Clinical Orthopaedics and Related Research®

, Volume 468, Issue 5, pp 1410–1417 | Cite as

Is There a Role for Tissue Biopsy in the Diagnosis of Periprosthetic Infection?

  • Geert MeermansEmail author
  • Fares S. Haddad
Clinical Research



Successful treatment of an infected joint arthroplasty depends on correctly identifying the responsible pathogens. The value of a preoperative biopsy remains controversial.


We (1) compared the sensitivity and specificity of both tests separately and in combination, and (2) asked whether the combination of tissue biopsy and aspiration would improve our diagnostic yield in the evaluation of periprosthetic joint infections.

Patients and Methods

We prospectively followed 120 patients with suspected infection of a total joint arthroplasty: 64 with THAs and 56 with TKAs. All patients had aspiration with culture and biopsy.


The sensitivity was 83% for aspiration, 79% for biopsy, and 90% for the combination of both techniques. The specificity was 100% for aspiration and biopsy and the combination. The overall accuracy was 84%, 81%, and 90%, respectively.


Our data suggest tissue biopsy alone offers no clear advantage over joint aspiration. However, the combination of both techniques provides improved sensitivity and accuracy. We recommend the use of tissue biopsy as an adjunct to joint aspiration in the diagnosis of total joint infection.

Level of Evidence

Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.


Tissue Biopsy Total Joint Arthroplasty Periprosthetic Joint Infection Joint Arthroplasty Periprosthetic Infection 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We acknowledge the microbiologic support provided by Geoff Ridgeway, Geoff Scott, Vanya Gant, John Holton, and Bruce Macrae.


