Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5205_Библиотеки_им_академика_М_И_Перельмана.pdf
292
F. Da Rin de Lorenzo and J. Parvizi
nated cement in total hip replacement.
Acta Orthop. 2008b;79:335–41. https://doi.
org/10.1080/17453670710015229.
114. Ghisellini F, Ceffa R. Trattamento delle infezioni di
protesi articolari. Mediprint s.r.l. Corso Trieste 61
Roma, Italy. 1997. ISBN 2021070172822.
115. Registro Scandinavo, Registro Australiano, Registro
dati regione Emilia Romagna. Scandinavian
Register, Australian Register, Emilia Romagna
Region Data Register.
116. Charnley L. Anchorage of the femoral head prostheses to the shaft of the femur. J Bone Joint Surg.
1960;42-B:28–30.
117. Stefánsdóttir A. The infected knee arthroplasty.
Doctoral thesis, Department of Orthopaedics,
Clinical Sciences, Lund University, Lund, Sweden.
2010.
118. Winkler H, Haiden P. Allograft bone as antibiotic
carrier. J Bone Joint Infect. 2017;2:52–62.
119. Franceschini M, Sandiford NM, Cerbone V,
Cappelli Toledo de Araujo L, Kendoff D.Defensive
antibacterial coating in revision total hip arthroplasty: new concept and early experience. Hip Int.
2020;30(1S):7–11.
120. Romanò CL, Malizos K, Capuano N, et al. Does
an anti-biotic-loaded hydrogel coating reduce early
post-surgical infection after joint arthroplasty? J
Bone Jt Infect. 2016;1:34–41.
121. Romanò CL, De Vecchi E, Bortolin M, et al.
Hyaluronicacid and its composites as a local antimicrobial/antiadhesive barrier. J Bone Jt Infect.
2017;2:63–72.
122. Romanò CL, Malizos K, Capuano N, et al. Does
an antibiotic-loaded hydrogel coating reduce early
post-surgical infection after joint arthroplasty? J
Bone Jt Infect. 2016;1:34–41.
123. Giavaresi G, Meani E, Sartori M, etal. Efcacy of
antibac-terial-loaded coating in an invivo model of
acutely highly contaminated implant. Int Orthop.
2014;38:1505–12.
124. Racano A, Pazionis T, Farrokhyar F, Deheshi B,
Ghert M.High infections rate outcomes in long-bone
tumor surgery with endoprosthetic reconstruction in
adults. Clin Orthop Relat Res. 2013;471(6):2017–27.
https://doi.org/10.1007/s11999- 013- 2842- 9. Epub
2013 Feb 12
125. Edwards D. Timeline history of colloidal silver.
HistoWiki, February 16, 2023.
126. Simpson WJ, Hewlett RT. Experiments on the
germicidal action of colloidal silver. Lancet.
1914;184:1359. https://doi.org/10.1016/
S0140- 6736(00)96700- X.
127. Fiore M, Sambri A, Zucchini R, Giannini C, Donati
DM, De Paolis M.Silver-coated megaprosthesis in
prevention and treatment of peri-prosthetic infections: a systematic review and meta-analysis about
efcacy and toxicity in primary and revision surgery.
Eur J Orthop Surg Traumatol. 2021;31(2):201–20.
https://doi.org/10.1007/s00590- 020- 02779- z. Epub
2020 Sep 5. PMID: 32889672
128. Sambri A, Zucchini R, Giannini C, Zamparini E,
Viale P, Donati DM, De Paolis M. Silver-coated
(PorAg®) endoprosthesis can be protective against
reinfection in the treatment of tumor prostheses
infection. Eur J Orthop Surg Traumatol Orthop
Traumatol. 2020;30(8):1345–53.
129. Hua L, Daofeng W, Wupeng Z, Gaoxiang X, Cheng
X, Wanheng L, Jiantao L.Potential side effects of
antibacterial coatings in orthopaedic implants: a
systematic review of clinical studies. Front Bioeng
Biotechnol. 2023;11:1111386.
130. Croes M, Bakhshandeh S, van Hengel IAJ, Lietaert
K, van Kessel KPM, Pouran B, van der Wal
BCH, Vogely HC, Van Hecke W, Fluit AC, Boel
CHE, Alblas J, Zadpoor AA, Weinans H, Amin
YS.Antibacterial and immunogenic behavior of silver coatings on additively manufactured porous titanium. Acta Biomater. 2018;81:315–27. https://doi.
org/10.1016/j.actbio.2018.09.051. Epub 2018 Sep
28. PMID: 30268917
131. Diez-Escudero A, Hailer NP. The role of silver coating for arthroplasty components. Bone
Joint J. 2021;103-B(3):423–9. https://doi.
org/10.1302/0301- 620X.103B3.BJJ- 2020- 1370.
R1. PMID: 33641432
132. Hardes J, Henrichs MP, Hauschild G, et al.
Silver-coated megaprosthesis of the proximal
tibia in patients with sarcoma. J Arthroplast.
2017;32:2208–13.
