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C OPYRIGHT Ó 2019 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Guest Editorial
What’s New in Musculoskeletal Infection
Thomas K. Fehring, MD, Keith A. Fehring, MD, Angela Hewlett, MD, MS, Carlos A. Higuera, MD,
Jesse E. Otero, MD, PhD, and Aaron Tande, MD
Investigation performed at the OrthoCarolina Hip & Knee Center, Charlotte, North Carolina; University of Nebraska Medical Center, Omaha,
Nebraska; Cleveland Clinic Florida, Weston, Florida; and the Mayo Clinic, Rochester, Minnesota

This update on musculoskeletal infection presents a review Prevention

of infection-related articles from January 2018 through the Prevention of periprosthetic joint infection has been a topic of
present from English-language journals, located using the considerable interest4-6 with a focus on preoperative, intra-
National Center for Biotechnology Information web site, with a operative, and perioperative considerations. Optimization of
special emphasis on periprosthetic infection. The additional patients’ comorbidities is important in the prevention of per-
sections will cover recent salient articles in the areas of spine, iprosthetic joint infection. In a meta-analysis study designed to
trauma, hand, and pediatrics. determine the influence of a bariatric surgical procedure prior
In a recent analysis of the Medicare Inpatient Data Set to arthroplasty, Li et al. found that a bariatric surgical proce-
from 2005 to 2015, the risk of periprosthetic joint infection was dure reduced short-term medical complications, length of stay,
1.09% for hips and 1.38% for knees at 5 years. This risk did not operative time, and short-term periprosthetic infection in the
change significantly during this 10-year period. Therefore, knees but not the hips. A bariatric surgical procedure did not
because the demand for total joint arthroplasty is projected reduce the long-term risk of infection or complications7. In a
to increase substantially in the coming years, the incidence retrospective cohort, Castano-Betancourt et al. determined
of periprosthetic joint infection is anticipated to scale up that patients with rheumatoid arthritis or ‡2 other defined
proportionally1. comorbidities, such as diabetes and anemia, are at elevated risk
Conversely, the risk of mortality after periprosthetic joint for periprosthetic joint infection8. Previous work has demon-
infection decreased significantly during the time frame studied. strated the importance of long-term glycemic control in the
However, the 5-year survival for Medicare patients was only prevention of periprosthetic joint infection9. Recently, there has
67% for periprosthetic infection after total hip arthroplasty been interest in glucose control more proximate to a surgical
and 72% for periprosthetic infection after total knee arthro- procedure10. Concern has been raised with regard to dexa-
plasty1. This high mortality rate following periprosthetic in- methasone administration in total joint arthroplasty in
fection was echoed in 2 other studies in which the 5-year patients with diabetes. O’Connell et al. observed an associ-
mortality for patients with periprosthetic joint infection after ation between dexamethasone administration and a signifi-
undergoing total joint arthroplasty was 21.12% for those cant increase in early postoperative blood glucose levels in
who underwent total hip arthroplasty2 and 21.64% for those patients with diabetes following total joint arthroplasty and
who underwent total knee arthroplasty3. The reported 1-year advised that dexamethasone be used with caution in this
mortality in these studies had an odds ratio of 3.58 for per- population11. The association between preoperative dexa-
iprosthetic joint infection after total hip arthroplasty2 and methasone and elevated postoperative blood glucose in
3.05 for periprosthetic joint infection after total knee patients with diabetes was confirmed in a separate study by
arthroplasty3 compared with the national age-adjusted risk of Godshaw et al.; however, the study did not demonstrate a
mortality. connection between dexamethasone and postoperative per-
Included in the cost of health care and, in particular, iprosthetic joint infection12.
periprosthetic infection is the cost of litigation. In a retro- The routine use of adjuvant antibiotic-laden cement in
spective review of medical malpractice lawsuits in a 5-county primary total joint arthroplasty has been called into question.
area in the Northeast United States including 113 total joint In a meta-analysis, King et al. found that the use of antibiotic-
surgeons, 27% (31 of 113) were named in at least 1 lawsuit. laden cement did not reduce the risk of postoperative peri-
Infection was the top reason for such litigation, representing prosthetic joint infection compared with regular cement but
26.5% of all lawsuits4. was associated with a significant increase in cost13.

Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest
forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial
relationship in the biomedical arena outside the submitted work ([Link]

J Bone Joint Surg Am. 2019;101:1237-44 d [Link]

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Substantial attention has been dedicated to local irriga- vancomycin had a significantly lower risk of surgical site
tion solutions for the prevention of periprosthetic joint infec- infection22,23. Two single-center studies demonstrated a lower
tion in primary total joint arthroplasty. In an in vitro study rate of surgical site infection in patients who underwent pri-
investigating commonly used solutions, Campbell et al. showed mary arthroplasty with the use of intrawound vancomycin
that the Dakin solution forms potentially toxic precipitates powder24,25. However, both studies were retrospective studies
when mixed with hydrogen peroxide and chlorhexidine glu- with historical controls. One of these studies24 was confounded
conate; the authors recommended that surgeons avoid mixing by the concomitant use of a povidone-iodine solution, and
irrigation solutions in the wound during a surgical procedure14. both authors noted the need for further study. One other study
Ernest et al. performed an in-depth, in vitro analysis to assess demonstrated an increased rate of sterile wound complications
the efficacy of povidone-iodine, chlorhexidine, hydrogen per- in the vancomycin group26. These authors recommended
oxide, the Dakin solution, and chlorine dioxide in reducing against the use of vancomycin powder, stating that higher-
adherent Staphylococcus aureus colonies on common ortho- powered studies were needed to demonstrate its efficacy.
paedic materials. The authors showed that the most effective Animal studies contributed to knowledge regarding the
solutions were hydrogen peroxide, with a 97% reduction in use of topical vancomycin. In a rat model of open contami-
colony-forming units (CFU)/cm2, and povidone-iodine, with a nated fractures, reduced bacterial growth was observed in both
98% reduction in CFU/cm2. However, these solutions did not antibiotic bead and vancomycin powder groups when com-
eliminate bacteria completely, and the authors recommended pared with a control group who underwent debridement alone.
continued pursuit of adjuvants to eliminate adherent bacteria There were no significant differences between the antibiotic
during irrigation and debridement for periprosthetic joint bead and vancomycin powder groups27. In a rabbit model with
infection15. fixation implants seeded with methicillin-resistant S. aureus
Efficiency and cleanliness in the surgical environment are (MRSA), the application of intraoperative vancomycin powder
critical for economic and clinical success in arthroplasty. Two at the time of fixation decreased the risk of bone infection and
studies demonstrated that prolonged surgical time is associated biofilm formation28.
with the development of infection after total joint arthro- Given the retrospective, uncontrolled study designs and
plasty16,17. In another study addressing the effect of the oper- conflicting results, the issue of whether topical vancomycin is
ating room environment on periprosthetic joint infection, beneficial in preventing surgical site infection remains unresolved.
Vijaysegaran et al. showed that space suits are associated with
increased particle and microbiological emission rates in a Antibiotic Complications
simulated operating room compared with standard operating There were several reports of complications of antibiotic use in
room attire, calling into question the safety of routine space suit orthopaedic patients, including red man syndrome and drug-
use during total joint arthroplasty18. induced linear immunoglobulin A (IgA) bullous dermatosis
after the routine use of vancomycin-loaded bone cement29,30.