  1. 1.
    Aalto K, Osterman K, Peltola H, Räsänen J. Changes in erythrocyte sedimentation rate and C-reactive protein after total hip arthroplasty. Clin Orthop Relat Res. 1984;184:118–120.PubMedGoogle Scholar
  2. 2.
    Ali F, Wilkinson JM, Cooper JR, Kerry RM, Hamer AJ, Norman P, Stockley I. Accuracy of joint aspiration for the preoperative diagnosis of infection in total hip arthroplasty. J Arthroplasty. 2006;21:221–226.CrossRefPubMedGoogle Scholar
  3. 3.
    Athanasou NA, Pandey R, de Steiger R, Crook D, Smith PM. Diagnosis of infection by frozen section during revision arthroplasty. J Bone Joint Surg Br. 1995;77:28–33.PubMedGoogle Scholar
  4. 4.
    Atkins BL, Athanasou N, Deeks JJ, Crook DW, Simpson H, Peto TE, McLardy-Smith P, Berendt AR. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty: The OSIRIS Collaborative Study Group. J Clin Microbiol. 1998;36:2932–2939.PubMedGoogle Scholar
  5. 5.
    Barrack RL, Harris WH. The value of aspiration of the hip joint before revision total hip arthroplasty. J Bone Joint Surg Am. 1993;75:66–76.PubMedGoogle Scholar
  6. 6.
    Barrack RL, Jennings RW, Wolfe MW, Bertot AJ. The Coventry Award: The value of preoperative aspiration before total knee revision. Clin Orthop Relat Res. 1997;345:8–16.CrossRefPubMedGoogle Scholar
  7. 7.
    Beaulé V, Larédo JD, Cywiner C, Bard M, Tubiana JM. Synovial membrane: percutaneous biopsy. Radiology. 1990;177:581–585.PubMedGoogle Scholar
  8. 8.
    Bernard L, Lübbeke A, Stern R, Bru JP, Feron JM, Peyramond D, Denormandie P, Arvieux C, Chirouze C, Perronne C, Hoffmeyer P; Groupe D’Etude Sur L’Ostéite. Value of preoperative investigations in diagnosing prosthetic joint infection: retrospective cohort study and literature review. Scand J Infect Dis. 2004;36:410–416.CrossRefPubMedGoogle Scholar
  9. 9.
    Buchholz HW, Elson RA, Engelbrecht E, Lodenkämper H, Röttger J, Siegel A. Management of deep infection of total hip replacement. J Bone Joint Surg Br. 1981;63:342–353.PubMedGoogle Scholar
  10. 10.
    Burnett RS, Kelly MA, Hanssen AD, Barrack RL. Technique and timing of two-stage exchange for infection in TKA. Clin Orthop Relat Res. 2007;464:164–178.PubMedGoogle Scholar
  11. 11.
    Canner GC, Steinberg ME, Heppenstall RB, Balderston R. The infected hip after total hip arthroplasty. J Bone Joint Surg Am. 1984;66:1393–1399.PubMedGoogle Scholar
  12. 12.
    Charnley J. Postoperative infection after total hip replacement with special reference to air contamination in the operating room. Clin Orthop Relat Res. 1972;87:167–187.CrossRefPubMedGoogle Scholar
  13. 13.
    Charnley J, Eftekhar NS. Postoperative infection in total prosthetic replacement arthroplasty of the hip joint: with special reference to the bacterial content of the air of the operating room. Br J Surg. 1969;56:641–649.CrossRefPubMedGoogle Scholar
  14. 14.
    Chesney D, Sales J, Elton R, Brenkel IJ. Infection after knee arthroplasty: a prospective study of 1509 cases. J Arthroplasty. 2008;23:355–359.CrossRefPubMedGoogle Scholar
  15. 15.
    Cheung A, Lachiewicz PF, Renner JB. The role of aspiration and contrast-enhanced arthrography in evaluating the uncemented hip arthroplasty. AJR Am J Roentgenol. 1997;168:1305–1309.PubMedGoogle Scholar
  16. 16.
    Costerton JW. Biofilm theory can guide the treatment of device-related orthopaedic infections. Clin Orthop Relat Res. 2005;437:7–11.CrossRefPubMedGoogle Scholar
  17. 17.
    Covey DC, Albright JA. Current concepts review: Clinical significance of the erythrocyte sedimentation rate in orthopaedic surgery. J Bone Joint Surg Am. 1987;69:148–151.PubMedGoogle Scholar
  18. 18.
    Duff GP, Lachiewicz PF, Kelley SS. Aspiration of the knee joint before revision arthroplasty. Clin Orthop Relat Res. 1996;331:132–139.CrossRefPubMedGoogle Scholar
  19. 19.
    Fehring TK, Cohen B. Aspiration as a guide to sepsis in revision total hip arthroplasty. J Arthroplasty. 1996;11:543–547.CrossRefPubMedGoogle Scholar
  20. 20.
    Fink B, Makowiak C, Fuerst M, Berger I, Schäfer P, Frommelt L. The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late peri-prosthetic infection of total knee replacements. J Bone Joint Surg Br. 2008;90:874–878.CrossRefPubMedGoogle Scholar
  21. 21.
    Friesecke C, Wodtke J. Periprosthetic knee infection: one-stage exchange. Orthopade. 2006;35:937–938, 940–945.Google Scholar
  22. 22.
    Fuerst M, Fink B, Rüther W. [The value of preoperative knee aspiration and arthroscopic biopsy in revision total knee arthroplasty] [in German]. Z Orthop Ihre Grenzgeb. 2005;143:36–41.CrossRefPubMedGoogle Scholar
  23. 23.
    Garvin KL, Hanssen AD. Current concepts review: Infection after total hip arthroplasty: past, present, and future. J Bone Joint Surg Am. 1995;77:1576–1588.PubMedGoogle Scholar
  24. 24.