133. Becker RO.Effects of electrically generated silver
ions on human cells and wound healing. ElectroMagnetobiol. 2000;19:1–19.
134. Hardes J, Hardes J, von Eiff C, Streitbuerger A,
Balke M, Budny T, Henrichs MP, Hauschild G,
Ahrens H.Reduction of periprosthetic infection with
silver-coated megaprostheses in patients with bone
sarcoma. J Surg Oncol. 2010;101(5):389–95. https://
doi.org/10.1002/jso.21498.
135. Shirai T, Tsuchiya H, Terauchi R, et al. The outcomes of reconstruction using frozen autograft
combined with iodine-coated implants for malignant
bone tumors: compared with non-coated implants.
Jpn J Clin Oncol. 2016;46:735–40.
136. Tsuchiya H, Shirai T, Nishida H, etal. Innovative
antimicrobial coating of titanium implants with
iodine. J Orthop Sci. 2012;17:595–604.
137. Shirai T, Tsuchiya H, Terauchi R, Tsuchida
S, Mizoshiri N, Mori Y, Takeuchi A, Hayashi
K, Yamamoto N, Ikoma K, Kubo T. A retrospective study of antibacterial iodine-coated
implants for postoperative infection. Medicine.
2019;98(45):e17932.
138. Ma PX, Zhang R. Synthetic nano-scale brous
extracellular matrix J Biomed Mater Res.
19 Periprosthetic Joint Infection: General Aspects
293
1999;46(1):60–72. https://doi.org/10.1002/
(sici)1097-4636(199907)46:160::aid-jbm73.0.co;2-h.
139. Pan C, Zhou Z, Yu X. Coatings as the useful drug
delivery system for the prevention of implant-related
infections. J Orthop Surg Res. 2018;13:220.
140. McLaren J, White L, Cox H, etal. A biodegradable
antibiotic-impregnated scaffold to prevent osteomyelitis in a contaminated invivo bone defect model.
Eur Cell Mater. 2014;27:332–49.
141. Shahid A, Aslam B, Khurshid M.The prospects of antimicrobial coated medical implants. J Appl Biomater
Funct Mater. 2021;19:22808000211040304.
142. Gallo J, Holinka M, Moucha CS.Antibacterial surface treatment for orthopaedic implants. Int J Mol
Sci. 2014;15:13849–80.
143. Antibiotic resistance www.epicentro.iss.it.
144. Mazza-Stalder J, Nicod L, Janssens
J-P.Extrapulmonary tuberculosis. Rev Mal Respir.
2012;29(4):566–78. https://doi.org/10.1016/j.
rmr.2011.05.021. Epub 2012 Mar 29.
145. Golden MP, Vikram HR. Extrapulmonary tuberculosis: an overview. Am Fam Physician.
2005;72(9):1761–8.
Low-Grade Periprosthetic Infections
TomasZamora, IanivKlaber, andEduardoBotello
20
Periprosthetic joint infection (PJI) is a complex
pathology with variable clinical presentation.
Acute, chronic, and/or severe clinical manifestations of infection can be present in up to 1–4% of
primary joint replacements, and it’s one of the
leading causes of overall revision [1, 2]. However,
growing awareness has gained the possibility of a
“low grade” PJI.Such infections can be challenging to diagnose as their symptoms are not severe,
and laboratory results may not be completely
abnormal [3, 4]. Low-grade infections can still
lead to procedure failure despite an otherwise
successful initial clinical, radiographic outcome.
Beswick etal. conducted a systematic review
of prospective studies involving patients who had
undergone total hip or knee replacement for
osteoarthritis. The review found that a signicant
proportion of people experienced long-term pain
of unknown origin after the surgery, ranging from
about 7%–23% after total hip joint replacement
and from 10% to 34% after knee replacement [5].
Other studies have shown that between 4% and
13% of patients with a preoperative diagnosis of
aseptic loosening and chronic pain were infected
when the retrieved implants were analyzed using
genomic identication methods [6]. All of this
has raised suspicion and awareness of low-grade
T. Zamora · I. Klaber · E. Botello (*)
Orthopaedic Surgery Department, Ponticia
Universidad Católica de Chile, Santiago, Chile
e-mail: tezamora@uc.cl; ebotello@med.puc.cl
subclinical infections as a cause of early or late
failure after joint replacement surgery.
Over the past 15years, several denitions of
periprosthetic joint infection have been suggested
by different organizations or consensus groups,
each with variations in their criteria. Examples of
these are the Musculoskeletal Infection Society
criteria (MSIS) [7], the International Consensus
Meeting (ICM—2013 and 2018 criteria) [8, 9],
the World Association against Infection in
Orthopedics and Trauma (WAIOT) [10], and
European Bone and Joints Infection Society
(EBJIS) [11]. However, despite these criteria and
abundant literature on the topic, there is no clear
and widely accepted denition of low versus
high-grade infections.
