Case Study
AAOS Clinical Practice Guideline:
Javad Parvizi, MD
Craig J. Della Valle, MD
From the Rothman Institute of Orthopedics,
Thomas Jefferson University Hospital,
Philadelphia, PA (Dr. Parvizi), and the
Department of Orthopaedic Surgery, Rush
University Medical Center, Chicago, IL
(Dr. Della Valle).
Dr. Della Valle or an immediate family
member serves as a paid consultant to
Angiotech, Biomet, Kinamed, and Smith &
Nephew; has received research or
institutional support from Pacira and
Zimmer; and serves as a board member,
owner, officer, or committee member of the
American Association of Hip and Knee
Surgeons and the Arthritis Foundation.
Dr. Parvizi or an immediate family member
serves as a paid consultant to Stryker; has
received research or institutional support
from 3M, the Musculoskeletal Transplant
Foundation, and Stryker; has received
royalties from Saunders/Mosby-Elsevier,
SLACK, Wolters Kluwer Health–Lippincott
Williams & Wilkins; and serves as a board
member, owner, officer, or committee
member of the American Association of Hip
and Knee Surgeons, American Board of
Orthopaedic Surgery, the British
Orthopaedic Association, the Hip Society,
the Orthopaedic Research and Education
Foundation, the Orthopaedic Research
Society, and SmartTech.
J Am Acad Orthop Surg 2010;18:771-772
Copyright 2010 by the American Academy
of Orthopaedic Surgeons.
December 2010, Vol 18, No 12
Diagnosis and Treatment of
Periprosthetic Joint Infections of
the Hip and Knee
Periprosthetic joint infection (PJI)
remains one of the major complica-
tions that can ensue following total
joint arthroplasty, with an inci-
dence of 1% to 2% at 2 years post-
operatively for both total hip and
knee arthroplasty1,2 and up to 7%
after revision surgery.3 Although
the incidence of infection appears
to be small, the total number of
joint arthroplasties being per-
formed is increasing,4 which likely
will lead to a greater number of in-
fected patients.
PJI poses a challenge on many
fronts. One of the main challenges
is to correctly diagnose PJI to im-
plement effective treatment regi-
mens. There is currently no stan-
dard of care for diagnosis of PJI,
and no concrete definition for PJI
exists.5 Hence, the preoperative
workup for PJI is not standardized,
and various tests, including inva-
sive procedures, are performed in
an effort to reach the diagnosis of
PJI. The AAOS work group was
convened to evaluate the available
evidence for each diagnostic modal-
ity and propose an algorithm that
can be used by clinicians in reach-
ing the diagnosis of PJI.
History
A 65-year-old woman who under-
went total knee arthroplasty 14
months ago has continued to have
pain in the operated knee that has
recently been increasing in severity.
The pain is anterior to the knee and
present at all times. She describes
the pain as moderate to severe. The
patient has difficulty ambulating
long distances. She denies fever or
chills and has not been systemically
ill. The knee appeared swollen and
red recently, which prompted the gen-
eral practitioner to start a course of
antibiotic therapy. The patient has
just completed a 14-day course of
oral antibiotics. On close questioning,
the patient admits to having had
wound-healing problems in the im-
mediate postoperative period follow-
ing total knee arthroplasty that re-
quired wash-out of the wound on
postoperative day 6.
The AAOS guideline recommends
against initiating antibiotic treat-
ment in patients with suspected
periprosthetic joint infection until
after cultures from the joint have
been obtained (Grade of Recom-
mendation: Strong).
Physical Examination
The clinical examination reveals a
slightly swollen knee with a range
of motion from 5° to 110°. Ex-
treme of motion is painful. There is
no identifiable instability of the
knee, and the extensor mechanism
is intact with good patellar track-
ing. A previous anterior incision is
well healed. The knee feels slightly
warm to the touch and is tender in
the medial joint line. The neurovas-
cular examination of the extremity
is normal. The skin is intact with
no evidence of ulceration. There is
minor ankle edema bilaterally.
Imaging Studies
Physical examination did not reveal
a specific diagnosis. Anteroposte-
rior, lateral, and skyline radio-
771
Case Study: Diagnosis and Treatment of Periprosthetic Joint Infections of the Hip and Knee
graphs of the knee were performed.