Antimicrobial Treatment Acute kidney injury requiring dialysis to lower toxic tobramycin
Oral Antibiotics in Arthroplasty levels after receipt of a vancomycin and tobramycin-impregnated
A randomized controlled trial did not show that preoperative cement spacers has also been reported31. A database review of
doxycycline reduced the prevalence of Cutibacterium acnes 83,806 patients who underwent revision total knee arthroplasty
(formerly Propionibacterium acnes) on the skin and in the deep due to periprosthetic joint infection found a 1.0% incidence
tissues at the time of periprosthetic joint implantation19. of a Clostridioides difficile (formerly Clostridium difficile) in-
Debridement, antibiotics, and implant retention followed by fection after a revision total knee arthroplasty. A diagnosis of
chronic oral antibiotic suppression for acute total knee C. difficile infection was associated with longer length of stay,
arthroplasty periprosthetic joint infection produced a 5-year higher costs, and greater in-hospital mortality32.
infection-free survival of 66% in 1 small single-center study
that lacked a control group20. A retrospective cohort study Intra-Articular Antibiotics
found that oral antibiotic prophylaxis for 7 days after a primary One study assessed local, plasma, and urine concentrations of a
total knee arthroplasty or total hip arthroplasty in patients gentamicin or vancomycin-loaded mineral composite antibi-
deemed at high risk for periprosthetic joint infection lowered otic carrier and found a low plasma concentration and high
the risk of periprosthetic joint infection21. However, the authors local concentration of both antibiotics. The results also indi-
did not have a control group of high-risk patients and thus cated that a deep surgical drain may decrease the amount of
recommended the need for further study before widespread antibiotic available for systemic absorption33. A small pro-
adoption of this protocol. spective study evaluated the concentrations of gentamicin and
vancomycin from antibiotic-impregnated spacers in 2-stage
Topical Vancomycin revision arthroplasty, as well as in vitro. The antibiotic con-
Two meta-analyses evaluating the effect of intrawound van- centration in spacer cement decreased rapidly in vitro within
comycin in spinal surgery found that the groups treated with the first 24 hours, but in vivo, antibiotics were present much
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longer in tissues34. Work on an improved antibiotic delivery in culture-negative cases, the identification of pathogens in
system using a layer-by-layer technique to load gentamicin on what are currently identified as aseptic cases is a source of
nanoparticles blended into the powder of bone cement dem- concern and needs further research. Similarly, Moshirabadi
onstrated longer antimicrobial activity when compared with et al.44 reported on the use of polymerase chain reaction-
control cement specimens35. restriction fragment length polymorphism (PCR-RFLP)
techniques to diagnose periprosthetic joint infection. They
Antibiotic Prophylaxis for Dental Procedures compared PCR-RFLP with cultures and found a sensitivity of
In a survey of antibiotic-prescribing practices of dentists, 39% 97.4% and a specificity of 100% for PCR-RFLP compared
of respondents identified the presence of a prosthetic joint as a with a sensitivity of 31.6% and a specificity of 100% for cul-
high-risk condition that required antibiotic prophylaxis. The tures. In contrast, in another related study using PCR, Fink
dentists included in the survey reported greater antibiotic use et al.45 reported limited operative characteristics of PCR in the
than currently recommended by existing guidelines36. diagnosis of periprosthetic joint infection, with a limited sensi-
tivity of 55.6% and a specificity of 82%. However, the PCR
Diagnosis of Periprosthetic Joint Infection techniques varied widely between studies, which can alter the
Synovial Biomarkers number of false positives when standard PCR techniques are used.
Renz et al.37 reported on a point-of-contact lateral flow test for Another study showed that PCR results may vary depending on
synovial alpha-defensin that showed a sensitivity of 54% to the source: synovial fluid compared with tissue or implant soni-
84% depending on the criteria defined by 3 different infection cation. Sonicated fluid had the best diagnostic accuracy46.
