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!
Researchers release the brakes on the immune system
18.10.2017 | Rheinische Friedrich-Wilhelms-Universität Bonn
Norovirus evades immune system by hiding out in rare gut cells
12.10.2017 | University of Pennsylvania School of Medicine
University of Maryland researchers contribute to historic detection of gravitational waves and light created by event
On August 17, 2017, at 12:41:04 UTC, scientists made the first direct observation of a merger between two neutron stars--the dense, collapsed cores that remain...
Seven new papers describe the first-ever detection of light from a gravitational wave source. The event, caused by two neutron stars colliding and merging together, was dubbed GW170817 because it sent ripples through space-time that reached Earth on 2017 August 17. Around the world, hundreds of excited astronomers mobilized quickly and were able to observe the event using numerous telescopes, providing a wealth of new data.
Previous detections of gravitational waves have all involved the merger of two black holes, a feat that won the 2017 Nobel Prize in Physics earlier this month....
Material defects in end products can quickly result in failures in many areas of industry, and have a massive impact on the safe use of their products. This is why, in the field of quality assurance, intelligent, nondestructive sensor systems play a key role. They allow testing components and parts in a rapid and cost-efficient manner without destroying the actual product or changing its surface. Experts from the Fraunhofer IZFP in Saarbrücken will be presenting two exhibits at the Blechexpo in Stuttgart from 7–10 November 2017 that allow fast, reliable, and automated characterization of materials and detection of defects (Hall 5, Booth 5306).
When quality testing uses time-consuming destructive test methods, it can result in enormous costs due to damaging or destroying the products. And given that...
Using a new cooling technique MPQ scientists succeed at observing collisions in a dense beam of cold and slow dipolar molecules.
How do chemical reactions proceed at extremely low temperatures? The answer requires the investigation of molecular samples that are cold, dense, and slow at...
Scientists from the Max Planck Institute of Quantum Optics, using high precision laser spectroscopy of atomic hydrogen, confirm the surprisingly small value of the proton radius determined from muonic hydrogen.
It was one of the breakthroughs of the year 2010: Laser spectroscopy of muonic hydrogen resulted in a value for the proton charge radius that was significantly...
17.10.2017 | Event News
10.10.2017 | Event News
10.10.2017 | Event News
20.10.2017 | Information Technology
20.10.2017 | Materials Sciences
20.10.2017 | Interdisciplinary Research