Guided and Unguided Biopsy in the Diagnostic of Periprosthetic Infections of the Knee – Evaluation of an Evidence-based Algorithm

Abstract

Background Periprosthetic joint infection (PPI) is one of the most common reasons for revision in total knee arthroplasty (TKA). Percutaneous synovial biopsy is considered as a well-established diagnostic tool in ambiguous cases of chronic pain after TKA. The exact number of undetected low-grade infections remains unclear.

Objectives The aim of this prospective study was to compare the diagnostic accuracy of arthroscopically guided and unguided synovial biopsy. Additionally, the prevalence of initially undetected PPI during synovial biopsy and revision surgery was assessed.

Materials and Methods 40 patients suffering from chronic pain after TKA and the clinical suspicion of PPI were included in the study. Synovial biopsies were collected in a standardized manner first without and then with arthroscopic visual control. Using both techniques, six samples were collected each (5 for microbiology, 1 for histology). 19 patients, initially classified aseptic, underwent revision surgery later.

Results The diagnosis of PPI was made in 10.0% of unguided biopsies (4 cases, 2× microbiologically, 2× histologically), 7.5% of arthroscopic biopsies (3 cases, 3× histologically) and 12.5% (5 cases, 3× histologically, 2× microbiologically) of all cases. Only histologic evaluation led to concordant positive findings using both techniques in two patients. The proportion of non-representative biopsies was twice as high after unguided tissue collection than after arthroscopic biopsy (30.0 vs. 15.0%). Microbiologic evaluation of arthroscopically collected biopsies did not lead to the diagnosis of PPI, which might have been essential to the selection of the appropriate antimicrobial therapy. During revision surgery the diagnosis of PPI was made in 22.2% of cases.

Conclusions In patients suffering from chronic pain after TKA, periprosthetic low-grade infection was diagnosed in a relevant proportion of cases. Therefore, synovial biopsies for histological and microbiological evaluation should be collected whenever thereʼs clinical suspicion of PPI. For histological evaluation, samples should be collected using arthroscopic control and ideally multiple biopsies should be taken. For microbiological evaluation, excessive joint lavage should be avoided.

Key words

periprosthetic infection - arthroscopy - total knee replacement - minimally invasive

