Are patients being evaluated for periprosthetic joint infection prior to referral to a tertiary care center?

Abstract

Background: Patients with a painful or failed total joint arthroplasties should be evaluated for periprosthetic joint infection (PJI). The purpose of this study is to determine if patients referred to a tertiary care center had been evaluated for PJI according to the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines.

Methods: One hundred thirteen patients with painful hip (43) or knee (70) arthroplasties were referred to a single provider by orthopaedic surgeons outside our practice between 2012 and 2014. We retrospectively evaluated the workup by referring physicians, including measurement of serum erythrocyte sedimentation rate and C-reactive protein, performance of a joint aspiration if these values were abnormal, and obtainment of synovial fluid white blood cell count, differential, and cultures.

Results: Sixty-two of 113 patients (55%) did not have a workup that followed AAOS guidelines. Serum erythrocyte sedimentation rate and C-reactive protein were ordered for 64 of the 113 patients (57%). Of 25 patients with elevated inflammatory markers warranting aspiration, 15 (60%) had an aspiration attempted, with synovial fluid white blood cell, differential, and cultures obtained in 9 of 12 (75%) aspirations that yielded fluid. Of the 62 patients with an incomplete infection workup, 11 (18%) had a bone scan, 6 (10%) a computed tomography scan, and 3 (5%) a magnetic resonance imaging. Twelve of the 113 patients (11%) were ultimately diagnosed with PJI, with 5 undiagnosed prior to referral.

Conclusions: The AAOS guidelines to evaluate for PJI are frequently not being followed. Improving awareness of these guidelines may avoid unnecessary and costly evaluations and delay in the diagnosis of PJI.

Keywords: arthroplasty infection; clinical practice guidelines; diagnosis; infection workup; periprosthetic joint infection.

Figure 1

Algorithm used to evaluate PJI workup compliance with AAOS recommendations.

Figure 2

Workup compliance with AAOS PJI recommendations for (a) all referred patients with painful hip or knee arthroplasties, (b) hip arthroplasties only, and (c) knee arthroplasties only. ^∗Includes 3 aspirations that yielded no fluid; ^∗∗includes 2 aspirations that yielded no fluid; ^∗∗∗includes 1 aspiration that yielded no fluid.