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The Microbiome oftheJoint
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> However, it is important to approach the concept of a
“sterile” compartment with a degree of hesitation, as
historically the concept has been challenged in various elds.
The idea that the bladder was devoid of any physiologic
microorganisms was a dogma dating back to initial
germ theory research in the mid-1800s. This was not
challenged until the 1950s, and since then it has become
accepted that the bladder contains a microbiome similar
to the digestive tract. It is the overall composition and
balance of this microbiome that confers pathology and
disease, not simply a threshold of the number of bacteria (Thomas-White etal. 2016).
More recent work has also challenged assumptions
of the sterility of other organs. Sequencing technologies
have allowed researchers insight into the native microbiome of the subepidermal skin (Nakatsuji et al. 2013),
cerebrospinal uid (Perlejewski etal. 2016), breast tissue
(Hieken et al. 2016; McGuire and McGuire 2017;
Urbaniak et al. 2016), and the lung (Berger and
Wunderink 2013; Charlson etal. 2011; Segal etal. 2013).
Similar to investigations into the gut microbiome, these
studies have identied associations of the composition
of each microbiome to malignancies and other pathologies related to each organ.
10.4 Chronic Colonization oftheNative
Joint
> This assumption of sterility has also been challenged
within orthopedics. Specically, recent literature has
suggested that there may be a reason to question the
sterility of joint uid and tissue.
One area of interest has been the microbial composition
of the shoulder, stemming from investigations into periprosthetic joint infections caused by Cutibacterium
acnes. C. acnes is a commensal species of skin ora and
is a common cause of infection following shoulder
arthroplasty. Data from revision cases estimate that C.
acnes is found in 19% to 70% of infected shoulders
(Hudek etal. 2014). However, it has been suggested that
a proportion of these results represent false positives,
leading researchers to investigate the microbial composition of non-infected shoulders (Frangiamore et al.
2015; Mook etal. 2015).
Multiple studies have identied C. acnes in the native
joint of individuals who have never undergone shoulder
surgery, suggesting that C. acnes is a commensal organ-
ism in this location, and infections may be a result of the
opportunistic expansion of the organism (Hudek etal.
2014; Levy et al. 2013; Mook et al. 2015; Rao et al.
2020). This is complicated by the ndings of Qiu etal.
(Qiu etal. 2018), who found in a series of 23 patients
undergoing primary shoulder arthroplasty, no C. acnes
was found in shoulder tissue after stringent removal of
contamination. They concluded that C. acnes infections
are derived from skin contamination rather than opportunistic expansion. Interestingly, they did note DNA
from Acinetobacterspecies and the Oxalobacteraceae
family, indicating the possibility of a microbiome other
than C. acnes.
In all, investigations into the shoulder have found the
presence of a microbiome, although the possibility of
skin contamination remains under question. Further
complicating the picture, it must be noted that the samples obtained in these studies are not taken from individuals with healthy shoulders, but rather taken from
patients with indications for primary arthroplasty. It is
possible that an osteoarthritic shoulder contains microorganisms that a healthy shoulder does not, and some
have postulated that the presence of bacteria, in fact,
represents the pathogenesis of osteoarthritis (Hudek
etal. 2014; Levy etal. 2013; Mook etal. 2015).
Alongside these studies examining the microbiome of
the shoulder, recent literature in total knee arthroplasty
(TKA) and total hip arthroplasty (THA) has identied
organisms using molecular technologies in these native
joints. In a 2018 study investigating the potential of NGS
in diagnosing culture-negative PJI, Tarabichi et al.
(Tarabichi etal. 2018a) noted organisms present in 35%
of 17 control patients undergoing primary TKA or
THA. Also using NGS, Torchia, et al. (Torchia et al.
2020) found that 30% of 40 patients undergoing primary
TKA had at least one positive organism identied. Two
further studies, both using PCR-based methods, found
evidence of a microbiome in native hips and knees.
Jacovides etal. (Jacovides etal. 2012) identied organisms from the knee joint in ve out of seven patients
undergoing TKA, and Témoin etal. (Témoin etal. 2012)
detected organisms in 13.9% of 36 native knees and hips
in patients with osteoarthritis and rheumatoid arthritis
undergoing joint aspiration in an ofce setting.
