The Role of Intraoperative Frozen Section in Decision Making in Revision Hip and Knee Arthroplasties in a Local Community Hospital

Ko, Put Shui; Ip, David; Chow, Kai Pun; Cheung, Florence; Lee, On Bong; Lam, James Joseph

doi:10.1016/j.arth.2004.06.034

Cited by 55 publications

(22 citation statements)

References 16 publications

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“…We initially identified 14 of 269 specimens associated with a positive Gram stain for a sensitivity of 23% and specificity of 92% (Table 1). This sensitivity is comparable to that reported in the literature, but the specificity is lower than most reports (ie, 97% [17] to 100% [2,3,6,12,14,17,19]) ( Table 2).…”

Section: Methodsmentioning

confidence: 33%

“…Similarly, in a study of tests to diagnose periprosthetic knee infections, Barrack et al reported only 10% sensitivity but 100% specificity of Gram stains of aspirated joint fluid [3]. Gram stain results were also collected by Ko and coworkers during a retrospective study primarily designed to test the interpretation of frozen sections [12]. In that study, all Gram stains were reported as negative, including nine cases believed to be infected.…”

Section: Discussionmentioning

confidence: 99%

“…The results of intraoperative Gram stains have a reported low sensitivity (ie, 0% [6] to 43% [2]) such that many authors do not recommend their routine use [7,15]. However, positive Gram stain results are often believed to have high specificity (ie, 97% [17] to 100% [2,3,6,12,14,17,19]) and, if so, could have important implications. For example, a positive intraoperative Gram stain may influence a surgeon to convert an intended revision arthroplasty to the first stage of a two-stage operation for periprosthetic infection or may help guide antibiotic therapy before culture results become available.…”

Section: Introductionmentioning

confidence: 99%

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Diagnosing Periprosthetic Infection: False-positive Intraoperative Gram Stains

Oethinger

Warner

Schindler

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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Background Intraoperative Gram stains have a reported low sensitivity but high specificity when used to help diagnose periprosthetic infections. In early 2008, we recognized an unexpectedly high frequency of apparent falsepositive Gram stains from revision arthroplasties. Questions/purposes The purpose of this report is to describe the cause of these false-positive test results. Methods We calculated the sensitivity and specificity of all intraoperative Gram stains submitted from revision arthroplasty cases during a 3-month interval using microbiologic cultures of the same samples as the gold standard. Methods of specimen harvesting, handling, transport, distribution, specimen processing including tissue grinding/ macerating, Gram staining, and interpretation were studied.After a test modification, results of specimens were prospectively collected for a second 3-month interval, and the sensitivity and specificity of intraoperative Gram stains were calculated. Results The retrospective review of 269 Gram stains submitted from revision arthroplasties indicated historic sensitivity and specificity values of 23% and 92%, respectively. Systematic analysis of all steps of the procedure identified Gram-stained but nonviable bacteria in commercial broth reagents used as diluents for maceration of periprosthetic membranes before Gram staining and culture. Polymerase chain reaction and sequencing showed mixed bacterial DNA. Evaluation of 390 specimens after initiating standardized Millipore filtering of diluent fluid revealed a reduced number of positive Gram stains, yielding 9% sensitivity and 99% specificity. Conclusions Clusters of false-positive Gram stains have been reported in other clinical conditions. They are apparently rare related to diagnosing periprosthetic infections but have severe consequences if used to guide treatment. Even occasional false-positive Gram stains should prompt review of laboratory methods. Our observations implicate dead bacteria in microbiologic reagents as potential sources of false-positive Gram stains.

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Section: Methodsmentioning

confidence: 33%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Diagnosing Periprosthetic Infection: False-positive Intraoperative Gram Stains

Oethinger

Warner

Schindler

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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“…Our results fall within the range of previously reported values for Gram staining in infected total hip arthroplasty (Table 1). While some authors have reported a complete inability of Gram stains to diagnose infection [8,16], other authors report sensitivity of Gram stain from tissue swabs between 19% and 36% [3,4,9,14,23]. These studies also all report specificities and positive predictive values at or near 100%.…”

Section: Discussionmentioning

confidence: 69%

Should Gram Stains Have a Role in Diagnosing Hip Arthroplasty Infections?

Johnson

Zywiel

Stroh

et al. 2010

Clinical Orthopaedics &Amp; Related Research

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“…Gram staining (GS) is a widely used test that is easily available. GS is also commonly used in the diagnosis of PJI, particularly in developing countries, as a result of its low cost, rapid turnaround time and ease of use; however, its value remains controversial due to conflicting results on the effectiveness of GS in the diagnosis of PJI (5,(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28). The present meta-analysis was therefore performed as one of a series of meta-analyses (6,7,29) in order to evaluate the detection validity of GS for the diagnosis of PJI and to provide evidence-based advice to clinicians.…”

Section: Introductionmentioning

confidence: 99%

Limitations of Gram staining for the diagnosis of infections following total hip or knee arthroplasty

Ouyang

Zhai

Qin

et al. 2015

Experimental and Therapeutic Medicine

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Abstract. The diagnosis of prosthetic joint infection (PJI)following total joint arthroplasty is difficult for clinicians to make decisions due to the similar symptoms presented by aseptic loosening and infection. Gram staining (GS) is a widely used test but its value remains controversial due to conflicting results in the diagnosis of PJI. The aim of the present study was therefore to evaluate the value of GS in the diagnosis of PJI. Searches using MEDLINE, EMBASE and OVID databases were conducted for data published between January 1990 and December 2013. Meta-analysis was used to pool the sensitivity, specificity, diagnostic odd ratios (DORs), area under the receiveroperating characteristic curve (AUC), positive-likelihood ratios (PLRs), negative-likelihood ratios (NLRs) and post-test probability. The heterogeneity and publication bias were assessed, and subgroup and meta-regression analyses were conducted. A total of 18 studies, including a total of 4,647 patients, were selected for analysis. The pooled sensitivity and specificity values for the diagnosis of PJI were 0.19 and 1.00, respectively. The AUC, PLR and NLR were 0.89, 41.6 and 0.82, respectively. Subgroup analyses indicated that the sensitivity/specificity for total hip arthroplasty was 0.14/0.99, whereas that for total knee arthroplasty was 0.14/1.00. Synovial fluid best reflected accurate GS-based diagnoses, with the highest DOR of 242, whereas tissue had the highest AUC of 0.96 (95% CI, 0.94-0.97). GS had a poor clinically acceptable diagnostic value for detecting PJI. These data do not support the routine use of GS, without additional proof of infection, for diagnosing PJI; instead, GS could be used as an adjuvant tool to support the results of other investigations.

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The Role of Intraoperative Frozen Section in Decision Making in Revision Hip and Knee Arthroplasties in a Local Community Hospital

Cited by 55 publications

References 16 publications

Diagnosing Periprosthetic Infection: False-positive Intraoperative Gram Stains

Diagnosing Periprosthetic Infection: False-positive Intraoperative Gram Stains

Should Gram Stains Have a Role in Diagnosing Hip Arthroplasty Infections?

Limitations of Gram staining for the diagnosis of infections following total hip or knee arthroplasty

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