New Guidelines for the Diagnosis of Periprosthetic Joint Infections

The American Academy of Orthopedic Surgeons (AAOS; Rosemont, IL, USA) has released an evidence-based clinical practice guideline on the diagnosis of periprosthetic joint infections of the hip and knee, to ensure that patients receive high quality care.

The clinical practice guideline is intended to improve the diagnostic process for patients who may have a periprosthetic joint infection, and serves as a point of reference and an educational tool for both primary care physicians and orthopedic surgeons, streamlining the diagnostic process. The final physician-oriented guidelines 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). In cases where both ESR and CRP are normal, chance of infection is low; Physicians should avoid starting antibiotic treatment until after culture results are obtained. 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.

Additional recommendations were made for patients being assessed for periprosthetic joint infections who are scheduled for revision surgeries. The panel recommends that multiple cultures should be obtained at the time of reoperation; that surgeons use frozen sections of tissues adjacent to the implant when infection has not already been established or excluded; and that prophylactic antibiotics should be given prior to revision (or repeat) surgery. The full guideline along with all supporting documentation and workgroup disclosures is available on the AAOS Website (please see related links below).

"Every orthopedic surgeon inevitably sees patients who come back with a problem such as stiffness or pain in the joint,” said Craig J. Della Valle, M.D., an associate professor of orthopedic surgery at Rush University Medical Center (Chicago, IL, USA), 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.”

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 resulting in the need for revision surgery. Periprosthetic infection is the leading cause of total knee replacement revision (25%) and the second-leading cause of total hip replacement revision (15%) in the United States.

Related Links:
American Academy of Orthopedic Surgeons
AAOS Guidelines