organizations. They concluded that, given the limited sensi-
tivity and high specificity, this test should be used as a confir- Reimplantation Criteria
matory test rather than as a screening test. Gehrke et al. also The diagnosis of persistent periprosthetic joint infection after
compared the accuracy of the laboratory-based quantitative the placement of a cement spacer is challenging with minimal
enzyme-linked immunosorbent assay (ELISA) alpha-defensin tools available to measure it. Kanwar et al.47 reported the
test with the point-of-contact lateral flow test and found no potential use of alpha-defensin in combination with Muscu-
significant difference in the diagnostic accuracy38. They also loskeletal Infection Society criteria to predict the success of
reported improved results using a similar methodology (n = reimplantation. However, in 27 patients who had negative
223), with a sensitivity of 92.1% and a specificity of 100%. In a alpha-defensin results prior to reimplantation, 3 (11%) had a
systematic review and meta-analysis, Marson et al.39 noted that recurrent infection within 1 year.
the point-of-contact lateral flow test had a lower pooled sen-
sitivity (85%) than the laboratory-based alpha-defensin test Treatment
pooled sensitivity (95%). The authors believed that these lower Published research in 2018 continues to clarify the role of each
pooled results for the lateral flow test were only comparable of the 3 major treatment options for periprosthetic joint
with the leukocyte esterase test and that further study was infection: irrigation and debridement, 2-stage exchange, and 1-
necessary prior to widespread adaption. stage exchange.
The alpha-defensin biomarker has some limitations in
certain cases. Stone et al.40 showed that alpha-defensin in com- Irrigation and Debridement
bination with synovial C-reactive protein (CRP) had a high Irrigation and debridement with retention of components
sensitivity for a periprosthetic joint infection diagnosis, but had continued to show a high failure rate of 57% in a multicenter
false-positive results in the presence of metallosis or false-negative study for periprosthetic joint infection after total knee ar-
results in the presence of low-virulence organisms. Another group throplasty at 4 years48. Patients treated with irrigation and
confirmed that alpha-defensin is prone to false-positive results in debridement with polyethylene exchange for periprosthetic
the presence of an adverse local tissue reaction41. joint infection within 2 weeks of the index arthroplasty had
higher success rates (82%) when compared with those treated
Molecular Diagnosis and Sonication beyond 2 weeks (50%)49.
Technical advances have decreased the cost of the molecular
diagnosis of periprosthetic joint infection. Tarabichi et al.42,43 Two-Stage Exchange
reported on the use of next-generation sequencing to identify It is often assumed that 2-stage treatment is very successful.
pathogens in synovial fluid and tissue. They showed that cul- However, a recent study questioned the validity of that as-
tures were positive in only 61% when compared with next- sumption. In a study of 80 patients who underwent a 2-stage
generation sequencing that identified a pathogen in 89.3% of procedure, 14 (17.5%) never underwent reimplantation, 24
the infected cases. However, next-generation sequencing also (30%) had a serious complication, and of the 66 patients with a
identified microbes in 25% of aseptic revisions with negative successful reimplantation, only 48 (73%) remained infection-
cultures and in 35.3% of primary total joint arthroplasties. free50. Additionally, 9 (11%) of 80 patients required a spacer
Therefore, despite the increased yield of identifying pathogens exchange for persistent infection, 3 of whom underwent
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eventual failure. Spacer exchange due to persistent infection is One-Stage Exchange
not uncommon, occurring in 59 of 3,417 patients in another However, in a recent European study of 22 patients using anti-
study, one-third of whom became reinfected within 5 years bacterial hydrogel-coated implants, 1-stage treatment showed
compared with one-fifth of patients without an interim spacer51. results at 2.5 years that were similar to a 2-stage group without a
Similarly, if a 2-stage hip procedure fails requiring a repeat coating61. Additionally, as noted previously, a decision-tree analysis
2-stage hip procedure, a reinfection rate of 42% (8 of 19) was found greater health utility while being more cost-effective when a
noted in a series of 19 patients52. 1-stage treatment strategy was utilized62.
