Unexpected positive intraoperative cultures (UPIC) in revision Hip and knee arthroplasty- A review of the literature

Abstract

Unexpected positive intraoperative culture (UPIC) in revision hip and knee arthroplasty has a prevalence of 10.5%, there is no consensus in the literature on how to interpret them and how to treat them. Our literature review showed that most authors would consider two or more positive cultures as significant and usually treat them with culture specific antibiotics for 4-6 weeks. A single positive intraoperative culture can or cannot be significant depending on the virulence of the organism, hence taking multiple tissue samples in and around the joint is recommended. All failed arthroplasty cases must be evaluated preoperatively according to musculoskeletal infection society criteria (MSIS) to rule out the possibility of infection as an etiology for failure of the arthroplasty. Most authors reported that large majority of these UPIC were from a low virulence organism. Our review showed that the implant survival is more than 85% with 4-6 weeks of antibiotic treatment.

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

“…Regarding patients with prosthetic loosening, the incidence of PJI in this particular group was high. The PJI incidence of 19% in patients with prosthetic loosening in our study is comparable with other reports [3][4][5][6]. We could not identify a subgroup of patients with prosthetic loosening in whom a PJI could be ruled out preoperatively without synovial fluid aspiration.…”

“…instability, malalignment or malpositioning) or loosening of the prosthesis [1,2]. Published records describe that around 10-20% of patients undergoing revision surgery have unexpected positive cultures during revision [3][4][5][6], and these patients have a worse outcome compared with aseptic cases [7][8][9][10]. Therefore, it is critical to rule out a periprosthetic joint infection (PJI) prior to revision surgery because the revision of an infected prosthesis requires other surgical and antibiotic interventions than a revision for a non-infected prosthesis.…”

Sampling challenges in diagnosis of chronic bacterial infections

“…In cases where preoperative evaluation does not support PJI, the purpose of intraoperative tissue sampling is to rule out infection. Unexpected presence of intraoperative cultures have been reported to have a prevalence between 4 and 38 % [29]. Sampling several specimens is helpful in discriminating contamination from infection.…”

“Unexpected” Infections in Revision Arthroplasty for Aseptic Loosening

“…Увеличение количества первичных артропластик в последние годы привело к значительному росту ревизионных вмешательств во всем мире [1, 2,3,4,5,6]. Данные национальных регистров эндопротезирования (ЭП) суставов показали, что около 12% эндопротезов тазобедренного (ТБС) и коленного (КС) суставов подвергаются ревизии в течение 10 лет после первичной операции [7,8,9].…”

“…В настоящее время для диагностики ППИ используются различные критерии и алгоритмы, в том числе разработанные на международном консенсусном совещании 2013 г. и затем на Второй международной согласительной конференции по скелетно-мышечной инфекции (International Consensus Meeting -ICM, 2018) [16,17], а также критерии и алгоритмы, предложенные Европейским обществом по инфекциям костей и суставов (The European Bone and Joint Infection Society -EBJIS) [18]. Однако в некоторых случаях ППИ могут быть вызваны низковирулентными микроорганизмами, например, Propionibacterium acnes, когда перечисленные критерии неприемлемы [8,12,14,18,19,20].…”