prosthetic joint infection.updated2 · hip and knee hip knee shoulder elbow all time periods early...
TRANSCRIPT
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Prosthetic Joint Infection Diagnosis Using Conventional Methods
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Presenter:
Robin Patel, M.D.Professor of Medicine and MicrobiologyChair, Division of Clinical Microbiology and the Elizabeth P. and Robert E. Allen Professor of Individualized Medicine
Department of Laboratory Medicine and Pathology
at Mayo Clinic, Rochester, Minnesota
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Disclosures• Dr. Robin Patel has a US patent for a method and an apparatus for sonication, but
has foregone her right to personally receive royalties.
Funding• National Institutes of Health
• Department of Defense
• National Science Foundation
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Total Hip and Knee Replacement Procedures United States1
Total knee
Total hip
Year
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Prosthetic Hip and Knee Infections: United States2
2001‐2020
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Surgical Management of Prosthetic Hip or Knee Infection3
Reprinted with permission from Massachusetts Medical Society.
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Prosthetic Joint Infection Microbiology4
Hip and Knee Hip Knee Shoulder Elbow
All time periods Early
Number of joints 2435 637 1979 1427 199 110
Staphylococcus aureus 27 38 13 23 18 42
Coagulase negative staphylococci 27 22 30 23 41 41
Streptococcus species 8 4 6 6 4 4
Enterococcus species 3 10 2 2 3 0
Aerobic gram negative bacilli 9 24 7 5 10 7
Anaerobic bacteria 4 3 9 5
Cutibacterium acnes 24 1
Other anaerobes 3 0
Culture negative 14 10 7 11 15 5
Polymicrobial 15 31 14 12 16 3
Other 3
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Unusual Causes of Prosthetic Joint Infection5
Actinomyces israelii
Aspergillus fumigatus
Arcanobacterium bernardie
Bacteroides species
Brucella species
Campylobacter species
Candida species
Capnocytophaga canimorsus
Chlamydophila pneumoniae
Chryseobacterium meningosepticum
Clostridium species
Corynebacterium species
Cryptococcus neoformans
Echinococcus species
Erysipelothrix rhusiopathiae
Francisella tularensis
Granulicatella adiacens
Haemophilus parainfluenzae
Histoplasma capsulatum
Listeria monocytogenes
Moraxella catarrhalis
Mycobacterium abscessus, avium complex, chelonae, farcinogenes, fortuitum, kansasii, smegmatis, tuberculosis complex, wolinskyi
Mycoplasma hominis, Mycoplasma salivarium
Oerskovia xanthineolytica
Pasteurella multocida
Rhodotorula mucilaginosa, minuta
Rothia species
Sporothrix schenkii
Tropheryma whipplei
Veillonella species
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Prosthetic Joint Infection Clinical Presentation
Courtesy of Douglas R. Osmon, MD
No. (%)
Author Pain Swelling Fever Drainage
Windsor et al. JBJS (Am) 1990;72:272 26 (100) 20 (77) 7 (27) 7 (27)
Morrey et al. CORR 1989;248:120 69 (95) 69 (95) ----- 26 (36)
McDonald et al. JBJS (Am) 1989;71:828 78 (95) ------ 3 (4) 19 (23)
Total 173/181 (96) 89/99 (90) 10/108 (9) 52/181 (29)
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Criteria for Diagnosis of Prosthetic Joint Infection6-8
Definitions of Prosthetic Joint Infection2011
Musculoskeletal Infection
Society6
2013
Infectious Diseases Society
of America7
2013
International Consensus8
Definitive
evidence
Supportive
evidence
Definitive
evidence
Supportive
evidence
Definitive
evidence
Supportive
evidence
Sinus tract communicating with the prosthesis x x x
Identical microorganism isolated from ≥2 cultures x x x
Purulence surrounding the prosthesis x x
Acute inflammation of periprosthetic tissue x x x
A single culture with any microorganism x x
A single culture with a virulent microorganism x
Elevated synovial fluid leukocyte count x x
Elevated synovial fluid neutrophil percentage x x
Elevated serum ESR and CRP x x
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C-Reactive Protein Erythrocyte Sedimentation Rate9
Knee Implants (n=297)
Aseptic Failure (n=215)
Prosthetic Joint Infection (n=82)
P-Value
ESR, mm/h 11 (0-68) 53.5 (6-128) <0.0001
CRP, mg/L 4 (0.1-174) 51 (3-444) <0.0001
Hip Implants (n=221)
Aseptic Failure (n=187)
Prosthetic Joint Infection (n=34)
ESR, mm/h 11 (0-94) 30 (3-137) <0.0001
CRP, mg/L 3 (0.3-141) 18 (3-288) <0.0001
Shoulder Implants (n=64)
Aseptic Failure (n=45)
Prosthetic Joint Infection (n=19)
ESR, mm/h 10 (0-32) 9 (1-71) 0.9883
CRP, mg/L 3 (3-26) 10 (3-40) 0.01
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C-Reactive Protein Erythrocyte Sedimentation Rate9
PPV=positive predictive value
NPV=negative predictive value
Sensitivity Specificity PPV NPV
Knee Implants ESR >30 mm/h 71 (58/82) 89 (191/215) 71 (58/82) 89 (191/215)
CRP >10 mg/L 83 (68/82) 79 (170/215) 60 (68/113) 92 (170/184)
Hip Implants ESR >30 mm/h 47 (16/34) 84 (158/187) 36 (16/45) 90 (158/176)
CRP >10 mg/L 74 (25/34) 78 (146/187) 38 (25/66) 94 (146/155)
Shoulder Implants ESR >30 mm/h 16 (3/19) 98 (44/45) 75 (3/4) 73 (44/60)
CRP >10 mg/L 42 (8/19) 84 (38/45) 53 (8/15) 78 (38/49)
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Anterior 111In-labeled leukocyte image showing accumulation of labeled leukocytes spatially congruent with the bone image.