The optimal timing for reimplantation following
placement of an antibiotic-loaded spacer remains elusive. Spine
Predicting which patients are at risk for failed treatment Although magnetic resonance imaging (MRI) remains the most
remains difficult. In a study of 205 patients who underwent a common radiographic technique for diagnosis of infection of the
2-stage procedure, 27% (56 of 205) had a recurrent peri- native spine, a fluorodeoxyglucose positron emission tomography
prosthetic joint infection. Failure was 1.8 to 2.5 times more (PET) scan may offer similar sensitivity and specificity and allows
likely if the preoperative synovial fluid white blood cell count for the evaluation of sites of metastatic infection63. There appears
was >60,000, a neutrophil percentage of >92%, or an eryth- to be a high degree of concordance between blood and spine
rocyte sedimentation rate (ESR) of >99 mm per hour53. In a biopsy cultures, not only in patients with S. aureus bloodstream
review of 81 infected knees, another group noted an 88% infection and infection of the native spine, but also in those in
success rate at 4 years. They noted poor diagnostic values of whom the infection involves other organisms64. Among patients
ESR and CRP but found a frozen section to have a sensitivity who require operative intervention for spinal infection, the ideal
of 90%, making it a good indicator of success or failure at the operative strategy is uncertain. A single-stage posterior approach
time of reimplantation50. or a 2-stage anterior and posterior approach was associated with
Articulating antibiotic spacers appear to be safe for similar clinical outcomes in patients with bacterial infection65. A
interim treatment. In a series of 135 hips undergoing a 2-stage single-stage approach may also be an option for selected patients
procedure with an articulating spacer, an 88% infection-free with an infection due to Mycobacterium tuberculosis66-68 and Bru-
survivorship at 5 years was noted54. In another study, 23 cella species69.
patients underwent a temporary 2-stage knee revision using an Although infection associated with spinal instrumenta-
articulating spacer made of a loosely cemented primary tion infection occurs most often in the first 3 months after the
implant; of these patients, 1 patient died, 13 patients under- surgical procedure70, the consequences of deep infection may
went re-revision, and, in 9 patients, the implant remained be long-lasting. An observational cohort study found that
in situ. No infections were noted at a 3.5-year follow-up55. spinal instrumentation infection was an independent risk fac-
The importance of treatment consolidation at a tertiary tor for unsuccessful fusion after instrumented lumbar spine
center was highlighted in a study regarding patients referred surgery, resulting in a >12-fold increase in risk of unsuccessful
to a tertiary center after resection arthroplasty and placement fusion71. The accurate identification of patients at high risk for
of an antibiotic spacer. A high rate of retained foreign material infection after spinal instrumentation remains difficult. A
was noted, requiring re-debridement in which persistently previously published prediction model performed poorly in a
positive cultures were present in 41% of cases56. subsequent study72, and the Revised Cardiac Risk Index dem-
Two-stage treatment with high-dose antibiotic spacers onstrated an inferior discriminative ability compared with the
can result in nephrotoxicity. Serum antibiotic levels American Society of Anesthesiologists (ASA) score73. A large
were collected in 21 patients with such spacers 57 . Sys- cohort study of patients with S. aureus infection after spinal
temic accumulation of antibiotics persisted for at least instrumentation demonstrated a failure rate of 36% for revi-
8 weeks, and, thus, patients should be monitored for sion procedures to eradicate the infection. Debridement with
complications related to systemic absorption of antibiotics retention of the implants and infection with MRSA were
postoperatively. independently associated with treatment failure, and the use of
Although the results of culture-negative periprosthetic rifampin-based combination therapy had a protective effect74.
joint infections after total hip arthroplasties were similar
when compared with culture-positive infections58, poly- Trauma
microbial and fungal infections are much more challenging Although infection after fracture fixation is a feared compli-
to treat. Polymicrobial infections were associated with sig- cation, a systematic review found no standardized definition,
nificantly lower treatment success compared with single- which hampers the study of this problem75. The risk of infec-
organism infections59, and the overall success for fungal tion after fracture fixation is higher than that of infection
infections at 5 years was 29% for irrigation and debridement following elective clean orthopaedic surgery, with rates of
and 46% for 2-stage exchange60. Acute kidney injury infection after fracture fixation ranging from 2% to 8% after
requiring dialysis to lower toxic tobramycin levels after operative fixation of an ankle fracture76,77, a high-energy fem-
spacer placement has been reported31. oral fracture78, and a closed tibial plateau fracture79. Reported
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risk factors for infection after fracture fixation were similar to therapy for pediatric septic arthritis, based on a meta-analysis
those previously reported, including obesity76,77,79, diabetes76, of 3 randomized controlled trials and 1 cohort study88.
