Utility of Intraoperative Frozen Section Histopathology in the Diagnosis of Periprosthetic Joint Infection

Tsaras, Geoffrey; Maduka-Ezeh, Awele N.; Inwards, Carrie Y.; Mabry, Tad M.; Erwin, Patricia J.; Murad, M. Hassan; Montori, Víctor M.; West, Colin P.; Osmon, Douglas R.; Berbari, Elie F.

doi:10.2106/jbjs.j.00756

Cited by 146 publications

(94 citation statements)

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“…In contrast, Janz et al [29] found that sonication was able to improve the sensitivity of the histological analysis. In this sense, a meta-analysis supports that frozen section histopathology performed well in predicting a diagnosis of culturepositive periprosthetic PJI but had moderate accuracy in ruling out this diagnosis [8]. This finding is in agreement with those of our study, as we did not find differences between both tests.…”

Section: Discussionsupporting

confidence: 92%

“…However, test performance may vary with joint type and with post-arthroplasty implantation removal time. There have been several studies reported in the literature dealing with the evaluation of sensitivity and specificity of different diagnostic methods for implant-related infections, however, there is a lack of published data outlining their usefulness based on the time to infection [7,8].…”

Section: Introductionmentioning

confidence: 99%

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Accuracy of different diagnostic tests for early, delayed and late prosthetic joint infection

et al. 2017

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Background: A combination of laboratory, histopathological and microbiological tests for diagnosis of prosthetic joint infection (PJI) have been strongly recommended. This study aims to characterize the accuracy of individual or group tests, such as culture of sonicate fluid, synovial fluid and peri-implant tissue, C-reactive protein (CRP) and histopathology for detection of early, delayed and late PJI. Methods: A prospective study of patients undergoing hip or knee arthroplasty from February 2009 to February 2014 was performed in a Spanish tertiary health care hospital. The diagnostic accuracy of the different methods was evaluated constructing receiver-operating-characteristic (ROC) curve areas. Results: One hundred thirty consecutive patients were included: 18 (13.8%) early PJI, 35 (27%) delayed PJI and 77 (59.2%) late PJI. For individual parameters, the area under the ROC curve for peri-implant tissue culture was larger for early (0.917) than for delayed (0.829) and late PJI (0.778), p = 0.033. There was a significantly larger difference for ROC area in the synovial fluid culture for delayed (0.803) than for early (0.781) and late infections (0.679), p = 0.039. The comparison of the areas under the ROC curves for the two microbiological tests showed that sonicate fluid was significantly different from peri-implant tissue in delayed (0.951 vs 0.829, p = 0.005) and late PJI (0.901 vs 0.778, p = 0.000). The conjunction of preoperative parameters, synovial fluid culture and CRP, improved the accuracy for late PJI (p = 0.01). The conjunction of histopathology and sonicate fluid culture increased the area under ROC curve of sonication in early (0.917 vs 1.000); p = 0.06 and late cases (0.901 vs 0.999); p < 0.001. Conclusion: For early PJI, sonicate fluid and peri-implant tissue cultures achieve the same best sensitivity. For delayed and late PJI, sonicate fluid culture is the most sensitive individual diagnostic method. By combining histopathology and peri-implant tissue, all early, 97% of delayed and 94.8% of late cases are diagnosed. The conjunction of histopathology and sonicate fluid culture yields a sensitivity of 100% for all types of infection.

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Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 99%

Accuracy of different diagnostic tests for early, delayed and late prosthetic joint infection

et al. 2017

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“…Our results show that frozen sections performed reasonably well at the second stage of revision with a high specificity when compared with MSIS criteria, although it had low sensitivity. The use of frozen sections has a high variability for the diagnosis of infection depending on the study design and patient population [33]. The two studies analyzing frozen section during reimplantation reported similar results as our study in terms of sensitivity and specificity, although the reference standards in those studies were cultures with or without permanent sections [3,10].…”

Section: Discussionsupporting

confidence: 74%

“…Previous studies have compared the use of frozen sections using permanent section analysis or microbiological results [33]. However, no studies have assessed frozen section using MSIS criteria as a reference standard for diagnosing infection at the second stage of revision surgery.…”

Section: Discussionmentioning

confidence: 99%

Are Frozen Sections and MSIS Criteria Reliable at the Time of Reimplantation of Two-stage Revision Arthroplasty?

