The diagnostic value of routine preliminary biopsy in diagnosing late prosthetic joint infection after hip and knee arthroplasty

Abstract

Aims Biopsy of the periprosthetic tissue is an important diagnostic tool for prosthetic joint infection (PJI) as it enables the detection of the responsible microorganism with its sensitivity to antibiotics. We aimed to investigate how often the bacteria identified in the tissue analysis differed between samples obtained from preoperative biopsy and intraoperative revision surgery in cases of late PJI; and whether there was a therapeutic consequence. Methods A total of 508 patients who required revision surgery of total hip arthroplasty (THA) (n = 231) or total knee arthroplasty (TKA) (n = 277) because of component loosening underwent biopsy before revision surgery. The tissue samples collected at biopsy and during revision surgery were analyzed according to the criteria of the Musculoskeletal Infection Society (MSIS). Results In total, 178 (113 THA, 65 TKA) were classified as infected. The biopsy procedure had a sensitivity of 93.8%, a specificity of 97.3%, a positive predictive value (PPV) of 94.9%, a negative predictive value (NPV) of 96.7%, and an accuracy of 96.1%. Of the 178 infected patients, 26 showed a difference in the detected bacteria from the biopsy and the revision surgery (14.6%). This difference required a change to antibiotic therapy in only two cases (1.1%). Conclusion Biopsy is a useful tool to diagnose PJI, but there may be a difference in the detected bacteria between the biopsy and revision surgery. However, this did not affect the choice of antibiotic therapy in most cases, rendering the clinical relevance of this phenomenon as low. Cite this article: Bone Joint J 2020;102-B(3):329–335

Comparing the Diagnostic Value of Serum D-Dimer to CRP and IL-6 in the Diagnosis of Chronic Prosthetic Joint Infection

“…It remains of paramount importance to use a combination of serum markers, synovial parameters, and microbiology as recommend by the MSIS and ICM criteria. Despite all efforts in preoperative diagnosis, some patients might require open biopsy [ 4 ] or additional testing such as next generation sequencing [ 5 ] or alpha defensin [ 35 ] that were not routinely used in our algorithm. Furthermore, it can be more useful in chronic, non-fistulating infection to perform repeat joint aspiration in order to obtain a synovial fluid sample considering the excellent diagnostic value [ 36 ].…”

“…The preoperative diagnosis of PJI is crucial for adequate treatment, but it is often challenging because there is no optimal test available. The correct diagnosis of PJI is based on a combination of clinical findings as well as serum, synovial, and microbiological tests [ 4 , 5 , 6 ]. While synovial and microbiological testing is the most reliable method, it is invasive and there is the risk of “dry taps” in joint aspirations and culture-negative infections necessitating the use of a combination of serum parameters to establish the diagnosis.…”

Antibiotic therapy alone does not have a high success rate in cases of unexpected positive cultures in intraoperative samples from hip and knee prosthesis revision

“…The data of this group and the value for this diagnostic procedure (biopsies and its combination with aspiration and blood CRP-analysis) of these 508 patients was previously published and showed a sensitivity of 93.8%, a specificity of 97.3%, a positive predictive value (PPV) of 94.9%, a negative predictive value (NPV) of 96.7%, and an accuracy of 96.1% [22]. The mean age of the 508 patients was 68 ± 10 (30-87) years.…”

“…A prospective study investigated a continuous series of 508 patients (253 female, 255 male) who required revision surgery of total hip (THA, n = 231) or knee arthroplasties (TKA, n = 277) because of component loosening [22]. Out of this 178 cases (113 THA, 65 TKA) had periprosthetic joint infection (PJI), as classified with the bacteriologic, histologic and serologic analyses at revision surgery using the ICM-2018 criteria [23].…”

“…Before revision surgery all 508 patients underwent a diagnostic intervention that involved blood C-reactive protein (CRP)-analysis and aspiration of the joint as well as biopsy of the periprosthetic tissue according to the methods already described in previous publications [22,24,25].…”