The Journal of Bone and Joint Surgery (American). 2006;88:869-882.
doi:10.2106/JBJS.E.01149
© 2006 The Journal of Bone and Joint Surgery, Inc.
Diagnosis of Periprosthetic Infection
Thomas W. Bauer, MD, PhD1,
Javad Parvizi, MD2,
Naomi Kobayashi, MD, PhD1 and
Viktor Krebs, MD3
1 Departments of Pathology and Orthopaedic Surgery, The Cleveland Clinic
Foundation, L25, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address for
T.W. Bauer:
osteoclast{at}aol.com
2 The Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA
19107
3 Department of Orthopaedic Surgery, The Cleveland Clinic Foundation, A41, 9500
Euclid Avenue, Cleveland, OH 44195
Investigation performed at the Departments of Pathology and Orthopaedic
Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio
In support of their research for or preparation of this manuscript, one or
more of the authors received grants or outside funding from Stryker. In
addition, one or more of the authors received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity
(Stryker). No commercial entity paid or directed, or agreed to pay or direct,
any benefits to any research fund, foundation, educational institution, or
other charitable or nonprofit organization with which the authors are
affiliated or associated.
Periprosthetic infections are rare, but there is evidence to suggest that
their frequency may be underestimated.
No single laboratory test has perfect sensitivity and specificity for
diagnosing infection. Most tests have better specificity when they are
performed for patients in whom infection is suspected clinically rather than
when they are used as screening tests.
Screening test results that may suggest the possibility of infection
include elevation of the erythrocyte sedimentation rate and/or serum
C-reactive protein level more than three months after an arthroplasty. Most
serologic tests are difficult to interpret when the patient has an underlying
inflammatory arthropathy.
Cultures of aspirated joint fluid can be especially helpful for patients
who have symptoms suggestive of infection, but their results are best
interpreted two weeks after administration of antibiotics has been
discontinued. Joint fluid cell counts may also be helpful, but Gram stains of
joint fluid have poor sensitivity and specificity.
Criteria for diagnosing infection on the basis of frozen sections of
implant membranes have not yet been standardized, but in many laboratories
more than five neutrophils per high-power field in five or more fields
(excluding surface fibrin) has been found to be suggestive of infection.
Most polymerase chain reactions that detect the universal 16S rRNA
bacterial gene have problems with false-positive results, but combining a
universal polymerase chain reaction with subsequent bacterial sequencing can
help improve specificity. Polymerase chain reactions can detect necrotic
bacteria, so the clinical importance of positive results of this analysis in
the absence of other features of infection remains to be determined.
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Letters to the Editor:
Read all Letters to the Editor
- Letter to the Editor
- Giovanni Pignatti, MD
- JBJS Online, 1 Oct 2009
[Full text]
- Dr. Bauer and colleagues respond to Dr. Pignatti
- Thomas W. Bauer, MD, PhD, et al.
- JBJS Online, 1 Oct 2009
[Full text]
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