Diagnosis of infected total hip arthroplasty

Diagnostic and prognostic relevance of plain radiographs for periprosthetic joint infections of the hip: a literature review

Conventional radiography is regularly used to evaluate complications after total hip arthroplasty. In various recent consensus meetings, however, plain radiographs of a potentially infected hip joint have been judged as being only relevant to exclude diagnoses other than infection. Solid data on radiographic presentations of periprosthetic joint infection (PJI) are scarce. As a result, the prognostic value of radiological features in low-grade PJI remains uncertain. The present review article aims to present an overview of the available literature and to develop ideas on future perspectives to define the diagnostic possibilities of radiography in PJIs of the hip. The primary outcome of interest of this systematic review was the radiologic presentation of periprosthetic joint infections of the hip. As secondary outcome of interest served the sensitivity and specificity of the radiologic presentation of periprosthetic joint infections. Of the included articles, 26 were reviews, essays, or case reports and only 18 were clinical studies. Typical radiologic abnormalities of PJI were a periosteal reaction, a wide band of radiolucency at the cement-bone or metal-bone interface, patchy osteolysis, implant loosening, bone resorption around the implant, and transcortical sinus tracts. The frequency of their occurrence is still inadequately defined. A deeper understanding of the underlying causes and the relation between microorganisms to radiologic abnormalities can probably help clinicians in the future to diagnose a PJI. This is why further research shall focus on the radiographic features of PJI.

Likelihood of hip infection with image-guided hip aspiration dry tap: a 10-year retrospective study

OBJECTIVE

To determine the rate of infection in patients with suspected hip septic arthritis who underwent image-guided aspiration (IHA) resulting in dry-tap, diagnostic value of subsequent lavage and re-aspiration, and if pre-aspiration MRI can help prevent a dry tap.

MATERIALS AND METHODS

Retrospective review between 2010 to 2020 identified native hip (NH) and total hip arthroplasty (THA) patients who had a dry-tap following aspiration for suspected infection or periprosthetic joint infection (PJI). Serology tests, lavage/re-aspiration volumes, and aspirate cell-count/culture were assessed. On pre-aspiration MRI, presence/grade of joint effusion (JE), pseudocapsule dehiscence (PD), extraarticular fluid and sinus-tract were recorded.

RESULTS

Out of 215 included dry-taps, 185 (86.0%) were non-infected and 30 (13.9%) infected. In subgroup analysis, 64/71(90.1%) NH and 121/144(84.0%) THA dry-taps were non-infected. Pre-aspiration MRI of THA group with dry-tap showed significant findings; PD with extraarticular fluid (8/12, 66.7%) and sinus tract (7/12, 58.3%) were higher in the infected compared to non-infected group (5/42, 11.9% and 0/42, 0.0%) (both p < 0.001). Among THA group, polymorphonuclear-leukocytes > 80% was present in 8/9 (88.9%) of infected versus 4/28 (14.3%) non-infected group (p < 0.001). Multivariable regression showed PD (p = 0.005) and JE (p = 0.042) being significant independent predictors of PJI, similarly the elevated CRP (p = 0.044) and JE (p = 0.017).

CONCLUSION

Majority of patients suspected of hip joint infection with dry-tap were non-infected. Synovial PMN% following lavage maintains high sensitivity for detection of PJI. In patients with THA, PD and subsequent extraarticular collection can be associated with dry-tap therefore, pre-aspiration MRI can help determine their presence and plan the aspiration.

Serum and Synovial Biomarkers for the Diagnosis of Implant-Associated Infection After Orthopedic Surgery

Implant-associated infection is one of the most devastating complications following orthopedic surgery. Early identification is crucial for treatment. Currently, however, a reliable diagnostic tool is lacking, partly due to disparate bacteria colonies (virulent vs non-virulent), difficulty in distinguishing infection from inflammatory disease, and highly diverse diagnostic thresholds and testing methods. Given the importance of biomarkers in the initial screening for the infection, an extensive effort has been made to develop serum and synovial biomarkers. In this review, the authors summarize the results from the most relevant studies to provide comprehensive information on biomarkers for the diagnosis of implant-associated infection. [Orthopedics. 2021;44(2):e158-e166.].

Current Guideline for Diagnosis of Periprosthetic Joint Infection: A Review Article

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.