Most recently, a multicenter study of 14 academic
institutions recruited patients undergoing primary joint
arthroplasty. Analyzing samples from 53 patients
undergoing TKA and 30 patients undergoing THA, this
multicenter workgroup found a rich diversity of
microbes after removal of reagent contamination. The
three most abundant genera identied in the hip samples
were Escherichia, Cutibacterium, and Acinetobacter.
Also of note, this microbial composition was present
irrespective of the type of specimen sampled (synovial
uid vs. tissue vs. swabs; p=0.80). Furthermore, while
microbiota in hips versus knees were noted to be statistically different (F = 2.86; p = 0.001), the joint type
explained <1% of overall compositional variation
(Goswami 2019).
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> The data supporting a microbiome of the hip and
knee are convincing.
While skin contamination is a possibility, as in the discussion of the shoulder, the species found in studies of
the hip and knee make this an unlikely explanation. All
studies mentioned above report the identication of
organisms present in the gut microbiome. For example,
the two aforementioned studies (Goswami 2019; Torchia et al. 2020) recognized the most predominant
organism as E.Coli—an intestinal commensal organism
and unlikely to represent a contaminant.
As in the shoulder, the possibility remains that ndings in the hip and knee do not represent a truly physiologic microbiome. Samples obtained from patients
undergoing primary joint arthroplasty are invariably
taken from joints with some amount of arthropathy.
The native joint of a truly healthy individual may not be
represented by this population, and therefore further
study is needed.
10.5 Colonization ofNative/Implanted Joint
Without Evidence ofDisease
The presence of a joint microbiome as suggested above
needs to be examined in the context of our current understanding of chronic joint colonization. In the presence of
an implanted device, chronic persistent colonization can
often occur, and the hallmark of most periprosthetic
joint infections is the inltration of skin microbiota into
the joint. The same properties that allow organisms such
as S. aureus and S. epidermitis to ourish on the skin
result in the formation of a biolm that forms on the surface of many devices. Biolm formation prevents penetration of antibiotics and host immune- mediated
clearance, allowing the microorganisms to persist as a
chronic and persistent infection (Scherr etal. 2014).
> Despite this clear mechanism involving the contami-
nation by skin microbiota, the suggestion of a native
joint microbiome as described above indicates that
chronic colonization can exist without any signs of
infection.
This is consistent with multiple studies that have detected
biolm formation on hardware explanted due to aseptic
loosening, with a lack of a diagnosed infection (Bereza
etal. 2017; Cazanave etal. 2013; Dempsey et al. 2007;
Holinka etal. 2011; Rak etal. 2016). However, it remains
unclear whether colonization of these implants can be
considered truly asymptomatic colonization of a device.
While not diagnosed as PJI based on our current standards of diagnosis, it has been postulated that aseptic
loosening could represent an unrecognized low-grade
infection that has simply not yet presented itself (Hudek
etal. 2014; Levy et al. 2013). Further research should
include patients who are fully asymptomatic with
implants in situ (Rohde and Goswami n.d.). With that
caveat, the established presence of chronic colonization
in both native and presumably aseptic hardware indicates the possibility that a microbiome can exist physiologically without necessarily causing disease.
10.6 Implications forPJI
Periprosthetic joint infection (PJI) is the most common
reason for revision of failed total knee arthroplasty, and
the third most common reason for revision of failed
total hip arthroplasty (Bozic et al. 2009; Bozic et al.
2010). Given the effects on morbidity and mortality as
well as the associated healthcare costs, determining
methods to accurately diagnose and treat PJI is of
utmost importance (Goswami etal. 2018).
The same advances in molecular technologies that have
made the study of the microbiome possible have demonstrated utility in diagnosing PJI.In particular, the increased
sensitivity of next-generation sequencing can provide a
much clearer picture of the microorganisms colonizing an
infected joint (Tarabichi etal. 2018b). Current methods for
diagnosing PJI rely on cultured tissue, but culture is unsuccessful in identifying an organism in 7–50% of PJI cases
(Goswami and Parvizi 2020), causing patients to be subjected to unnecessary broad- spectrum antibiotics and
worse outcomes (Mortazavi et al. 2011). Recent studies
have shown that NGS can identify microorganisms in the
hip and knee for culture- negative infections (Street etal.