open fracture76,77, high ASA score76, high-energy mechanism of
fracture76,77, prolonged surgical duration79, smoking79, increased Conclusions
age77, and lack of antimicrobial prophylaxis76. In a retrospective The prevention, diagnosis, and treatment of musculoskeletal
study that used propensity score analysis, the ultimate rate of infection remain challenging. Preoperative patient optimization
fracture union did not differ between patients treated with and vigilance with regard to sterile technique are essential
primary intramedullary nailing compared with a 2-stage components of infection prevention. A high index of suspicion
approach initially using external fixation for high-energy for the possibility of infection is critical when a patient with
femoral fractures78. painful musculoskeletal symptoms presents, and the appropri-
ate use of the currently available diagnostic tools is important for
Hand the clinician to fully understand. Prompt intervention using
Any open fracture presents a risk for infection. However, a evidence-based treatment guidelines should maximize results.
systematic review found that the infection rate for upper-
extremity open fractures is lower than that commonly reported Evidence-Based Orthopaedics
for lower-extremity open fractures80. The authors concluded The editorial staff of The Journal reviewed a large number of
that prompt administration of empiric antimicrobials and recently published studies related to the musculoskeletal sys-
urgent debridement and treatment of open upper-extremity tem that received a higher Level of Evidence grade. In addition
fractures are both important components to prevent infection. to articles cited already in this update, 4 other articles with a
A prospective cohort study of hand infections requiring oper- higher Level of Evidence grade relevant to musculoskeletal
ative intervention found that patients with diabetes were more infection are appended to this review after the standard bibli-
likely to have deep infections, require repeat intervention, and ography, with a brief commentary about each article to help
require eventual amputation, compared with patients without guide your further reading, in an evidence-based fashion, in
diabetes81. A 4-year, single-center, cohort study of flexor ten- this subspecialty area.
osynovitis observed that staphylococcal and streptococcal
infection predominated, and 90% of patients required >1
surgical debridement82. Among patients with upper-extremity
nontuberculous mycobacterial infections, outcomes were
similar between immunocompetent patients and immuno- Thomas K. Fehring, MD1
compromised patients, and a delay of diagnosis of >4 months Keith A. Fehring, MD1
was associated with a more than fourfold risk of treatment Angela Hewlett, MD, MS2
failure83. Carlos A. Higuera, MD3
Jesse E. Otero, MD, PhD1
Aaron Tande, MD4
Pediatrics
1OrthoCarolina
A multicenter, retrospective study of infections of the native Hip & Knee Center, Charlotte, North Carolina
spine in pediatric patients found that S. aureus was the most
2University of Nebraska Medical Center, Omaha, Nebraska
common pathogen, but that Kingella kingae continues to be
important among patients who are 6 months to 4 years of age84. 3Cleveland Clinic Florida, Weston, Florida
The risk of osteoarticular infection with K. kingae, a com-
mensal organism in the oropharynx of young children, was 4Mayo Clinic, Rochester, Minnesota
significantly associated with the incidence of human rhinovirus
infection, but not other community respiratory viral infections, E-mail address for T.K. Fehring: [Link]@[Link]
supporting a postulated pathophysiologic mechanism85. Com-
pared with children with methicillin-susceptible S. aureus ORCID iD for T.K. Fehring: 0000-0001-5410-4292
ORCID iD for K.A. Fehring: 0000-0001-6635-0343
(MSSA) infection, children with MRSA osteoarticular infection ORCID iD for A. Hewlett: 0000-0003-2772-6437
have more surgical procedures, more complications, longer ORCID iD for C.A. Higuera: 0000-0001-9143-2455
hospital stays, and more frequent intensive care unit admis- ORCID iD for J.E. Otero: 0000-0003-2142-6863
sions86,87. Dexamethasone may have a role as an adjunctive ORCID iD for A. Tande: 0000-0001-9775-7082

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Evidence-Based Orthopaedics belief that injecting saline risks contamination and that joints without
Löwik CAM, Jutte PC, Tornero E, Ploegmakers JJW, Knobben BAS, de Vries fluid are rarely infected.