Some authors use the term “low-grade infection” to refer to an infection caused by lowvirulence microorganisms, such as
Methicillin-sensitive Staphylococci epidermidis,
streptococci, anaerobic cocci, and Cutibacterium
acnes. On the contrary, bacteria that are intrinsically resistant to antimicrobial agents and antibiotics, such as methicillin-resistant staphylococci,
enterococci, and gram-negative organisms, are
considered to be of high virulence [12]. These
low-grade infections may present a challenge as
classical serum markers of infection may not be
reliable in this setting [13, 14]. For example,
Choe etal. found that almost 20% of their patients
with Periprosthetic Joint Infection (PJI), diagnosed using the 2018 ICM criteria, had a level of
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
P. Ruggieri et al. (eds.), Bone and Joint Infections, https://doi.org/10.1007/978-3-031-96383-4_20
295
296
T. Zamora et al.
C-reactive protein (CRP) less than 10mg/L [15].
This cutoff level is commonly used for infection
screening in most institutions. Similarly, Akgun
etal. [14] reported that low-virulence organisms
were found in 86% of PJIs with normal CRP levels, reinforcing that typical parameters for infection screening may not always be reliable in this
setting.
Other authors classify infections based on
their severity and duration of symptoms. Those
that do not produce systemic illness are then
referred to as low-grade infections [16]. These
are characterized by subclinical and slowevolving symptoms. Typically, a low-grade infection is only observed as a painful prosthetic joint
with little to no alteration in inammatory parameters. There is no draining sinus, fever, or other
systemic manifestations. Occasionally, mildly
elevated inammatory parameters may be present in an otherwise healthy, asymptomatic
patient, but most commonly, only a painful joint
or loosening is observed.
Factors such as medical conditions, medications, and treatments can weaken the immune
system and alter the course of an infection.
Examples include autoimmune diseases, chemotherapy, and radiation therapy. Awareness of
these factors and their potential impact on the
immune system is essential. Several authors,
including McPherson and Wimmer, have suggested a staging system for PJIs based on the
host’s quality. McPherson etal. found a correlation between declining host grade, limb score,
and poorer outcomes in total hip and knee arthroplasties [17, 18]. Immunosuppression is a clear
risk factor for overall infection. Still, it is crucial
in this setting since it has the highest correlation
with fungal infections and other microorganisms
because of its close association with the innate
immune response and can manifest as low-grade
indolent infections [19, 20].
The WAIOT Study Group on Bone and Joint
Infections recently proposed a new denition for
PJI.The denition is based on available tests to
conrm or exclude this condition. The new denition includes the possibility of different clinical
presentations. Patients with “otherwise unexplained pain, swelling, and/or reduced range of
motion or functional impairment” and “lack of
acute local inammatory signs and in the absence
of an alternative explanation” are considered at
risk of having a low-grade infection. This is conrmed with a dened balance (more or equal to
zero) of specic tests, which allows for postanalysis conrmation [10].
20.1 Diagnosis
Low-grade infections can be challenging to diagnose in an otherwise healthy patient who experiences chronic symptoms but not acute signs of
infection. Sometimes, these infections are only
detected during preoperative work-up for joint
revision or after a theoretically “aseptic” revision
with positive cultures (known as type 1 infection
as classied by Tsukayama et al. [21]). In the
same way, there may be conicting laboratory
results, with false-negative and low values of
serum biomarkers often present, highlighting the
need for an organized and systematic diagnostic
process.
Standard radiographs should always be
obtained as part of the work-up of a symptomatic
joint replacement. However, they may not be
instrumental in the diagnosis of a low-grade
infection, especially in the acute setting, as they
may usually appear normal. In the chronic setting, scattered foci of osteolysis, periosteal reaction, or bone resorption may be present and can
mimic a conventional aseptic loosening
(Fig.20.1).
Serologic biomarkers, including erythrocyte
sedimentation rate (ESR) and C-reactive protein
(CRP), remain helpful for laboratory investigations. However, their sensitivity may be signicantly reduced in this context [16, 22]. For
example, Pérez-Prieto etal. [22] showed that in
almost one-third of culture-positive PJIs, most
with low-grade bacteria, CRP levels could be
normal and be missed in the initial diagnosis.
Similar ndings have been observed with the isolated use of ESR [23]. On the other hand, serum
interleukin-6 (IL-6) [24] and D-dimer [25] could
represent more reliable markers of periprosthetic
low-grade infection. Both tests have shown
20 Low-Grade Periprosthetic Infections
abc
297
Fig. 20.1 A 65-year-old man with a right total hip arthroplasty. The initial procedure was performed without any
complications. Three years post-surgery, there was evidence of periosteal reaction and cortical thickening, with
only mild pain during weight-bearing (a). After a year,
femoral loosening and signicant femoral subsidence (b)
were observed. Laboratory results were normal. During
higher diagnostic properties and are an essential
aid in the decision of reimplantation, with a
threshold of more than 10pg/mL for serum IL-6
and > 850 ng/mL for D-Dimer. However, less
evidence is available regarding both studies compared to other classic serum biomarkers.
