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21 st Century Approach Javad Parvizi MD, FRCS Professor Rothm an - PowerPoint PPT Presentation

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Diagnosis of Periprosthetic Joint Infection 21 st Century Approach Javad Parvizi MD, FRCS Professor Rothm an Institute at Thom as Jefferson University, Philadelphia PJI Conclusions Incidence and prevalence is higher than believed 12%

  1. Diagnosis of Periprosthetic Joint Infection 21 st Century Approach Javad Parvizi MD, FRCS Professor Rothm an Institute at Thom as Jefferson University, Philadelphia

  2. PJI Conclusions • Incidence and prevalence is higher than believed • 12% of so called “aseptic” could have PJI Parvizi J , et al CORR 2011

  3. The true PJI incidence rates is underestim ated in the registries Pag

  4. Diagnosis of PJI  Remains a real challenge  No gold standard exists  No uniform criteria for diagnosis exists

  5. Diagnosis of PJI  As many definitions as investigators/ public ations

  6. Diagnosis of PJI  Difficult

  7. Diagnosis of PJI  Difficult

  8. Diagnosis of PJI  Remains a real challenge  Because

  9. Intracellular S. S. aur ureus us in Periprosthetic Tissue Osteoblast S. aureus Parham S et al, Clin Infect Dis 2006

  10.  Osteoblasts infected with S aureus  Inoculated into open rat fracture

  11. All fractures got infected

  12. Courtesy of Edward Schwarz A B C

  13. Biofilm Quarum sensing Glycocalyx

  14. The Problem  None of the test being used were developed specifically for PJI diagnosis

  15. Definition of PJI (MSIS)  There is a sinus tract communicating with the prosthesis; or Parvizi J et al CORR 20 11

  16. Definition of PJI (MSIS)  There is a sinus tract communicating with the prosthesis; or  A pathogen is isolated by culture from two separate tissue or fluid samples obtained from the affected prosthetic joint; or Parvizi J et al CORR 20 11

  17. Definition of PJI (MSIS)  There is a sinus tract communicating with the prosthesis; or  A pathogen is isolated by culture from two separate tissue or fluid samples obtained from the affected prosthetic joint; or  When four out of the following six criteria exists Parvizi J et al CORR 20 11

  18. Definition of PJI (MSIS/ International Consensus) ESR AND CRP  synovial WBC count or ++ leukocyte  esterase synovial PMN%,   Positive histological analysis of periprosthetic tissue,  A single positive culture

  19. Definition of PJI (MSIS)  PJI may be present if less than 4 of these criteria are met Parvizi J et al CORR 20 11

  20. AAOS Guidelines www.aaos.org/ guidelines • 15 recommendations • Majority strong • Review of literature Parvizi et al. JAAOS 2010 Della Valle et al. JAAOS 2010

  22. AAOS ESR and CRP for all patients undergoing revision arthroplasty

  23. PPFx or PJI? • 82 year ol old • 12 12 years out ut from hemiarthropl plas asty Patient was infact infected

  24. Recent Data from the RI ESR and CRP may be normal in up to 18% of PJI cases Tan T et al -Pending

  25. International Consensus Aspiration of the joint before any further imaging

  26. AAOS Guidelines Strong Patients be off antibiotics before aspiration (2 weeks) No Antibiotics until diagnosis reached or refuted

  27. RI Data- 20 15 • Administration of ABX also affects the level of neutrophil % and total count in the synovial fluid Shahi et al CORR 2015

  28. AAOS Guidelines Rec 9: Weak Bone scan (leukocyte labeled) and PET scan is an option for patients not scheduled for reoperation or diagnosis not reached

  29. Recent Data from the RI Meta-analysis Bone scan is pretty much useless!! Diaz-Lodezma JOA 2015

  31. Opportunities in Managem ent of PJI Era of Biomarkers is here

  32. Diagnosis of PJI Simple Test  UA strips for leukocyte esterase

  33. Data

  34. Alpha-Defensin Antimicrobial Peptide Secreted by Neutrophils to fight Infection Alpha-Defensin

  35. Overall study data Gold Study N Sensitivity Specificity Standard Rothman 97% 96% 149 MSIS Criteria Institute (95% CI: 86-100%) (95% CI: 90-99%) 100% 95% 61 Mayo Arizona MSIS Criteria (95% CI: 79-100%) (95% CI: 83-99%) 96% 99% Cleveland Clinic 111 MSIS Criteria (95% CI: 82-99%) (95% CI: 93-100%) 98% 97% 320 Combined MSIS Criteria (95%CI: 92-100%) (95% CI: 93-99%)

  36. Issues  Synovial Fluid  Invasive  Inadequate  Insufficient

  37. Issues  Adverse local tissue reaction

  38. ALTR  Leukocyte esterase test = 92% sensitivity  Tischler E et al JOA 2015  Alpha defensin = 74%  Synovial CRP = 91%  Combined = 95%  Higuera et al Pending

  39. Issues  Pathogen  Parvizi et al JBJS 2013

  40. • Koch- 1886 • Anthrax • Little has changed

  42. Molecular Diagnostics of Microbial DNA Next Generation Sequencing PCR- Panel of Microbes (8-20) NGS- 25,000 species

  44. Multi-National, Multi-center Study Supported by: MicrogenDx

  45. • PJI (and others infections) may be polymicrobial… ……..

  46. ?

  47. • Signal that NGS isolated organisms (ignored) may result in later failure

  48. • Polymicrobial • “Reinfection” • Present at index infection • Ignored • Professional pathogen

  49. Opportunities in Managem ent of PJI Serum Markers for PJI (reimplantation)

  51. D-dim er: A Potential Serum Biom arker for Diagnosis of Periprosthetic Joint Infection Alisina Shahi MD Majd Tarabichi MD; Timothy L. Tan MD; Javad Parvizi MD, FRCS

  52. Erythrocyte Sedim entation Sensitivity = 73% Specificity = 78%

  53. C-Reactive Protein Sensitivity = 78% Specificity = 80%

  54. D-dim er Sensitivity = 89% Specificity = 92%

  55. Consensus On Orthopedic Infections July 26-27, 2018 Philadelphia

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