Diagnosis of Periprosthetic Joint Infection Following Hip and Knee Arthroplasty




The diagnosis of periprosthetic joint infection (PJI) following total hip arthroplasty and total knee arthroplasty has been one of the major challenges in orthopedic surgery. As there is no single absolute test for diagnosis of PJI, diagnostic criteria for PJI have been proposed that include using several diagnostic modalities. Focused history, physical examination, plain radiographs, and initial serologic tests should be followed by joint aspiration and synovial analysis. Newer diagnostic techniques, such as alpha-defensin and interleukin-6, hold great promise in the future diagnosis of equivocal infections.





  • In the case of indolent infections, newer diagnostic modalities, such as alpha-defensin or interleukin-6, show great potential to complement current techniques in future clinical practice.





  • In the case of indolent infections, newer diagnostic modalities, such as alpha-defensin or interleukin-6, show great potential to complement current techniques in future clinical practice.








  • Also of note, The Society of Unicondylar Research and Continuing Education suggested that these criteria, including ESR and CRP threshold values, can also be used in suspected PJI following unicompartmental knee arthroplasty (UKA), but that the aspiration biomarker thresholds in UKA can deviate significantly from the ICM values for TKA.









  • Increased duration of surgery




  • Subperiosteal reaction




    ESR has no diagnostic utility in acute PJI (<6 weeks)






    In cases of bloody joint aspirations, 1.5 mL of synovial fluid should be transferred to a microcentrifuge tube, loaded into a minicentrifuge symmetrically, and spun for 2 to 3 minutes at maximum speed (ideally ≥6600 revolutions per minute). The synovial fluid separates as the supernatant, which can be needle aspirated and transferred for accurate LE testing.












    References



    1. 1. Callaghan J.J., Albright J.C., Goetz D.D., et al: Charnley total hip arthroplasty with cement. Minimum twenty-five-year follow-up. J Bone Joint Surg Am 2000; 82: pp. 487-497

    2. 2. Knight S.R., Aujla R., and Biswas S.P.: Total hip arthroplasty – over 100 years of operative history. Orthop Rev (Pavia) 2011; 3: pp. E16

    3. 3. Insall J.N., and Clarke H.D.: Historical development, classification, and characteristics of knee prostheses. In Insall J.N., and Clarke H.D. (eds): Insall & Scott Surgery of the Knee, 3rd edition. New York: Churchill Livingstone, 2001. pp. 1516-1552

    4. 4. Moran C.G., and Horton T.C.: Total knee replacement: the joint of the decade. BMJ 2000; 320: pp. 820

    5. 5. Pivec R., Johnson A.J., Mears S.C., et al: Hip arthroplasty. Lancet 2012; 380: pp. 1768-1777

    6. 6. Kurtz S., Ong K., Lau E., et al: Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89: pp. 780-785

    7. 7. Namba R.S., Inacio M.C., and Paxton E.W.: Risk factors associated with deep surgical site infections after primary total knee arthroplasty. J Bone Joint Surg Am 2013; 95: pp. 775-782

    8. 8. NIH consensus conference: total hip replacement. NIH consensus development panel on total hip replacement. JAMA 1995; 273: pp. 1950-1956

    9. 9. Ulrich S.D., Seyler T.M., Bennett D., et al: Total hip arthroplasties: what are the reasons for revision? Int Orthop 2007; 32: pp. 597-604

    10. 10. Narkbunnam R., and Chareancholvanich K.: Causes of failure in total knee arthroplasty. J Med Assoc Thai 2012; 95: pp. 667-673

    11. 11. Jafari S.M., Coyle C., Mortazavi S.M., et al: Revision hip arthroplasty: infection is the most common cause of failure. Clin Orthop Relat Res 2010; 468: pp. 2046-2051

    12. 12. Mortazavi S.M., Molligan J., Austin M.S., et al: Failure following revision total knee arthroplasty: infection is the major cause. Int Orthop 2010; 35: pp. 1157-1164

    13. 13. Iamthanaporn K., Chareancholvanich K., and Pornrattanamaneewong C.: Revision primary total hip replacement: causes and risk factors. J Med Assoc Thai 2015; 98: pp. 93-99