Anterior bone (99mTc methylene diphosphonate) scan image showing increased activity around the femoral component of a left hip replacement.
© Weisheng Ye, Wei Shang and Yaqiong Yang (2012). Licensee InTechOpen.10 (open access)
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18F-fluoro-2-deoxyglucose Positron Emission Tomography/Computed Tomography Increased Activity Around the Bone-Prosthesis Interface
© Weisheng Ye, Wei Shang and Yaqiong Yang (2012). Licensee InTechOpen.10 (open access)
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Synovial Fluid Leukocyte/Differential Prosthetic Knee11
*
*
**
Leukocytes >1.7 94% 88%Neutrophils >65% 97% 98%
Studies of Intrasurgical Frozen-Section Histopathologic Findings of Acute Inflammation in Prosthetic Joint Infection Diagnosis
Reference Specimen Joint #PMN* n Sensitivity Specificity PPV**
Feldman et al. JBJS(Am) 1995;77:1807 JC, IM Hip/knee 5 33 100 100 100
Athanasou et al. JBJS(Br) 1995;77:28 JC, IM Hip/knee 1 106 90 96 88
Lonner et al. JBJS(Am) 1996;78:1553 JC, IM, ASPI Hip/knee 5 175 84 96 70
10 84 99 89
Pace et al. J Arthroplasty 1997;12:64 JC, IM Hip/knee 5 18 82 93 82
Abdul‐Karim et al. Mod Pathol 1998;11:427 IM, ST, UDT Hip/knee 5 64 43 97 60
Banit et al. CORR 2002;401:230 JC, ASPI Knee 10 55 100 96 82
Hip 10 63 45 92 55
Musso et al. Postgrad Med J 2003;79:590 JC, IM, ASPI Hip/knee 5 45 50 95 60
Wong et al. J Arthroplasty 2005;20:1015 JC, IM, SS Hip/knee 5 33 93 77 68
10 86 85 75
Ko et al. J Arthroplasty 2005;20:189 JC, IM, ASPI Hip/knee 5 40 67 97 86
Frances Borrego et al. Int Orthop 2007;31:33 PST Hip 10 63 67 90 80
Knee 83 50 100 100
Nunez et al. Acta Orthop 2007;78:226 JC, IM, ASPI Hip 5 136 86 87 79
Tohtz et al. CORR 2010;468:762 IM Hip 10 52 87 100 100
*Some studies used >, others ≥ the number shown, **Positive predictive valueJC, joint pseudocapsule; IM, interface membrane; ASPI, any area that appears suspicious for possible infection; ST, synovial tissue; SS, synovial surface; UDT, unusually discolored tissue; PST, periprosthetic soft tissue
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Prospective Vortexing/Sonication Clinical StudyHip or Knee Implants12
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Staphylococcus epidermidis Biofilm on Polycarbonate Coupons Scanning Electron Microscopy
Soaking Scraping SonicationMagnification x 4.00k, WD=14.4 mm
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SonicateTissue
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Prospective Vortexing/Sonication Clinical Study Hip or Knee Implants12
• Patients undergoing total knee or hip revision or resection for aseptic failure or presumed infection
• Mayo Clinic: August 2003–December 2005
• Exclusion criteria: • Components contaminated in OR
• Components did not fit in container
• <2 tissues were cultured
• Partial revision
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Definition of Prosthetic Hip and Knee Infection
• At least 1 of the following criteria6:• Visible purulence of synovial fluid or intraoperatively
• Acute inflammation on histopathologic tissue examination
• Presence of a sinus tract communicating with the prosthesis
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Number of Microorganisms Detected by Sonicate Fluid Culture12
Reprinted with permission from Massachusetts Medical Society.
