The management of peri-prosthetic infection in total joint arthroplasty

Toms, Andrew; Davidson, Darin; Masri, Bassam A.; Duncan, Clivе P.

doi:10.1302/0301-620x.88b2.17058

Cited by 204 publications

(143 citation statements)

References 78 publications

Supporting

Mentioning

125

Contrasting

Unclassified

Order By: Relevance

“…Acute infection was defined as presentation within 6 weeks of an index procedure [3,10,13,28,30,34] and any infection beyond that time was classified as chronic. The patients in the infected and noninfected groups had similar demographics [7] ( Table 1).…”

Section: Methodsmentioning

confidence: 99%

Is Synovial C-reactive Protein a Useful Marker for Periprosthetic Joint Infection?

Tetreault

Wetters

Moric

et al. 2014

Clin Orthop Relat Res

102

View full text Add to dashboard Cite

Background Serum C-reactive protein (CRP) is a general marker of inflammation, and recent studies suggest that measurement of CRP in synovial fluid may be a more accurate method for diagnosing periprosthetic joint infection (PJI). Questions/purposes We aimed to (1) determine if there is a correlation between serum and synovial CRP values, (2) establish cutoff values for diagnosing infection based on serum and synovial CRP, and (3) compare the utility of measuring CRP in synovial fluid versus serum for the diagnosis of PJI using standard assay equipment available at most hospitals. Methods Between February 2011 and March 2012, we invited all 150 patients scheduled for revision TKA (84) or THA (66) to participate in this prospective study, of whom 100% agreed. Data ultimately were missing for 31 patients, leaving 60 patients undergoing revision TKA and 59 undergoing revision THA (71% and 89% of the original group, respectively) for whom CRP level was measured in serum and synovial fluid samples. Patients were deemed to have a PJI (32) or no infection (87) using Musculoskeletal Infection Society criteria. Serum and synovial CRP levels were assayed using the same immunospectrophotometer and the correlation coefficient was calculated. Receiver operating characteristic curve analyses were performed to compare utility in diagnosing PJI, which included area under the curve, diagnostic threshold, and test sensitivity, specificity, predictive values, and accuracy. In 22 of 150 patients (14.7%), synovial CRP could not be measured because the sample was too viscous or hemolyzed. Results In the analyzed 119 samples, there was a strong correlation (r = 0.76; p \ 0.001) between synovial and serum CRP. The area under the curve was 0.90 both for the synovial fluid (95% CI, 0.82-0.97) and serum (95% CI, 0.84-0.96) CRP assays. The diagnostic thresholds were 6.6 mg/L for synovial fluid and 11.2 mg/L for serum. Sensitivities, specificities, positive predictive value, negative predictive value, and accuracies were similar for synovial fluid and serum assays. Conclusions Although recent studies have suggested a superiority of synovial fluid CRP over serum CRP for the diagnosis of PJI, we found that measurement of CRP in synovial fluid rather than serum using readily available

show abstract

Section: Methodsmentioning

confidence: 99%

Is Synovial C-reactive Protein a Useful Marker for Periprosthetic Joint Infection?

Tetreault

Wetters

Moric

et al. 2014

Clin Orthop Relat Res

102

View full text Add to dashboard Cite

show abstract

“…A diagnosis of chronic prosthetic knee infection, at more than 6 weeks after TKA, [8,40,54,71,77,93], defined by at least three of the following, was the inclusion criteria (Table 1): (1) unexplained pain with no radiographic evidence of implant malpositioning; (2) 10 mg/L or greater C-reactive protein (CRP) without preexisting inflammatory joint disease [4,75,86]; (3) 30 mm/hour or greater erythrocyte sedimentation rate (ESR) without preexisting inflammatory joint disease [4,75,86]; (4) radiographic implant loosening and/or periosteal osteogenesis and/or progressive nonfocal osteolysis without implant malpositioning [90]; (5) sinus or fistula communicating with prosthesis; (6) abnormal leukocytes labeled technetium-99 m bone scan (LeukoScan 1 , Immunomedics GmbH, Darmstadt, Germany) [61]; (7) a positive culture of synovial fluid collected preoperatively; (8) five or more polymorphonuclear cells in at least five highpower fields in periprosthetic tissue samples, collected on removal of primary implant [9,32,91]; (9) a positive synovial fluid cell count (more than 2000 polymorphonuclear cells with greater than 64% polymorphonuclear leukocytes) without preexisting inflammatory joint disease [75,91]. A high American Society of Anesthesiologists (ASA) score [59] excluded four patients.…”

Section: Methodsmentioning

confidence: 99%

“…The lateral radiograph was used to assess healing (presence of bridging callus [16,34,47,70]) of the osteotomy fragment and proximal displacement (greater than 5-mm gap between the distal end of the fragment and the tibia) [16]. The integrity of the wires and progressive radiolucencies between the prosthesis and the host bone also were assessed [90]. Interobserver correlation coefficient was 0.87.…”