    14. 14. Zmistowski B., Karam J.A., Durinka J.B., et al: Periprosthetic joint infection increases the risk of one-year mortality. J Bone Joint Surg Am 2013; 95: pp. 2177-2184

    15. 15. Kurtz S.M., Lau E., Schmier J., et al: Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty 2008; 23: pp. 984-991

    16. 16. Parvizi J., Zmistowski B., Berbari E.F., et al: New definition for periprosthetic joint infection: from the workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 2011; 469: pp. 2992-2994

    17. 17. CDC – ACH Surveillance for surgical site infection (SSI) event – NHSN. Available at: http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf. Accessed August 3, 2015.

    18. 18. Zmistowski B., Della Valle C., Bauer T.W., et al: Diagnosis of periprosthetic joint infection. J Arthroplasty 2014; 29: pp. 77-83

    19. 19. Society of Unicondylar Research and Continuing Education : Diagnosis of periprosthetic joint infection after unicompartmental knee arthroplasty. J Arthroplasty 2012; 27: pp. 46-50

    20. 20. Diaz-Ledezma C., Lichstein P.M., Dolan J.G., et al: Diagnosis of periprosthetic joint infection in Medicare patients: multicriteria decision analysis. Clin Orthop Relat Res 2014; 472: pp. 3275-3284

    21. 21. Della Valle C., Parvizi J., Bauer T.W., American Academy of Orthopaedic Surgeons , et al: Diagnosis of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg 2010; 18: pp. 760-770

    22. 22. Lima A.L., Oliveira P.R., Carvalho V.C., et al: Periprosthetic joint infections. Interdiscip Perspect Infect Dis 2013; 2013: pp. 542796

    23. 23. Rodríguez D., Pigrau C., Euba G., et al: Acute haematogenous prosthetic joint infection: prospective evaluation of medical and surgical management. Clin Microbiol Infect 2010; 16: pp. 1789-1795

    24. 24. Berbari E.F., Hanssen A.D., Duffy M.C., et al: Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis 1998; 27: pp. 1247-1254

    25. 25. Enayatollahi M.A., and Parvizi J.: Diagnosis of infected total hip arthroplasty. Hip Int 2015; 25: pp. 294-300

    26. 26. Poss R., Thornhill T.S., Ewald F.C., et al: Factors influencing the incidence and outcome of infection following total joint arthroplasty. Clin Orthop Relat Res 1984; undefined: pp. 117-126

    27. 27. Osmon D.R., Berbari E.F., Berendt A.R., et al: Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013; 56: pp. e1-e25

    28. 28. Osmon D.R., Berbari E.F., Berendt A.R., et al: Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2012; 56: pp. 1-10

    29. 29. Sofka C.M.: Current applications of advanced cross-sectional imaging techniques in evaluating the painful arthroplasty. Skeletal Radiol 2007; 36: pp. 183-193

    30. 30. Chryssikos T., Parvizi J., Ghanem E., et al: FDG-PET imaging can diagnose periprosthetic infection of the hip. Clin Orthop Relat Res 2008; 466: pp. 1338-1342

    31. 31. Sousa R., Massada M., Pereira A., et al: Diagnostic accuracy of combined 99mTc-sulesomab and 99mTc-nanocolloid bone marrow imaging in detecting prosthetic joint infection. Nucl Med Commun 2011; 32: pp. 834-839

    32. 32. Tigges S., Stiles R.G., and Roberson J.R.: Appearance of septic hip prostheses on plain radiographs. AJR Am J Roentgenol 1994; 163: pp. 377-380

    33. 33. Spangehl M.J., Masri B.A., O’Connell J.X., et al: Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am 1999; 81: pp. 672

    34. 34. Ghanem E., Antoci V., Pulido L., et al: The use of receiver operating characteristics analysis in determining erythrocyte sedimentation rate and c-reactive protein levels in diagnosing periprosthetic infection prior to revision total hip arthroplasty. Int J Infect Dis 2009; 13: pp. e444-e449

    35. 35. Johnson A.J., Zywiel M.G., Stroh A., et al: Serological markers can lead to false negative diagnoses of periprosthetic infections following total knee arthroplasty. Int Orthop 2010; 35: pp. 1621-1626