    Glithero PR, Grigoris P, Harding LK, Hesslewood SR, McMinn DJ. White cell scans and infected joint replacements: failure to detect chronic infection. J Bone Joint Surg Br. 1993;75:371–374.PubMedGoogle Scholar
  25. 25.
    Gollwitzer H, Diehl P, Gerdesmeyer L, Mittelmeier W. [Diagnostic strategies in cases of suspected periprosthetic infection of the knee: a review of the literature and current recommendations] [in German]. Orthopade. 2006;35:904, 906–908, 910–916.Google Scholar
  26. 26.
    Haddad FS, Masri BA, Garbuz DS, Duncan CP. The treatment of the infected hip replacement: the complex case. Clin Orthop Relat Res. 1999;369:144–156.CrossRefPubMedGoogle Scholar
  27. 27.
    Hanssen AD, Spangehl MJ. Treatment of the infected hip replacement. Clin Orthop Relat Res. 2004;420:63–71.CrossRefPubMedGoogle Scholar
  28. 28.
    Ince A, Rupp J, Frommelt L, Katzer A, Gille J, Löhr JF. Is “aseptic” loosening of the prosthetic cup after total hip replacement due to nonculturable bacterial pathogens in patients with low-grade infection? Clin Infect Dis. 2004;39:1599–1603.CrossRefPubMedGoogle Scholar
  29. 29.
    Itasaka T, Kawai A, Sato T, Mitani S, Inoue H. Diagnosis of infection after total hip arthroplasty. J Orthop Sci. 2001;6:320–326.CrossRefPubMedGoogle Scholar
  30. 30.
    James ET, Hunter GA, Cameron HU. Total hip revision arthroplasty: does sepsis influence the results? Clin Orthop Relat Res. 1982;170:88–94.PubMedGoogle Scholar
  31. 31.
    Johnson JA, Christie MJ, Sandler MP, Parks PF Jr, Homra L, Kaye JJ. Detection of occult infection following total joint arthroplasty using sequential technetium-99 m HDP bone scintigraphy and indium-111 WBC imaging. J Nucl Med. 1988;29:1347–1353.PubMedGoogle Scholar
  32. 32.
    Kordelle J, Klett R, Stahl U, Hossain H, Schleicher I, Haas H. [Infection diagnosis after knee-TEP-implantation] [in German]. Z Orthop Ihre Grenzgeb. 2004;142:337–343.CrossRefPubMedGoogle Scholar
  33. 33.
    Kraemer WJ, Saplys R, Waddell JP, Morton J. Bone scan, gallium scan, and hip aspiration in the diagnosis of infected total hip arthroplasty. J Arthroplasty. 1993;8:611–616.CrossRefPubMedGoogle Scholar
  34. 34.
    Lachiewicz PF, Rogers GD, Thomason HC. 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;78:749–754.PubMedGoogle Scholar
  35. 35.
    Levitsky KA, Hozack WJ, Balderston RA, Rothman RH, Gluckman SJ, Maslack MM, Booth RE Jr. Evaluation of the painful prosthetic joint: relative value of bone scan, sedimentation rate, and joint aspiration. J Arthroplasty. 1991;6:237–244.CrossRefPubMedGoogle Scholar
  36. 36.
    Lieberman JR, Huo MH, Schneider R, Salvati EA, Rodi S. Evaluation of painful hip arthroplasties: are technetium bone scans necessary? J Bone Joint Surg Br. 1993;75:475–478.PubMedGoogle Scholar
  37. 37.
    Lonner JH, Desai P, Dicesare PE, Steiner G, Zuckerman JD. The reliability of analysis of intraoperative frozen sections for identifying active infection during revision hip or knee arthroplasty. J Bone Joint Surg Am. 1996;78:1553–1558.PubMedGoogle Scholar
  38. 38.
    Lonner JH, Siliski JM, Della Valle C, DiCesare P, Lotke PA. Role of knee aspiration after resection of the infected total knee arthroplasty. Am J Orthop. 2001;30:305–309.PubMedGoogle Scholar
  39. 39.
    Malhotra R, Morgan DA. Role of core biopsy in diagnosing infection before revision hip arthroplasty. J Arthroplasty. 2004;19:78–87.CrossRefPubMedGoogle Scholar
  40. 40.
    Merkel KD, Brown ML, Dewanjee MK, Fitzgerald RH Jr. Comparison of indium-labeled-leukocyte imaging with sequential technetium-gallium scanning in the diagnosis of low-grade musculoskeletal sepsis: a prospective study. J Bone Joint Surg Am. 1985;67:465–476.PubMedGoogle Scholar
  41. 41.
    Mirra JM, Amstutz HC, Matos M, Gold R. The pathology of the joint tissues and its clinical relevance in prosthesis failure. Clin Orthop Relat Res. 1976;117:221–240.PubMedGoogle Scholar
  42. 42.
    Mont MA, Waldman BJ, Hungerford DS. 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. 2000;82:1552–1557.PubMedGoogle Scholar
  43. 43.
    Mulcahy DM, Fenelon GC, McInerney DP. Aspiration arthrography of the hip joint: its uses and limitations in revision hip surgery. J Arthroplasty. 1996;11:64–68.CrossRefPubMedGoogle Scholar
  44. 44.
    Müller M, Morawietz L, Hasart O, Strube P, Perka C, Tohtz S. Diagnosis of periprosthetic infection following total hip arthroplasty: evaluation of the diagnostic values of pre- and intraoperative parameters and the associated strategy to preoperatively select patients with a high probability of joint infection. J Orthop Surg. 2008;3:31.CrossRefGoogle Scholar
  45. 45.
    Neut D, van Horn JR, van Kooten TG, van der Mei HC, Busscher HJ. Detection of biomaterial-associated infections in orthopaedic joint implants. Clin Orthop Relat Res. 2003;413:261–268.CrossRefPubMedGoogle Scholar