Nuclear medicine studies have been widely
used for diagnosing joint infections. Their role
has not been clearly established, especially in the
acute setting. The conventional Technetium-99
bone scan has been shown to be sensitive but with
a low specicity. However, a combination of leukocyte and bone marrow scintigraphy (in the
form of Technetium-99 bisphosphonate scan in
conjunction with indium-111-labeled leukocyte
scan) has been found to have better specicity
according to a recent systematic review and
meta-analysis [26] and could help in the differentiation of an aseptic loosening and low-grade
infection.
femoral revision (c), two positive cultures were obtained
for Methicillin-sensitive staphylococcus epidermidis,
conrming a type I infection, according to Tsukayama.
(Source: Based on [10], reproduce under the terms and
conditions of the Creative Commons Attribution (CC BY)
license (http://creativecommons.org/licenses/by/4.0/))
Joint aspiration is a crucial diagnostic tool for
detecting PJIs before surgery. Synovial markers
can be useful in detecting infections. Still, their
effectiveness can be compromised in low-grade
infections due to low bacterial load and weak
inammatory response, similar to serum markers. In both acute and chronic settings, an increase
in synovial white blood cell count (WBC) and the
percentage of neutrophils can point toward an
underlying infection. In traditional settings, diagnostic cutoffs can vary between 1500 and 4000
cells/μL for WBC and from 65% to 80% for the
percentage of neutrophils. The WAIOT and
EBJIS [10, 11] denitions of periprosthetic joint
infection include a WBC count of over 1500
cells/μL and a neutrophil percentage of over 65%
to suspect an infection among their criteria [27].
Therefore, these parameters and cutoff values
could be helpful in detecting low-grade infections but with lower specicity than MSIS, ICM
298
T. Zamora et al.
2013, and 2018 cutoffs for chronic infections. In
the same way, cutoff values for settings other
widely available, and their clinical utility has yet
to be proven in extensive comparative studies.
than the hip and knee are less dened.
Promising results have been shown for Alpha
defensin, Leukocyte esterase, and synovial CRP
in the context of PJI evaluation and have been
added to the previously mentioned PJI diagnostic
criteria. Recent research has demonstrated that
Alpha defensin and synovial CRP may present
>80% discrimination of suspected low-grade
infections against aseptic loosening [28].
The identication and detection of the causative microorganisms are crucial for appropriate
management. Antibiotics should be suspended
for at least 2weeks before aspiration and culture
analysis to avoid false negative results. The aspirate should be sent for aerobic, anaerobic, and
fungal cultures. Cultures should be kept for at
ing a single positive culture, whether from preoperative aspiration or tissue culture. An
infection is likely present if uncommon contaminants or virulent organisms, such as
Staphylococcus aureus or Gram-negative rods,
are detected. On the other hand, a single positive
culture of a common contaminant or low-grade
microorganism, like coagulase- negative staphylococci or Cutibacterium acnes (previously
referred to as P. acnes), should prompt further
investigation and a complete analysis of all available tests to conrm or rule out an infection versus contamination [30]. It is advisable to avoid
swab cultures as there is a high possibility of
skin contamination.
least 14days in case of revision surgery or a preoperative joint aspirate for suspected infection,
which is especially relevant in low-grade infections, which commonly take longer than 5days
to retrieve; however, antibiotic prophylaxis
should not be withheld and should be given prior
to surgical incision [29].
When performing revision surgery, it is essential to obtain at least ve reliable tissue samples,
in addition to synovial uid, using separate
instruments and transfer them immediately to the
laboratory. The tissue samples should be anatomically representative, especially those from the
bone-implant interface membrane. These cultures should also be processed for at least 14days
to allow retrieving slow-growing
microorganisms.
Detection of bacterial genetic material could
be helpful in low-grade infections in which bacterial load is low and should be unaffected by
acnes is a hidden cause of pain after shoulder
prosthesis and a major cause of shoulder PJI
[31, 32]. However, the culture time for C. acnes
is long, with a mean delay of 6days to show
positivity, reinforcing the need for prolonged
cultures [28, 33]. Lutz and his colleagues [34]
have proposed a three-grade classication to
determine the likelihood of C. acnes infection.
If a patient shows clinical signs of infection and
has more than two positive samples, they are
considered to have a certain C. acnes
PJI.Patients who exhibit clinical signs of infection but have only one positive sample for C.
acnes are classied as having a probable infection. Patients who do not show any clinical
signs of infection and have any number of C.
acnes cultures will only present the possibility
of infection; however, contamination should
also be ruled out in such cases.
antibiotic administration. Multiplex Polymerase
chain reaction (PCR) on joint uid aspirate has
shown good diagnostic accuracy for low-grade
prosthetic joint infections in small series, even
better than classic cultures [27, 28
]. Nextgeneration sequencing (NGS) with microbial
DNA amplication may also play a role in this
setting. Still, molecular techniques cannot distinguish between live and dead organisms. They
may generate false-positive results, are not
as a low-grade indolent infection with nonspecic symptoms such as chronic pain, often without erythema, swelling, or effusion. Fungal
organisms usually develop a robust biolm and
avoid the immune response; therefore, systemic
symptoms are generally not present [20].
