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High Diagnostic Value of Synovial Biopsy in Periprosthetic Joint Infection of the Hip

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

The role of the synovial biopsy in the preoperative diagnosis of a periprosthetic joint infection (PJI) of the hip has not been clearly defined.

Questions/purposes

We asked whether the value of a biopsy for a PJI is greater than that of aspiration and C-reactive protein (CRP).

Methods

Before revision in 100 hip endoprostheses, we obtained CRP values, aspirated the joint, and obtained five synovial biopsy samples for bacteriologic analysis and five for histologic analysis. Microbiologic and histologic analyses of the periprosthetic tissue during revision surgery were used to verify the results of the preoperative diagnostic methods. The minimum followup was 24 months (median 32; range, 24–47 months).

Results

Forty-five of the 100 prostheses were identified as infected. The biopsy, with a combination of the bacteriologic and histologic examinations, showed the greatest diagnostic value of all the diagnostic procedures and led to a sensitivity of 82% (95% CI, ± 11%), specificity of 98% (95% CI, ± 4%), positive predictive value of 97% (95% CI, ± 5%), negative predictive value of 87% (95% CI, ± 8.3%), and accuracy of 91%.

Conclusions

The biopsy technique has a greater value than aspiration and CRP in the diagnosis of PJI of the hip (Masri et al. J Arthroplasty 22:72–78, 2007). In patients with a negative aspirate, but increased CRP or clinical signs of infection, we regard biopsy to be preferable to just repeating the aspiration.

Level of Evidence

Level II prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

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References

  1. AAOS Work Group. The diagnosis of periprosthetic joint infections of the hip and knee: guideline and evidence report. Available at: http://www.aaos.org/research/guidelines/PJIguideline.pdf. Accessed June 21, 2012.

  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.

    Article  PubMed  Google Scholar 

  3. Antti-Poika I, Josefsson G, Konttinen Y, Lidgren L, Santavirta S, Sanzén L. Hip arthroplasty infection: current concepts. Acta Orthop Scand. 1990;61:163–169.

    Article  PubMed  CAS  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  6. Bori G, Soriano A, García S, Mallofré C, Riba J, Mensa J. 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. 2007;89:1232–1237.

    Article  PubMed  Google Scholar 

  7. Botser IB, Smith TW Jr, Nasser R, Domb BG. Open surgical dislocation versus arthroscopy for femoroacetabular impingement: a comparison of clinical outcomes. Arthroscopy. 2011;27:270–278.

    Article  PubMed  Google Scholar 

  8. Brand RA, Pederson DR, Yoder SA. How definition of “loosening” affects the incidence of loose total hip reconstructions. Clin Orthop Relat Res. 1986;210:185–191.

    PubMed  Google Scholar 

  9. Buttaro MA, Tanoira I, Comba F, Piccaluga F. Combining C-reactive protein and Interleukin-6 may be useful to detect periprosthetic hip infection. Clin Orthop Relat Res. 2010;468:3263–3267.

    Article  PubMed  Google Scholar 

  10. CLSI. Performance Standards for Antimicrobial Susceptibility Testing. Twentieth Informational Supplement. CLSI document M100-S20. Wayne, PA: Clinical and Laboratory Standards Institute; 2010.

  11. Costerton JW. Biofilm theory can guide the treatment of device-related orthopaedic infections. Clin Orthop Relat Res. 2005;437:7–11.

    Article  PubMed  Google Scholar 

  12. Della Valle CJ, Zuckermann JD, Di Cesare PE. Periprosthetic sepsis. Clin Orthop Relat Res. 2004;420:26–31.

    Google Scholar 

  13. Fehring TK, Cohen B. Aspiration as a guide to sepsis in revision total hip arthroplasty. J Arthroplasty. 1996;11:543–547.

    Article  PubMed  CAS  Google Scholar 

  14. Feldman DS, Lonner JH, Desai P, Zuckerman JD. The role of intraoperative frozen sections in revision total joint arthroplasty. J Bone Joint Surg Am. 1995;77:1807–1813.

