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!
Hot cars can hit deadly temperatures in as little as one hour
24.05.2018 | Arizona State University
3D images of cancer cells in the body: Medical physicists from Halle present new method
16.05.2018 | Martin-Luther-Universität Halle-Wittenberg
The more electronics steer, accelerate and brake cars, the more important it is to protect them against cyber-attacks. That is why 15 partners from industry and academia will work together over the next three years on new approaches to IT security in self-driving cars. The joint project goes by the name Security For Connected, Autonomous Cars (SecForCARs) and has funding of €7.2 million from the German Federal Ministry of Education and Research. Infineon is leading the project.
Vehicles already offer diverse communication interfaces and more and more automated functions, such as distance and lane-keeping assist systems. At the same...
A research team led by physicists at the Technical University of Munich (TUM) has developed molecular nanoswitches that can be toggled between two structurally different states using an applied voltage. They can serve as the basis for a pioneering class of devices that could replace silicon-based components with organic molecules.
The development of new electronic technologies drives the incessant reduction of functional component sizes. In the context of an international collaborative...
At the LASYS 2018, from June 5th to 7th, the Laser Zentrum Hannover e.V. (LZH) will be showcasing processes for the laser material processing of tomorrow in hall 4 at stand 4E75. With blown bomb shells the LZH will present first results of a research project on civil security.
At this year's LASYS, the LZH will exhibit light-based processes such as cutting, welding, ablation and structuring as well as additive manufacturing for...
There are videos on the internet that can make one marvel at technology. For example, a smartphone is casually bent around the arm or a thin-film display is rolled in all directions and with almost every diameter. From the user's point of view, this looks fantastic. From a professional point of view, however, the question arises: Is that already possible?
At Display Week 2018, scientists from the Fraunhofer Institute for Applied Polymer Research IAP will be demonstrating today’s technological possibilities and...
So-called quantum many-body scars allow quantum systems to stay out of equilibrium much longer, explaining experiment | Study published in Nature Physics
Recently, researchers from Harvard and MIT succeeded in trapping a record 53 atoms and individually controlling their quantum state, realizing what is called a...
25.05.2018 | Event News
02.05.2018 | Event News
13.04.2018 | Event News
25.05.2018 | Event News
25.05.2018 | Machine Engineering
25.05.2018 | Life Sciences