    36. 36. Rasouli M.R., Harandi A.A., Adeli B., et al: Revision total knee arthroplasty: infection should be ruled out in all cases. J Arthroplasty 2012; 27: pp. 1239-1243.e1-2

    37. 37. Greidanus N.V., Masri B.A., Garbuz D.S., et al: Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before revision total knee arthroplasty. A prospective evaluation. J Bone Joint Surg Am 2007; 89: pp. 1409

    38. 38. Squire M.W., Della Valle C.J., Parvizi J., et al: Preoperative diagnosis of periprosthetic joint infection: role of aspiration. AJR Am J Roentgenol 2011; 196: pp. 875-879

    39. 39. Bedair H., Ting N., Jacovides C., et al: The Mark Coventry Award: diagnosis of early postoperative TKA infection using synovial fluid analysis. Clin Orthop Relat Res 2011; 469: pp. 34-40

    40. 40. Schinsky M.F., Della Valle C.J., Sporer S.M., et al: Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am 2008; 90: pp. 1869-1875

    41. 41. Trampuz A., Hanssen A.D., Osmon D.R., et al: Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med 2004; 117: pp. 556-562

    42. 42. Ghanem E., Parvizi J., Burnett R.S., et al: Cell count and differential of aspirated fluid in the diagnosis of infection at the site of total knee arthroplasty. J Bone Joint Surg Am 2008; 90: pp. 1637

    43. 43. Parvizi J., Jacovides C., Zmistowski B., et al: Definition of periprosthetic joint infection: is there a consensus? Clin Orthop Relat Res 2011; 469: pp. 3022-3030

    44. 44. Cipriano C.A., Brown N.M., Michael A.M., et al: Serum and synovial fluid analysis for diagnosing chronic periprosthetic infection in patients with inflammatory arthritis. J Bone Joint Surg Am 2012; 94: pp. 594-600

    45. 45. Ghanem E., Houssock C., Pulido L., et al: Determining “true” leukocytosis in bloody joint aspiration. J Arthroplasty 2008; 23: pp. 182-187

    46. 46. Wyles C.C., Larson D.R., Houdek M.T., et al: Utility of synovial fluid aspirations in failed metal-on-metal total hip arthroplasty. J Arthroplasty 2013; 28: pp. 818-823

    47. 47. Parvizi J., Jacovides C., Antoci V., et al: Diagnosis of periprosthetic joint infection: the utility of a simple yet unappreciated enzyme. J Bone Joint Surg Am 2011; 93: pp. 2242-2248

    48. 48. Aggarwal V.K., Tischler E., Ghanem E., et al: Leukocyte esterase from synovial fluid aspirate: a technical note. J Arthroplasty 2013; 28: pp. 193-195

    49. 49. Lachiewicz P.F., Rogers G.D., and Thomason H.C.: Aspiration of the hip joint before revision total hip arthroplasty. clinical and laboratory factors influencing attainment of a positive culture. J Bone Joint Surg Am 1996; 78: pp. 749

    50. 50. Spangehl M.J., Younger A.S., Masri B.A., et al: Diagnosis of infection following total hip arthroplasty. Instr Course Lect 1998; 47: pp. 285-295

    51. 51. Larsen L.H., Lange J., Xu Y., et al: Optimizing culture methods for diagnosis of prosthetic joint infections: a summary of modifications and improvements reported since 1995. J Med Microbiol 2012; 61: pp. 309-316

    52. 52. Atkins B.L., Athanasou N., Deeks J.J., et al: Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. J Clin Microbiol 1998; 36: pp. 2932

    53. 53. Wadey V.M., Huddleston J.I., Goodman S.B., et al: Use and cost-effectiveness of intraoperative acid-fast bacilli and fungal cultures in assessing infection of joint arthroplasties. J Arthroplasty 2010; 25: pp. 1231-1234

    54. 54. Tokarski A.T., O’Neil J., Deirmengian C.A., et al: The routine use of atypical cultures in presumed aseptic revisions is unnecessary. Clin Orthop Relat Res 2013; 471: pp. 3171-3177

    55. 55. Malekzadeh D., Osmon D.R., Lahr B.D., et al: Prior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infection. Clin Orthop Relat Res 2010; 468: pp. 2039-2045