Section: Methodsmentioning

confidence: 99%

“…Infection was considered to have recurred if at any evaluation patients had at least two of the following: (1) unexplained pain and discomfort with no implant malpositioning observed on radiographs; (2) CRP of 10 mg/L or greater without preexisting inflammatory joint disease [4,75,86]; (3) ESR of 30 mm/hour or greater without preexisting inflammatory joint disease [4,75,86]; (4) radiographic evidence of implant loosening, periosteal bone formation, and/or progressive nonfocal osteolysis without malpositioning [90]; or (5) a sinus tract or fistula communicating with the prosthesis.…”

Section: Methodsmentioning

confidence: 99%

See 1 more Smart Citation

Tibial Tubercle Osteotomy or Quadriceps Snip in Two-stage Revision for Prosthetic Knee Infection? A Randomized Prospective Study

Bruni

Iacono

Sharma

et al. 2013

Clinical Orthopaedics &Amp; Related Research

View full text Add to dashboard Cite

Background Although 7% to 38% of revision total knee arthroplasties (RTKAs) are attributable to prosthetic knee infections, controversy exists regarding the best surgical approach while reducing the risk of extensor mechanism complications and the reinfection rate. Questions/purposes We compared The Knee Society Score Ó (KSS), incidences of complications, maximum knee flexion, residual extension lag, and reinfection rate in patients with prosthetic knee infections treated with two-stage RTKAs using either the tibial tubercle osteotomy (TTO) or the quadriceps snip (QS) for exposure at the time of reimplantation. Methods We prospectively followed 81 patients with chronic prosthetic knee infections treated between 1997 and 2004. Patients were randomized to receive a TTO or QS for exposure at the time of reimplantation. All patients had the same rehabilitation protocol. The minimum followup was 8 years (mean, 12 years; range, 8-15 years). Results Patients in the TTO group had a higher mean KSS than the QS group (88 versus 70, respectively). Mean maximum knee flexion was greater in the TTO group (113°v ersus 94°); with a lower incidence of extension lag (45% versus 13%). We observed no differences in reinfection rate between groups. Conclusions We found the TTO combined with an early rehabilitation protocol associated with superior KSS did not impair extensor mechanism function or increase the reinfection rate. We believe a two-stage RTKA with TTO is a reasonable approach for treating prosthetic knee infections.

show abstract

“…Infection was diagnosed when one or more of the following criteria were fulfilled: 1) isolation of the same microorganism from two or more cultures of joint aspirates or intraoperative periprosthetic-tissue specimens, 2) gross purulence in the joint space or sinus tract communication with the prosthesis, as identified by the surgeon at the time of surgery [17], or 3) positive intraoperative histological findings (at least ten neutrophils per highpower field), even in the absence of culture growth [18]. In the absence of any of the above evidence, the prosthesis was considered to be uninfected.…”

Section: Diagnosis Of Infectionmentioning

confidence: 99%

The Clinical Usefulness of 99mTc HMPAO Leukocyte/99mTc Phytate Bone Marrow Scintigraphy for Diagnosis of Prosthetic Knee Infection: A Preliminary Study

Jung

Park

Lee

et al. 2012

Nucl Med Mol Imaging

View full text Add to dashboard Cite

Purpose The preferred radionuclide imaging procedure for diagnosing prosthetic joint infection is combined radiolabeled leukocyte/ 99m Tc sulfur colloid bone marrow scintigraphy, which has an accuracy of over 90 %. Unfortunately, sulfur colloid is no longer available in South Korea. In this study, we evaluated the usefulness of 99m Tc phytate, a substitute for 99m Tc sulfur colloid, when combined with radiolabeled leukocyte scintigraphy in suspected prosthetic knee infections. Methods Eleven patients (nine women, two men; mean age 72±6 years) with painful knee prostheses and a suspicion of infection underwent both 99m Tc HMPAO leukocyte scintigraphy (LS) and 99m Tc phytate bone marrow scintigraphy (BMS). The combined images were interpreted as positive for infection when radioactivity in the LS at the site of clinical interest clearly exceeded that of the BMS (discordant); they were interpreted as negative when the increased activity in the LS was consistent with an increased activity in the BMS (concordant). The final diagnosis was made with microbiological or intraoperative findings and a clinical follow-up of at least 12 months. Results Five of eleven patients were diagnosed as having an infected prosthesis. The overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of the combined LS/BMS were 100 %, 83 %, 83 %, 100 % and 91 %, respectively. Conclusion We find that combined 99m Tc HMPAO LS/ 99m Tc phytate BMS shows comparable diagnostic performance to other studies utilizing sulfur colloid. Combined 99m Tc HMPAO LS/ 99m Tc phytate BMS is therefore expected to be an acceptable alternative to combined radiolabeled LS/ 99m Tc sulfur colloid BMS for diagnosing prosthetic knee infections.

show abstract

The management of peri-prosthetic infection in total joint arthroplasty

Cited by 204 publications

References 78 publications

Is Synovial C-reactive Protein a Useful Marker for Periprosthetic Joint Infection?

Is Synovial C-reactive Protein a Useful Marker for Periprosthetic Joint Infection?

Tibial Tubercle Osteotomy or Quadriceps Snip in Two-stage Revision for Prosthetic Knee Infection? A Randomized Prospective Study

The Clinical Usefulness of 99mTc HMPAO Leukocyte/99mTc Phytate Bone Marrow Scintigraphy for Diagnosis of Prosthetic Knee Infection: A Preliminary Study

Contact Info

Product

Resources

About