    PubMed  CAS  Google Scholar 

  15. Fink B. Revision of late periprosthetic infections of total hip endoprostheses: pros and cons of different concepts. Int J Med Sci. 2009;6:287–295.

    Article  PubMed  Google Scholar 

  16. Fink B, Grossmann A, Fuerst M, Schäfer P, Frommelt L. Two-stage cementless revision of infected hip endoprostheses. Clin Orthop Relat Res. 2009;467:1848–1858.

    Article  PubMed  Google Scholar 

  17. Fink B, Makowiak C, Fuerst M, Berger I, Schäfer P, Frommelt L. The values of synovial biopsy and joint aspiration in the diagnosis of late peri-prosthetic infection of total knee replacements. J Bone Joint Surg Br. 2008;90:874–878.

    Article  PubMed  CAS  Google Scholar 

  18. Fitzgerald RH Jr. Total hip arthroplasty sepsis: prevention and diagnosis. Orthop Clin North Am. 1992;23:259–264.

    PubMed  Google Scholar 

  19. Frommelt L. [Diagnosis and treatment of foreign-body-associated infection in orthopaedic surgery][in German]. Orthopäde. 2009;38:806–811.

    Article  PubMed  CAS  Google Scholar 

  20. 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.

    PubMed  CAS  Google Scholar 

  21. Haddad FS, Muirhead-Allwood SK, Manktelow AR, Bacarese-Hamilton I. Two-stage uncemented revision hip arthroplasty for infection. J Bone Joint Surg Br. 2000;82:689–694.

    Article  PubMed  CAS  Google Scholar 

  22. Harris WH, Sledge CB. Total hip and total knee replacement (2). N Engl J Med. 1990;323:801–807.

    Article  PubMed  CAS  Google Scholar 

  23. Heinecke A, Hultsch E, Repges R, eds. Medizinische Biometrie. Berlin, Germany: Springer; 1992.

    Google Scholar 

  24. 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.

    Article  PubMed  CAS  Google Scholar 

  25. Itasaka T, Kawai A, Sato T, Mitani S, Inoue H. Diagnosis of infection after total hip arthroplasty. J Orthop Sci. 2001;6:320–326.

    Article  PubMed  CAS  Google Scholar 

  26. 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.

    PubMed  CAS  Google Scholar 

  27. Kilcoyne RF, Kaplan P. The lateral approach for hip arthrography. Skeletal Radiol. 1992;21:239–240.

    Article  PubMed  CAS  Google Scholar 

  28. Kraemer WL, 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.

    Article  PubMed  CAS  Google Scholar 

  29. 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.

    Google Scholar 

  30. 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.

    Article  PubMed  CAS  Google Scholar 

  31. 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.

    PubMed  CAS  Google Scholar 

  32. Manaster BJ. From the RSNA refresher courses. Total hip arthroplasty: radiographic evaluation. Radiographics. 1996;16:645–660.

    PubMed  CAS  Google Scholar 

  33. Malhotra R, Morgan DA. Role of core biopsy in diagnosing infection before revision hip arthroplasty. J Arthroplasty. 2004;19:78–87.

    Article  PubMed  Google Scholar 

  34. Masri BA, Panagiotopoulos KP, Greidanus NV, Garbuz DS, Duncan CP. Cementless two-stage exchange arthroplasty for infection after total hip arthroplasty. J Arthroplasty. 2007;22:72–78.

    Article  PubMed  Google Scholar 

  35. McCurdy WE, Moore TE, Walker CW. The superolateral approach for aspiration of total hip arthroplasties. Australas Radiol. 2000;44;349–350.

    Article  PubMed  CAS  Google Scholar 

  36. Meermans G, Haddad FS. Is there a role for tissue biopsy in the diagnosis of periprosthetic infection? Clin Orthop Relat Res. 2010;468:1410–1417.

    Article  PubMed  Google Scholar 

  37. Mirra JM, Amstutz HC, Matos M, Gold R. The pathology of the joint tissues and its clinical relevance in prosthetic failure. Clin Orthop Relat Res. 1976;117:221–240.