• References/Literatur

• 1 Phillips JE, Crane TP, Noy M. et al. The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey. J Bone Joint Surg Br 2006; 88: 943-948
• 2 Parvizi J, Ghanem E, Sharkey P. et al. Diagnosis of infected total knee: findings of a multicenter database. Clin Orthop Relat Res 2008; 466: 2628-2633
• 3 Peersman G, Laskin R, Davis J. et al. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res 2001; (392) 15-23
• 4 Zmistowski B, Tetreault MW, Alijanipour P. et al. Recurrent periprosthetic joint infection: persistent or new infection?. J Arthroplasty 2013; 28: 1486-1489
• 5 Bozic KJ, Kurtz SM, Lau E. et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res 2010; 468: 45-51
• 6 Sharkey PF, Hozack WJ, Rothman RH. et al. Insall Award paper. Why are total knee arthroplasties failing today?. Clin Orthop Relat Res 2002; (404) 7-13
• 7 Mortazavi SM, Molligan J, Austin MS. et al. Failure following revision total knee arthroplasty: infection is the major cause. Int Orthop 2011; 35: 1157-1164
• 8 Rasouli MR, Harandi AA, Adeli B. et al. Revision total knee arthroplasty: infection should be ruled out in all cases. J Arthroplasty 2012; 27: 1239-1243.e1–e2
• 9 Parvizi J, Adeli B, Zmistowski B. et al. Management of periprosthetic joint infection: the current knowledge: AAOS exhibit selection. J Bone Joint Surg Am 2012; 94: e104
• 10 Aggarwal VK, Rasouli MR, Parvizi J. Periprosthetic joint infection: Current concept. Indian J Orthop 2013; 47: 10-17
• 11 Osmon DR, Berbari EF, Berendt AR. et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013; 56: e1-e25
• 12 Mortazavi SM, Vegari D, Ho A. et al. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res 2011; 469: 3049-3054
• 13 Sabry FY, Buller L, Ahmed S. et al. Preoperative prediction of failure following two-stage revision for knee prosthetic joint infections. J Arthroplasty 2014; 29: 115-121
• 14 George J, Kwiecien G, Klika AK. et al. Are frozen sections and MSIS criteria reliable at the time of reimplantation of two-stage revision arthroplasty?. Clin Orthop Relat Res 2016; 474: 1619-1626
• 15 Mahmud T, Lyons MC, Naudie DD. et al. Assessing the gold standard: a review of 253 two-stage revisions for infected TKA. Clin Orthop Relat Res 2012; 470: 2730-2736
• 16 Parvizi J, Della Valle CJ. AAOS Clinical Practice Guideline: diagnosis and treatment of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg 2010; 18: 771-772
• 17 Bauer TW, Parvizi J, Kobayashi N. et al. Diagnosis of periprosthetic infection. J Bone Joint Surg Am 2006; 88: 869-882
• 18 Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004; 351: 1645-1654
• 19 Parvizi J, Gehrke T. International Consensus Group on Periprosthetic Joint Infection. Definition of periprosthetic joint infection. J Arthroplasty 2014; 29: 1331
• 20 Fink B, Makowiak C, Fuerst M. et al. The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late peri-prosthetic infection of total knee replacements. J Bone Joint Surg Br 2008; 90: 874-878
• 21 Fuerst M, Fink B, Ruther W. [The value of preoperative knee aspiration and arthroscopic biopsy in revision total knee arthroplasty]. Z Orthop Ihre Grenzgeb 2005; 143: 36-41
• 22 Shukla SK, Ward JP, Jacofsky MC. et al. Perioperative testing for persistent sepsis following resection arthroplasty of the hip for periprosthetic infection. J Arthroplasty 2010; 25: 87-91
• 23 Trampuz A, Hanssen AD, Osmon DR. et al. Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med 2004; 117: 556-562
• 24 Dinneen A, Guyot A, Clements J. et al. Synovial fluid white cell and differential count in the diagnosis or exclusion of prosthetic joint infection. Bone Joint J 2013; 95-B: 554-557
• 25 Claassen L, Ettinger S, Pastor MF. et al. The value of arthroscopic neosynovium biopsies to diagnose periprosthetic knee joint low-grade infection. Arch Orthop Trauma Surg 2016; 136: 1753-1759
• 26 Costerton JW. Biofilm theory can guide the treatment of device-related orthopaedic infections. Clin Orthop Relat Res 2005; (437) 7-11
• 27 Vasso M, Schiavone Panni A. Low-grade periprosthetic knee infection: diagnosis and management. J Orthop Traumatol 2015; 16: 1-7
• 28 Dodson CC, Craig EV, Cordasco FA. et al. Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. J Shoulder Elbow Surg 2010; 19: 303-307
• 29 Heller KD. [Diagnosis of periprosthetic infection – whatʼs obligation, whatʼs optional?]. Z Orthop Unfall 2016; 154: 398-405
• 30 Koski JM, Helle M. Ultrasound guided synovial biopsy using portal and forceps. Ann Rheum Dis 2005; 64: 926-929
• 31 Hügle T, Leumann A, Pagenstert G. et al. Retrograde synovial biopsy of the knee joint using a novel biopsy forceps. Arthrosc Tech 2014; 3: e317-e319
