Insufficient sensitivity of joint aspiration during the two-stage exchange of the hip with spacers

Boelch, Sebastian Philipp; Weißenberger, Manuel; Spohn, Frederik; Rudert, Maximilian; Luedemann, Martin

doi:10.1186/s13018-017-0703-z

Cited by 19 publications

(18 citation statements)

References 23 publications

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“…The duration of an antibiotic holiday seems to be less related with reinfection than the time the antibiotic cement spacer is implanted [75]. Joint aspiration before reimplantation is not recommended, as synovial markers do not correlate with reinfection rates, and the diagnostic accuracy is very low (sensitivity of 4.6% and 25.0% and specificity of 94.3% and 96.9% for synovial fluid and cell count, respectively) [75][76][77]. To date, there is no reliable marker to prove the eradication of infection at the time of reimplantation.…”

Section: Errors Using Antibiotic-loaded Cement Spacersmentioning

confidence: 99%

Twenty common errors in the diagnosis and treatment of periprosthetic joint infection

Renz

Trampuž

et al. 2019

International Orthopaedics (SICOT)

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Background Misconceptions and errors in the management of periprosthetic joint infection (PJI) can compromise the treatment success. The goal of this paper is to systematically describe twenty common mistakes in the diagnosis and management of PJI, to help surgeons avoid these pitfalls. Materials and methods Common diagnostic and treatment errors are described, analyzed and interpreted. Results Diagnostic errors include the use of serum inflammatory biomarkers (such as C-reactive protein) to rule out PJI, incomplete evaluation of joint aspirate, and suboptimal microbiological procedures (such as using swabs or collection of insufficient number of periprosthetic samples). Further errors are missing possible sources of distant infection in hematogenous PJI or overreliance on suboptimal diagnostic criteria which can hinder or delay the diagnosis of PJI or mislabel infections as aseptic failure. Insufficient surgical treatment or inadequate antibiotic treatment are further reasons for treatment failure and emergence of antimicrobial resistance. Finally, wrong surgical indication, both underdebridement and overdebridement or failure to individualize treatment can jeopardize surgical results. Conclusion Multidisciplinary teamwork with infectious disease specialists and microbiologists in collaboration with orthopedic surgeons have a synergistic effect on the management of PJI. An awareness of the possible pitfalls can improve diagnosis and treatment results.

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Section: Errors Using Antibiotic-loaded Cement Spacersmentioning

confidence: 99%

Twenty common errors in the diagnosis and treatment of periprosthetic joint infection

Renz

Trampuž

et al. 2019

International Orthopaedics (SICOT)

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“…With our approach we must conclude that the value of IA for the question what to expect from sampling at planned reimplantation is insignificant. This conclusion is emphasized by the low sensitivities that have been recently reported for the hip or combined for the hip and the knee, irrespectively of the definition of infection persistence ( Table 4 ) [ 12 , 14 , 20 , 27 ]. The current study confirms these low sensitivities particularly at the knee.…”

Section: Discussionmentioning

confidence: 99%

“…Additionally, more complex infection persistence definitions bear the risk of lacking traceability [ 13 , 15 ]. In accordance with other authors, we defined infection persistence as detection of the same pathogen in at least two intraoperative cultures or detection of a virulent pathogen in a single [ 12 , 16 , 20 ]. But still, derived from the results of PJI diagnosis, infection can occur without pathogen detection in up to 24% [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

Synovial Fluid Aspiration Should Not Be Routinely Performed during the Two-Stage Exchange of the Knee

