scholarly journals Poor performance of open incisional biopsy for the microbiological diagnosis of periprosthetic knee joint infection

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Jan Schwarze ◽  
Burkhard Moellenbeck ◽  
Georg Gosheger ◽  
Tom Schmidt-Braekling ◽  
Lukas Lampe ◽  
...  
Keyword(s):  
Revision Surgery ◽  
Joint Infection ◽  
Positive Culture ◽  
Poor Performance ◽  
Low Grade ◽  
Microbiological Analysis ◽  
Incisional Biopsy ◽  
Open Biopsy ◽  
Level Of Evidence ◽  
Cutibacterium Acnes

AbstractThe accurate preoperative diagnosis of periprosthetic joint infection (PJI) of total knee arthroplasty (TKA) can be difficult despite the use of a combination of serum and synovial markers. In such inconclusive cases, incisional open biopsy might be considered. This study investigates the usefulness of biopsies in patients with inconclusive diagnostic findings. We retrospectively identified 63 patients who underwent incisional biopsy for chronic PJI in the operation theatre following TKA revision between 2010 and 2018 after inconclusive preoperative diagnostics for PJI. In all cases, 5 independent biopsies were taken. Results from open biopsy for PJI were analyzed for diagnostic accuracy using the intraoperative results from following revision surgery as gold standard. 27 patients (43%) had a positive culture taken during biopsy. 15 cases (24%) met the diagnostic criteria for a chronic PJI. Most common organisms were Coagulase-negative staphylococci (67%) and Cutibacterium acnes (30%). Compared to the findings during revision surgery, biopsies showed a sensitivity of 47% and a specificity of 77% for PJI. Open incisional biopsy following inconclusive serum- and synovial diagnostics for low grade PJI may be considered for identification of microorganisms. Due to its low sensitivity and moderate specificity found in the present cohort, microbiological analysis should be combined with additional diagnostic markers and histological investigation.Level of Evidence. Retrospective cohort study (Level III).

scholarly journals The role of serum C-reactive protein in the diagnosis of periprosthetic shoulder infection

2021 ◽  
Author(s):  
Doruk Akgün ◽  
Mats Wiethölter ◽  
Paul Siegert ◽  
Victor Danzinger ◽  
Marvin Minkus ◽  
...  
Keyword(s):  
Sensitivity And Specificity ◽  
Joint Infection ◽  
Receiver Operating Curve ◽  
C Reactive Protein ◽  
Level Of Evidence ◽  
Reactive Protein ◽  
Median Serum ◽  
Cutibacterium Acnes ◽  
Serum Crp ◽  
Receiver Operating

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.

Guided and Unguided Biopsy in the Diagnostic of Periprosthetic Infections of the Knee – Evaluation of an Evidence-based Algorithm

2019 ◽  
Vol 157 (06) ◽  
pp. 684-694
Author(s):  
Christian Scheele ◽  
Isabelle Krauel ◽  
Florian Pohlig ◽  
Heinrich Muehlhofer ◽  
Ludger Gerdesmeyer ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Revision Surgery ◽  
Joint Infection ◽  
Clinical Suspicion ◽  
Synovial Biopsy ◽  
Histological Evaluation ◽  
Low Grade ◽  
Multiple Biopsies ◽  
Histologic Evaluation ◽  
Made In

Abstract Background Periprosthetic joint infection (PPI) is one of the most common reasons for revision in total knee arthroplasty (TKA). Percutaneous synovial biopsy is considered as a well-established diagnostic tool in ambiguous cases of chronic pain after TKA. The exact number of undetected low-grade infections remains unclear. Objectives The aim of this prospective study was to compare the diagnostic accuracy of arthroscopically guided and unguided synovial biopsy. Additionally, the prevalence of initially undetected PPI during synovial biopsy and revision surgery was assessed. Materials and Methods 40 patients suffering from chronic pain after TKA and the clinical suspicion of PPI were included in the study. Synovial biopsies were collected in a standardized manner first without and then with arthroscopic visual control. Using both techniques, six samples were collected each (5 for microbiology, 1 for histology). 19 patients, initially classified aseptic, underwent revision surgery later. Results The diagnosis of PPI was made in 10.0% of unguided biopsies (4 cases, 2× microbiologically, 2× histologically), 7.5% of arthroscopic biopsies (3 cases, 3× histologically) and 12.5% (5 cases, 3× histologically, 2× microbiologically) of all cases. Only histologic evaluation led to concordant positive findings using both techniques in two patients. The proportion of non-representative biopsies was twice as high after unguided tissue collection than after arthroscopic biopsy (30.0 vs. 15.0%). Microbiologic evaluation of arthroscopically collected biopsies did not lead to the diagnosis of PPI, which might have been essential to the selection of the appropriate antimicrobial therapy. During revision surgery the diagnosis of PPI was made in 22.2% of cases. Conclusions In patients suffering from chronic pain after TKA, periprosthetic low-grade infection was diagnosed in a relevant proportion of cases. Therefore, synovial biopsies for histological and microbiological evaluation should be collected whenever thereʼs clinical suspicion of PPI. For histological evaluation, samples should be collected using arthroscopic control and ideally multiple biopsies should be taken. For microbiological evaluation, excessive joint lavage should be avoided.

