Are Frozen Sections and MSIS Criteria Reliable at the Time of Reimplantation of Two-stage Revision Arthroplasty?

Abstract

Background Frozen section histology is widely used to aid in the diagnosis of periprosthetic joint infection at the second stage of revision arthroplasty, although there are limited data regarding its utility. Moreover, there is no definitive method to assess control of infection at the time of reimplantation. Because failure of a two-stage revision can have serious consequences, it is important to identify the cases that might fail and defer reimplantation if necessary. Thus, a reliable test providing information about the control of infection and risk of subsequent failure is necessary.Questions/purposes (1) At second-stage reimplantation surgery, what is the diagnostic accuracy of frozen sections as compared with the Musculoskeletal Infection Society (MSIS) as the gold standard? (2) What are the diagnostic accuracy parameters for the MSIS criteria and frozen sections in predicting failure of reimplantation? (3) Do positive MSIS criteria or frozen section at the time of reimplantation increase the risk of subsequent failure? Methods A total of 97 patients undergoing the second stage of revision total hip arthroplasty or total knee arthroplasty in 2013 for a diagnosis of periprosthetic joint infection (PJI) were considered eligible for the study. Of these, 11 had incomplete MSIS criteria and seven lacked 1-year followup, leaving 79 patients (38 knees and 41 hips) available for analysis. At the time of reimplantation, frozen section results were compared with modified MSIS criteria as the gold standard in detecting infection. Subsequently, success or failure of reimplantation was defined by (1) control of infection, as characterized by a healed wound without fistula, drainage, or pain; (2) no subsequent surgical intervention for infection after reimplantation surgery; and (3) no occurrence of PJI-related mortality; and diagnostic parameters in predicting treatment failure were calculated for both the modified MSIS criteria and frozen sections.One author (WB) has received research support in the amount of USD 100,001 to USD 1,000,000 from grants from Stryker (Kalamazoo, Conclusions On the basis of our results, both frozen section and MSIS are recommended at the time of the second stage of revision arthroplasty. Both frozen section and modified MSIS criteria had limited screening capabilities to identify failure, although both demonstrated high specificity. MSIS criteria should be evaluated at the second stage of revision arthroplasty because performing reimplantation in a joint that is positive for infection significantly increases the risk for subsequent failure. Level of Evidence Level III, diagnostic study.MI123 Clin Orthop Relat Res (2016) 474:1619-1626 DOI 10.1007/s11999-015-4673-3 Clinical Orthopaedics and Related Research ® A Publication of The Association of Bone and Joint Surgeons® Results At the time of second-stage reimplantation sur

What is the Diagnostic Accuracy of Aspirations Performed on Hips With Antibiotic Cement Spacers?

“…If we also considered patients who had a failure as cases with persistent infection when followed long-term, the diagnostic parameters in this study might have been different and the failure rates may have been higher. Because positive cultures and positive MSIS criteria at the time of the second-stage reimplantation have been reported to increase the risk of subsequent failure, the criteria we used can be considered to be a reliable indicator of persistent infection [10,29]. Moreover, changing the diagnostic criteria to include long-term followup is unlikely to change the conclusions of our study that a lower threshold for synovial fluid parameters should be considered in hips with antibiotic cement spacers, as the same diagnostic criteria was used when comparing the MSIS thresholds with the new thresholds Saline lavage may produce a dilutional effect on synovial fluid samples.…”

Inadequacy of Joint Aspiration for Detection of Persistent Periprosthetic Infection During Two-Stage Septic Revision Knee Surgery

“…23 Evidence for the use of frozen tissue sections to exclude periprosthetic joint infection before TKA reimplantation is even worse, with reported sensitivity of 25% to 33%. 24,25 In light of the study findings, the authors no longer perform synovial spacer aspiration before second-stage surgery. After temporary arthrodesis and continuous antibiotic therapy are maintained for a minimum of 6 weeks, TKA reimplantation is performed if serum infection findings (C-reactive protein level and erythrocyte sedimentation rate) are normal and if the knee does not show clinical signs of persistent infection (effusion, calor, and rubor).…”

Histological Findings in Infected and Noninfected Second Stage Revision Knee Arthroplasties

“…Most of these studies examined the utility of using frozen section histology to diagnose PJI in this clinical context. George et al 27 examined the results of frozen section histology in 38 revision total knee replacements and 41 revision total hip replacements and concluded that MSIS criteria have high specificity but low sensitivity for the diagnosis of infection. Della Valle et al 28 also examined frozen section histology in hip and knee revisions and concluded that a negative finding on intraoperative analysis of frozen sections had a high predictive value with regard to ruling out the presence of infection, although detection of persistent infection was poor.…”