Similarly, laboratory affection is typically mild,
adding to their difcult diagnosis. A high level of
awareness is essential in patients with negative
It is important to be cautious when interpret-
Recently, it has been discovered that C.
Fungal PJI is another entity that can manifest
20 Low-Grade Periprosthetic Infections
299
cultures, multiple revisions for infection, or loosening with no other explanation, especially in the
immunocompromised patient. Prolonged fungal
cultures in the adequate medium remain the most
critical step for fungal PJI diagnosis. Candida
species are the predominant pathogen [35]; however, a high risk of concomitant bacterial PJI
exists.
Culture of samples obtained by sonication of
the removed prosthesis has been shown to be
more sensitive than conventional tissue cultures,
especially in patients with low-virulence microorganisms or treated with antibiotics before surgery [16]. Sonication dislodges adherent bacteria
from prostheses using ultrasound technology and
has been long studied as an adjuvant to conventional culture analysis [36, 37]. Similarly, histopathological analysis obtained during surgery via
a frozen section of periprosthetic tissue could add
to previous diagnostic methods and has been
included in all diagnostic denitions. More than
ve neutrophils per high-power eld in at least
ve elds is considered consistent with infection.
However, surgeon and pathologist experience
plays a crucial role in histological diagnosis, and
threshold values for the presence of neutrophils
may have variability.
Nowadays, no single test can accurately diagnose a PJI, even less a low-grade infection, with
adequate sensitivity and specicity. The most
accurate and comprehensive method for detecting low-grade infections is the combination of a
high clinical suspicion with an ordered set of
diagnostic investigations with postoperative conrmation. The development of the middle groups
“infection likely” in the EBJIS denition and
“Low-Grade PJI” in the WAIOT denition
(Tables 20.1 and 20.2) is a reection of this elevated awareness necessity with a more “exible”
approach to detect this pathologies; however,
independent and large series validation is still
needed for this approach.
Table 20.1 WAIOT denition tests
Rule OUT tests (each
Rule IN tests (each negative
scores 0; positive scores +1)
1. Purulence or draining
sinus or exposed joint
prosthesis
2. Serum IL-6>10pg/mL 2. CRP >10mg/L
3. Serum Procalcitonin
>0.5ng/mL
4. Serum D-Dimer >850ng/mL4. Leukocyte esterase
5. Synovial WBC >3000/mL 5. Alpha-defensin
6. Leukocyte esterase strip
(++)
7. Alpha-defensin
immunoassay (>5.2mg/L)
or lateral ow test
8. Positive cultural
examination
9. Positive histology—Frozen
section (5 neutrophils in at
least 3 HPFs)
10. Combined leukocyte and
bone marrow
scintigraphy
ESR erythrocyte sedimentation rate, CRP C-reactive protein, IL-6 interleukin-6, HPFs high power elds, WBC
white blood cell count
Table 20.2
infection (PJI) and conditions
Conditions Score Conrmation
No Infection <0 Negative culture
Contamination <0 One positive
Biolm-related
implant malfunction
Low-grade periprosthetic joint
infection
High-grade periprosthetic joint
infection
WAIOT denition of periprosthetic joint
negative scores −1;
positive scores 0)
1. ESR >30mm/hr
3. WBC count >1500/
μL
strip (++)
immunoassay
(>5.2mg/L)
6. Tc99 bone scan
culture, negative
histology
<0 Positive culture and/
or histology
0 or
Positive culture and/
more
or histology
1 or
Positive culture and/
more
or histology
300
T. Zamora et al.
20.2 Treatment ofLow-grade PJI
The management principles for PJI do not differ
signicantly between low-grade and other PJIs.
Numerous treatment options have been proposed,
but the goal remains the same for all: infection
eradication and maintenance of a painless and
functional joint. The denitive surgical treatment
can be performed in either one or two stages,
provided the causative agent was identied
before the operation.
In cases of low-grade infections, debridement, antibiotics, and implant retention (DAIR)
may be suitable for healthy patients affected by
acute gram-positive infections, provided they
have a stable and well-functioning implant; however, ensuring debridement and prompt antibiotic treatment before biolm accumulation is
crucial for a successful outcome. Another scenario where DAIR (with or without chronic antibiotic suppression) could be appealing is in the
elderly, frail, or challenging cases where resection and eventual reconstruction may not be feasible. Since these agents are usually more
receptive to antibiotic treatments and less frequently resistant, less invasive alternatives may
be considered.
A two-stage exchange is considered the gold
standard for PJI in all conditions, with success
rates as high as 79–96%, depending on the
severity of the infection and host [38–40].