scholarly journals Nuclear imaging does not have clear added value in patients with low a priori chance of periprosthetic joint infection. A retrospective single-center experience

2022 ◽  
Vol 7 (1) ◽  
pp. 1-9
Author(s):  
Karsten D. Ottink ◽  
Stefan J. Gelderman ◽  
Marjan Wouthuyzen-Bakker ◽  
Joris J. W. Ploegmakers ◽  
Andor W. J. M. Glaudemans ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Revision Surgery ◽  
Periprosthetic Joint Infection ◽  
Joint Infection ◽  
A Priori ◽  
Nuclear Imaging ◽  
Added Value ◽  
Low Grade ◽  
Predictive Values ◽  
Sensitivity Specificity

Abstract. Background: A low-grade periprosthetic joint infection (PJI) may present without specific symptoms, and its diagnosis remains a challenge. Three-phase bone scintigraphy (TPBS) and white blood cell (WBC) scintigraphy are incorporated into recently introduced diagnostic criteria for PJI, but their exact value in diagnosing low-grade PJI in patients with nonspecific symptoms remains unclear. Methods: In this retrospective study, we evaluated patients with a prosthetic joint of the hip or knee who underwent TPBS and/or WBC scintigraphy between 2009 and 2016 because of nonspecific symptoms. We reviewed and calculated diagnostic accuracy of the TPBS and/or WBC scintigraphy to diagnose or exclude PJI. PJI was defined based on multiple cultures obtained during revision surgery. In patients who did not undergo revision surgery, PJI was ruled out by clinical follow-up of at least 2 years absent of clinical signs of infection based on MSIS 2011 criteria. Results: A total of 373 patients were evaluated, including 340 TPBSs and 142 WBC scintigraphies. Thirteen patients (3.5 %) were diagnosed with a PJI. TPBS sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were 71 %, 65 %, 8 % and 98 %, respectively. Thirty-five percent of TPBS showed increased uptake. Stratification for time intervals between the index arthroplasty and the onset of symptoms did not alter its diagnostic accuracy. WBC scintigraphy sensitivity, specificity, PPV and NPV were 30 %, 90 %, 25 % and 94 %, respectively. Conclusion: Nuclear imaging does not have clear added value in patients with low a priori chance of periprosthetic joint infection.

scholarly journals The W.A.I.O.T. Definition of High-Grade and Low-Grade Peri-Prosthetic Joint Infection

2019 ◽  
Vol 8 (5) ◽  
pp. 650 ◽  
Author(s):  
Carlo Luca Romanò ◽  
Hazem Al Khawashki ◽  
Thami Benzakour ◽  
Svetlana Bozhkova ◽  
Hernán del Sel ◽  
...  
Keyword(s):  
Prosthetic Joint Infection ◽  
Clinical Presentation ◽  
Joint Infection ◽  
Low Grade ◽  
Microbiological Analysis ◽  
High Grade ◽  
Prosthetic Joint ◽  
Definition Of ◽  
Operative Findings ◽  
Rule Out