The patient has also had bone scan
images performed at an outside insti-
tution, copies of which were brought
for evaluation.
The AAOS guideline includes rec-
ommendations for risk stratification
of the patients (Grade of Recommen-
dation: Consensus). Because this pa-
tient had a history of wound-related
problems in the postoperative period
following the index arthroplasty, she
is considered high risk for chronic
PJI. Hence, further tests need to be
ordered.
The AAOS guideline states that for
patients in whom diagnosis of PJI
cannot be reached, performing other
tests, such as nuclear imaging
(labeled-leukocyte imaging combined
with bone or bone marrow imaging,
F-18 fluorodeoxyglucose–positron
emission tomography imaging, gal-
lium imaging, or labeled-leukocyte
imaging) is an option. Bone scan
alone without labeling of the white
cell, performed in this case study, has
no role in diagnosis of PJI (Grade of
Recommendation: Weak).
Further Tests
At this point, there is no specific di-
agnosis for this patient. However, PJI
remains as a possible diagnosis.
Thus, a series of tests was ordered,
including erythrocyte sedimentation
rate (ESR), C-reactive protein (CRP)
level, and white blood cell count
with differential. The ESR is 35
mm/h (normal, 0 to 15 mm/h for
772
men, 0 to 20 mm/h for women); the
CRP level is 12 mg/dL (normal, <1
mg/dL). Aspiration of the joint is
performed. The neutrophil count of
the fluid is 2,350 cells/µl, with a neu-
trophil differential of 85%. The
Gram stain of the aspirate is nega-
tive, and cultures showed no growth.
Reaspiration of the joint is planned
in 3 weeks, given the recent history
of antibiotic use. The patient is in-
structed to stop the antibiotics that
were started recently by her primary
care physician.
The AAOS recommendations en-
dorse ordering serology (ESR and
CRP level) for workup of patients
with suspected PJI. There is no evi-
dence supporting the role of white
blood cell count and/or white blood
cell differential in diagnosis of PJI
(Grade of Recommendation: Strong).
The AAOS guideline recommends
that, for patients with abnormal se-
rology (defined as ESR >30 mm/h
and CRP level >1 mg/dL), aspiration
of the joint be performed (Grade of
Recommendation: Strong).
The AAOS guideline recommends
that joint aspirate fluid be sent for
microbiologic culture, synovial fluid
white blood cell count, and differen-
tial (Grade of Recommendation:
Strong).
The AAOS guideline recommends
against the use of intraoperative
Gram stain to rule out periprosthetic
joint infection (Grade of Recommen-
dation: Strong).
The AAOS guideline recommends
Journal of the American Academy of Orthopaedic Surgeons
that patients be off antibiotics for
≥2 weeks before obtaining intra-
articular culture (Grade of Recom-
mendation: Consensus).
Follow-up
Repeat aspiration in this patient is
performed. The synovial fluid white
blood cell count is now 7,383, and
the differential is 89%, which are
both consistent with PJI. The sam-
ples sent for Gram stain do not re-
veal any organisms. The culture iso-
lates Staphylococcus aureus after 3
days. The diagnosis of PJI is reached,
and surgical treatment is planned.
References
1. Kurtz SM, Ong KL, Lau E, Bozic KJ,
Berry D, Parvizi J: Prosthetic joint
infection risk after TKA in the Medicare
population. Clin Orthop Relat Res 2010;
468(1):52-56.
2. Ong KL, Kurtz SM, Lau E, Bozic KJ,
Berry DJ, Parvizi J: Prosthetic joint
infection risk after total hip arthroplasty
in the Medicare population. J Arthro-
plasty 2009;24(6 suppl):105-109.
3. Hanssen AD, Rand JA: Evaluation and
treatment of infection at the site of a
total hip or knee arthroplasty. Instr
Course Lect 1999;48:111-122.
4. Kurtz SM, Lau E, Ong K, Zhao K, Kelly
M, Bozic KJ: Future young patient
demand for primary and revision joint
replacement: National projections from
2010 to 2030. Clin Orthop Relat Res
2009;467(10):2606-2612.
5. Bauer TW, Parvizi J, Kobayashi N,
Krebs V: Diagnosis of periprosthetic
infection. J Bone Joint Surg Am 2006;
88(4):869-882.