2017; Tarabichi et al. 2018a; Tarabichi et al. 2018b).
However, the possibility of a native joint microbiome as
discussed in this chapter necessitates a cautioned approach
when interpreting these results. It is plausible that some of
the increased sensitivity of NGS is simply due to detecting
organisms that are present in the native joint, and do not
represent organisms causing disease.
The joint microbiome also has important implications on the prevention of PJI, particularly regarding
the timing of steroid injections. While steroid injections
in the hip and knee are a valuable treatment for symptomatic osteoarthritis (Jüni et al. 2015; Zhong et al.
2020), evidence points to an increased risk of PJI if per-
formed shortly after administration (Richardson etal.
2019; Werner etal. 2016).
> As such, current recommendations suggest avoiding
primary joint arthroplasty within a few months of
ipsilateral steroid injection (Cizmic etal. 2019). The
presence of a joint microbiome bolsters this recom-
mendation.
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There is evidence that steroids alter the microbiome in
other niches of the body (Tetel etal. 2018), and recent
evidence suggests that the joint microbiome is similarly
altered. In 2015, Mook et al. (2015) found that an
increased number of preoperative corticosteroid injections prior to shoulder arthroplasty is associated with a
higher likelihood of bacterial growth in the native
shoulder. Recent ndings also suggest that the composition of the microbiome is altered when analyzed
within 6months following steroid injection (Goswami
2019). These ndings strengthen the recommendation
to avoid primary joint arthroplasty during this window
and suggests a specic pathogenetic pathway as the
cause.
Conclusion
z
Emerging evidence suggests that a microbiome may
exist in native, osteoarthritic, and implanted joints. NGS
has shown potential in both characterizing this microbiome and identifying organisms when a true infection
occurs. We now have a comprehensive means of identifying organisms in the native joint, infected joints with
negative cultures, as well as implanted joints assumed to
be non-infected. Continuing to identify the composition
of the native joint microbiome will be crucial to our ability to differentiate signal from noise when an infection is
suspected.
Take-Home Messages
5 The human microbiome, which consists of all
microorganisms residing in ecological niches of
the human body, outnumbers human cells and
plays an important role in health and disease.
5 Technological advances in DNA sequencing have
allowed researchers to rapidly characterize large
amounts of genomic data and take an in-depth
look into the composition of the microbiome.
5 While the microbiome of the digestive tract, skin,
and other locations are considered commensal and
consistent with normal physiology, there are many
areas of the body such as joints that are traditionally considered to be sterile.
5 The assumption of the sterility of the native joint
has been challenged, with recent literature demonstrating evidence of a commensal microbiome in
the shoulder, hip, and knee.
5 Recent literature suggests that disruptions in the
native microbiome could play a role in the development of osteoarthritis, and a patient’s susceptibility
to periprosthetic joint infection.
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Radiographs
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and Outcomes
Contents
Chapter 11 Radiographic Analysis of Knee Arthritis – 111
Musa B. Zaid and Jeffrey Barry
Chapter 12 Patient-Reported Outcomes in Total Knee
Arthroplasty – 123
Anas Saleh and Denis Nam
109
III
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Radiographic Analysis ofKnee
Arthritis
MusaB.Zaid andJeffreyBarry
Contents
11.1 Introduction – 112
11.2 Plain Radiographs – 112
11.2.1 Technique – 112
11.3 Radiographic Grading – 115
11.4 Radiographic Assessment ofNon-Osteoarthritic
Arthritis – 115
11
11.5 Correlation ofOA Severity andTKA Outcomes – 117
11.6 Radiographic Evaluation ofTKA – 117
11.7 Cross-Sectional andAdvanced Imaging – 119
11.7.1 Computed Tomography – 119
11.7.2 Magnetic Resonance Imaging – 120
11.7.3 Nuclear Medicine – 120
References – 121
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_11
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M. B. Zaid and J. Barry
11
11.1 Introduction
As emphasized in this chapter, osteoarthritis (OA), and
specically OA of the knee, represents a growing global
healthcare burden. OA of the knee encompasses a broad
range of etiologies from primary (idiopathic) to secondary causes such as the following:
