72 revision surgeries for aseptic failure after hip or knee arthroplasty: a prospective study with an extended diagnostic algorithm

Khalid, Vesal; Schønheyder, Henrik Carl; Nielsen, Poul; Kappel, Andreas; Thomsen, Trine Rolighed; Aleksyniene, Ramune; Lorenzen, Jan; Rasmussen, Sten

doi:10.1186/s12891-019-2944-y

Cited by 7 publications

(14 citation statements)

References 29 publications

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“…These so-called aseptic failures were defined as the patients with implant instability and/or polyethylene wear but also included cases with implant loosening. Within this population, five patients turned out to have an unrecognized PJI (6.9%), but it was not reported if the infections were only observed in the patients with prosthetic loosening [23]. The absence of infection in our patient population with mechanical failure should be interpreted with some caution.…”

Section: Discussionmentioning

confidence: 76%

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

Staphorst

Jutte

Boerboom

et al. 2021

Arch Orthop Trauma Surg

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Aims It is essential to exclude a periprosthetic joint infection (PJI) prior to revision surgery. It is recommended to routinely aspirate the joint before surgery. However, this may not be necessary in a subgroup of patients. The aim of our study was to investigate if specific clinical and implant characteristics could be identified to rule out a PJI prior to revision surgery. Methods We retrospectively evaluated clinical and implant characteristics of patients who underwent a hip or knee revision surgery between October 2015 and October 2018. Patients were diagnosed with a PJI according to the MSIS diagnostic criteria. Results A total of 156 patients were analyzed, including 107 implants that were revised because of prosthetic loosening and 49 because of mechanical failure (i.e. instability, malalignment or malpositioning). No PJI was diagnosed in the group with mechanical failure. In the prosthetic loosening group, 20 of 107 were diagnosed with a PJI (19%). Although there was a significantly lower chance of having a PJI with an implant age of > 5 years combined with a CRP < 5 mg/L, an infection was still present in 3 out of 39 cases (8%). Conclusion Implants with solely mechanical failure without signs of loosening and low inflammatory parameters probably do not require a synovial fluid aspiration. These results need to be confirmed in a larger cohort of patients. In case of prosthetic loosening, all joints need to be aspirated before surgery as no specific characteristic could be identified to rule out an infection.

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Section: Discussionmentioning

confidence: 76%

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

Staphorst

Jutte

Boerboom

et al. 2021

Arch Orthop Trauma Surg

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“…Nine studies matching our inclusion criteria were reviewed [4, 5, 7, 18, 24, 26, 41, 48, 49]. The flowchart is presented in Fig.…”

Section: Methodsmentioning

confidence: 99%

Prevalence, interpretation, and management of unexpected positive cultures in revision TKA: a systematic review

Kloos

Linden

Vermote

et al. 2022

Knee Surg Sports Traumatol Arthrosc

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PurposeUnexpected positive intraoperative cultures (UPIC) found in revision total knee arthroplasty (TKA) are difficult to interpret. Management goes along with risks for both over‐ and undertreating a potential periprosthetic joint infection (PJI). The objective of this systematic review was to determine the prevalence of UPIC in revision TKA surgery, evaluate the diagnostic workup process and the postoperative treatment, and assess outcome regarding re‐revision rates. MethodsEvidence was gathered from Medline (PubMed) and Embase published from January 2000 until April 2021. Nine studies with data of UPIC in revision TKA and outcome after at least 2 years of follow‐up were identified. ResultsThe calculated prevalence of UPIC in aseptic knee revision surgery was 8.32%. However, the diagnostical approach differs as well as the used criteria to confirm PJI in presumed aseptic revision surgery. The work‐up generally consists of a serum C‐reactive protein and Erythrocyte Sedimentation Rate, joint fluid aspiration for culture and white blood cell count and formula, and radiographic imaging. Collection of intraoperative cultures is widely used, but inconsistent in sample amount and incubation time. Once a single UPIC is found, surgeons tend to treat it in different ways. Regarding re‐revision rates, the weighted arithmetic mean in the included studies was 18.45% in the unsuspected PJI group compared to 2.94% in the aseptic group. There also seems to be a trend towards higher re‐revision rates when a higher number of intraoperative cultures are positive. ConclusionThe interpretation of UPIC in revision TKA is of utmost importance since the decision whether to treat a UPIC as an unsuspected PJI has a major impact on implant survival and re‐revision rate. Different criteria are used to differentiate between unsuspected PJI and contamination in true aseptic failure, and the heterogeneity amongst the included papers impedes to state a clear recommendation, integrating not only quantitative findings, but also qualitative data such as virulence of the identified microorganism. Level of evidenceSystematic review, III.

