital of Canary Islands, La Laguna, Calle El Pilar 50 4 piso, 38002 Tenerife, Spain
| | - Raymond Y Hsu
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Victor Valderrabano
- Orthopaedic Department, Swiss Ortho Center, Schmerzklinik Basel, Swiss Medical Network, Hirschgässlein 15, Basel 4010, Switzerland.
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46
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Affiliation(s)
- F. S. Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK
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47
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C-reactive protein may misdiagnose prosthetic joint infections, particularly chronic and low-grade infections. INTERNATIONAL ORTHOPAEDICS 2017; 41:1315-1319. [DOI: 10.1007/s00264-017-3430-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/12/2017] [Indexed: 02/08/2023]
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Pohlig F, Mühlhofer HML, Lenze U, Lenze FW, Suren C, Harrasser N, von Eisenhart-Rothe R, Schauwecker J. Diagnostic accuracy of arthroscopic biopsy in periprosthetic infections of the hip. Eur J Med Res 2017; 22:6. [PMID: 28259167 PMCID: PMC5336685 DOI: 10.1186/s40001-017-0246-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 02/28/2017] [Indexed: 01/26/2023] Open
Abstract
Background Diagnosis of a low-grade periprosthetic joint infection (PJI) prior to revision surgery can be challenging, despite paramount importance for further treatment. Arthroscopic biopsy of synovial and periprosthetic tissue with subsequent microbiological and histological examination can be beneficial but its specific diagnostic value has not been clearly defined. Methods 20 consecutive patients who underwent percutaneous synovial fluid aspiration as well as arthroscopic biopsy due to suspected PJI of the hip and subsequent one- or two-stage revision surgery at our institution between January 2012 and May 2015 were enrolled. Indication was based on the criteria (1) history of PJI and increased levels of erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), (2) suspicious cell count and differential but negative bacterial culture in synovial aspirate, (3) early loosening (<less than 2 years), or (4) persisting pain without loosening but history of a PJI. At least two criteria had to be fulfilled in order to perform an arthroscopic biopsy. Results Best overall diagnostic value was identified for arthroscopic biopsy and a combination of bacteriological and histological analysis with a sensitivity of 87.5%, specificity of 100% and accuracy of 95%. Bacteriological assessment of synovial aspirate revealed a sensitivity of 50.0%, specificity of 91.7%, and accuracy of 75%. ESR and CRP yielded a sensitivity of 75.0% for either hematologic test and specificities of 87.5 and 66.7%, respectively. Conclusions In conclusion, our data indicate that arthroscopic biopsy is superior to ESR and CRP as well as joint aspiration and their combinations. Concurrent microbiological and histological examination of the biopsy specimens allows for identification of the causative pathogen and its susceptibility pattern in order to preoperatively plan the surgical strategy as well as the antibiotic regimen. Moreover, intraarticular mechanical failure can be detected during hip arthroscopy emphasizing its diagnostic value. Level II diagnostic study.
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Affiliation(s)
- Florian Pohlig
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Heinrich M L Mühlhofer
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Ulrich Lenze
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Florian W Lenze
- Department of Traumatology, Klinikum Traunstein, Cuno-Niggl-Str. 3, 83278, Traunstein, Germany
| | - Christian Suren
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Norbert Harrasser
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Johannes Schauwecker
- Department of Orthopedic Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
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Wang C, Wang Q, Li R, Duan JY, Wang CB. Synovial Fluid C-reactive Protein as a Diagnostic Marker for Periprosthetic Joint Infection: A Systematic Review and Meta-analysis. Chin Med J (Engl) 2017; 129:1987-93. [PMID: 27503025 PMCID: PMC4989431 DOI: 10.4103/0366-6999.187857] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Periprosthetic joint infection (PJI) is the main cause of failure following total joint arthroplasty. Until now, the diagnosis of PJI is still confronted with technical limitations, and the question of whether synovial fluid biomarker, C-reactive protein (CRP), can provide high value in the diagnosis of PJI remains unanswered and, therefore, was the aim of the study. Methods: First, we conducted a systematic review on CRP in the diagnosis of PJI by searching online databases using keywords such as “periprosthetic joint infection”, “synovial fluid”, and “C-reactive protein”. Eligible studies providing sufficient data to construct 2 × 2 contingency tables were then selected based on the list of criteria and the quality of included studies was assessed subsequently. Finally, the reported sensitivity, specificity, diagnostic odds ratio (DOR), summary receiver operating characteristic (SROC) curve, and the area under the SROC (AUSROC) were pooled together and used to evaluate overall diagnostic performance. Results: Seven studies were included in our review, six of which comprising a total of 456 participants were further investigated in our meta-analysis. The pooled sensitivity, specificity, and DOR were 0.92 (95% confidence interval [CI]: 0.86–0.96), 0.90 (95% CI: 0.87–0.93), and 101.40 (95% CI: 48.07–213.93), respectively. The AUSROC was 0.9663 (standard error, 0.0113). Conclusions: Synovial fluid CRP is a good biomarker for the diagnosis of PJI with high sensitivity and specificity.
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Affiliation(s)
- Chi Wang
- Department of Clinical Laboratory, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Qi Wang
- Outpatient Department of Chinese People's Liberation Army, Beijing, 101123, China
| | - Rui Li
- Department of Orthopedics, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Jin-Yan Duan
- Department of Clinical Laboratory, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Cheng-Bin Wang
- Department of Clinical Laboratory, Chinese People's Liberation Army General Hospital, Beijing 100853, China
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Abstract
Host optimization, reduction of bacteria, and establishing proper wound environment in the preoperative, intraoperative, and postoperative periods are the traditional cornerstones of infection prevention. Most institutions have standardized a systems approach to reduce the incidence of surgical site infections. Typically, these systems-based approaches promote protocols for hand and environmental hygiene, patients risk assessment and screening, surgical delays for identifiable and modifiable risk factors, infection surveillance, antibiotic stewardship programs, communication/coordination of care, physician 360° reporting, and unit-based safety programs. Despite the institution of these prevention efforts, there remains controversy about the efficacy and cost-effectiveness of a number of these approaches.
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