Noninvasive diagnostic of periprosthetic joint infection by urinary peptide markers: A preliminary study

Previous immunohistochemical analyses revealed altered protein expression in the periprosthetic membranes of patients with periprosthetic joint infection (PJI). Proteins are degraded to peptides that may pass the blood-kidney barrier depending on their size. The aim of this study was to evaluate if PJI can be diagnosed based on the urinary peptide excretion pattern. Thirty patients undergoing removal of their hip or knee prostheses due to septic or aseptic loosening were enrolled. Specimen sampling was performed according to the MusculoSkeletal Infection Society criteria. A urinary sample was analyzed before surgery using capillary electrophoresis coupled with mass spectrometry. Peptides with differential urinary excretion between groups were used to establish a multimarker model. A total of 137 peptides were differentially excreted between the septic and aseptic groups. The majority of identified peptide markers were fragments of structural extracellular matrix proteins, potentially due to their origin from the periprosthetic membrane. A marker model with 83 peptides achieved the best diagnostic performance for diagnosing PJI with a sensitivity of 95%, a specificity of 90%, and an area under the curve of 0.96. The altered protein expression pattern in the periprosthetic membrane of PJI is most likely reflected in excreted urinary peptides. Thus, the diagnosis of PJI by urinary peptide markers seems to be a reasonable approach.

Should scintigraphy be completely excluded from the diagnosis of periprosthetic joint infection?

AIM

To analyse the diagnostic performance of bone and leukocyte scintigraphy for periprosthetic joint infection before excluding the test from routine practice, and to analyse the possible benefit of bone marrow scintigraphy in inconclusive cases.

MATERIALS AND METHODS

From 2012 to 2018, all patients with a total hip or knee arthroplasty who had a bone and leukocyte scintigraphy performed and underwent revision surgery were included. Bone marrow scintigraphy was indicated only in cases in which bone and leukocyte scintigraphy were inconclusive. Diagnosis of periprosthetic joint infection was confirmed by positive intraoperative cultures after revision surgery.

RESULTS

A total of 105 patients were included. Eighteen patients had total hip arthroplasties (18.1%) and 86 had total knee arthroplasties (81.9%). Mean age was 74 years. Nineteen cases were diagnosed with a periprosthetic joint infection. Bone and leukocyte scintigraphy had 64% sensitivity and 97% specificity. Bone marrow scintigraphy increased sensitivity and specificity to 88% and 100%, respectively.

CONCLUSION

Bone and leukocyte scintigraphy possesses high sensitivity and specificity for the diagnosis of chronic periprosthetic joint infection. The additional use of bone marrow scintigraphy significantly increases diagnostic performance. For these reasons, bone scintigraphy is reserved for inconclusive cases of chronic periprosthetic joint infection.

Treatment Outcomes of Periprosthetic Joint Infection in HIV-positive Patients

Relevance. There is a limited number of publications reporting outcomes of primary large joint arthroplasty in patients with human immunodeficiency virus (HIV). The authors were unable to find papers on revision arthroplasty in patients with periprosthetic infection. Purpose of the study — to evaluate short term outcomes after revision arthroplasty in HIV-positive patients with periprosthetic infection of the hip and knee joint. Materials and methods. 13 HIV-positive patients with periprosthetic infection of the hip (10 cases) and knee (3 cases) joint underwent treatment in the period from 2015 to 2019. Patients were examined by clinical, laboratory and roentgenological methods. Harris Hip Score and Knee Society Score were used for evaluation prior to and after the surgery. Results. Mean follow up period was 21,4±2,6 months. Successful two-stage treatment was performed in two (15,4%) out of 13 patients with periprosthetic infection. In 5 cases (38,5%) control over infection was achieved by resection arthroplasty, and in one case (7,7%) – by arthrodesis. Five patients (38,5%) refused from interchange of spacer to prosthesis. Mean Harris Hip score demonstrated insignificant increase postoperatively — from 45,3±2,2 to 52,2±4,15 (р = 0,2). Conclusion. Despite following the international protocols for treatment of implant-associated infection the infection recurrence rate in HIV-positive patients in the asymptomatic phase remains very high. Efficiency of twostage treatment using antibacterial spacers in the present group of patients amounted only to 15,4%.

Saline Solution Lavage and Reaspiration for Culture with a Blood Culture System Is a Feasible Method for Diagnosing Periprosthetic Joint Infection in Patients with Insufficient Synovial Fluid

BACKGROUND

Culture is a key step for detecting periprosthetic joint infection (PJI) before surgery. However, using saline solution lavage and reaspiration in patients with insufficient synovial fluid remains controversial. The objective of this study was to evaluate this technique.

METHODS

This study included 286 aspirations performed by 1 surgeon in patients after total joint arthroplasty during the period of April 2015 to August 2018. If >1.0 mL of synovial fluid was obtained, then we directly used the fluid for culture. For cases in which ≤1.0 mL of synovial fluid was aspirated, 10 mL of saline solution was injected and the joint was reaspirated for culture. The samples were injected into 2 blood culture bottles for anaerobic bacterial culture and aerobic bacterial and fungal culture, and were inoculated for 14 days in a BACT/ALERT 3D blood culture system unless microorganisms were detected. A PJI diagnosis was determined on the basis of the modified Musculoskeletal Infection Society criteria.