5 Post-traumatic.
5 Dysplastic.
5 Infectious.
5 Osteonecrosis.
5 Inammatory.
Because of this diverse pathogenesis, dening OA is
often difcult but has broadly been dened as “a heterogenous group of conditions that leads to joint symptoms and signs which are associated with defective
integrity of articular cartilage, in addition to related
changes in the underlying bone and at the joint margins”
(Altman etal. 1986). Diagnosis of knee OA is crucial to
the delivery of appropriate treatment. Typically, a clinical diagnosis of OA synthesizes the patient-reported history with a physical exam and concordant radiographic
ndings.
Imaging plays a vital role in the entire care contin-
uum of knee OA.
> Radiographs aid the physician in conrming the diag-
nosis, determining the compartments of the knee
involved and severity, as well as assisting in presurgical planning and outcome prediction and postoperative implant surveillance.
Numerous imaging modalities are used diagnostically in
knee OA including the following:
5 Plain radiographs (XR).
5 Magnetic resonance imaging (MRI).
5 Computed tomography (CT) scans.
The purpose of this chapter is to highlight the uses of
the aforementioned imaging modalities in the diagnosis
and treatment and surveillance of knee arthritis as well
as correlate preoperative imaging ndings with postoperative total knee arthroplasty (TKA) outcomes.
11.2 Plain Radiographs
Plain radiographs are the mainstay of diagnostic imaging for knee OA.For the majority of cases, they should
be the only imaging required throughout the care pathway.
> Plain radiographs are non-invasive, low-cost, low-
radiation, readily obtainable, and have been validated
as a diagnostic tool for determining cartilage wear
and OA severity (Buckland-Wright etal. 1995).
Cartilage, being uncalcied, is radiolucent on conventional X-rays. XR imaging provides an indirect measurement of cartilage thickness and subsequently
cartilage wear via the radiolucent joint space between
the bone of two subchondral surfaces.
11.2.1 Technique
A knee OA plain radiograph series should include at a
minimum the following four standard views:
5 A weight-bearing anterior–posterior view.
5 A 45-degreeposteroanterior exion weight-bearing
view.
5 A lateral view.
5 Apatellofemoral view (.
Fig.11.1).
Each provides the clinician with different information
that can guide treatment options and surgical decisionmaking.
Other views that are sometimes incorporated into
clinical practice include the following:
5 Full-extension anteroposterior.
5 Varus/valgus stress.
5 Full-limb alignment radiographs.
Consistent technique must be utilized when obtaining radiographs of the knee to allow for reproducibility
in assessment and interpretation.
The 45-degree exion weight-bearing posteroanterior
view (. Fig.11.1b) (also known as a Rosenberg view) is
obtained with the patient standing upright with 45° of
knee exion (Rosenberg etal. 1988). The imaging beam
should be angled 10–20° caudal, a small amount distal
to the proximal pole of the patella, and centered on the
knee joint. In this view, the tibial plateau should be
clearly visualized without any superimposition and the
intercondylar notch should be clearly visualized without
any overlap of the femoral condyles. The posteroanterior
projection should be used to determine the degree of
medial and lateral joint space narrowing as well as tibiofemoral alignment. Weight-bearing PA radiographs
allow for improved visualization of the anterior femoral
condyle. This view can be useful in patients with isolated
medial compartment osteoarthritis as the wear is predominantly located in the anteromedial femoral condyle
(Weidow etal. 2002).
ab
Radiographic Analysis ofKnee Arthritis
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cd
. Fig. 11.1 Standard preoperative radiographs consisting of a weight-bearing PA view a, Rosenberg view b, lateral view c, and patello-
femoral view d. Joint space narrowing, osteophyte formation, and cystic changes are characteristic of osteoarthritis
Placing the knee in exion allows for improved visualization of the central and posterior aspects of the femoral condyles, which are more involved in advanced
osteoarthritis as compared to the anterior medial
femoral condyles (Bae etal. 2010), which are typically
involved in isolated medial compartment osteoarthritis
(Weidow etal. 2002). This exed position allows for contact between the tibial plateau and the central to poste-
rior aspect of the femoral condyles providing a true
estimate of cartilage wear in the most commonly affected
areas (Buckland-Wright 1995). Numerous studies have
demonstrated that the degree of joint space narrowing
can be signicantly underestimated if the knee is locked
in full extension as the femoral condyles can appear articially elevated when sitting up on the anterior cartilage
rim of the tibia (Messieh etal. 1990; Rueckl etal. 2018).
