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% of so called “aseptic” could have PJI Parvizi J , et al CORR 2011
The true PJI incidence rates is underestim ated in the registries Pag
Diagnosis of PJI Remains a real challenge No gold standard exists No uniform criteria for diagnosis exists
Diagnosis of PJI As many definitions as investigators/ public ations
Diagnosis of PJI Difficult
Diagnosis of PJI Difficult
Diagnosis of PJI Remains a real challenge Because
Intracellular S. S. aur ureus us in Periprosthetic Tissue Osteoblast S. aureus Parham S et al, Clin Infect Dis 2006
Osteoblasts infected with S aureus Inoculated into open rat fracture
All fractures got infected
Courtesy of Edward Schwarz A B C
Biofilm Quarum sensing Glycocalyx
The Problem None of the test being used were developed specifically for PJI diagnosis
Definition of PJI (MSIS) There is a sinus tract communicating with the prosthesis; or Parvizi J et al CORR 20 11
Definition of PJI (MSIS) There is a sinus tract communicating with the prosthesis; or A pathogen is isolated by culture from two separate tissue or fluid samples obtained from the affected prosthetic joint; or Parvizi J et al CORR 20 11
Definition of PJI (MSIS) There is a sinus tract communicating with the prosthesis; or A pathogen is isolated by culture from two separate tissue or fluid samples obtained from the affected prosthetic joint; or When four out of the following six criteria exists Parvizi J et al CORR 20 11
Definition of PJI (MSIS/ International Consensus) 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) PJI may be present if less than 4 of these criteria are met Parvizi J et al CORR 20 11
AAOS Guidelines www.aaos.org/ guidelines • 15 recommendations • Majority strong • Review of literature Parvizi et al. JAAOS 2010 Della Valle et al. JAAOS 2010
AAOS ESR and CRP for all patients undergoing revision arthroplasty
PPFx or PJI? • 82 year ol old • 12 12 years out ut from hemiarthropl plas asty Patient was infact infected
Recent Data from the RI ESR and CRP may be normal in up to 18% of PJI cases Tan T et al -Pending
International Consensus Aspiration of the joint before any further imaging
AAOS Guidelines Strong Patients be off antibiotics before aspiration (2 weeks) No Antibiotics until diagnosis reached or refuted
RI Data- 20 15 • Administration of ABX also affects the level of neutrophil % and total count in the synovial fluid Shahi et al CORR 2015
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
Recent Data from the RI Meta-analysis Bone scan is pretty much useless!! Diaz-Lodezma JOA 2015
Opportunities in Managem ent of PJI Era of Biomarkers is here
Diagnosis of PJI Simple Test UA strips for leukocyte esterase
Data
Alpha-Defensin Antimicrobial Peptide Secreted by Neutrophils to fight Infection Alpha-Defensin
Overall study data Gold Study N Sensitivity Specificity Standard Rothman 97% 96% 149 MSIS Criteria Institute (95% CI: 86-100%) (95% CI: 90-99%) 100% 95% 61 Mayo Arizona MSIS Criteria (95% CI: 79-100%) (95% CI: 83-99%) 96% 99% Cleveland Clinic 111 MSIS Criteria (95% CI: 82-99%) (95% CI: 93-100%) 98% 97% 320 Combined MSIS Criteria (95%CI: 92-100%) (95% CI: 93-99%)
Issues Synovial Fluid Invasive Inadequate Insufficient
Issues Adverse local tissue reaction
ALTR Leukocyte esterase test = 92% sensitivity Tischler E et al JOA 2015 Alpha defensin = 74% Synovial CRP = 91% Combined = 95% Higuera et al Pending
Issues Pathogen Parvizi et al JBJS 2013
• Koch- 1886 • Anthrax • Little has changed
Molecular Diagnostics of Microbial DNA Next Generation Sequencing PCR- Panel of Microbes (8-20) NGS- 25,000 species
Multi-National, Multi-center Study Supported by: MicrogenDx
• PJI (and others infections) may be polymicrobial… ……..
?
• Signal that NGS isolated organisms (ignored) may result in later failure
• Polymicrobial • “Reinfection” • Present at index infection • Ignored • Professional pathogen
Opportunities in Managem ent of PJI Serum Markers for PJI (reimplantation)
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
Erythrocyte Sedim entation Sensitivity = 73% Specificity = 78%
C-Reactive Protein Sensitivity = 78% Specificity = 80%
D-dim er Sensitivity = 89% Specificity = 92%
Consensus On Orthopedic Infections July 26-27, 2018 Philadelphia
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