RESULTS

Saline solution lavage and reaspiration were used in 82 cases (47 PJI cases and 35 non-PJI cases), while direct aspiration was used in 204 cases (99 PJI cases and 105 non-PJI cases). The overall rate for the use of saline solution lavage was 28.7% (82 of 286). Among knee cases, the saline solution lavage rate was 15.0% (21 of 140), and among hip cases, the rate was 41.8% (61 of 146). The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of culture were 0.795 (95% confidence interval [CI], 0.720 to 0.857), 0.957 (95% CI, 0.909 to 0.984), 0.951 (95% CI, 0.896 to 0.982), and 0.817 (95% CI, 0.749 to 0.873); and for "dry tap" cases, they were 0.851 (95% CI, 0.717 to 0.938), 0.857 (95% CI, 0.697 to 0.952), 0.889 (95% CI, 0.760 to 0.963), and 0.811 (95% CI, 0.648 to 0.920), respectively.

CONCLUSIONS

Saline solution lavage and reaspiration for culture in patients with insufficient synovial fluid before surgery may be a sound practice.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Classic Markers for Infection Perform Poorly in Predicting Residual Infection Prior to Reimplantation

Two-stage exchange arthroplasty remains the treatment of choice for chronic periprosthetic joint infections. This retrospective study conducted between 2009 and 2015 examined the diagnostic value of biomarkers for residual infection between stages. The biomarkers evaluated included C-reactive protein prior to reimplantation, preimplantation synovial fluid white blood cell count and percent neutrophils, and the intraoperative histologic synovial white blood cell count per high-power field (×400) on permanent sections. Residual infection was defined as either positive cultures (more than 1) at second stage, any further surgery (eg, amputation, arthrodesis, or another 2-stage revision), or the need for infection suppression with antibiotics. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios were calculated accordingly. A total of 182 two-stage exchange operations that included 109 (59.9%) prosthetic hips and 73 (40.1%) prosthetic knees met the inclusion criteria. Residual infection was present in 38 (20.9%) of the procedures. The area under the curve-receiver operating characteristic values were 0.677 for C-reactive protein (P=.002), 0.506 for aspiration white blood cell count (P=.944), 0.623 for aspiration percent neutrophils (P=.200), and 0.524 for white blood cell count per high-power field (P=.801). Positive and negative predictive values were poor and ranged between 26% and 57% and 78% and 85%, respectively. Analyses using specific combinations of biomarkers did not significantly improve predictive values. This study showed that classic markers perform poorly in identifying residual infection prior to second-stage revision. Further research is necessary to evaluate the diagnostic utility of other, more recently introduced biomarkers to determine whether infection has been eradicated between stages. [Orthopedics. 2019; 42(1):34-40.].

What Is the Role of Repeat Aspiration in the Diagnosis of Periprosthetic Hip Infection?

BACKGROUND

The American Academy of Orthopedic Surgeons clinical practice guideline currently recommends repeat joint aspiration when workup of periprosthetic joint infection (PJI) reveals conflicting data. This guideline is based on a single study of 31 patients published 25 years ago. We sought to determine the correlation between first and second aspirations and factors that may play a role in variability between them.

METHODS

Sixty patients with less than 90 days between aspirations and no intervening surgery were identified at our institution and classified by Musculoskeletal Infection Society (MSIS) criteria as infected, not infected, or not able to determine after both aspirations. Culture results from both aspirations were recorded. The rates of change and correlation in clinical diagnosis and culture results between aspirations were determined.

RESULTS

Repeat aspiration changed the diagnosis in 26 cases (43.3%, 95% confidence interval 31.6-55.9, kappa coefficient 0.32, P < .001), and the culture results in 25 cases (41.7%, 95% confidence interval 30.1-54.3, kappa coefficient 0.27, P < .01). Among patients initially MSIS negative, the proportion who changed to MSIS positive was greater for those with a history of prior PJI compared to those without (66.7% vs 0%, P < .05), and the first aspiration mean volume was higher for those changed to MSIS positive compared to those that remained MSIS negative (12.0 vs 3.0 mL, P < .01). Among patients initially MSIS positive, the proportion of patients who changed to MSIS negative was greater for those with a history of adverse local tissue reaction (ALTR) to metal debris compared to patients without suspicion of ALTR (100% vs 7.7%, P < .05).

CONCLUSION

Repeat aspiration is particularly useful in patients with conflicting clinical data and prior history of PJI, suspicion of ALTR, or with high clinical suspicion of infection.

