Skip to main content
SpringerLink
Log in

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

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  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 21:221–226

    Article  PubMed  Google Scholar 

  2. Archibeck MJ, Jacobs JJ, Roebuck KA, Glant TT (2001) The basic science of periprosthetic osteolysis. Instr Course Lect 50:185–195

    PubMed  CAS  Google Scholar 

  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 77:28–33

    PubMed  CAS  Google Scholar 

  4. Baré J, MacDonald SJ, Bourne RB (2006) Preoperative evaluations in revision total knee arthroplasty. Clin Orthop Relat Res 446:40–44

    Article  PubMed  Google Scholar 

  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):94–99

    Article  PubMed  Google Scholar 

  6. Berger RA, Crossett LS, Jacobs JJ, Rubasi HE (1998) Malrotation causing patellofemoral complication after total knee arthroplasty. Clin Orthop 356:144–153

    Article  PubMed  Google Scholar 

  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 89:1232–1237

    Article  PubMed  Google Scholar 

  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 326:41–44

    Article  PubMed  Google Scholar 

  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):90–93

    Article  PubMed  Google Scholar 

  10. Dellon AL, Mont MA, Mullick T, Hungerford DS (1996) Partial denervation for persistent neuroma pain around the knee. Clin Orthop Relat Res 329:216–222

    Article  PubMed  Google Scholar 

  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 31:33–37

    Article  PubMed  Google Scholar 

  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 89:1409–1416

    Article  PubMed  Google Scholar 

  13. Katz MM, Hungerford DS (1987) Reflex sympathetic dystrophy affecting the knee. J Bone Joint Surg Br 69:797–803

    PubMed  CAS  Google Scholar 

  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 331:11–22

    Article  PubMed  Google Scholar 

  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 18:1038–1043

    Article  PubMed  Google Scholar 

  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 82:1552–1557

    PubMed  Google Scholar 

  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 242:101–108

    Article  PubMed  Google Scholar 

  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 55:388–395

    Article  PubMed  CAS  Google Scholar 

  19. Parvizi J, Ghanem E, Menashe S, Barrack RL, Bauer TW (2006) Periprosthetic infection: what are the diagnostic challenges? J Bone Joint Surg Am 88:138–147

    Article  PubMed  Google Scholar 

  20. Pizzoferrato A, Fiori F, Savarino L (1980) Microbiological investigation on 161 cases of hip endoarthroprosthesis failure. Chir Organi Mov 66:297–307

    PubMed  CAS  Google Scholar 

  21. Pizzoferrato A, Ciapetti G, Savarino L, Stea S, Tarabusi C (1988) Results of histopathological grading on 100 cases of HIP prosthesis failure. Biomaterials 9:314–318

    Article  PubMed  CAS  Google Scholar 

  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 70:139–145

    Article  PubMed  CAS  Google Scholar 

  23. Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM (2002) Why are total knee arthroplasties failing today? Clin Orthop Relat Res 404:7–13

    Article  PubMed  Google Scholar 

  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 79:1578–1588

    Google Scholar 

  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 81:672–683

    PubMed  CAS  Google Scholar 

  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):257–267

    PubMed  CAS  Google Scholar 

  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 117:556–562

    Article  PubMed  Google Scholar 

  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–S80

    PubMed  Google Scholar 

Download references

Acknowledgments

This research was partially supported by grants from Istituto Ortopedico Rizzoli, ‘Ricerca Corrente’.

Author information

Authors and Affiliations

  1. Laboratory for Pathophysiology of Orthopaedic Implants, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136, Bologna, Italy

    Lucia Savarino, Nicola Baldini & Armando Giunti

  2. 7th Division, Istituto Ortopedico Rizzoli, Bologna, Italy

    Domenico Tigani, Nicola Baldini, Valerio Bochicchio & Armando Giunti

  3. Department of Orthopaedic Surgery, University of Bologna, Bologna, Italy

    Armando Giunti

Authors
  1. Lucia Savarino
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Domenico Tigani
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nicola Baldini
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Valerio Bochicchio
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Armando Giunti
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Lucia Savarino.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Savarino, L., Tigani, D., Baldini, N. et al. Pre-operative diagnosis of infection in total knee arthroplasty: an algorithm. Knee Surg Sports Traumatol Arthrosc 17, 667–675 (2009). https://doi.org/10.1007/s00167-009-0759-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-009-0759-3

Keywords

Search

Navigation