However, if certain conditions are met, such as
the identication of a non-resistant pathogen
prior to revision, the absence of a sinus tract or
signicant soft tissue damage, and an adequate
host, a one-stage exchange may provide similar
infection eradication with the added benet of
better functionality and shorter overall treatment duration [41]. Even more, in cases of a
low-grade bacterial infection with low virulence, the single-stage approach of explantation
of all components and cement, followed by
debridement and implantation of new components with antibiotic cement, has shown good
results [42]. This should be followed by systemic antibiotic therapy or antifungals, depending on the isolated microorganism.
20.3 Outcomes
The success rate for different treatment modalities for low-grade infections is predominantly
based on a global series with mixed etiologies
and grades of infection. The debridement, antibiotics, and implant retention (DAIR) approach has
shown variable success rates, ranging from 11%
to 100% [43]. Still, as previously mentioned, it
could be an alternative in the acute setting or in
the frail patient where a less morbid approach is
warranted. Nevertheless, more data is required to
determine which patients would benet from this
approach [44].
Singer etal. [42] reported a 95% success rate
in a selected low-grade infection series with a
single-stage approach where methicillin-resistant
organisms and culture-negative infections were
excluded from the analysis. Other studies have
shown equivalent outcomes for selected cases
with a one-stage exchange.
Two-stage exchange procedures have been
found to have high success rates in treating infections, regardless of their cause or when they
occur [38–40]. In fact, this approach may be even
more effective when utilized for low-grade infections compared to those caused by resistant
microorganisms, as reported by several authors
[45–47].
According to a systematic review of 30 articles on shoulder PJI, the isolation of C. acnes
was found to be an independent risk factor for
failed treatment. However, the review also found
that there was no signicant difference in success
rates among 1-stage, 2-stage, or resection arthroplasty revision, with each having a success rate of
over 90% [48].
20.4 Conclusion
Low-grade PJI can be a challenging diagnosis to
make. A high suspicion is necessary when a
patient has persistent pain in an otherwise healthy
arthroplasty. A thorough laboratory workup and
synovial uid analysis are essential, and prolonged cultures and additional techniques such as
20 Low-Grade Periprosthetic Infections
301
molecular analysis and signication of the
retrieved implants should be considered. In some
cases, the diagnosis will only be conrmed retrospectively after an assumed aseptic revision.
These cases should be handled with a multidisciplinary approach involving orthopedic surgeons
and infectious disease specialists, among other
specialists.
References
1. Delanois RE, Mistry JB, Gwam CU, Mohamed NS,
Choksi US, Mont MA.Current epidemiology of revision total knee arthroplasty in the United States. J
Arthroplasty. 2017;32(9):2663–8.
2. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail DTP,
Berry DJ. The epidemiology of revision total hip
arthroplasty in the United States. J Bone Joint Surg.
2009;91(1):128–33.
3. Berbari EF, Marculescu C, Sia I, Lahr BD, Hanssen
AD, Steckelberg JM, etal. Culture-negative prosthetic
joint infection. Clin Infect Dis. 2007;45(9):1113–9.
4. Parvizi J, Suh DH, Jafari SM, Mullan A, Purtill
JJ.Aseptic loosening of total hip arthroplasty: infection always should be ruled out. Clin Orthop Relat
Res. 2011;469(5):1401–5. Available from: https://
pubmed.ncbi.nlm.nih.gov/21365337/.
5. Beswick AD, Wylde V, Gooberman-Hill R, Blom A,
Dieppe P.What proportion of patients report long-term
pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in
unselected patients. BMJ Open. 2012;2(1). Available
from: https://pubmed.ncbi.nlm.nih.gov/22357571/.
6. Moojen DJF, Van Hellemondt G, Vogely HC, Burger
BJ, Walenkamp GHIM, Tulp NJA, et al. Incidence
of low-grade infection in aseptic loosening of total
hip arthroplasty. Acta Orthop. 2010;81(6):667–73.
Available from: https://pubmed.ncbi.nlm.nih.
gov/20919816/.
7. Parvizi J, Zmistowski B, Berbari EF, Bauer TW,
Springer BD, Della Valle CJ, etal. New denition for
periprosthetic joint infection: from the Workgroup of
the Musculoskeletal Infection Society. Clin Orthop
Relat Res. 2011;469(11):2992–4. Available from:
https://pubmed.ncbi.nlm.nih.gov/21938532/.
8. Parvizi J, Tan TL, Goswami K, Higuera C, Della Valle
C, Chen AF, etal. The 2018 denition of periprosthetic
hip and knee infection: an evidence-based and validated criteria. J Arthroplasty. 2018;33(5):1309–1314.
e2. Available from: https://pubmed.ncbi.nlm.nih.
gov/29551303/.
9. Parvizi J, Gehrke T, Chen AF. Proceedings of the
international consensus on periprosthetic joint infection. Bone Joint J. 2013;95-B(11):1450–2. Available
from: https://pubmed.ncbi.nlm.nih.gov/24151261/
10. Romanò CL, AI Khawashki H, Benzakour T,
Bozhkova S, del Sel H, Hafez M, etal. The W.A.I.O.T.
denition of high-grade and low-grade peri-prosthetic
joint infection. J Clin Med. 2019;8(5). Available from:
https://pubmed.ncbi.nlm.nih.gov/31083439/.