AJ, Zijlstra WP, Dijkstra B, Soriano A, Wouthuyzen-Bakker M; Northern
Infection Network Joint Arthroplasty (NINJA). Predicting failure in early Parvizi J, Tan TL, Goswami K, Higuera C, Della Valle C, Chen AF, Shohat N.
acute prosthetic joint infection treated with debridement, antibiotics, and The 2018 definition of periprosthetic hip and knee infection: an evidence-based
implant retention: external validation of the KLIC score. J Arthroplasty. 2018 and validated criteria. J Arthroplasty. 2018 May;33(5):1309-1314.e2. Epub 2018
Aug;33(8):2582-7. Epub 2018 Mar 27. Feb 26.
Irrigation and debridement is a commonly used treatment for This study evaluated a more comprehensive definition of periprosthetic
acute periprosthetic joint infection; however, results are variable. A joint infection using 11 different diagnostic variables. Assigning points to each
risk score was developed to predict the success of irrigation and variable, they found that the new definition correlated 100% with the current
debridement in periprosthetic joint infection, consisting of renal failure, major criteria from the Musculoskeletal Infection Society definition of peri-
cirrhosis, the index surgical procedure, a cemented prosthesis, and a prosthetic joint infection. Concerns about complexity, the availability of alpha
CRP of >115 mg/L. However, it had an area under the curve of only 0.64; defensin, and the weighting of individual variables will limit widespread
in comparison, the original study describing this risk score had an acceptance of this definition.
area under the curve of 0.84. Unfortunately, an instrument to
consistently predict outcomes in a procedure that has variable results
Zahar A, Lausmann C, Cavalheiro C, Dhamangaonkar AC, Bonanzinga T,
remains lacking.
Gehrke T, Citak M. How reliable is the cell count analysis in the diagnosis of
prosthetic joint infection? J Arthroplasty. 2018 Oct;33(10):3257-62. Epub 2018
Partridge DG, Winnard C, Townsend R, Cooper R, Stockley I. Joint aspira- May 17.
tion, including culture of reaspirated saline after a ‘dry tap’, is sensitive and Cell counts and polymorphonuclear cell percentages are sensitive
specific for the diagnosis of hip and knee prosthetic joint infection. Bone Joint J. methods for diagnosing periprosthetic joint infection. Although polymorpho-
2018 Jun 1;100-B(6):749-54. nuclear percentages are similar between hips and knees, the cutoff levels for cell
The purpose of this study was to evaluate the practice of injecting counts may be somewhat different. The best cutoff levels for all patients with
saline solution into an aspirated joint that initially was without fluid. periprosthetic joint infection were 2,500 leukocytes/mL and a polymorphonuclear
Using intraoperative tissue cultures as the gold standard for infection, for percentage of 66%. Elevated cell counts with a high percentage of polymorpho-
313 wet aspirations, the sensitivity was 81% and the specificity was 90%; nuclear cells have been a useful to diagnose periprosthetic joint infection.
saline solution-injected dry aspirates had 81% sensitivity and 79% spec- Although multiple attempts have been made to determine an exact cutoff, such
ificity. The sensitivity of dry taps is surprising in light of the conventional efforts should be used only as a general guide without a focus on an exact number.