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Because of this, the Rosenberg view has been demonstrated to be more sensitive for detecting tibiofemoral
osteoarthritis as compared to an extension AP view
(Ritchie etal. 2004; Fontboté etal. 2008).
The lateral knee image can be obtained in the supine
position and be non-weight-bearing with the X-ray
beam passing through the knee from medial to lateral.
Alternatively, weight-bearing lms can be utilized. In a
well-performed lateral image of the knee, the medial and
lateral femoral condyle should evenly overlap one
another and the patellofemoral joint should be free of
superimposition. The lateral projection is typically useful for assessing patellofemoral engagement, height, and
osteoarthritis of the patellofemoral joint (Carrillon
2008).
> Additionally, the lateral projection can be useful for
surgical planning as it allows for the determination of
the native posterior tibial slope.
The lateral radiograph can help diagnose anteromedial
osteoarthritis of the knee, which is a common pattern of
arthritis where posteromedial cartilage remains intact
but the anteromedialtibial cartilage is eroded and worn
(White etal. 1991).
> In this pattern, with the ACL still intact a exion lat-
eral will demonstrate correction of the extension
varus deformity as the femur rolls back onto the
intact posterior tibial cartilage.
> The main distinguishing feature between the
Merchant and sunrise views is the amount of knee
exion that the image is obtained with.
While the knee is usually at 45° of exion in a Merchant
view, which better allows subtle maltracking, a sunrise
view is usually a prone hyperexion view past 90° and is
less accurate in nding subtle issues.
In addition to the posterior–anterior bent, lateral,
and patellofemoral views, some surgeons routinely obtain
full-length standing weight-bearing X-rays (. Fig.11.2)
to determine lower extremity alignment for presurgical
planning; however, the routine use of these images is controversial. Standing alignment images are obtained by
having the patient stand upright in front of a long X-ray
cassette with their hips centered, feet forward, or rotated
slightly inward to allow for the patellae to face directly
forward, and the knees not touching. The beam is shot in
an anterior to posterior direction. A good quality standing alignment X-ray should clearly show the femoral
heads, have the patellae centered, and the ankles should
be clearly visualized. From this image, the mechanical
and anatomic axis can be measured and used for surgical
planning. While some studies have found a signicant
difference in the degree of deformity as measured on a
standard PA image of the knee as compared to fulllength X-rays (Petersen and Engh
1988; Patel etal. 1991;
Odenbring etal. 1993), others have found this difference
to be insignicant (McGrory etal. 2002).
This pattern of arthritis can be successfully treated with
unicompartmental knee replacements.
A patellofemoral view or tangential view of the patel-
lofemoral joint can be performed in several ways. The
most typical is the Merchant view which is done with the
patient supine and the knee held in 45° of exion. The
X-ray beam is then positioned at a 45° angle relative to
the tibia and shot inferior to the superior providing an
axial view of the patellofemoral joint. A well-performed
patellofemoral image should demonstrate clear visualization of the patellofemoral joint space and the patella
should not be superimposed upon the trochlear groove.
This view is useful for assessing patellar tracking and the
degree of patellofemoral arthritis that may be present.
The patellofemoral projection is more sensitive for judging the degree of severe patellofemoral joint arthritis as
compared to the lateral X-ray, however, both are poor
for detecting early stages of patellofemoral osteoarthritis (McDonnell et al. 2009). Furthermore, the patellofemoral view can also provide information with regard
to patellar tracking and whether or not any subluxation
is present. In addition to the Merchant view, the “sunrise” view also provides a tangential view of the patellofemoral joint.
. Fig. 11.2 Full-length standing alignment lms can be useful in
cases of deformity such as in the depicted image. Understanding the
location and degree of deformity is critical to performing a wellfunctioning TKA
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