CORR Insights^®: Synovial Cytokines and the MSIS Criteria Are Not Useful for Determining Infection Resolution After Periprosthetic Joint Infection Explantation

Excerpt

Identifying persistent infection in patients with hip or knee arthroplasty infection who are undergoing treatment with two-stage exchange is often difficult [1, 7]. Providers currently use clinical and follow up systemic inflammatory markers as a surrogate for periprosthetic joint infection (PJI) eradication. Satisfactory wound healing after resection arthroplasty (Stage 1) is often used as a clinical surrogate. A decrease in an elevated systemic C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have also been advocated as being predictive of PJI eradication [3]. But in a study by Kusuma and colleagues [4], the ESR remained persistently elevated in 54% and CRP in 21% of patients with TKA infection despite documented eradication of infection based on preestablished microbiologic and histopathologic criteria. The lack of a decrease in systemic inflammatory markers is often due to noninfectious etiologies or to a normal variation rather than the persistence of PJI. This often leads to unnecessary extension of antimicrobial therapy or additional surgical débridements. Nuclear scans often remain positive for up to 1 year after treatment and are not useful in documenting sepsis arrest. Due to the limitations of systemic inflammatory markers and imaging studies, many investigators have advocated repeat diagnostic joint aspiration for cell count and culture prior to reimplantation surgery. The sensitivity of culture in this setting is very low and is often associated with a high contamination rate [5]. …