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Laboratory Tests for Diagnosis of Chronic Periprosthetic Joint Infection Can Help Predict Outcomes of Two-Stage Exchange.
J Bone Joint Surg Am. 2018 Jun 20; 100(12):1009-1015.JB

Abstract

BACKGROUND

Although 2-stage exchange arthroplasty is the most effective treatment among available strategies for managing chronic periprosthetic joint infection (PJI), rates of its success vary greatly. The purpose of our study was to examine whether objective measurements collected at the time of the diagnosis of PJI could be used to identify patients at risk of failure of 2-stage exchange.

METHODS

We identified 205 patients across 4 institutions who underwent 2-stage exchange arthroplasty for the treatment of PJI following total hip or total knee arthroplasty. Demographic, surgical, and laboratory data were obtained for each patient from their medical chart. Laboratory values included serum erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) level, synovial fluid white blood-cell (WBC) count and neutrophil percentage, synovial fluid and/or tissue culture, and Gram stain. Patients who underwent revision surgery for recurrent infection were considered to have failed the 2-stage procedure. Demographic, surgical, and laboratory variables were compared between the 2 groups. Receiver operating characteristic (ROC) curves were constructed to determine threshold cutoffs for significant laboratory values. Risk ratios and 95% confidence intervals were calculated.

RESULTS

Overall, 2-stage exchange was unsuccessful for 27.3% of the patients. Preoperative serum ESR (p = 0.035) and synovial fluid WBC count (p = 0.008) and neutrophil percentage (p = 0.041) were greater in patients with recurrent infection. ROC curve analysis revealed a threshold of >60,000 cells/μL for synovial fluid WBC count, >92% for synovial fluid WBC neutrophil percentage, and >99 mm/hr for serum ESR. Failure of 2-stage exchange was 2.5 times more likely for patients with an elevated preoperative synovial fluid WBC count, 2.0 times more likely for those with an elevated preoperative synovial fluid WBC neutrophil percentage, and 1.8 times more likely for those with an elevated preoperative serum ESR.

CONCLUSIONS

Our results demonstrated that a greater number of patients in whom 2-stage exchange arthroplasty ultimately failed had a preoperative synovial fluid WBC count of >60,000 cells/μL, a synovial fluid WBC neutrophil percentage of >92%, or a serum ESR of >99 mm/hr. Patients with elevated laboratory values had 1.8 to 2.5 times the risk of treatment failure. These data can serve as a clinical guideline to identify patients most at risk for failure of 2-stage exchange.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Authors+Show Affiliations

Kaplan Joint Center, Newton Wellesley Hospital, Newton, Massachusetts. Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts.New England Baptist Hospital, Boston, Massachusetts.Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania.Tufts University School of Medicine, Boston, Massachusetts.Tufts University School of Medicine, Boston, Massachusetts.Boston Medical Center, Boston, Massachusetts.New England Baptist Hospital, Boston, Massachusetts.Kaplan Joint Center, Newton Wellesley Hospital, Newton, Massachusetts. Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

29916927

Citation

Dwyer, Maureen K., et al. "Laboratory Tests for Diagnosis of Chronic Periprosthetic Joint Infection Can Help Predict Outcomes of Two-Stage Exchange." The Journal of Bone and Joint Surgery. American Volume, vol. 100, no. 12, 2018, pp. 1009-1015.
Dwyer MK, Damsgaard C, Wadibia J, et al. Laboratory Tests for Diagnosis of Chronic Periprosthetic Joint Infection Can Help Predict Outcomes of Two-Stage Exchange. J Bone Joint Surg Am. 2018;100(12):1009-1015.
Dwyer, M. K., Damsgaard, C., Wadibia, J., Wong, G., Lazar, D., Smith, E., Talmo, C., & Bedair, H. (2018). Laboratory Tests for Diagnosis of Chronic Periprosthetic Joint Infection Can Help Predict Outcomes of Two-Stage Exchange. The Journal of Bone and Joint Surgery. American Volume, 100(12), 1009-1015. https://doi.org/10.2106/JBJS.17.00599
Dwyer MK, et al. Laboratory Tests for Diagnosis of Chronic Periprosthetic Joint Infection Can Help Predict Outcomes of Two-Stage Exchange. J Bone Joint Surg Am. 2018 Jun 20;100(12):1009-1015. PubMed PMID: 29916927.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Laboratory Tests for Diagnosis of Chronic Periprosthetic Joint Infection Can Help Predict Outcomes of Two-Stage Exchange. AU - Dwyer,Maureen K, AU - Damsgaard,Christopher, AU - Wadibia,Jason, AU - Wong,Gordon, AU - Lazar,Damien, AU - Smith,Eric, AU - Talmo,Carl, AU - Bedair,Hany, PY - 2018/6/20/entrez PY - 2018/6/20/pubmed PY - 2019/9/17/medline SP - 1009 EP - 1015 JF - The Journal of bone and joint surgery. American volume JO - J Bone Joint Surg Am VL - 100 IS - 12 N2 - BACKGROUND: Although 2-stage exchange arthroplasty is the most effective treatment among available strategies for managing chronic periprosthetic joint infection (PJI), rates of its success vary greatly. The purpose of our study was to examine whether objective measurements collected at the time of the diagnosis of PJI could be used to identify patients at risk of failure of 2-stage exchange. METHODS: We identified 205 patients across 4 institutions who underwent 2-stage exchange arthroplasty for the treatment of PJI following total hip or total knee arthroplasty. Demographic, surgical, and laboratory data were obtained for each patient from their medical chart. Laboratory values included serum erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) level, synovial fluid white blood-cell (WBC) count and neutrophil percentage, synovial fluid and/or tissue culture, and Gram stain. Patients who underwent revision surgery for recurrent infection were considered to have failed the 2-stage procedure. Demographic, surgical, and laboratory variables were compared between the 2 groups. Receiver operating characteristic (ROC) curves were constructed to determine threshold cutoffs for significant laboratory values. Risk ratios and 95% confidence intervals were calculated. RESULTS: Overall, 2-stage exchange was unsuccessful for 27.3% of the patients. Preoperative serum ESR (p = 0.035) and synovial fluid WBC count (p = 0.008) and neutrophil percentage (p = 0.041) were greater in patients with recurrent infection. ROC curve analysis revealed a threshold of >60,000 cells/μL for synovial fluid WBC count, >92% for synovial fluid WBC neutrophil percentage, and >99 mm/hr for serum ESR. Failure of 2-stage exchange was 2.5 times more likely for patients with an elevated preoperative synovial fluid WBC count, 2.0 times more likely for those with an elevated preoperative synovial fluid WBC neutrophil percentage, and 1.8 times more likely for those with an elevated preoperative serum ESR. CONCLUSIONS: Our results demonstrated that a greater number of patients in whom 2-stage exchange arthroplasty ultimately failed had a preoperative synovial fluid WBC count of >60,000 cells/μL, a synovial fluid WBC neutrophil percentage of >92%, or a serum ESR of >99 mm/hr. Patients with elevated laboratory values had 1.8 to 2.5 times the risk of treatment failure. These data can serve as a clinical guideline to identify patients most at risk for failure of 2-stage exchange. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. SN - 1535-1386 UR - https://www.unboundmedicine.com/medline/citation/29916927/Laboratory_Tests_for_Diagnosis_of_Chronic_Periprosthetic_Joint_Infection_Can_Help_Predict_Outcomes_of_Two_Stage_Exchange_ L2 - http://dx.doi.org/10.2106/JBJS.17.00599 DB - PRIME DP - Unbound Medicine ER -