    PubMed  Google Scholar 

  38. Mirra JM, Marder RA, Amstutz HC. The pathology of failed total joint arthroplasty. Clin Orthop Relat Res. 1982;170:175–183.

    PubMed  Google Scholar 

  39. Morello JA, Matushek SM, Dunne WM, Hinds DB. Performance of a BACTEC nonradiometric medium for pediatric blood cultures. J Clin Microbiol. 1991;29:359–362.

    PubMed  CAS  Google Scholar 

  40. 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 Res. 2008;3:31

    Article  PubMed  Google Scholar 

  41. 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.

    Article  PubMed  Google Scholar 

  42. Pandey R, Drakouilakis E, Athanasou NA. An assessment of the histological criteria used to diagnose infection in hip revision arthroplasty tissues. J Clin Pathol. 1999;52:118–123.

    Article  PubMed  CAS  Google Scholar 

  43. Panousis K, Grigoris P, Butchler 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.

    PubMed  Google Scholar 

  44. Saleh KJ, Clark CR, Sharkey PF, Goldberg VM, Rand JA, Brown GA. Modes of failure and preoperative evaluation. J Bone Joint Surg Am. 2003;85(suppl 1):21–25.

    Google Scholar 

  45. Schäfer P, Fink B, Sandow D, Margull A, Berger I, Frommelt L. Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis. 2008;47:1403–1409.

    Article  PubMed  Google Scholar 

  46. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90:1869–1875.

    Article  PubMed  Google Scholar 

  47. 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.

    Article  PubMed  Google Scholar 

  48. 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.

    PubMed  CAS  Google Scholar 

  49. Steinbrink K, Frommelt L. [Treatment of periprosthetic infection of the hip using one-stage exchange surgery][in German]. Orthopäde. 1995;24:335–343.

    PubMed  CAS  Google Scholar 

  50. 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.

    Article  PubMed  Google Scholar 

  51. Tohtz SW, Müller M, Morawietz L, Winkler T, Perka C. Validity of frozen sections for analysis of periprosthetic loosening membranes. Clin Orthop Relat Res. 2010;468:762–768.

    Article  PubMed  Google Scholar 

  52. Virolainen P, Lahteenmaki 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.

    PubMed  CAS  Google Scholar 

  53. 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.

    Article  PubMed  Google Scholar 

  54. Wilson MG, Dorr LD. Reimplantation of infected total hip arthroplasties in the absence of antibiotic cement. J Arthroplasty. 1989;4:263–269.

    Article  PubMed  CAS  Google Scholar 

  55. Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE. Role of rifampicin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA. 1998;279:1537–1541.

    Article  PubMed  CAS  Google Scholar 

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Acknowledgment

We thank Lars Frommelt MD (Service for Infectious Diseases, Clinical Microbiology and Infection Control, ENDO-Klinik, Hamburg) for recommendations in local and systemic antibiotic therapy for treatment of the infected total hip arthroplasties.

Author information

Authors and Affiliations

  1. Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen, Kurt-Lindemann-Weg 10, Markgröningen, 71706, Germany

    Bernd Fink MD & Alexander Gebhard MD

  2. Department of Joint Replacement and Rheumatology, MedBaltic and Sankt Elisabeth Hospital Kiel, Neumünster, Germany

    Martin Fuerst MD

  3. Institute of Pathology, University Heidelberg, Heidelberg, Germany

    Irina Berger MD

  4. Joint Practice of Laboratory Medicine Ludwigsburg, Ludwigsburg, Germany

    Peter Schäfer MD

Authors
  1. Bernd Fink MD
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  2. Alexander Gebhard MD
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  3. Martin Fuerst MD
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  4. Irina Berger MD
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  5. Peter Schäfer MD
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Corresponding author

Correspondence to Bernd Fink MD.

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Each author certifies that he or she, or a member of their immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

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Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This study was performed at the Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen.

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Fink, B., Gebhard, A., Fuerst, M. et al. High Diagnostic Value of Synovial Biopsy in Periprosthetic Joint Infection of the Hip. Clin Orthop Relat Res 471, 956–964 (2013). https://doi.org/10.1007/s11999-012-2474-5

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