The definition of peri-prosthetic joint infection (PJI) has a strong impact on the diagnostic pathway and on treatment decisions. In the last decade, at least five different definitions of peri-prosthetic joint infection (PJI) have been proposed, each one with intrinsic limitations. In order to move a step forward, the World Association against Infection in Orthopedics and Trauma (W.A.I.O.T.) has studied a possible alternative solution, based on three parameters: 1. the relative ability of each diagnostic test or procedure to Rule OUT and/or to Rule IN a PJI; 2. the clinical presentation; 3. the distinction between pre/intra-operative findings and post-operative confirmation. According to the WAIOT definition, any positive Rule IN test (a test with a specificity > 90%) scores +1, while a negative Rule OUT test (a test with a sensitivity > 90%) scores −1. When a minimum of two Rule IN and two Rule OUT tests are performed in a given patient, the balance between positive and negative tests, interpreted in the light of the clinical presentation and of the post-operative findings, allows to identify five different conditions: High-Grade PJI (score ≥ 1), Low-Grade PJI (≥0), Biofilm-related implant malfunction, Contamination and No infection (all scoring < 0). The proposed definition leaves the physician free to choose among different tests with similar sensitivity or specificity, on the basis of medical, logistical and economic considerations, while novel tests or diagnostic procedures can be implemented in the definition at any time, provided that they meet the required sensitivity and/or specificity thresholds. Key procedures to confirm or to exclude the diagnosis of PJI remain post-operative histological and microbiological analysis; in this regard, given the biofilm-related nature of PJI, microbiological investigations should be conducted with proper sampling, closed transport systems, antibiofilm processing of tissue samples and explanted biomaterials, and prolonged cultures. The proposed WAIOT definition is the result of an international, multidisciplinary effort. Next step will be a large scale, multicenter clinical validation trial.

scholarly journals A spacer infection by Candida albicans secondary to a Staphylococcus capitis prosthetic joint infection: a case report

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Marta Bottagisio ◽  
Alessandro Bidossi ◽  
Nicola Logoluso ◽  
Antonio Pellegrini ◽  
Elena De Vecchi
Keyword(s):  
Candida Albicans ◽  
Synovial Fluid ◽  
Prosthetic Joint Infection ◽  
Revision Surgery ◽  
Hip Prosthesis ◽  
Joint Infection ◽  
Microbiological Analysis ◽  
Two Stage ◽  
Staphylococcus Capitis ◽  
Prosthetic Joint

Abstract Background Prosthetic joint infection (PJI) is one of the most feared complications following total arthroplasty surgeries. Gram-positive bacteria are the most common microorganisms implicated in PJIs, while infections mediated by fungi only account for 1% of cases. When dealing with PJIs, a two-stage revision arthroplasty is widely used. Briefly, a spacer is introduced until re-implantation of the definitive prosthesis to provide skeleton stabilization while delivering antibiotics in the site of the infection. Sometimes, antimicrobial therapy may fail, but the isolation of a second microorganism from the spacer is uncommon and even less frequent that of a yeast. Case presentation Here is described a case of a 75-year-old woman who underwent two-stage revision surgery of the left hip prosthesis secondary to a Staphylococcus capitis infection, whose spacer was found to be infected by Candida albicans at a later time. Briefly, the patient underwent revision surgery of the hip prosthesis for a suspected PJI. After the debridement of the infected tissue, an antibiotic-loaded spacer was implanted. The microbiological analysis of the periprosthetic tissues and the implant depicted a S. capitis infection that was treated according to the antimicrobial susceptibility profile of the clinical isolate. Three months later, the patient was admitted to the emergency room due to local inflammatory signs. Synovial fluid was sent to the laboratory for culture. No evidence of S. capitis was detected, however, a yeast was identified as Candida albicans. Fifteen days later, the patient was hospitalized for the removal of the infected spacer. Microbiological cultures confirmed the results of the synovial fluid analysis. According to the susceptibility profile, the patient was treated with fluconazole (400 mg/day) for 6 months. Seven months later, the patient underwent second-stage surgery. The microbiological tests on the spacer were all negative. After 12 months of follow-up, the patient has fully recovered and no radiological signs of infection have been detected. Conclusions Given the exceptionality of this complication, it is important to report these events to better understand the clinical outcomes after the selected therapeutic options to prevent and forestall the development of either bacterial or fungal spacer infections.

Unexpected positive cultures in presumed aseptic revision spine surgery using sonication

2019 ◽  
Vol 101-B (5) ◽  
pp. 621-624 ◽  
Author(s):  
M. Pumberger ◽  
J. Bürger ◽  
P. Strube ◽  
D. Akgün ◽  
M. Putzier
Keyword(s):  
Spine Surgery ◽  
Revision Surgery ◽  
Clinical Signs ◽  
Positive Culture ◽  
Adjacent Segment ◽  
Study Cohort ◽  
Hardware Failure ◽  
Cutibacterium Acnes ◽  
Aseptic Revision ◽  
The Mean