11. McNally M, Sousa R, Wouthuyzen-Bakker M, Chen
AF, Soriano A, Vogely HC, etal. The EBJIS denition of periprosthetic joint infection. Bone Joint
J. 2021;103-B(1):18–25. Available from: https://
pubmed.ncbi.nlm.nih.gov/33380199/
12. Fehring TK, Odum SM, Berend KR, Jiranek WA,
Parvizi J, Bozic KJ, et al. Failure of irrigation and
débridement for early postoperative periprosthetic
infection. Clin Orthop Relat Res. 2013;471(1):250–7.
Available from: https://pubmed.ncbi.nlm.nih.
gov/22552768/.
13. Kheir MM, Tan TL, Shohat N, Foltz C, Parvizi
J. Routine diagnostic tests for periprosthetic joint
infection demonstrate a high false-negative rate and
are inuenced by the infecting organism. J Bone Joint
Surg (Am Vol). 2018;100(23):2057–65.
14. Akgün D, Müller M, Perka C, Winkler T.The serum
level of C-reactive protein alone cannot be used for
the diagnosis of prosthetic joint infections, especially
in those caused by organisms of low virulence. Bone
Joint J. 2018;100-B(11):1482–6. Available from:
https://pubmed.ncbi.nlm.nih.gov/30418061/
15. Choe H, Kobayashi N, Abe K, Hieda Y, Tezuka T,
Inaba Y.Evaluation of serum albumin and globulin in
combination with C-reactive protein improves serum
diagnostic accuracy for low-grade periprosthetic
joint infection. J Arthroplasty. 2023;38(3):555–61.
Available from: https://pubmed.ncbi.nlm.nih.
gov/36115535/.
16. Vasso M, Schiavone Panni A. Low-grade periprosthetic knee infection: diagnosis and management.
J Orthop Traumatol. 2015;16(1). Available from:
https://pubmed.ncbi.nlm.nih.gov/24821631/.
17. McPherson EJ, Woodson C, Holtom P, Roidis N,
Shufelt C, Patzakis M.Periprosthetic total hip infection: outcomes using a staging system. Clin Orthop
Relat Res. 2002;(403):8–15.
18. Wimmer MD, Randau TM, Friedrich MJ, Ploeger
MM, Schmolder J, Strauss AC, et al. Outcome predictors in prosthetic joint infections– validation of a
risk stratication score for prosthetic joint infections
in 120 cases. Acta Orthop Belg. 2016;82(1):143–8.
19. Garcia-Vidal C, Viasus D, Carratalà J.Pathogenesis
of invasive fungal infections. Curr Opin Infect Dis.
2013;26(3):270–6. Available from: https://pubmed.
ncbi.nlm.nih.gov/23449139/.
20. Nace J, Siddiqi A, Talmo CT, Chen AF. Diagnosis
and management of fungal periprosthetic joint infections. J Am Acad Orthop Surg. 2019;27(18):e804–18.
Available from: https://pubmed.ncbi.nlm.nih.
gov/30520804/.
21. Tsukayama DT, Estrada R, Gustilo RB.Infection after
total hip arthroplasty. A study of the treatment of one
hundred and six infections. J Bone Joint Surg Am.
302
T. Zamora et al.
1996;78(4):512–23. Available from: https://pubmed.
ncbi.nlm.nih.gov/8609130/.
22. Pérez-Prieto D, Portillo ME, Puig-Verdié L, Alier
A, Martínez S, Sorlí L, etal. C-reactive protein may
misdiagnose prosthetic joint infections, particularly chronic and low-grade infections. Int Orthop.
2017;41(7):1315–9. Available from: https://pubmed.
ncbi.nlm.nih.gov/28321490/
23. Berbari E, Mabry T, Tsaras G, Spangehl M, Erwin PJ,
Murad MH, etal. Inammatory blood laboratory levels as markers of prosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am.
2010;92(11):2102–9. Available from: https://pubmed.
ncbi.nlm.nih.gov/20810860/
24. Yoon JR, Yang SH, Shin YS. Diagnostic accuracy
of interleukin-6 and procalcitonin in patients with
periprosthetic joint infection: a systematic review
and meta-analysis. Int Orthop. 2018;42(6):1213–26.
Available from: https://pubmed.ncbi.nlm.nih.
gov/29294147/
25. Shahi A, Kheir MM, Tarabichi M, Hosseinzadeh
HRS, Tan TL, Parvizi J.Serum D-Dimer test is promising for the diagnosis of periprosthetic joint infection and timing of reimplantation. J Bone Joint Surg
Am. 2017;99(17):1419–27. Available from: https://
pubmed.ncbi.nlm.nih.gov/28872523/
26. Verberne SJ, Sonnega RJA, Temmerman OPP,
Raijmakers PG. What is the accuracy of nuclear
imaging in the assessment of periprosthetic knee
infection? A meta-analysis. Clin Orthop Relat Res.
