Are patients being evaluated for periprosthetic joint infection prior to referral to a tertiary care center?

Abstract

BackgroundPatients with a painful or failed total joint arthroplasties should be evaluated for periprosthetic joint infection (PJI). The purpose of this study is to determine if patients referred to a tertiary care center had been evaluated for PJI according to the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines.MethodsOne hundred thirteen patients with painful hip (43) or knee (70) arthroplasties were referred to a single provider by orthopaedic surgeons outside our practice between 2012 and 2014. We retrospectively evaluated the workup by referring physicians, including measurement of serum erythrocyte sedimentation rate and C-reactive protein, performance of a joint aspiration if these values were abnormal, and obtainment of synovial fluid white blood cell count, differential, and cultures.ResultsSixty-two of 113 patients (55%) did not have a workup that followed AAOS guidelines. Serum erythrocyte sedimentation rate and C-reactive protein were ordered for 64 of the 113 patients (57%). Of 25 patients with elevated inflammatory markers warranting aspiration, 15 (60%) had an aspiration attempted, with synovial fluid white blood cell, differential, and cultures obtained in 9 of 12 (75%) aspirations that yielded fluid. Of the 62 patients with an incomplete infection workup, 11 (18%) had a bone scan, 6 (10%) a computed tomography scan, and 3 (5%) a magnetic resonance imaging. Twelve of the 113 patients (11%) were ultimately diagnosed with PJI, with 5 undiagnosed prior to referral.ConclusionsThe AAOS guidelines to evaluate for PJI are frequently not being followed. Improving awareness of these guidelines may avoid unnecessary and costly evaluations and delay in the diagnosis of PJI.

Has the time come for regional periprosthetic joint infection centers in the United States? A first-year experience

“…Fewer than half of patients referred to our outpatient clinic (42.9 %) had what was deemed a minimum complete workup of erythrocyte sedimentation rate, C-reactive protein, and joint aspiration with cell count and culture. This is remarkably similar to the deficit that was reported by Tetreault et al (2017). Education for referring physicians about their responsibilities prior to sending their patients remains a challenge and is a priority for our center.…”

“…This is despite a similarly complex treatment algorithm, necessitating close, multidisciplinary collaboration, and a heavy, increasing burden of disease, projected to reach USD 1.85 billion by the year 2030 (Premkumar et al, 2021). As well established in sarcoma care, PJI surgical treatment initiated prior to referral to a tertiary center leads to worse 2-year infection-free survival (Tetreault et al, 2017). A PJI referral center could improve the success rate of PJI treatment by concentrating resources and expertise, and limiting the current care fragmentation.…”

Who Should Manage Periprosthetic Joint Infection? The Case for a Multidisciplinary Approach

“…While the number of required revisions to define "highvolume" is currently unknown, ICM has set the recommendation for case volume to be a minimum of 25 based off this knowledge [17]. In addition to surgical technique, surgeons must be familiar with diagnostic and treatment algorithms that have been empirically proven on an international level to improve outcomes after PJI [3,4].…”

“…Ideally, PJI cases should be treated by subspecialized surgeons who have experience treating a high volume of cases. Hospitals that aren't able to accommodate such patients should refer to centers that can, except in the unstable patient [3,12,19]. If this is not feasible, patients should be risk stratified, and transfer of the most complex cases to centers with experience in treating such cases is recommended.…”

“…Tetreault et al evaluated the consistency of current methods for evaluating PJI according to American Academy of Orthopaedic Surgeons (AAOS) guidelines and noted an alarming gap between expectation and reality, even amongst orthopedic-trained surgeons. The study concluded that there is still significant underdiagnosis of PJI, leading to unnecessary order of advanced diagnostic imaging, adding to medical costs and a delay in treatment [3,4].…”