Should all hip and knee prosthetic joints be aspirated prior to revision surgery?

Abstract

Aims It is essential to exclude a periprosthetic joint infection (PJI) prior to revision surgery. It is recommended to routinely aspirate the joint before surgery. However, this may not be necessary in a subgroup of patients. The aim of our study was to investigate if specific clinical and implant characteristics could be identified to rule out a PJI prior to revision surgery. Methods We retrospectively evaluated clinical and implant characteristics of patients who underwent a hip or knee revision surgery between October 2015 and October 2018. Patients were diagnosed with a PJI according to the MSIS diagnostic criteria. Results A total of 156 patients were analyzed, including 107 implants that were revised because of prosthetic loosening and 49 because of mechanical failure (i.e. instability, malalignment or malpositioning). No PJI was diagnosed in the group with mechanical failure. In the prosthetic loosening group, 20 of 107 were diagnosed with a PJI (19%). Although there was a significantly lower chance of having a PJI with an implant age of > 5 years combined with a CRP < 5 mg/L, an infection was still present in 3 out of 39 cases (8%). Conclusion Implants with solely mechanical failure without signs of loosening and low inflammatory parameters probably do not require a synovial fluid aspiration. These results need to be confirmed in a larger cohort of patients. In case of prosthetic loosening, all joints need to be aspirated before surgery as no specific characteristic could be identified to rule out an infection.

Should all patients with a culture-negative periprosthetic joint infection be treated with antibiotics?

“…The prevalence of culture-negative infections may be underestimated in our study, since the complete diagnostic work-up, including all minor criteria of infection, was not performed in patients with a very low chance of infection undergoing revision surgery, such as those with obviously malaligned components. 12 In addition, D-dimer measurement, as part of the ICM criteria, was not performed since its introduction for the diagnosis of PJI appeared after the period of study. As a consequence, culture-negative PJIs are potentially underdiagnosed when using the MSIS and ICM criteria in our analysis, since not all tests that make up the criteria were performed in our patients.…”

Extensive Preoperative Work Is Required for Revision Hip and Knee Arthroplasty

“…We anticipated that revision cases would require more preparation time for the surgical team. Besides standard POW, it may be necessary to obtain prior operative records and imaging, coordinate and interpret further imaging, perform an infection workup including arrangement of joint aspirations, and medically optimize patients who have more comorbid conditions than primary TJA patients [24].…”

Prevalence, interpretation, and management of unexpected positive cultures in revision TKA: a systematic review

“…Infections by virulent microorganisms manifest themselves earlier than low‐grade infections with less virulent microorganisms [10, 12, 43, 51, 57, 58]. Treatment strategies for septic and aseptic failure modes differ significantly [3, 9, 17, 41, 45], making a right preoperative diagnosis the key to success [13, 53, 60]. Nevertheless, in some presumed aseptic revisions intraoperative cultures turn out to be positive.…”