2017;475(5):1395–410. Available from: https://
pubmed.ncbi.nlm.nih.gov/28050818/
27. Lee YS, Koo KH, Kim HJ, Tian S, Kim TY,
Maltenfort MG, etal. Synovial uid biomarkers for
the diagnosis of periprosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg
Am. 2017;99(24):2077–84. Available from: https://
pubmed.ncbi.nlm.nih.gov/29257013/
28. Ettinger M, Savov P, Calliess T, Windhagen H,
Lichtinghagen R, Lukasz A, et al. Improved diagnostic accuracy with the classication tree method
for diagnosing low-grade periprosthetic joint infections by quantitative measurement of synovial uid
alpha-defensin and C-reactive protein. Int Orthop.
2020;44(1):31–8. Available from: https://pubmed.
ncbi.nlm.nih.gov/31127365/.
29. Wouthuyzen-Bakker M, Benito N, Soriano A. The
effect of preoperative antimicrobial prophylaxis on
intraoperative culture results in patients with a suspected or conrmed prosthetic joint infection: a systematic review. J Clin Microbiol. 2017;55(9):2765–74.
Available from: https://pubmed.ncbi.nlm.nih.
gov/28659322/.
30. Schwarze J, Moellenbeck B, Gosheger G, Puetzler J,
Deventer N, Kalisch T, etal. The role of single positive cultures in presumed aseptic total hip and knee
revision surgery-a systematic review of the literature.
Diagnostics (Basel). 2023;13(9). Available from:
https://pubmed.ncbi.nlm.nih.gov/37175046/.
31. Millett PJ, Yen YM, Price CS, Horan MP, Van Der
Meijden OA, Elser F. Propionibacterium acnes
infection as an occult cause of postoperative shoulder pain: a case series. Clin Orthop Relat Res.
2011;469(10):2824–30. Available from: https://
pubmed.ncbi.nlm.nih.gov/21240577/.
32. Hsu JE, Bumgarner RE, Matsen
FA. Propionibacterium in shoulder arthroplasty:
what we think we know today. J Bone Joint Surg
Am. 2016;98(7):597–606. Available from: https://
pubmed.ncbi.nlm.nih.gov/27053589/.
33. Boisrenoult P. Cutibacterium acnes prosthetic joint
infection: diagnosis and treatment. Orthop Traumatol
Surg Res. 2018;104(1):S19–24.
34. Lutz MF, Berthelot P, Fresard A, Cazorla C, Carricajo
A, Vautrin AC, etal. Arthroplastic and osteosynthetic
infections due to Propionibacterium acnes: a retrospective study of 52 cases, 1995-2002. Eur J Clin
Microbiol Infect Dis. 2005;24(11):739–44.
35. Schoof B, Jakobs O, Schmidl S, Klatte TO, Frommelt
L, Gehrke T, etal. Fungal periprosthetic joint infection of the hip: a systematic review. Orthop Rev
(Pavia). 2015;7(1):18–22. Available from: https://
pubmed.ncbi.nlm.nih.gov/25874063/.
36. Trampuz A, Piper KE, Jacobson MJ, Hanssen AD,
Unni KK, Osmon DR, etal. Sonication of removed
hip and knee prostheses for diagnosis of infection.
N Engl J Med. 2007;357(7):654–63. Available from:
https://pubmed.ncbi.nlm.nih.gov/17699815/.
37. Li C, Renz N, Thies CO, Trampuz A.Meta-analysis
of sonicate uid in blood culture bottles for diagnosing periprosthetic joint infection. J Bone Jt
Infect. 2018;3(5):273. Available from: /pmc/articles/
PMC6328302/
38. Biring GS, Kostamo T, Garbuz DS, Masri BA,
Duncan CP.Two-stage revision arthroplasty of the hip
for infection using an interim articulated Prostalac hip
spacer: a 10- to 15-year follow-up study. J Bone Joint
Surg Series B. 2009;91(11):1431–7.
39. Leung F, Richards CJ, Garbuz DS, Masri BA, Duncan
CP.Two-stage total hip arthroplasty: how often does
it control methicillin-resistant infection? Clin Orthop
Relat Res. 2011;469(4):1009. Available from: /pmc/
articles/PMC3048283/.
40. Zamora T, Garbuz DS, Greidanus NV, Masri BA.An
articulated spacer made of new primary implants in
two-stage exchange for infected total knee arthroplasty may provide durable results. Bone Joint J.
2020;102-B(7):852–60. Available from: https://
pubmed.ncbi.nlm.nih.gov/32600135/.
41. Zahar A, Klaber I, Gerken AM, Gehrke T, Gebauer
M, Lausmann C, et al. Ten-year results following
one-stage septic hip exchange in the management
of periprosthetic joint infection. J Arthroplasty.
2019;34(6):1221–6. Available from: https://pubmed.
ncbi.nlm.nih.gov/30857953/
42. Singer J, Merz A, Frommelt L, Fink B.High rate of
infection control with one-stage revision of septic
knee prostheses excluding MRSA and MRSE. Clin