21 st Century Approach Javad Parvizi MD, FRCS Professor Rothm an - - PowerPoint PPT Presentation

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21 st Century Approach Javad Parvizi MD, FRCS Professor Rothm an - - PowerPoint PPT Presentation

Sep 30, 2022 348 likes •915 views

Diagnosis of Periprosthetic Joint Infection 21 st Century Approach Javad Parvizi MD, FRCS Professor Rothm an Institute at Thom as Jefferson University, Philadelphia PJI Conclusions Incidence and prevalence is higher than believed 12%

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Diagnosis of Periprosthetic Joint Infection

21st Century Approach

Javad Parvizi MD, FRCS

Professor Rothm an Institute at Thom as Jefferson University, Philadelphia

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PJI Conclusions

  • Incidence and prevalence is

higher than believed

  • 12% of so called “aseptic”

could have PJI

Parvizi J , et al CORR 2011

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Pag

The true PJI incidence rates is underestim ated in the registries

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 Remains a real challenge

No gold standard exists

Diagnosis of PJI

No uniform criteria for diagnosis

exists

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As many definitions

as investigators/ public ations

Diagnosis of PJI

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 Difficult

Diagnosis of PJI

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 Difficult

Diagnosis of PJI

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 Remains a real challenge

Because

Diagnosis of PJI

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Intracellular S.

  • S. aur

ureus us in Periprosthetic Tissue

Parham S et al, Clin Infect Dis 2006

  • S. aureus

Osteoblast

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 Osteoblasts infected with S

aureus

Inoculated into open rat fracture

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All fractures got infected

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B C A

Courtesy of Edward Schwarz

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Biofilm

Glycocalyx Quarum sensing

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None of the test being

used were developed specifically for PJI diagnosis

The Problem

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 There is a sinus tract communicating

with the prosthesis; or

Definition of PJI (MSIS)

Parvizi J et al CORR 20 11

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 A pathogen is isolated by culture from

two separate tissue or fluid samples

  • btained from the affected prosthetic

joint; or

Definition of PJI (MSIS)

Parvizi J et al CORR 20 11

 There is a sinus tract communicating

with the prosthesis; or

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 There is a sinus tract communicating

with the prosthesis; or

 A pathogen is isolated by culture from

two separate tissue or fluid samples

  • btained from the affected prosthetic

joint; or

Definition of PJI (MSIS)

Parvizi J et al CORR 20 11

 When four out of the following six

criteria exists

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ESR AND CRP

synovial WBC count or ++ leukocyte esterase

synovial PMN%,

 Positive histological analysis of

periprosthetic tissue,

A single positive culture

Definition of PJI

(MSIS/ International Consensus)

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PJI may be present if

less than 4 of these criteria are met

Definition of PJI (MSIS)

Parvizi J et al CORR 20 11

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AAOS Guidelines www.aaos.org/ guidelines

  • 15 recommendations
  • Majority strong
  • Review of literature

Parvizi et al. JAAOS 2010 Della Valle et al. JAAOS 2010

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AAOS

ESR and CRP for all patients undergoing revision arthroplasty

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  • 82 year ol
  • ld
  • 12

12 years out ut from hemiarthropl plas asty PPFx or PJI?

Patient was infact infected

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Recent Data from the RI

ESR and CRP may be normal in up to 18% of PJI cases

Tan T et al -Pending

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International Consensus

Aspiration of the joint before any further imaging

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Patients be off antibiotics before aspiration (2 weeks)

No Antibiotics until diagnosis reached or refuted

AAOS Guidelines Strong

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  • Administration of ABX

also affects the level of neutrophil % and total count in the synovial fluid

Shahi et al CORR 2015

RI Data- 20 15

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AAOS Guidelines Rec 9: Weak

Bone scan (leukocyte labeled) and PET scan is an option for patients not scheduled for reoperation or diagnosis not reached

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Recent Data from the RI

Meta-analysis Bone scan is pretty much useless!!

Diaz-Lodezma JOA 2015

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Opportunities in Managem ent of PJI

Era of Biomarkers is here

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Diagnosis of PJI Simple Test

 UA strips for leukocyte esterase

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Data

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Alpha-Defensin

Antimicrobial Peptide Secreted by Neutrophils to fight Infection

Alpha-Defensin

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Overall study data Study

N Gold Standard Sensitivity Specificity

Rothman Institute

149

MSIS Criteria

97%

(95% CI: 86-100%)

96%

(95% CI: 90-99%)

Mayo Arizona

61

MSIS Criteria

100%

(95% CI: 79-100%)

95%

(95% CI: 83-99%)

Cleveland Clinic 111 MSIS Criteria

96%

(95% CI: 82-99%)

99%

(95% CI: 93-100%)

Combined

320

MSIS Criteria

98%

(95%CI: 92-100%)

97%

(95% CI: 93-99%)

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Synovial Fluid

 Invasive  Inadequate  Insufficient

Issues

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 Adverse local tissue reaction

Issues

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 Leukocyte esterase test = 92%

sensitivity

Tischler E et al JOA 2015

 Alpha defensin = 74%  Synovial CRP = 91%  Combined = 95%

 Higuera et al Pending

ALTR

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Pathogen

Parvizi et al JBJS 2013

Issues

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  • Koch- 1886
  • Anthrax
  • Little has changed
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Molecular Diagnostics of Microbial DNA Next Generation Sequencing

PCR- Panel of Microbes (8-20) NGS- 25,000 species

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Multi-National, Multi-center Study

Supported by:

MicrogenDx

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  • PJI (and others

infections) may be polymicrobial… ……..

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?

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  • Signal that NGS

isolated organisms (ignored) may result in later failure

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  • Polymicrobial
  • “Reinfection”
  • Present at index infection
  • Ignored
  • Professional pathogen
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Opportunities in Managem ent of PJI

Serum Markers for PJI (reimplantation)

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D-dim er: A Potential Serum Biom arker for Diagnosis of Periprosthetic Joint Infection

Alisina Shahi MD Majd Tarabichi MD; Timothy L. Tan MD; Javad Parvizi MD, FRCS

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Erythrocyte Sedim entation

Sensitivity = 73% Specificity = 78%

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C-Reactive Protein

Sensitivity = 78% Specificity = 80%

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D-dim er

Sensitivity = 89% Specificity = 92%

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Consensus On Orthopedic Infections July 26-27, 2018 Philadelphia