    56. 56. Schwotzer N., Wahl P., Fracheboud D., et al: Optimal culture incubation time in orthopedic device-associated infections: a retrospective analysis of prolonged 14-day incubation. J Clin Microbiol 2014; 52: pp. 61-66

    57. 57. Ghanem E., Parvizi J., Clohisy J., et al: Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection. Clin Orthop Relat Res 2007; 461: pp. 44-47

    58. 58. Tsaras G., Maduka-Ezeh A., Inwards C.Y., et al: Utility of Intraoperative frozen section histopathology in the diagnosis of periprosthetic joint infection. J Bone Joint Surg Am 2012; 94: pp. 1700-1711

    59. 59. Morawietz L., Tiddens O., Mueller M., et al: Twenty-three neutrophil granulocytes in 10 high-power fields is the best histopathological threshold to differentiate between aseptic and septic endoprosthesis loosening. Histopathology 2009; 54: pp. 847-853

    60. 60. Zimmerli W., Trampuz A., and Ochsner P.E.: Prosthetic-joint Infections. N Engl J Med 2004; 351: pp. 1645

    61. 61. Kwee T.C., Kwee R.M., and Alavi A.: FDG-PET for diagnosing prosthetic joint infection: systematic review and metaanalysis. Eur J Nucl Med Mol Imaging 2008; 35: pp. 2122-2132

    62. 62. Kobayashi N., Inaba Y., Choe H., et al: Use of F-18 fluoride PET to differentiate septic from aseptic loosening in total hip arthroplasty patients. Clin Nucl Med 2011; 36: pp. e156-e161

    63. 63. Berbari E., Mabry T., Tsaras G., et al: Inflammatory blood laboratory levels as markers of prosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am 2010; 92: pp. 2102-2109

    64. 64. Parvizi J., Jacovides C., Adeli B., et al: Coventry Award: synovial C-reactive protein: a prospective evaluation of a molecular marker for periprosthetic knee joint infection. Clin Orthop Relat Res 2012; 470: pp. 54-60

    65. 65. Deirmengian C., Kardos K., Kilmartin P., et al: The alpha-defensin test for periprosthetic joint infection outperforms the leukocyte esterase test strip. Clin Orthop Relat Res 2015; 473: pp. 198-203

    66. 66. Deirmengian C., Kardos K., Kilmartin P., et al: Diagnosing periprosthetic joint infection: has the era of the biomarker arrived? Clin Orthop Relat Res 2014; 472: pp. 3254-3262

    67. 67. Trampuz A., Piper K.E., Jacobson M.J., et al: Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med 2007; 357: pp. 654-663

    68. 68. Tunney M.M., Patrick S., Curran M.D., et al: Detection of prosthetic 287 hip infection at revision arthroplasty by immunofluorescence microscopy and PCR amplification of the bacterial 16S rRNA gene. J Clin Microbiol 1999; 37: pp. 3281

    69. 69. Panousis K., Grigoris P., Butcher I., et al: Poor predictive value of broad-range PCR for the detection of arthroplasty infection in 92 cases. Acta Orthop 2005; 76: pp. 341

    70. 70. Levine M.J., Mariani B.A., Tuan R.S., et al: Molecular genetic diagnosis of infected total joint arthroplasty. J Arthroplasty 1995; 10: pp. 93

    71. 71. Mariani B.D., Martin D.S., Levine M.J., et al: The Coventry Award. Polymerase chain reaction detection of bacterial infection in total knee arthroplasty. Clin Orthop Relat Res 1996; undefined: pp. 11

    72. 72. Achermann Y., Vogt M., Leunig M., et al: Improved diagnosis of periprosthetic joint infection by multiplex PCR of sonication fluid from removed implants. J Clin Microbiol 2010; 48: pp. 1208-1214

    73. 73. Ecker D.J., Sampath R., Massire C., et al: Ibis T5000: a universal biosensor approach for microbiology. Nat Rev Microbiol 2008; 6: pp. 553-558

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    Feb 23, 2017 | Posted by in ORTHOPEDIC | Comments Off on Diagnosis of Periprosthetic Joint Infection Following Hip and Knee Arthroplasty

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