Diagnosis of Periprosthetic Joint Infections of the Hip and Knee

Valle, Craig Delia; Parvızı, Javad; Bauer, Thomas W.; DiCesare, Paul; Evans, Richard P.; Segreti, John; Spangehl, Mark J.; Walters, William C.; Keith, Michael W.; Turkelson, Charles M.; Wies, Janet L.; Sluka, Patrick; Hitchcock, Kristin

doi:10.5435/00124635-201012000-00006

Cited by 259 publications

(163 citation statements)

References 74 publications

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“…Although evidence-based recommendations for standardizing the diagnosis exist [9,23,27], there is no gold standard for diagnosis [2,24,36]. Efforts are ongoing to elucidate novel methods for detecting PJI, such as sonication of implants [32], molecular techniques [1,4,19,20], and analysis of circulating cytokines [5,12,29].…”

Section: Introductionmentioning

confidence: 99%

Is Synovial C-reactive Protein a Useful Marker for Periprosthetic Joint Infection?

Tetreault

Wetters

Moric

et al. 2014

Clin Orthop Relat Res

100

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Background Serum C-reactive protein (CRP) is a general marker of inflammation, and recent studies suggest that measurement of CRP in synovial fluid may be a more accurate method for diagnosing periprosthetic joint infection (PJI). Questions/purposes We aimed to (1) determine if there is a correlation between serum and synovial CRP values, (2) establish cutoff values for diagnosing infection based on serum and synovial CRP, and (3) compare the utility of measuring CRP in synovial fluid versus serum for the diagnosis of PJI using standard assay equipment available at most hospitals. Methods Between February 2011 and March 2012, we invited all 150 patients scheduled for revision TKA (84) or THA (66) to participate in this prospective study, of whom 100% agreed. Data ultimately were missing for 31 patients, leaving 60 patients undergoing revision TKA and 59 undergoing revision THA (71% and 89% of the original group, respectively) for whom CRP level was measured in serum and synovial fluid samples. Patients were deemed to have a PJI (32) or no infection (87) using Musculoskeletal Infection Society criteria. Serum and synovial CRP levels were assayed using the same immunospectrophotometer and the correlation coefficient was calculated. Receiver operating characteristic curve analyses were performed to compare utility in diagnosing PJI, which included area under the curve, diagnostic threshold, and test sensitivity, specificity, predictive values, and accuracy. In 22 of 150 patients (14.7%), synovial CRP could not be measured because the sample was too viscous or hemolyzed. Results In the analyzed 119 samples, there was a strong correlation (r = 0.76; p \ 0.001) between synovial and serum CRP. The area under the curve was 0.90 both for the synovial fluid (95% CI, 0.82-0.97) and serum (95% CI, 0.84-0.96) CRP assays. The diagnostic thresholds were 6.6 mg/L for synovial fluid and 11.2 mg/L for serum. Sensitivities, specificities, positive predictive value, negative predictive value, and accuracies were similar for synovial fluid and serum assays. Conclusions Although recent studies have suggested a superiority of synovial fluid CRP over serum CRP for the diagnosis of PJI, we found that measurement of CRP in synovial fluid rather than serum using readily available

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Section: Introductionmentioning

confidence: 99%

Is Synovial C-reactive Protein a Useful Marker for Periprosthetic Joint Infection?

Tetreault

Wetters

Moric

et al. 2014

Clin Orthop Relat Res

100

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“…Although several studies identified in this review reported neutrophils in apparently uninfected cases of failed ceramic-on-ceramic implants, most studies of periprosthetic tissue around failed ceramicon-ceramic implants have not identified neutrophils. This observation requires further studies, but based on the available evidence, we do not recommend deviating from the morphologic criteria of infection as recommended by the American Academy of Orthopaedic Surgeons Practice Guidelines Committee [11] when reviewing periprosthetic tissue samples from different bearing couples. This review has illustrated the variability of histologic findings in tissues adjacent to failed implants with several different types of bearing surfaces.…”

Section: Do Some Kinds Of Debris Induce Acute Inflammation Similar Tomentioning

confidence: 99%

“…The presence or absence of acute inflammation in periprosthetic tissues is widely regarded as suggestive of infection. Although cutoff thresholds for morphologically suggesting infection have varied, a Practice Guidelines Committee of the American Academy of Orthopaedic Surgeons recently found adequate published data to support thresholds of either (1) five neutrophils in each of five high-power fields; or (2) five neutrophils in each of 10 highpower fields [11]. Another recent publication suggested that finding 23 neutrophils in a total of 10 high-power fields is strongly suggestive of infection [31].…”

Section: Do Some Kinds Of Debris Induce Acute Inflammation Similar Tomentioning

confidence: 99%

How Have New Bearing Surfaces Altered the Local Biological Reactions to Byproducts of Wear and Modularity?