• 32 Mühlhofer HM, Pohlig F, Kanz KG. et al. Prosthetic joint infection development of an evidence-based diagnostic algorithm. Eur J Med Res 2017; 22: 8
• 33 Hughes JG, Vetter EA, Patel R. et al. Culture with BACTEC Peds Plus/F bottle compared with conventional methods for detection of bacteria in synovial fluid. J Clin Microbiol 2001; 39: 4468-4471
• 34 Thomas P, Summer B. Diagnosis and management of patients with allergy to metal implants. Expert Rev Clin Immunol 2015; 11: 501-509
• 35 Trampuz A, Piper KE, Jacobson MJ. et al. Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med 2007; 357: 654-663
• 36 Krenn V, Morawietz L, Perino G. et al. Revised histopathological consensus classification of joint implant related pathology. Pathol Res Pract 2014; 210: 779-786
• 37 Fink B, Gebhard A, Fuerst M. et al. High diagnostic value of synovial biopsy in periprosthetic joint infection of the hip. Clin Orthop Relat Res 2013; 471: 956-964
• 38 Müller M, Trampuz A, Winkler T. et al. [The economic challenge of centralised treatment of patients with periprosthetic infections]. Z Orthop Unfall 2018; 156: 407-413
• 39 Mühlhofer HM, Schauwecker J, Banke IJ. et al. [Septic endoprosthesis exchange: preoperative diagnosis and reimplantation]. Orthopade 2015; 44: 946-951
• 40 Della Valle C, Parvizi J, Bauer TW. et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am 2011; 93: 1355-1357
• 41 Parvizi J, Gehrke T. Proceedings of the International Consensus Meeting of Periprosthetic Joint Infection. Bone Joint J 2013; 95-B: 1450-1452
• 42 Ahmad SS, Shaker A, Saffarini M. et al. Accuracy of diagnostic tests for prosthetic joint infection: a systematic review. Knee Surg Sports Traumatol Arthrosc 2016; 24: 3064-3074
• 43 Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004; 351: 1645-1654
• 44 Nodzo SR, Westrich GH, Henry MW. et al. Clinical analysis of Propionibacterium acnes infection after total knee arthroplasty. J Arthroplasty 2016; 31: 1986-1989
• 45 Corona P, Gil E, Guerra E. et al. Percutaneous interface biopsy in dry-aspiration cases of chronic periprosthetic joint infections: a technique for preoperative isolation of the infecting organism. Int Orthop 2012; 36: 1281-1286
• 46 Wimmer MD, Ploeger MM, Friedrich MJ. et al. Pre-operative intra-articular deep tissue sampling with novel retrograde forceps improves the diagnostics in periprosthetic joint infection. Int Orthop 2017; 41: 1355-1359
• 47 McMillan S, Saini S, Alyea E. et al. Office-based needle arthroscopy: a standardized diagnostic approach to the knee. Arthrosc Tech 2017; 6: e1119-e1124
• 48 Fink B, Gebhard A, Fuerst M. et al. High diagnostic value of synovial biopsy in periprosthetic joint infection of the hip. Clin Orthop Relat Res 2013; 471: 956-964
• 49 Ploeger MM, Groezinger A, Randau TM. et al. [Intra-articular sampling with novel biopsy forceps: a simple and reliable diagnostic procedure for patients with periprosthetic infections of the knee joint]. Z Orthop Unfall 2016; 154: 521-523
• 50 Lützner J, Hübel U, Kirschner S. et al. [Long-term results in total knee arthroplasty. A meta-analysis of revision rates and functional outcome]. Chirurg 2011; 82: 618-624
• 51 Fernandez-Sampedro M, Farinas-Alvarez C, Garces-Zarzalejo C. et al. Accuracy of different diagnostic tests for early, delayed and late prosthetic joint infection. BMC Infect Dis 2017; 17: 592
• 52 Knobben BA, Engelsma Y, Neut D. et al. Intraoperative contamination influences wound discharge and periprosthetic infection. Clin Orthop Relat Res 2006; 452: 236-241
• 53 Ritter MA, Stringer EA. Intraoperative wound cultures: their value and long-term effect on the patient. Clin Orthop Relat Res 1981; (155) 180-185
• 54 Atkins BL, Athanasou N, Deeks JJ. et al. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. The OSIRIS Collaborative Study Group. J Clin Microbiol 1998; 36: 2932-2939
• 55 Pons M, Angles F, Sanchez C. et al. Infected total hip arthroplasty–the value of intraoperative histology. Int Orthop 1999; 23: 34-36
• 56 Morawietz L, Classen RA, Schroder JH. et al. Proposal for a histopathological consensus classification of the periprosthetic interface membrane. J Clin Pathol 2006; 59: 591-597
• 57 Meermans G, Haddad FS. Is there a role for tissue biopsy in the diagnosis of periprosthetic infection?. Clin Orthop Relat Res 2010; 468: 1410-1417
• 58 Williams JL, Norman P, Stockley I. The value of hip aspiration versus tissue biopsy in diagnosing infection before exchange hip arthroplasty surgery. J Arthroplasty 2004; 19: 582-586
• 59 Fink B, Makowiak C, Fuerst M. et al. The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late peri-prosthetic infection of total knee replacements. J Bone Joint Surg Br 2008; 90: 874-878