Aims During revision procedures for aseptic reasons, there remains a suspicion that failure may have been the result of an undetected subclinical infection. However, there is little evidence available in the literature about unexpected positive results in presumed aseptic revision spine surgery. The aims of our study were to estimate the prevalence of unexpected positive culture using sonication and to evaluate clinical characteristics of these patients. Patients and Methods All patients who underwent a revision surgery after instrumented spinal surgery at our institution between July 2014 and August 2016 with spinal implants submitted for sonication were retrospectively analyzed. Only revisions presumed as aseptic are included in the study. During the study period, 204 spinal revisions were performed for diagnoses other than infection. In 38 cases, sonication cultures were not obtained, leaving a study cohort of 166 cases. The mean age of the cohort was 61.5 years (sd 20.4) and there were 104 female patients Results Sonication cultures were positive in 75 cases (45.2%). Hardware failure was the most common indication for revision surgery and revealed a positive sonication culture in 26/75 cases (35%) followed by adjacent segment disease (ASD) in 23/75 cases (30%). Cutibacterium acnes and Staphylococcus epidermidis were the most commonly isolated microorganisms, observed in 45% and 31% of cases, respectively. C. acnes was isolated in 65.2% of cases when the indication for revision surgery was ASD. Conclusion Infection must always be considered as a possibility in the setting of spinal revision surgery, especially in the case of hardware failure, regardless of the lack of clinical signs. Sonication should be routinely used to isolate microorganisms adherent to implants. Cite this article: Bone Joint J 2019;101-B:621–624.

Is There a Role for Measuring Synovial Biomarkers for Diagnosis of Infected Total Ankle Arthroplasty (TAA)?

2019 ◽  
Vol 40 (1_suppl) ◽  
pp. 27S-29S
Author(s):  
Khaled Emara ◽  
John M. Embil
Keyword(s):  
Knee Arthroplasty ◽  
Periprosthetic Joint Infection ◽  
Joint Infection ◽  
Positive Culture ◽  
Total Ankle Arthroplasty ◽  
Level Of Evidence ◽  
Ankle Arthroplasty ◽  
Biomarker Analysis ◽  
Hip And Knee Arthroplasty ◽  
Strong Consensus

Recommendation: Based on the hip and knee arthroplasty literature, measuring synovial biomarkers may play a role in the diagnosis of infected total ankle arthroplasty (TAA). The diagnosis of periprosthetic joint infection (PJI) in the setting of a TAA can be confirmed with cultures, provided that a plausible pathogen is recovered in the context of a compatible clinical picture. In the absence of a positive culture, synovial biomarker analysis may help in establishing the diagnosis. Level of Evidence: Moderate. Delegate Vote: Agree: 92%, Disagree: 8%, Abstain: 0% (Super Majority, Strong Consensus)

scholarly journals The W.A.I.O.T. Definition of Peri-Prosthetic Joint Infection: A Multi-center, Retrospective Validation Study

2020 ◽  
Vol 9 (6) ◽  
pp. 1965 ◽  
Author(s):  
Svetlana Bozhkova ◽  
Virginia Suardi ◽  
Hemant K Sharma ◽  
Hiroyuki Tsuchiya ◽  
Hernán del Sel ◽  
...  
Keyword(s):  
Prosthetic Joint Infection ◽  
Revision Surgery ◽  
Joint Infection ◽  
Average Score ◽  
Low Grade ◽  
Prosthetic Joint ◽  
Therapeutic Decisions ◽  
Confirmatory Tests ◽  
Operative Findings ◽  
Rule Out

Peri-prosthetic joint infection (PJI) definition plays an important role in diagnostic and therapeutic decisions. However, while several criteria have been proposed by eminent institutions to define a PJI in the last decade, their clinical validation has been rarely performed. Aim of the present multicenter, international, retrospective study was to validate the World Association against Infection in Orthopedics and Trauma (WAIOT) pre/intra-operative PJI definition with post-operative confirmatory tests. A total of 210 patients, undergoing hip (n = 86) or knee (n = 124) revision surgery for any reason in six orthopedic centers in Africa, Asia, Europe and South America, were retrospectively evaluated at a two years minimum follow-up after surgery. All the available pre-, intra- and post-operative findings were collected and analyzed according to the WAIOT criteria, which include a set of tests to confirm (Rule In) or to exclude (Rule Out) a PJI. On average, patients were investigated pre/intra-operatively with 3.1 ± 1.1 rule out and 2.7 ± 0.9 rule in tests; the presence of a fistula or exposed implant was reported in 37 patients (17.6%). According to pre/intraoperative findings, 36.2% of the patients were defined as affected by high-grade PJI (n = 76; average score: 2.3 ± 0.8), 21.9% by low-grade PJI (n = 46; average score: 0.8 ± 0.8), 10.5% by biofilm-related implant malfunction (n = 22; average score: –1.6 ± 0.8), 2.9% as contamination (n = 6; average score: –3.5 ± 1.0), and 28.6% as no infection (n = 60; average score: –3.0 ± 1.4). Pre/intra-operative PJI definitions matched post-operative confirmatory tests, in 97.1% of the patients. This is, to our knowledge, one of the largest study ever conducted to validate a PJI definition The retrospective analysis in different centers was greatly facilitated by the structure of the WAIOT definition, that allows to include different tests on the basis of their sensitivity/specificity, while the comparison between pre/intra-operative and post-operative findings offered the internal validation of the scoring system. Our results authenticate the WAIOT definition as a reliable, simple tool to identify patients affected by PJI prior to joint revision surgery.

