Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 17, Issue 6, pp 667–675

Pre-operative diagnosis of infection in total knee arthroplasty: an algorithm

  • Lucia Savarino
  • Domenico Tigani
  • Nicola Baldini
  • Valerio Bochicchio
  • Armando Giunti
Knee

Abstract

The aim of our study was to construct an algorithm for the pre-operative diagnosis of infection in total knee arthroplasty. We analyzed the currently used parameters in a consecutive series of 31 patients with failed implants. An outcome of at least 2 years was prospectively considered to validate our algorithm. Patient history, imaging, laboratory studies, histology, pre- and intra-operative cultures were considered. The optimal cutoffs of the inflammation tests for diagnosing infection were determined by constructing the receiver operating-characteristic curves. Sensitivity, specificity and accuracy of these tests as infection markers were determined. The combination of at least two tests with values higher than the cutoffs is reliable for predicting the infection. Scintigraphy, needle-aspirate cell count and culture can integrate the pre-operative evaluation. Doubtful cases can be clarified by microbiological and histological analyses. As a result an algorithm helpful to identify the cause of loosening has been developed. In our opinion, adherence to this algorithm could contribute to preoperatively define a rational surgical and antibiotic treatment strategy.

Keywords

Knee Arthroplasty Infection Pre-operative diagnosis Algorithm 

References

  1. 1.
    Ali F, Wilkinson JM, Cooper JR, Kerry RM, Hamer AJ, Norman P, Stockley I (2006) Accuracy of joint aspiration for the preoperative diagnosis of infection in total hip arthroplasty. J Arthroplasty 21:221–226PubMedCrossRefGoogle Scholar
  2. 2.
    Archibeck MJ, Jacobs JJ, Roebuck KA, Glant TT (2001) The basic science of periprosthetic osteolysis. Instr Course Lect 50:185–195PubMedGoogle Scholar
  3. 3.
    Athanasou NA, Pandey R, de Steiger R, Crook D, McLardy Smith P (1995) Diagnosis of infection by frozen section during revision arthroplasty. J Bone Joint Surg Br 77:28–33PubMedGoogle Scholar
  4. 4.
    Baré J, MacDonald SJ, Bourne RB (2006) Preoperative evaluations in revision total knee arthroplasty. Clin Orthop Relat Res 446:40–44PubMedCrossRefGoogle Scholar
  5. 5.
    Barrack RL, Aggarwal A, Burnett RS, Clohisy JC, Ghanem E, Sharkey P, Parvizi J (2007) The fate of the unexpected positive intraoperative cultures after revision total knee arthroplasty. J Arthroplasty 22(6 suppl 2):94–99PubMedCrossRefGoogle Scholar
  6. 6.
    Berger RA, Crossett LS, Jacobs JJ, Rubasi HE (1998) Malrotation causing patellofemoral complication after total knee arthroplasty. Clin Orthop 356:144–153PubMedCrossRefGoogle Scholar
  7. 7.
    Bori G, Soriano A, Garcia S, Mallofré C, Riba J, Mensa J (2007) Usefulness of histological analysis for predicting the presence of microorganisms at the time of reimplantation after hip resection arthroplasty for the treatment of infection. J Bone Joint Surg Am 89:1232–1237PubMedCrossRefGoogle Scholar
  8. 8.
    Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM, Lijmer JG, Moher D, Rennie D, de Vet HC, Standards for Reporting of Diagnostic Accuracy Group (2003) Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. BMJ 326:41–44PubMedCrossRefGoogle Scholar
  9. 9.
    Della Valle CJ, Sporer SM, Jacobs JJ, Berger RA, Rosenberg AG, Paprosky WG (2007) Preoperative testing for sepsis before revision total knee arthroplasty. J Arthroplasty 22(6 suppl2):90–93PubMedCrossRefGoogle Scholar
  10. 10.
    Dellon AL, Mont MA, Mullick T, Hungerford DS (1996) Partial denervation for persistent neuroma pain around the knee. Clin Orthop Relat Res 329:216–222PubMedCrossRefGoogle Scholar
  11. 11.
    Francés Borrego A, Martínez FM, Cebrian Parra JL, Grañeda DS, Crespo RG, López-Durán Stern L (2007) Diagnosis of infection in hip and knee revision surgery: intraoperative frozen section analysis. Int Orthop 31:33–37PubMedCrossRefGoogle Scholar