  46. 46.
    O’Neill DA, Harris WH. Failed total hip replacement: assessment by plain radiographs, arthrograms, and aspiration of the hip joint. J Bone Joint Surg Am. 1984;66:540–546.PubMedGoogle Scholar
  47. 47.
    Panousis K, Grigoris P, Butcher I, Rana B, Reilly JH, Hamblen DL. Poor predictive value of broad-range PCR for the detection of arthroplasty infection in 92 cases. Acta Orthop. 2005;76:341–346.PubMedGoogle Scholar
  48. 48.
    Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res. 2001;392:15–23.CrossRefPubMedGoogle Scholar
  49. 49.
    Raut VV, Siney PD, Wroblewski BM. One-stage revision of infected total hip replacements with discharging sinuses. J Bone Joint Surg Br. 1994;76:721–724.PubMedGoogle Scholar
  50. 50.
    Raut VV, Siney PD, Wroblewski BM. One-stage revision of total hip arthroplasty for deep infection: long-term followup. Clin Orthop Relat Res. 1995;321:202–207.PubMedGoogle Scholar
  51. 51.
    Roberts P, Walters AJ, McMinn DJ. Diagnosing infection in hip replacements: the use of fine-needle aspiration and radiometric culture. J Bone Joint Surg Br. 1992;74:265–269.PubMedGoogle Scholar
  52. 52.
    Sadiq S, Wootton JR, Morris CA, Northmore-Ball MD. Application of core biopsy in revision arthroplasty for deep infection. J Arthroplasty. 2005;20:196–201.CrossRefPubMedGoogle Scholar
  53. 53.
    Salvati EA, Robinson RP, Zeno SM, Koslin BL, Brause BD, Wilson PD Jr. Infection rates after 3175 total hip and knee replacements performed with and without a horizontal unidirectional filtered air-flow system. J Bone Joint Surg Am. 1982;64:525–535.PubMedGoogle Scholar
  54. 54.
    Salvati EA, Wilson PD Jr, Jolley MN, Vakili F, Aglietti P, Brown GC. A ten-year follow-up study of our first one hundred consecutive Charnley total hip replacements. J Bone Joint Surg Am. 1981;63:753–767.PubMedGoogle Scholar
  55. 55.
    Schulak DJ, Rayhack JM, Lippert FG III, Convery FR. The erythrocyte sedimentation rate in orthopaedic patients. Clin Orthop Relat Res. 1982;167:197–202.PubMedGoogle Scholar
  56. 56.
    Schutzer SF, Harris WH. Deep-wound infection after total hip replacement under contemporary aseptic conditions. J Bone Joint Surg Am. 1988;70:724–727.PubMedGoogle Scholar
  57. 57.
    Shih LY, Wu JJ, Yang DJ. Erythrocyte sedimentation rate and C-reactive protein values in patients with total hip arthroplasty. Clin Orthop Relat Res. 1987;225:238–246.PubMedGoogle Scholar
  58. 58.
    Somme D, Ziza JM, Desplaces N, Chicheportiche V, Chazerain P, Leonard P, Lhotellier L, Jacquenod P, Mamoudy P. Contribution of routine joint aspiration to the diagnosis of infection before hip revision surgery. Joint Bone Spine. 2003;70:489–495.CrossRefPubMedGoogle Scholar
  59. 59.
    Spangehl MJ, Masri BA, O’Connell JX, Duncan CP. 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;81:672–683.PubMedGoogle Scholar
  60. 60.
    Steinbrink K, Frommelt L. [Treatment of periprosthetic infection of the hip using one-stage exchange surgery] [in German]. Orthopade. 1995;24:335–343.PubMedGoogle Scholar
  61. 61.
    Taylor T, Beggs I. Fine needle aspiration in infected hip replacements. Clin Radiol. 1995;50:149–152.CrossRefPubMedGoogle Scholar
  62. 62.
    Teller RE, Christie MJ, Martin W, Nance EP, Haas DW. Sequential indium-labeled leukocyte and bone scans to diagnose prosthetic joint infection. Clin Orthop Relat Res. 2000;373:241–247.CrossRefPubMedGoogle Scholar
  63. 63.
    Tigges S, Stiles RG, Meli RJ, Roberson JR. Hip aspiration: a cost effective and accurate method of evaluating the potentially infected hip prosthesis. Radiology. 1993;189:485–488.PubMedGoogle Scholar
  64. 64.
    Van den Bekerom MP, Stuyck J. The value of pre-operative aspiration in the diagnosis of an infected prosthetic knee: a retrospective study and review of literature. Acta Orthop Belg. 2006;72:441–447.PubMedGoogle Scholar
  65. 65.
    Virolainen P, Lähteenmäki H, Hiltunen A, Sipola E, Meurman O, Nelimarkka O. The reliability of diagnosis of infection during revision arthroplasties. Scand J Surg. 2002;91:178–181.PubMedGoogle Scholar
  66. 66.
    Williams JL, Norman P, Stockley I. The value of hip aspiration versus tissue biopsy in diagnosing infection before exchange hip arthroplasty surgery. J Arthroplasty. 2004;19:582–586.CrossRefPubMedGoogle Scholar
  67. 67.
    Wukich DK, Abreu SH, Callaghan JJ, Van Nostrand D, Savory CG, Eggli DF, Garcia JE, Berrey BH. Diagnosis of infection by preoperative scintigraphy with indium-labeled white blood cells. J Bone Joint Surg Am. 1987;69:1353–1360.PubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2010

Authors and Affiliations

  1. 1.University College London HospitalLondonUK
  2. 2.BerchemBelgium

Personalised recommendations