Diagnostic accuracy of arthroscopic biopsy in periprosthetic infections of the hip

Abstract

BackgroundDiagnosis of a low-grade periprosthetic joint infection (PJI) prior to revision surgery can be challenging, despite paramount importance for further treatment. Arthroscopic biopsy of synovial and periprosthetic tissue with subsequent microbiological and histological examination can be beneficial but its specific diagnostic value has not been clearly defined.Methods20 consecutive patients who underwent percutaneous synovial fluid aspiration as well as arthroscopic biopsy due to suspected PJI of the hip and subsequent one- or two-stage revision surgery at our institution between January 2012 and May 2015 were enrolled. Indication was based on the criteria (1) history of PJI and increased levels of erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), (2) suspicious cell count and differential but negative bacterial culture in synovial aspirate, (3) early loosening (<less than 2 years), or (4) persisting pain without loosening but history of a PJI. At least two criteria had to be fulfilled in order to perform an arthroscopic biopsy.ResultsBest overall diagnostic value was identified for arthroscopic biopsy and a combination of bacteriological and histological analysis with a sensitivity of 87.5%, specificity of 100% and accuracy of 95%. Bacteriological assessment of synovial aspirate revealed a sensitivity of 50.0%, specificity of 91.7%, and accuracy of 75%. ESR and CRP yielded a sensitivity of 75.0% for either hematologic test and specificities of 87.5 and 66.7%, respectively.ConclusionsIn conclusion, our data indicate that arthroscopic biopsy is superior to ESR and CRP as well as joint aspiration and their combinations. Concurrent microbiological and histological examination of the biopsy specimens allows for identification of the causative pathogen and its susceptibility pattern in order to preoperatively plan the surgical strategy as well as the antibiotic regimen. Moreover, intraarticular mechanical failure can be detected during hip arthroscopy emphasizing its diagnostic value. Level II diagnostic study.

Twenty common errors in the diagnosis and treatment of periprosthetic joint infection

“…Hyman et al [65] described favorable results in a series of eight patients with late acute hip PJIs-all patients were, however, managed with chronic antibiotic suppression in addition to arthroscopic lavage. Arthroscopy has a limited role in the diagnostic workup of a painful prosthesis, allowing for inspection of the components in search of instability and wear, exclusion of non-infectious causes, visualization of the synovium, and retrieval of samples for microbiology and histology in selected cases [14,[66][67][68]. Importantly, arthroscopy is an invasive intervention, which is associated with a small risk of infection; therefore, the indication for diagnostic arthroscopy should be considered carefully.…”

Is combining serum interleukin-6 and C-reactive protein a reliable diagnostic tool in periprosthetic joint infections?

“…The most commonly used method is the comprehensive consideration of multiple tests to distinguish between aseptic loosening and PJI [1]. However, the combined test, which was more suitable for the diagnosis of PJI was unclear [2,3].…”

“…The most commonly used method is the comprehensive consideration of multiple tests to distinguish between aseptic loosening and PJI [1]. However, the combined test, which was more suitable for the diagnosis of PJI was unclear [2,3].Previous studies have indicated that serum interleukin-6 (IL-6) seems to be a promising tool for the diagnosis of PJI [4,5], and a meta-analysis of 11 studies reported that the pooled sensitivity and specificity of serum IL-6 were 0.72 (95% confidence interval [CI], 0.63-0.80) and 0.89 (95% CI, 0.77-0.95), respectively [6]. In recent years, the combination of serum IL-6 and C-reactive protein (CRP)…”

Is combining serum interleukin-6 and C-reactive protein a reliable diagnostic tool in periprosthetic joint infections?

“…Although a variety of serum, synovial uid, periprosthetic tissue, and sonication uid tests are currently performed for the diagnosis of periprosthetic joint infection (PJI), there is no single indicator that can detect infection with 100% accuracy [1]. Combined tests appear to further improve the diagnostic value, although which combined test is more suitable for diagnosis remained uncleared [2,3].…”

“…Staphylococcus epidermidis (8) Cutibacterium acnes (3) Culture negative infection (3) Staphylococcus capitis (2) Staphylococcus haemolyticus (1) Polymicrobial infection (1) Staphylococcus auricularis (1) Micrococcus luteus (1) Forest plots of the diagnostic odds ratio for the combined method (a), IL-6 (b) and CRP (c).…”