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Results Prosthetic Hip or Knee InfectionAseptic failure
(n=252)Prosthetic joint infection
(n=79)
Synovial fluid 1.9% 56.3%
Periprosthetic tissue 0.8% 60.8%
Sonicate fluid 1.2% 78.5%P <0.001
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Prospective Clinical Study Shoulder Implants• Patients undergoing total shoulder implant revision or
resection for aseptic failure or presumed infection7
• Mayo Clinic: August 2004–November 2008
• Exclusion criteria: • <2 tissues were cultured
• Partial revision
• Sonicate fluid not archived
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Definition of Definite Prosthetic Shoulder Infection
• At least 1 of the following criteria7:• Visible purulence of synovial fluid or intraoperatively
• Acute inflammation on histopathologic tissue examination
• Presence of a sinus tract communicating with the prosthesis
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P=0.046
Prospective Clinical Study Shoulder Implants
Aseptic failure (n=101)
Definite prosthetic shoulder infection
(n=33)
Periprosthetic tissue 96 (95.1%) 18 (54.5%)
Sonicate fluid 99 (98.0%) 22 (66.7%)
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Acknowledgments• Kerryl Greenwood-Quaintance, MS
• Melissa Karau
• Suzannah Schmidt, MS
• Matt Thoendel, MD, PhD
• Morgan Ivy
• Aaron Tande, MD
• Patricio Jeraldo, PhD
• Nicholas Chia, PhD
• Trisha Peel, MD
• Douglas Osmon, MD
• Thao Masters, PhD
• Charles Cazanave, MD
• Marta Fernandez-Sampedro, MD
• Trisha Peel, PhD
• Yu Mi Wi, MD
• Andrej Trampuz, MD
• Paolo Melendez, MD
• Eric Gomez-Urena, MD
• Cassandra Brinkman, PhD
• Mark Rouse
• Jon Badiola, MD
• Qun Yan, MD
• Kimberly Perez
• Morgan Ivy
• Paloma Anguita Alonso, MD
• Maria Ruiz Ruizgomez, MD
• Awele Maduka-Ezeh, MD
• Jin Won Chung, MD
• Jose del Pozo, MD
• Seong Yeol Ryu, MD
• Larry Baddour, MD
• Rizwan Sohail, MD
• Harmony Tyner, MD
• Paschalis Vergidis, MD
• James Steckelberg, MD
• Elie Berbari, MD
• Franklin Cockerill, MD
• Jayawant Mandrekar, PhD
• Arlen Hanssen, MD
• Matt Abdek, MD
• David Lewallen, MD
• Robert Trousdale, MD
• Mark Pagnano, MD
• Miguel Cabanela, MD
• David Jacofsky, MD
• Franklin Sim, MD
• Daniel Berry, MD
• Michael Stuart, MD
• Robert Cofield, MD
• Paul Huddleston, MD
• John Sperling, MD
• Joaquin Sanchez-Sotelo, MD
• Mark Dekutoski, MD
• Bradford Currier, MD
• Mike Yaszemski, MD
• Youlonda Loechler
• Krishnan Unni, MD
• James Greenleaf, PhD
• James Uhl
• Scott Cunningham, MS
• Clinical Microbiology Bacteriology and IP Staff
• Mayo Clinic patients
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References1. Kurtz S, Ong K, Lau E, et al: Projections of primary and revision hip and knee arthroplasty in the
United States from 2005 to 2030. J Bone Joint Surg Am. Apr 2007;89:780–5.
2. Kurtz S, Lau E, Watson H, et al: Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. Sept 2002;8:61-653.
3. Del Pozo J, Patel Robin: Infection associated with prosthetic joints. N Engl J Med. Aug 2009;361:787-794.
4. Tande A, Patel R: Prosthetic joint infection. Clin Microbiol Rev. Apr 2014;27(2):302-345.
5. Marculescu C, Berbari EF, Cockerill III FR, et al: Unusual aerobic and anaerobic bacteria associated with prosthetic join infections. Clin Orthop Relat Res 2006;451:55-72.
6. Parvizi J, Zmistowski B, Berbari EF, et al: New definition of periprosthetic joint infection: from the workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. Nov 2011;469(11):2992-2994.
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References7. Osmon D, Berbari EF, Berendt AR, et al: Diagnosis and management of prosthetic joint infection: clinical
practice guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases. Jan 2013;56(1):e1-e25.
8. Parvizi J, Gehrke T, Chen AF: Proceedings of the international consensus on periprosthetic joint injection. Bone Joint J. 2013;95-B:1450-1452.
9. Piper K, Fernandez-Sampedro M, Steckelberg K, et al: C-reactive protein, erythrocyte sedimentation rate and orthopedic implant infection. PLoS One. Feb 2010;5(2):e9358.
10. Ye W, Shang W, Yang Y: Staphylococcus infection associated with arthroplasty, recent advances in artoplasty, Dr. Samo Fokter (Ed.), ISBN: 978-953-307-990-5, InTech, Available from: http://www.intechopen.com/books/recent-advances-in-arthroplasty/staphylococcus-infection-associated-with-arthroplasty.
11. Trampuz A, Hanssen AD, Osmon D, et al: Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med. Oct 2004;117(8):556-562.
12. Trampuz A, Piper K, Jacobson M, et al: Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med. Aug 2007;357:654-663.
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