Bauer

Campbell

Hallerberg

2014

Clin Orthop Relat Res

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Background The biologic reactions to byproducts of wear or corrosion can involve innate and adaptive processes and are dependent on many factors, including the composition, size, surface properties, shape, and concentration of debris. Questions/purposes We used a systematic literature review to compare the reported patterns of inflammation in tissues around total hip implants with the goal of identifying whether there are unique or characteristic patterns associated with the newer bearing options or modular components. Methods A search of the Ovid Medline database between 1996 and early December 2013 identified articles that compared the histology around six implant groups: (1) metal-on-metal; (2) ceramic-on-ceramic; (3) metalon-crosslinked polyethylene; (4) metal-on-conventional polyethylene with or (5) without modularity; and (6) tissue obtained at primary arthroplasty. Our initial search yielded 865 citations. After excluding articles that lacked a quantitative or semiquantitative description of histologic findings in periprosthetic tissue, we reviewed 34 articles. Results No pattern of inflammation is specific for any given bearing combination. Histologic features suggestive of an adaptive immune response appear to be more frequent and of greater magnitude in failed metal-on-metal implants, but tissues around many failed metal-on-metal implants show features of an ''innate'' foreign body reaction without lymphocytes. Occasional nonmetal-on-metal implants show features of an immune reaction, possibly associated with metal particles. Modular connections are one source of metal debris in nonmetal-on-metal implants. Features of an immune reaction appear rare in ceramicon-ceramic implants that lack corrosion. Insufficient reports are available to characterize the biologic response to crosslinked polyethylene.

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“…Numerous tests and algorithms have been proposed to guide the workup of hip and knee periprosthetic joint infection (PJI) [6,15,16,18]. The American Academy of Orthopaedic Surgeons (AAOS) published a clinical guideline in 2010 to assist in the evaluation of patients for PJI [6,17] and subsequently the Musculoskeletal Infection Society (MSIS) developed a consensus definition for PJI diagnosis in 2011 (Table 1) [21].…”

Section: Introductionmentioning

confidence: 99%

“…The American Academy of Orthopaedic Surgeons (AAOS) published a clinical guideline in 2010 to assist in the evaluation of patients for PJI [6,17] and subsequently the Musculoskeletal Infection Society (MSIS) developed a consensus definition for PJI diagnosis in 2011 (Table 1) [21]. A key characteristic of the MSIS PJI definition is its multidimensional quality, whereby a definitive diagnosis is dependent on the presence of major and/or minor criteria.…”

Section: Introductionmentioning

confidence: 99%

Diagnosis of Periprosthetic Joint Infection in Medicare Patients: Multicriteria Decision Analysis

Díaz-Ledezma¹,

Lichstein²,

Parvızı³

2014

Clinical Orthopaedics &Amp; Related Research

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Background In the setting of finite healthcare resources, developing cost-efficient strategies for periprosthetic joint infection (PJI) diagnosis is paramount. The current levels of knowledge allow for PJI diagnostic recommendations based on scientific evidence but do not consider the benefits, opportunities, costs, and risks of the different diagnostic alternatives. Questions/purposes We determined the best diagnostic strategy for knee and hip PJI in the ambulatory setting for Medicare patients, utilizing benefits, opportunities, costs, and risks evaluation through multicriteria decision analysis (MCDA). Methods The PJI diagnostic definition supported by the Musculoskeletal Infection Society was employed for the MCDA. Using a preclinical model, we evaluated three diagnostic strategies that can be conducted in a Medicare patient seen in the outpatient clinical setting complaining of a painful TKA or THA. Strategies were (1) screening with serum markers (erythrocyte sedimentation rate [ESR]/ C-reactive protein [CRP]) followed by arthrocentesis in positive cases, (2) immediate arthrocentesis, and (3) serum markers requested simultaneously with arthrocentesis. MCDA was conducted through the analytic hierarchy process, comparing the diagnostic strategies in terms of benefits, opportunities, costs, and risks. Results Strategy 1 was the best alternative to diagnose knee PJI among Medicare patients (normalized value: 0.490), followed by Strategy 3 (normalized value: 0.403) and then Strategy 2 (normalized value: 0.106). The same ranking of alternatives was observed for the hip PJI model (normalized value: 0.487, 0.405, and 0.107, respectively). The sensitivity analysis found this sequence to be robust with respect to benefits, opportunities, and risks. However, if during the decisionmaking process, cost savings was given a priority of higher than 54%, the ranking for the preferred diagnostic strategy changed. Conclusions After considering the benefits, opportunities, costs, and risks of the different available alternatives, our preclinical model supports the American Academy of Orthopaedic Surgeons recommendations regarding the use of serum markers (ESR/CRP) before arthrocentesis as the best diagnostic strategy for PJI among Medicare patients. Level of Evidence Level II, economic and decision analysis. See Instructions to Authors for a complete description of levels of evidence.

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Diagnosis of Periprosthetic Joint Infections of the Hip and Knee

Cited by 259 publications

References 74 publications

Is Synovial C-reactive Protein a Useful Marker for Periprosthetic Joint Infection?

Is Synovial C-reactive Protein a Useful Marker for Periprosthetic Joint Infection?

How Have New Bearing Surfaces Altered the Local Biological Reactions to Byproducts of Wear and Modularity?

Diagnosis of Periprosthetic Joint Infection in Medicare Patients: Multicriteria Decision Analysis

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