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“…Patients presenting with a prosthetic problem related to either a TKA or THA were included and followed the multidisciplinary algorithm (Appendix A, Figure A1). The full project overview with inclusion criteria, detailed patient characteristics, pre-and postoperative findings, and a full description of the multidisciplinary algorithm was described by Khalid et al [2,24].…”

Section: Methodsmentioning

confidence: 99%

“…A total of 156 patients with 163 arthroplasties were included in the PRIS project [2,24]. According to the project algorithm (Figure A1), fifty-five patients (26 women and 29 men, mean age 64 years) were included in a group for chronic problems (29 knees and 26 hips).…”

Section: Patient Populationmentioning

confidence: 99%

“…Less stringent criteria have been proposed by recent studies [27], and therefore, an additional analysis was performed for patients with two positive tissue biopsy cultures with identical microorganism(s). A diagnosis of culture-negative PJI was made if clinical findings, including intra-operative view, were suggestive of PJI without fulfilling other criteria for PJI [2,24] (Figure A2).…”

Section: Reference Standardmentioning

confidence: 99%

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The Role of Nuclear Medicine Imaging with 18F-FDG PET/CT, Combined 111In-WBC/99mTc-Nanocoll, and 99mTc-HDP SPECT/CT in the Evaluation of Patients with Chronic Problems after TKA or THA in a Prospective Study

et al. 2022

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Background: The aim of this prospective study was to assess the diagnostic value of nuclear imaging with 18F-FDG PET/CT (FDG PET/CT), combined 111In-WBC/99mTc-Nanocoll, and 99mTc-HDP SPECT/CT (dual-isotope WBC/bone marrow scan) for patients with chronic problems related to knee or hip prostheses (TKA or THA) scheduled by a structured multidisciplinary algorithm. Materials and Methods: Fifty-five patients underwent imaging with 99mTc–HDP SPECT/CT (bone scan), dual-isotope WBC/bone marrow scan, and FDG PET/CT. The final diagnosis of prosthetic joint infection (PJI) and/or loosening was based on the intraoperative findings and microbiological culture results and the clinical follow-up. Results: The diagnostic performance of dual-isotope WBC/bone marrow SPECT/CT for PJI showed a sensitivity of 100% (CI 0.74–1.00), a specificity of 97% (CI 0.82–1.00), and an accuracy of 98% (CI 0.88–1.00); for PET/CT, the sensitivity, specificity, and accuracy were 100% (CI 0.74–1.00), 71% (CI 0.56–0.90), and 79% (CI 0.68–0.93), respectively. Conclusions: In a standardized prospectively scheduled patient group, the results showed highly specific performance of combined dual-isotope WBC/bone marrow SPECT/CT in confirming chronic PJI. FDG PET/CT has an appropriate accuracy, but the utility of its use in the clinical diagnostic algorithm of suspected PJI needs further evidence.

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72 revision surgeries for aseptic failure after hip or knee arthroplasty: a prospective study with an extended diagnostic algorithm

Cited by 7 publications

References 29 publications

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

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

Prevalence, interpretation, and management of unexpected positive cultures in revision TKA: a systematic review

The Role of Nuclear Medicine Imaging with 18F-FDG PET/CT, Combined 111In-WBC/99mTc-Nanocoll, and 99mTc-HDP SPECT/CT in the Evaluation of Patients with Chronic Problems after TKA or THA in a Prospective Study

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