George

Kwiecień

Klika

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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Background Frozen section histology is widely used to aid in the diagnosis of periprosthetic joint infection at the second stage of revision arthroplasty, although there are limited data regarding its utility. Moreover, there is no definitive method to assess control of infection at the time of reimplantation. Because failure of a two-stage revision can have serious consequences, it is important to identify the cases that might fail and defer reimplantation if necessary. Thus, a reliable test providing information about the control of infection and risk of subsequent failure is necessary.Questions/purposes (1) At second-stage reimplantation surgery, what is the diagnostic accuracy of frozen sections as compared with the Musculoskeletal Infection Society (MSIS) as the gold standard? (2) What are the diagnostic accuracy parameters for the MSIS criteria and frozen sections in predicting failure of reimplantation? (3) Do positive MSIS criteria or frozen section at the time of reimplantation increase the risk of subsequent failure? Methods A total of 97 patients undergoing the second stage of revision total hip arthroplasty or total knee arthroplasty in 2013 for a diagnosis of periprosthetic joint infection (PJI) were considered eligible for the study. Of these, 11 had incomplete MSIS criteria and seven lacked 1-year followup, leaving 79 patients (38 knees and 41 hips) available for analysis. At the time of reimplantation, frozen section results were compared with modified MSIS criteria as the gold standard in detecting infection. Subsequently, success or failure of reimplantation was defined by (1) control of infection, as characterized by a healed wound without fistula, drainage, or pain; (2) no subsequent surgical intervention for infection after reimplantation surgery; and (3) no occurrence of PJI-related mortality; and diagnostic parameters in predicting treatment failure were calculated for both the modified MSIS criteria and frozen sections.One author (WB) has received research support in the amount of USD 100,001 to USD 1,000,000 from grants from Stryker (Kalamazoo, Conclusions On the basis of our results, both frozen section and MSIS are recommended at the time of the second stage of revision arthroplasty. Both frozen section and modified MSIS criteria had limited screening capabilities to identify failure, although both demonstrated high specificity. MSIS criteria should be evaluated at the second stage of revision arthroplasty because performing reimplantation in a joint that is positive for infection significantly increases the risk for subsequent failure. Level of Evidence Level III, diagnostic study.MI123 Clin Orthop Relat Res (2016) 474:1619-1626 DOI 10.1007/s11999-015-4673-3 Clinical Orthopaedics and Related Research ® A Publication of The Association of Bone and Joint Surgeons® Results At the time of second-stage reimplantation sur

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“…PPE, aynı mikroorganizmanın üremiş olduğu iki farklı zamanda alınmış kültür, eklem ile ilişkili bir sinus varlığı ya da aşağıdaki minör kriterlerden üçünün varlığı olarak tanımlanmıştır: [8] • Serum CRP ve ESR düzeylerinin ikisinde birden artış [9] • Sinoviyal sıvı WBC (white blood cell) sayısında artış veya lökosit esteraz strip testinde ++ değişiklik [10] • Sinoviyal sıvı %PMN'de (polymorphonuclear leukocyte) artış [10] • Protez çevresi dokuların pozitif histolojik analizi [11] • Tek pozitif kültür [12] Bu kriterleri karşılamayan klinik PPE'ler, daha az virülan mikroorganizmalar (Propionibacterium acnes vb.) ile de oluşabilir.…”