Management of periprosthetic infections

Periprosthetic joint infection (PJI) is considered one of the most challenging complications compromising patient health and is considered an economic burden. Despite all strategies PJI prevalence is between 1%-2%. Considerable efforts have been investigated in the past decade to diminish or erradicate PJI prevalence. This article manages the definition of PJI and the new major and minor criteria from Parvizi et al Then a scientific analysis of every minor and major criteria. Multidisciplinary management is reccommended according to guidelines. A numerous of surgical options exist each and everyone with its indications, contraindications and specific antibiotic therapy regimen. Surgical options are: (1) irrigation and cleaning with retention of the prosthesis with a success rate 0%-89%; (2) single-stage revision surgery with a succes rate of > 80%; and (3) two-stage revision surgery (authors preferred method) with a succes rate of 87%. Radical treatment options like arthrodesis and amputation are reserved for specific group of patients, with a succes rate varying from 60%-100%. The future of PJI is focused on improving the diagnostic tools and to combat biofilm. The cornerstone of management consists in a rapid diagnosis and specific therapy. This article presents the most current diagnostic and treatment criteria as well as the different surgical treatment options depending on the type of infection, bacterial virulence and patient comorbidities.

Diagnosis of Periprosthetic Joint Infection Following Hip and Knee Arthroplasty

The diagnosis of periprosthetic joint infection (PJI) following total hip arthroplasty and total knee arthroplasty has been one of the major challenges in orthopedic surgery. As there is no single absolute test for diagnosis of PJI, diagnostic criteria for PJI have been proposed that include using several diagnostic modalities. Focused history, physical examination, plain radiographs, and initial serologic tests should be followed by joint aspiration and synovial analysis. Newer diagnostic techniques, such as alpha-defensin and interleukin-6, hold great promise in the future diagnosis of equivocal infections.

Histopathological characterization of corrosion product associated adverse local tissue reaction in hip implants: a study of 285 cases

Background

Adverse local tissue reaction (ALTR), characterized by a heterogeneous cellular inflammatory infiltrate and the presence of corrosion products in the periprosthetic soft tissues, has been recognized as a mechanism of failure in total hip replacement (THA). Different histological subtypes may have unique needs for longitudinal clinical follow-up and complication rates after revision arthroplasty. The purpose of this study was to describe the histological patterns observed in the periprosthetic tissue of failed THA in three different implant classes due to ALTR and their association with clinical features of implant failure.

Methods

Consecutive patients presenting with ALTR from three major hip implant classes (N = 285 cases) were identified from our prospective Osteolysis Tissue Database and Repository. Clinical characteristics including age, sex, BMI, length of implantation, and serum metal ion levels were recorded. Retrieved synovial tissue morphology was graded using light microscopy. Clinical characteristics and features of synovial tissue analysis were compared between the three implant classes. Histological patterns of ALTR identified from our observations and the literature were used to classify each case. The association between implant class and histological patterns was compared.

Results

Our histological analysis demonstrates that ALTR encompasses three main histological patterns: 1) macrophage predominant, 2) mixed lymphocytic and macrophagic with or without features of associated with hypersensitivity/allergy or response to particle toxicity (eosinophils/mast cells and/or lymphocytic germinal centers), and 3) predominant sarcoid-like granulomas. Implant classification was associated with histological pattern of failure, and the macrophagic predominant pattern was more common in implants with metal-on-metal bearing surfaces (MoM HRA and MoM LHTHA groups). Duration of implantation and composition of periprosthetic cellular infiltrates was significantly different amongst the three implant types examined suggesting that histopathological features of ALTR may explain the variability of clinical implant performance in these cases.

Conclusions

ALTR encompasses a diverse range of histological patterns, which are reflective of both the implant configuration independent of manufacturer and clinical features such as duration of implantation. The macrophagic predominant pattern and its mechanism of implant failure represent an important subgroup of ALTR which could become more prominent with increased length of implantation.

Treatment of Vancouver type B2 periprosthetic femoral fractures

PURPOSE

Stem loosening in both cemented and uncemented total hip arthroplasty is the hallmark of the Vancouver type B2 classification of periprosthetic hip fractures.

METHODS

We discuss the technique we use at our institution for treating these fractures.

RESULTS

Periprosthetic femoral-shaft fractures are associated with a relatively high mortality rate, approximating that of patients with hip fractures. Outcomes are directly associated with early mobilisation and construct stability.

CONCLUSIONS

We recommend performing the procedure only when the surgeon is proficient in revision hip surgery and trauma care. A well-selected portfolio of different stem designs and an array of osteosynthesis devices should be available, as well.