Boelch

Roth

Arnholdt

et al. 2018

BioMed Research International

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Purpose Detection of infection persistence during the two-stage exchange of the knee for periprosthetic joint infection is challenging. Synovial fluid culture (SFC) and synovial white blood cell count (SWBCC) before joint reimplantation are widespread diagnostic means for this indication. The sensitivity and specificity of SFC and of SWBCC for infection persistence before planned reimplantation were evaluated. Methods 94 two-stage exchanges of the knee with synovial fluid aspiration performed after a drug holiday of at least 14 days and before reimplantation or spacer exchange (planned reimplantation) were retrospectively analyzed. Only cases with at least 3 intraoperative samples at planned reimplantation were included. SFC and SWBCC were compared to pathogen detection (SFC(culture)/SWBCC(culture)) and to histopathological signs of infection persistence (SFC(histo)/SWBCC(histo)) from intraoperative samples at planned reimplantation. For SFC, the sensitivity and specificity were calculated. For SWBCC, the optimal cut-off value with its sensitivity and specificity was calculated with the Youden-Index. Results Sensitivity and specificity of SFC(culture) were 0.0% and 98.9%. Sensitivity and specificity of SFC(histo) were 3.4% and 100%. The optimal cut-off value for SWBCC(culture) was 4450 cells/μl with a sensitivity of 50.0% and a specificity of 86.5%. The optimal cut-off value for SWBCC(histo) was 3250 cells/μl with a sensitivity of 35.7% and a specificity of 92.9%. Conclusion The detection of infection persistence remains challenging and a consented approach is lacking. The results do not warrant the routine performance of SFC during the two-stage exchange at the knee. SWBCC can be used to confirm infection persistence at high cut-offs, but they only occur in few patients and are therefore inappropriate for the routine use.

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“…The problem of minimal detection rates is also known for periprosthetic infections of the hip and the knee. Boelch et al described a sensitivity of 5% for the hip respectively 0% for the knee (30,31). In parallel, a shift from negative aspirations to low-virulent, bio lm-forming bacteria in intraoperative cultures is described (31).…”

Section: Discussionmentioning

confidence: 99%

“…Boelch et al described a sensitivity of 5% for the hip respectively 0% for the knee (30,31). In parallel, a shift from negative aspirations to low-virulent, bio lm-forming bacteria in intraoperative cultures is described (31). It seems likely that this effect is even more relevant in shoulder infections as Cutibacterium spp.…”

Section: Discussionmentioning

confidence: 99%

The Role of Synovial Fluid Aspiration in Shoulder Joint Infections

Streck¹,

Förster²,

Hertzberg-Boelch³

et al. 2021

Preprint

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Background: Joint aspiration with analysis of synovial fluid white blood cell count (WBC) and microbiological culture is a widely established aspect in the diagnosis of shoulder joint infections (SJI). In case of a two stage revision for SJI, joint aspiration before re-/implantation of an total shoulder arthroplasty (TSA) was used to rule out persistent infection for years but its value is under debate. Shoulder specific data on all aspects is rare. The current study aims to answer the following research questions: Joint aspiration has an insufficient predictive value in the diagnosis of SJI in (1) initial workup and (2) before definite arthroplasty with polymethylmethacrylate (PMMA)-Spacer in place. Methods: This retrospective evaluation investigates 35 patients that were treated for SJI with a two staged implantation of a TSA after debridement and implantation of an PMMA-Spacer. Joint aspirations were performed preoperatively (PA) and before re‑/implantation of the prosthesis while spacer was in place (interstage aspiration, IA). Samples were taken for microbiological culture and analysis of WBC. Sensitivity and specificity were calculated with reference to intraoperative microbiological samples. Receiver Operating Characteristic (ROC), Area-Under-Curve analysis (AUC) and calculation of the Youden index were performed to find optimum cut-off for WBC. Results: The sensitivity of microbiological cultures from PA was 58.3% and the specificity was 88.9%. The mean WBC was 27 800 leucocytes/mm3 (range 400-96 300). The maximum Youden index (0.857) was a cut-off of 2600 leucocytes/mm³ with a sensitivity of 85.7% and a specificity of 100.0%. The sensitivity and specificity of IA were 0.0% and 88.5%, respectively. Conclusions: PA is likely to miss Cutibacteria spp. Cuand CoNS and cannot rule out infection for sure. However, we recommend PA for its advantages of targeted antibiotic therapy in case of germ identification. Empiric antibiotic therapy should therefore cover these bacteria even if aspiration showed negative microbiological cultures. In contrast, diagnostic value of IA does not qualify for routine use. Trial registration: The study was approved by the ethic committee of the author`s institution (registration number 235/16-mk). The patients gave written informed consent to their inclusion in the study.

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Insufficient sensitivity of joint aspiration during the two-stage exchange of the hip with spacers

Cited by 19 publications

References 23 publications

Twenty common errors in the diagnosis and treatment of periprosthetic joint infection

Twenty common errors in the diagnosis and treatment of periprosthetic joint infection

Synovial Fluid Aspiration Should Not Be Routinely Performed during the Two-Stage Exchange of the Knee

The Role of Synovial Fluid Aspiration in Shoulder Joint Infections

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