Hip and Knee Section, Diagnosis, Algorithm: Proceedings of International Consensus on Orthopedic Infections

Periprosthetic joint infections after total hip replacement: an algorithmic approach

“…Despite the relatively low rates of PJIs after THAs, they remain a leading cause of revision surgery due to an everincreasing number of hip arthroplasties performed yearly for an ageing population [8]. Difficulties with reaching a consensus on what defines infection and which strategy best eradicates it led to extensive variability in infection rates in the literature, until recent efforts from the International consensus meeting on managing PJIs defined what constitutes an infection [12]. Specialist tertiary centres dealing with PJIs on a regular basis may improve infection-free survival and contribute to a global approach for managing PJI.…”

“…Principles for treating such difficult cases remain the same but with special considerations for each case. For example, in culture negative and resistant organisms, diagnosis can be challenging, but once established using all the diagnostic tools available and applying the International Consensus Meeting (ICM) on management of PJIs diagnostic criteria [12], treatment strategies should follow a two-stage reimplantation procedure as debridement and exchange of mobile parts and single-stage revisions are associated with higher failure rates [18,[46][47][48][49]. Patients who fail treatment may require salvage procedures such as long-term antibiotics, resection arthroplasty, fusion and amputation [50].…”

“…Metal on metal bearings constitute another challenge due to the difficulty of establishing the correct diagnostic thresholds for inflammatory markers in the serum and synovial fluid samples. In fact, a number of studies suggested that CRP and ESR are not reliable alone in diagnosing PJI in metal on metal cases and that the synovial fluid WBC count can frequently be falsely positive and, therefore, should be relied on only if a manual count is done and a differential can be performed [12,51,52]. The ICM also suggests being cautious whilst applying its diagnostic criteria for PJIs in metal on metal cases for the same reasons [12].…”

“…Clinical presentation (pain, fever, swelling, skin redness, discharging sinus), serologic testing (erythrocyte sedimentation rate [ESR] > 30 mm/h; C-reactive protein [CRP] > 10 mg/L), hip aspiration and biopsy with microbiology and cell count analyses help us diagnose PJI [8][9][10]. Definitive diagnosis however, is established when threeto-six specimens are sampled from different sites at the time of surgery (e.g., capsule, femur and acetabulum) and the same microorganism is cultured from at least two specimens [10][11][12][13]. The extent of infection and the interval for which it has been present play a role in the choice of treatment and the chances for successful eradication of infection as follows:…”

“…in a previously well-functioning implant [12,14,15]. In haematogenous infections, a full workup to establish the source of infection should be undertaken preoperatively, including a comprehensive history of recent systemic infections or invasive procedures causing bacteremic seeding of the hip, and investigations should include a throat swab, chest radiograph, and urine, stool and blood cultures [14].…”