The American Academy of Orthopaedic Surgeons (AAOS) recently approved and released an evidence-based clinical practice guideline on the diagnosis of periprosthetic joint infections of the hip and knee.
Clinical practice guidelines are one avenue the Academy uses to ensure that patients receive high quality care. A periprosthetic joint infection occurs when bacteria or other foreign organisms enter the wound during or at any point following joint replacement surgery, sometimes even years after surgery. An infection can cause the joint to be painful or cause the implant to loosen, often times resulting in the need for revision surgery.
Research indicates that periprosthetic infection, also known as "septic failure," is the leading cause of total knee replacement revision (25 percent) and the second-leading cause of total hip replacement revision (15 percent) in the U.S.
"Every orthopaedic surgeon inevitably sees patients who come back with a problem such as stiffness or pain in the joint," said Craig J. Della Valle, MD, associate professor of orthopaedic surgery, Rush University Medical Center and chair of the physician work group that developed the guideline. "It is very important to determine whether the problem was caused by an infection or not, primarily since treatments of septic versus aseptic joint failure are so vastly different."
However, Dr. Della Valle noted that a diagnosis of septic joint failure can be very difficult to make and, since some diagnostic procedures are somewhat costly and invasive, physicians should ensure the most appropriate course of action is followed.
"The Academy created this clinical practice guideline to improve the diagnostic process for patients who may have a periprosthetic joint infection," he said. "This serves as a point of reference and an educational tool for both primary care physicians and orthopaedic surgeons, streamlining the process while minimizing costs, patient discomfort and risk. We were able to make several strong recommendations due to the prevalence of good, evidence-based data."
The final physician-oriented guidelines for diagnosing periprosthetic joint infection contain 15 recommendations overall, including the following:Diagnosis should begin with a simple blood test for erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).
"The recommendation to withhold antibiotics prior to obtaining appropriate cultures is particularly important," explains Dr. Della Valle. While there may be rare situations when a patient has systemic symptoms (such as fever and low blood pressure) that require immediate antibiotic administration, in the vast majority of cases, the indiscriminate use of antibiotics is discouraged. "The first rule of treatment in medicine is always to make the diagnosis first. Unfortunately, we often times see patients who are given antibiotics prior to having appropriate cultures drawn from within the joint that can lead to a delay in diagnosis and a subsequent delay in appropriate treatment. Further, identification of the specific bacteria which is causing the infection is important in administering the most effective antibiotic to cure the infection and if antibiotics are given before we can get a good culture, we may not have the advantage of knowing exactly which antibiotics to give as the cultures can turn negative even after a single dose of antibiotics."
Additional recommendations, particularly those involving the diagnostic procedure known as joint aspiration (removal of fluid from the joint for laboratory testing including an assessment of the number of white blood cells, the type of white blood cells and cultures of the fluid), vary depending on the location of the arthroplasty (hip or knee), the probability of infection based on established risk factors (including patient history) and whether or not the patient is scheduled for reoperation on the affected joint.
"Since the hip joint is deeper in the body than the knee, aspiration is more difficult and more uncomfortable for the patient," said Dr. Della Valle. "Because of this difference, we suggest a more selective approach for using this procedure on patients with a total hip arthroplasty."
The following recommendations were among those made by the work group for patients being assessed for periprosthetic joint infections who are scheduled for revision surgeries:multiple cultures should be obtained at the time of reoperation;
prophylactic antibiotics should be given prior to revision (or repeat) surgery.
According to the work group, one key question that needs to be addressed through further research is whether one single test can be identified that will consistently allow clinicians to rule in or rule out the presence of a periprosthetic infection in all patients. For example, continued studies evaluating the efficacy and cost-effectiveness of using advanced imagery and molecular testing to diagnose periprosthetic joint infection are warranted.
Editor's Note: A volunteer, physician work group developed this Clinical Practice based on a systematic review of the current scientific and clinical information and accepted approaches to treatment and/or diagnosis. The entire process included a review panel consisting of internal and external committees, public commentaries and final approval by the AAOS Board of Directors.
Disclaimer: This Clinical Practice Guideline is not intended to be a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. Clinical patients may not necessarily be the same as those found in a clinical trial. Patient care and treatment should always be based on a clinician's independent medical judgment, given the individual patient's clinical circumstances.
The full guideline along with all supporting documentation and workgroup disclosures is available on the AAOS website: http://www.aaos.org/guidelines.
About AAOS (www.aaos.org)
For more information on joint replacement, visit www.orthinfo.org
Fan and Follow the AAOS on Facebook.com/AAOS1 and Twitter.com/AAOS1
Lauren L. Pearson | EurekAlert!
A whole-body approach to understanding chemosensory cells
13.12.2017 | Tokyo Institute of Technology
Research reveals how diabetes in pregnancy affects baby's heart
13.12.2017 | University of California - Los Angeles Health Sciences
MPQ scientists achieve long storage times for photonic quantum bits which break the lower bound for direct teleportation in a global quantum network.
Concerning the development of quantum memories for the realization of global quantum networks, scientists of the Quantum Dynamics Division led by Professor...
Researchers have developed a water cloaking concept based on electromagnetic forces that could eliminate an object's wake, greatly reducing its drag while...
Tiny pores at a cell's entryway act as miniature bouncers, letting in some electrically charged atoms--ions--but blocking others. Operating as exquisitely sensitive filters, these "ion channels" play a critical role in biological functions such as muscle contraction and the firing of brain cells.
To rapidly transport the right ions through the cell membrane, the tiny channels rely on a complex interplay between the ions and surrounding molecules,...
The miniaturization of the current technology of storage media is hindered by fundamental limits of quantum mechanics. A new approach consists in using so-called spin-crossover molecules as the smallest possible storage unit. Similar to normal hard drives, these special molecules can save information via their magnetic state. A research team from Kiel University has now managed to successfully place a new class of spin-crossover molecules onto a surface and to improve the molecule’s storage capacity. The storage density of conventional hard drives could therefore theoretically be increased by more than one hundred fold. The study has been published in the scientific journal Nano Letters.
Over the past few years, the building blocks of storage media have gotten ever smaller. But further miniaturization of the current technology is hindered by...
With innovative experiments, researchers at the Helmholtz-Zentrums Geesthacht and the Technical University Hamburg unravel why tiny metallic structures are extremely strong
Light-weight and simultaneously strong – porous metallic nanomaterials promise interesting applications as, for instance, for future aeroplanes with enhanced...
11.12.2017 | Event News
08.12.2017 | Event News
07.12.2017 | Event News
13.12.2017 | Health and Medicine
13.12.2017 | Physics and Astronomy
13.12.2017 | Life Sciences