New Definition for Periprosthetic Joint Infection: From the Workgroup of the Musculoskeletal Infection Society

• DOI: 10.1007/s11999-011-2102-9
• Publication Date: 2011-09-21T19:52:43Z
• Authors: Javad Parvizi; Benjamin Zmistowski; Elie F. Berbari; Thomas W. Bauer; Bryan D. Springer; Craig J. Della Valle; Kevin L. Garvin; Michael A. Mont; Montri D. Wongwor...; Charalampos G. Za...
• Keywords: Workgroup; Joint infections; Sports medicine

Introduction Periprosthetic joint infection (PJI) is one of the most challenging and frequent complications after lower-extremity (hip knee) arthroplasty. However, there no single accepted set diagnostic criteria for PJI. Various definitions have been proposed; however, none widely adopted. Furthermore, some these disagree with each other [14]. Therefore, a workgroup convened by Musculoskeletal Infection Society (MSIS) analyzed available evidence to propose new definition A summary recommendations those in attendance at premeeting workshop 21st Annual Meeting MSIS on August 4, 2011, pertaining PJI outlined below. Existing published data was discussed e-mail preceding 6 months executive members group experts known interest this field. The intention proposal "gold standard" that can be universally adopted all physicians, surveillance authorities (including Centers Disease Control, medical surgical journals, medicolegal community), involved management panel acknowledged, certain low-grade infections (ie, Propionibacterium acnes), several may not routinely met despite presence Using definition, clinicians confident their diagnosis therefore provide appropriate treatment. Additionally, adoption research purposes will allow consistency between studies potential improvement quality body evidence. Definition Joint Based proposed criteria, definite exists when: There sinus tract communicating prosthesis; or pathogen isolated culture from least two separate tissue fluid samples obtained affected prosthetic joint; Four following six exist: Elevated serum erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) concentration, synovial leukocyte count, neutrophil percentage (PMN%), Presence purulence joint, Isolation microorganism periprosthetic fluid, Greater than five neutrophils per high-power field fields observed histologic analysis ×400 magnification. present if fewer four are met. Considerations Microbiologic Testing It imperative representative fluid. To limit risk contamination, sample should taken separate, sterile instruments. phenotypically identical organisms based phenotypic similarities vitro antimicrobial susceptibility testing since confirmation genetic identity performed clinical isolates. We recommend three more specimen incubated an aerobic anaerobic environment. Fungal mycobacterial cultures reserved higher-risk scenarios. time incubation has standardized yet. low-virulence such as coagulase-negative Staphylococcus, P. acnes, Corynebacteria absence believed represent infection. virulent organism S. aureus recent identified tests, Gram stain, sensitive diagnosing [7]. Serum Tests previous publications, ESR greater 30 mm/hour CRP 10 mg/L would elevated levels [11, 15]. it important note variations measuring markers laboratories. level age, sex, comorbidities patient. also reported approximately 60 days immediate postoperative period [3, 9]. Synovial Multiple provided thresholds count PMN% differential. In chronically infected knee arthroplasty, values 1100 4000 cells/μL 64% 69%, respectively [5, 8, 16]. patients acute infections, cell much higher (approximately 20,000 89%, respectively). Acute defined less 3 index surgery onset symptoms [1]. hip arthroplasty well delineated. sole study threshold 3000 leukocytes 80% [15]. None included underlying inflammatory arthropathies related diseases. Current proceeding definitive patients. Histology Examination tissues traditionally conducted specially trained musculoskeletal pathologists. Histologic examination consequently operator dependent. incumbent surgeons ensure pathologists agreement When examining neutrophils, histopathologist disregard entrapped superficial fibrin adherent endothelium small veins. Also, caution exercised analyzing test cases where might expected, fractures arthropathy. Future Developments This current supporting role various tests literature. recognize numerous currently being evaluated, including measurement [12], esterase [13], sonication explanted prosthetics [17], molecular techniques PCR [10] IL-6 [2, 6]. As become validated available, require modification. Acknowledgments thank individuals involvement invaluable input throughout development document: Robert Barrack MD, Keith Berend Sandra Berrios-Torres (from Control Prevention), Kevin Bozic John Esterhai Ryan Fagan Thomas Fehring Terry Gioe Teresa Horan Steven Kurtz PhD, Bas Masri Arvind Nana Douglas Osmon Segreti Mark Spangehl MD.