  12. 12.
    Greidanus NV, Masri BA, Garbuz DS, Wilson SD, McAlinden MG, Xu M, Duncan CP (2007) 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 89:1409–1416PubMedCrossRefGoogle Scholar
  13. 13.
    Katz MM, Hungerford DS (1987) Reflex sympathetic dystrophy affecting the knee. J Bone Joint Surg Br 69:797–803PubMedGoogle Scholar
  14. 14.
    Mariani BD, Martin DS, Levine MJ, Booth RE Jr, Tuan RS (1996) Polymerase chain reaction detection of bacterial infection in total knee arthroplasty. Clin Orthop Relat Res 331:11–22PubMedCrossRefGoogle Scholar
  15. 15.
    Mason JB, Fehring TK, Odum SM, Griffin WL, Nussman DS (2003) The value of white blood cell counts before revision total knee arthroplasty. J Arthroplasty 18:1038–1043PubMedCrossRefGoogle Scholar
  16. 16.
    Mont MA, Waldman BJ, Hungerford DS (2000) Evaluation of preoperative cultures before second-stage reimplantation of a total knee prosthesis complicated by infection. A comparison-group study. J Bone Joint Surg Am 82:1552–1557PubMedGoogle Scholar
  17. 17.
    Pakos EE, Trikalinos TA, Fotopoulos AD, Ioannidis JP (2007) Prosthesis infection: diagnosis after total joint arthroplasty with antigranulocyte scintigraphy with 99mTc-labeled monoclonal antibodies—a meta-analysis. Radiology 242:101–108PubMedCrossRefGoogle Scholar
  18. 18.
    Pandey R, Quinn J, Joyner C, Murray DW, Triffitt JT, Athanasou NA (1996) Arthroplasty implant biomaterial particle associated macrophages differentiate into lacunar bone resorbing cells. Ann Rheum Dis 55:388–395PubMedCrossRefGoogle Scholar
  19. 19.
    Parvizi J, Ghanem E, Menashe S, Barrack RL, Bauer TW (2006) Periprosthetic infection: what are the diagnostic challenges? J Bone Joint Surg Am 88:138–147PubMedCrossRefGoogle Scholar
  20. 20.
    Pizzoferrato A, Fiori F, Savarino L (1980) Microbiological investigation on 161 cases of hip endoarthroprosthesis failure. Chir Organi Mov 66:297–307PubMedGoogle Scholar
  21. 21.
    Pizzoferrato A, Ciapetti G, Savarino L, Stea S, Tarabusi C (1988) Results of histopathological grading on 100 cases of HIP prosthesis failure. Biomaterials 9:314–318PubMedCrossRefGoogle Scholar
  22. 22.
    Savarino L, Baldini N, Tarabusi C, Pellacani A, Giunti A (2004) Diagnosis of infection after total hip replacement. J Biomed Mater Res B Appl Biomater 70:139–145PubMedCrossRefGoogle Scholar
  23. 23.
    Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM (2002) Why are total knee arthroplasties failing today? Clin Orthop Relat Res 404:7–13PubMedCrossRefGoogle Scholar
  24. 24.
    Spangehl MJ, Younger ASE, Masri BA, Duncan CP (1997) Instructional course lectures, The American Academy of Orthopaedic Surgeons—diagnosis of infection following total hip arthroplasty. J Bone Joint Surg Am 79:1578–1588Google Scholar
  25. 25.
    Spangehl MJ, Masri BA, O’Connell JX, Duncan CP (1999) 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 81:672–683PubMedGoogle Scholar
  26. 26.
    Sudanese A, Toni A, Busanelli L, Furno A, Montina PP, Marraro MD, Terzi S, Giunti A (1994) Diagnostic protocol in prosthetic loosening. Chir Organi Mov 79(4):257–267PubMedGoogle Scholar
  27. 27.
    Trampuz A, Hanssen AD, Osmon DR, Mandrekar J, Steckelberg JM, Patel R (2004) Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med 117:556–562PubMedCrossRefGoogle Scholar
  28. 28.
    Tsukayama DT, Goldberg VM, Kyle R (2003) Diagnosis and management of infection after total knee arthroplasty. J Bone Joint Surg Am 85(Suppl 1):S75–S80PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Lucia Savarino
    • 1
  • Domenico Tigani
    • 2
  • Nicola Baldini
    • 1
    • 2
  • Valerio Bochicchio
    • 2
  • Armando Giunti
    • 1
    • 2
    • 3
  1. 1.Laboratory for Pathophysiology of Orthopaedic ImplantsIstituto Ortopedico RizzoliBolognaItaly
  2. 2.7th DivisionIstituto Ortopedico RizzoliBolognaItaly
  3. 3.Department of Orthopaedic SurgeryUniversity of BolognaBolognaItaly

Personalised recommendations