scholarly journals The significance of synovial biopsy in the diagnostic workup of the low-grade periprosthetic joint infection of shoulder arthroplasty

2021 ◽  
Author(s):  
Moritz Mederake ◽  
Ulf Krister Hofmann ◽  
Bernd Fink
Keyword(s):  
Revision Surgery ◽  
Periprosthetic Joint Infection ◽  
Shoulder Arthroplasty ◽  
Joint Infection ◽  
Diagnostic Value ◽  
Synovial Biopsy ◽  
Diagnostic Workup ◽  
Low Grade ◽  
Diagnostic Challenge ◽  
Shoulder Arthroplasties

Abstract Introduction A common reason for painful shoulder arthroplasties and revision surgery is a low-grade periprosthetic joint infection (PJI). Diagnosing a low-grade infection is, however, a major diagnostic challenge. This applies even more to the shoulder, which differs from other large joints in terms of clinical features and microbiological spectrum. Aim of this study was to evaluate the diagnostic value of the synovial biopsy in the diagnostic workup of low-grade PJI of the shoulder. Materials and methods A retrospective evaluation was conducted on 56 patients receiving revision surgery on their shoulder arthroplasty. A standardized preoperative workup was performed comprising CRP value, leukocyte blood count, synovial fluid microbiological analyses and leukocyte count from joint aspiration, and five synovial biopsy samples for bacteriologic and histologic analysis obtained through an arthroscopic approach. During revision surgery, five samples of periprosthetic tissue were harvested for bacteriologic and histologic analyses. The MSIS-Criteria 2014 were used to evaluate the diagnostic results. Results In total, 15 of 56 revised prostheses turned out as PJI (27%). When applying our diagnostic workup, we obtained a sensitivity of 67% with a specificity of 95%. When performing a subgroup analysis on those patients that had received diagnostic biopsy, a sensitivity of 100% and a specificity of 83% could be achieved. With a sensitivity and specificity of 90% and 83%, respectively, the biopsy is the single method with the highest diagnostic value. Conclusions The sensitivity of only 67% of our standard workup emphasizes the difficulty to adequately diagnose low-grade infections after shoulder arthroplasty. The excellent specificity of 95% ensures, however, that non-infected prostheses are not incorrectly explanted. This study highlights that synovial biopsy has a high diagnostic value and should be done prior to complex revision surgeries to raise sensitivity in diagnosing a PJI.

Does Intra-articular Injection of the Ankle With Corticosteroids Increase the Risk of Subsequent Periprosthetic Joint Infection (PJI) Following Total Ankle Arthroplasty (TAA)? If So, How Long After a Prior Intra-articular Injection Can TAA Be Safely Performed?

2019 ◽  
Vol 40 (1_suppl) ◽  
pp. 3S-4S
Author(s):  
Ilker Uçkay ◽  
Christopher B. Hirose ◽  
Mathieu Assal
Keyword(s):  
Periprosthetic Joint Infection ◽  
Corticosteroid Injection ◽  
Joint Infection ◽  
Invasive Procedure ◽  
Total Ankle Arthroplasty ◽  
Level Of Evidence ◽  
Ankle Arthroplasty ◽  
Strong Consensus ◽  
Healthcare Associated ◽  
The Ideal

Recommendation: Every intra-articular injection of the ankle is an invasive procedure associated with potential healthcare-associated infections, including periprosthetic joint infection (PJI) following total ankle arthroplasty (TAA). Based on the limited current literature, the ideal timing for elective TAA after corticosteroid injection for the symptomatic native ankle joint is unknown. The consensus workgroup recommends that at least 3 months pass after corticosteroid injection and prior to performing TAA. Level of Evidence: Limited. Delegate Vote: Agree: 92%, Disagree: 8%, Abstain: 0% (Super Majority, Strong Consensus)

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