Adherence to a reliable PJI diagnostic protocol minimizes unsuspected positive cultures rate

Pérez-Prieto, Daniel; Hinarejos, Pedro; Alier, Albert; Sorlí, Lluïsa; Martínez, Santos; Puig, Lluís; Monllau, Juan Carlos

doi:10.1186/s12891-021-04431-1

Cited by 9 publications

(7 citation statements)

References 40 publications

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“…Another fact that may explain the result of the present study is that some literature may misdiagnose LAH PJI [9, 14]. To distinguish between LAH PJI and acute on chronic PJI, it may be difficult as the latter usually presents with mild to moderate pain for a long period of months or years (with no other symptom).…”

Section: Discussionmentioning

confidence: 76%

Incidence, functional outcomes and cure rate of hematogenous infection in a 2,498 Total Knee Arthroplasties cohort

Pérez‐Prieto,

Pardo,

Fontanellas

et al. 2023

J. exp. orthop.

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Purpose The primary aim of the present study is to report the late acute hematogenous (LAH) prosthetic joint infection (PJI) cure rate following Total knee arthroplasty (TKA) treated by means of debridement, antibiotics, and implant retention (DAIR) in a long-term follow-up. The secondary purpose is to report the functional outcomes at that follow-up and to compare them with a non-infected group. Material and Methods This study cohort consists of 2,498 TKA performed from September 2005 to April 2010 that had a minimum follow-up of 10 years. The diagnosis of PJI and classification into LAH was done in accordance with the Zimmerli criteria. The primary outcome was the failure rate, defined as death before the end of antibiotic treatment, a further surgical intervention for treatment of infection, life-long antibiotic suppressive treatment or chronic infection. The Knee Society Score (KSS) was used to evaluate clinical outcomes. Results Ten patients were diagnosed with acute hematogenous PJI during the study period (0.4%). All of them were managed with DAIR, which was performed by a knee surgeon and/or PJI surgeon. The failure rate was 0% at the 8.5-year (SD, 2.4) follow-up mark. The KSS score was 82.1 vs. 84.1 (p n.s.) at final follow-up. Conclusion Although the literature suggests that TKA DAIR for LAH periprosthetic joint infection is associated with high rates of failure, the results presented here suggest a high cure rate with good functional outcomes. Level of evidence Level II, prospective cohort study.

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Section: Discussionmentioning

confidence: 76%

Incidence, functional outcomes and cure rate of hematogenous infection in a 2,498 Total Knee Arthroplasties cohort

Pérez‐Prieto,

Pardo,

Fontanellas

et al. 2023

J. exp. orthop.

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“…study design with intrinsic biases, differences in preoperative work‐up, number of cultures harvested, contamination rates in the operation theatre or the laboratory, and interpretation of findings. A recent article stated that a thorough and systematically performed preoperative workup reduces the risk of unexpected positive cultures and leads to less diagnostic uncertainty [40].…”

Section: Discussionmentioning

confidence: 99%

Prevalence, interpretation, and management of unexpected positive cultures in revision TKA: a systematic review

Kloos

Linden

Vermote

et al. 2022

Knee Surg Sports Traumatol Arthrosc

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PurposeUnexpected positive intraoperative cultures (UPIC) found in revision total knee arthroplasty (TKA) are difficult to interpret. Management goes along with risks for both over‐ and undertreating a potential periprosthetic joint infection (PJI). The objective of this systematic review was to determine the prevalence of UPIC in revision TKA surgery, evaluate the diagnostic workup process and the postoperative treatment, and assess outcome regarding re‐revision rates. MethodsEvidence was gathered from Medline (PubMed) and Embase published from January 2000 until April 2021. Nine studies with data of UPIC in revision TKA and outcome after at least 2 years of follow‐up were identified. ResultsThe calculated prevalence of UPIC in aseptic knee revision surgery was 8.32%. However, the diagnostical approach differs as well as the used criteria to confirm PJI in presumed aseptic revision surgery. The work‐up generally consists of a serum C‐reactive protein and Erythrocyte Sedimentation Rate, joint fluid aspiration for culture and white blood cell count and formula, and radiographic imaging. Collection of intraoperative cultures is widely used, but inconsistent in sample amount and incubation time. Once a single UPIC is found, surgeons tend to treat it in different ways. Regarding re‐revision rates, the weighted arithmetic mean in the included studies was 18.45% in the unsuspected PJI group compared to 2.94% in the aseptic group. There also seems to be a trend towards higher re‐revision rates when a higher number of intraoperative cultures are positive. ConclusionThe interpretation of UPIC in revision TKA is of utmost importance since the decision whether to treat a UPIC as an unsuspected PJI has a major impact on implant survival and re‐revision rate. Different criteria are used to differentiate between unsuspected PJI and contamination in true aseptic failure, and the heterogeneity amongst the included papers impedes to state a clear recommendation, integrating not only quantitative findings, but also qualitative data such as virulence of the identified microorganism. Level of evidenceSystematic review, III.

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“…Cierny et al conducted a similar study to determine the need for medical/surgical treatment by performing preoperative staging of osteomyelitis [ 24 ]. Many similar studies also show that it is very difficult and important to predict the risk of infection before surgery [ 25 – 27 ]. However, by analyzing various influencing factors, this study substantially improves the prediction accuracy.…”

Section: Discussionmentioning

confidence: 99%

Retrospective Study from a Single Center to Identify Risk Factors Associated with Reinfection in Patients Undergoing 2-Stage Revision Surgery for Periprosthetic Joint Infection

Zhang

Liu

et al. 2022

Med Sci Monit

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Background This study identified risk factors associated with reinfection and created a scoring system designed for patients with periprosthetic joint infection (PJI) who have undergone prosthetic resection and spacer implantation. Material/Methods Patients who underwent 2-stage revision for PJI from January 2010 to December 2017 were retrospectively analyzed in this study. Patients were divided into 2 groups: infection recurrence and infection cure. Demographic and clinical information, laboratory test results, and radiological images that were potentially associated with infection were obtained and analyzed. Results Seven independent risk (protective) factors for infection recurrence in patients with PJI who underwent 2-stage hip revision surgery were identified: C-reactive protein level, type of bacterial infection, age, immunosuppression, albumin/globulin ratio, glucose level, and magnetic resonance imaging findings. Finally, a weighted scoring system of 100-mark system was established and the area under the curve was 0.965 (95% confidential interval=0.947–0.983). The predictive scores for low risk (≤30%), moderate risk (31–69%), and high risk (≥70%) of infection recurrence were ≤45, 46–77, and ≥78, respectively. Conclusions For patients with PJI who had already undergone joint resection and spacer implantation, this newly established scoring system might help determine the accurate risk of infection recurrence after a definitive new prosthesis implantation. Patients with scores greater than 78 points would be considered very likely to have an infection recurrence. Therefore, the second-stage revision surgery should be changed to an additional anti-infection treatment or a debridement surgery instead of a definitive prosthesis implantation surgery.

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Adherence to a reliable PJI diagnostic protocol minimizes unsuspected positive cultures rate

Cited by 9 publications

References 40 publications

Incidence, functional outcomes and cure rate of hematogenous infection in a 2,498 Total Knee Arthroplasties cohort

Incidence, functional outcomes and cure rate of hematogenous infection in a 2,498 Total Knee Arthroplasties cohort

Prevalence, interpretation, and management of unexpected positive cultures in revision TKA: a systematic review

Retrospective Study from a Single Center to Identify Risk Factors Associated with Reinfection in Patients Undergoing 2-Stage Revision Surgery for Periprosthetic Joint Infection

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