Section: Protez çEvresi̇ Eklem Enfeksi̇yonlarinin Tanisiunclassified

Enfeksiyon – iki aşamalı revizyon

Yıldız¹,

Tuncay²

2015

TOTBID

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komplikasyonlardan biridir. PPE tedavisinin zor ve maliyetli olması, uzun sürmesi ve fonksiyonel sonuçlarının primer olgulara göre daha kötü olması nedeniyle; bu tedavinin komplikasyonları, total diz artroplastisinde (TDA) en yıkıcı olanlardandır.[1] Bu nedenle ortopedistler, cerrahi saha enfeksiyonlarını (CSE) en aza indirmek için büyük çaba sarf etmektedirler. ABD verilerine göre PPE, revizyon total diz artroplastilerinin en T otal eklem artroplastisi, yüzyılımızın hasta memnuniyeti en yüksek cerrahilerinden biridir. Bütün dünya ile birlikte, ülkemizde de artroplasti ameliyatlarının giderek daha sık yapılıyor olması nedeniyle, bu alandaki çeşitli komplikasyonlarla daha sık karşılaşacağımız söylenebilir. Periprostetik enfeksiyonlar (PPE), hastaların ve bu ameliyatları yapan ortopedistlerin karşılaştıkları en can sıkıcı İnsan ömrünün artması ile birlikte total eklem artroplastileri her geçen gün daha fazla sayıda hastada ve hastanede uygulanmaktadır. Buna paralel olarak, bu tedavi yönte-minin en can sıkıcı komplikasyonlarından biri olan protez çevresi enfeksiyona (PPE) maruz kalan hastaların sayısı da artmaktadır. PPE, uygun yapılmış bir total diz artroplastisinin tüm başarılı sonuçlarını ortadan kaldırabilir. PPE'nin tanı ve tedavisinin zor olması, maliyetli ve uzun zaman alması, hasta ve hekim memnuniyetini azaltmaktadır. Güncel tanıda; eritrosit sedimentasyon hızı (ESR), C-reaktif protein (CRP), sinoviyal beyaz hücre sayısı, kültürler, histolojik incelemeler ve görüntüleme yöntemlerinin yanında, yeni geliştirilen testler de yer almaktadır. Tedavide, yalnızca irrigasyon ve debridman, tek seansta protez değişimi, iki seanslı protez değişimi ve antibiyotikli yer kaplayıcı uygulama veya cerrahi yapılamayanlarda antibiyotik ile baskılama tedavisi seçenekler arasındadır. Tedavi seçeneği, enfeksiyon semptomlarının ortaya çıkış zamanı, mikroorganizmanın virülansı, izole edilebilmesi ve hastaya bağlı faktörlere göre belirlenmektedir. Günümüzde popüler hale gelmeye başlayan tek aşamalı revizyonlar hasta morbiditesi ve fonksiyonları açısından avantajlı olsalar bile, iki aşamalı revizyonlar halen altın standarttır ve başarı oranları yüksektir. Enfeksiyonun tanımlanması, radikal debridman, implant değişimi ve uygun bir antibiyotik tedavisi ile başarılı sonuçlar elde edilebilir. Bu derleme, diz PPE'nin iki aşamalı revizyonla tedavisi ile ilgili güncel bilgileri özetlemektedir. Enfeksiyon -iki aşamalı revizyonAnahtar sözcükler: artroplasti; diz; enfeksiyon; cerrahi düzeltme, iki aşamalıWith the increased life expectancies, total joint arthroplasties have been performed increasingly day by day on more patients. Simultaneously, the number of patients who suffered periprosthetic joint infections (PJI), which is one of the most troublesome complications of this treatment method, is also increasing. PJI can destroy the successful results of a well-performed total knee arthroplasty. Patient and surgeon satisfaction rates are decreased due to difficulties in the diagnosis and the treatment of the disease, as well as long time of r...

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Utility of Intraoperative Frozen Section Histopathology in the Diagnosis of Periprosthetic Joint Infection

Cited by 146 publications

References 2 publications

Accuracy of different diagnostic tests for early, delayed and late prosthetic joint infection

Accuracy of different diagnostic tests for early, delayed and late prosthetic joint infection

Are Frozen Sections and MSIS Criteria Reliable at the Time of Reimplantation of Two-stage Revision Arthroplasty?

Enfeksiyon – iki aşamalı revizyon

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