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Paper of the week: Propidium monoazide-polymerase chain reaction for detection of residual periprosthetic joint infection in two-stage revision.

Paper of the week: Propidium monoazide-polymerase chain reaction for detection of residual periprosthetic joint infection in two-stage revision. Askar M, Sajid M, Nassif Y, Ashraf W, Scammell B, Bayston R. Mol Biol Rep. 2019 Oct 5. doi: 10.1007/s11033-019-05092-z.

Summary by Dr Sreeram Penna

In this study, researchers compare the efficacy of propidium monoazide-polymerase chain reaction (PMA-PCR or Viability PCR) for detecting residual periprosthetic joint infection in two-stage revision to a traditional polymerase chain reaction (PCR) and cultures. According to the authors, pre-treatment of propidium monoazide improves efficacy PCR testing by binding to residual DNA and RNA from the sample. Also, propidium monoazide does not cross the bacterial cell membrane and therefore, does not affect DNA from viable bacteria. Based on these actions authors postulate that by inhibiting residual DNA from both dead bacteria and human DNA in a sample using propidium monoazide, the overall efficacy of PCR in diagnosing infection is increased.

Cohort consists of 60 episodes of care in 58 patients. 14 of these episodes were considered infected using Muskulo Skeletal Infection Society criteria. The PCR assay done included only genus-specific primers for staphylococci and enterococci and species-specific primers for Cutibacterium acnes. Results showed that sensitivity of culture, PCR, and PMA-PCR were 50%, 71%, and 79%, respectively, and specificities were 98%, 72%, and 89%, respectively. Authors note that the increase in sensitivity of PMA-PCR compared to traditional PCR is due to the removal of large quantities of residual free-floating human DNA present in the sample by PMA.

In conclusion, PMA-PCR is better than traditional PCR with increased specificity and sensitivity. However, further research with broader PCR panel, including all possible bacteria causing PJI and larger sample size is needed.

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ICM Document Update: Volume 1 of Português (Brasil) translation available online

Volume 1 of Português (Brasil) translation available online at the following link.  Volume 1 is composed of Parts I (General Assembly) and Part II (Hip and Knee), with 553 pages plus the Prologue.

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Paper of the week: Dilute Betadine Lavage Reduces the Risk of Acute Postoperative Periprosthetic Joint Infection in Aseptic Revision Total Knee and Hip Arthroplasty: A Randomized Controlled Trial.

Paper of the week: Dilute Betadine Lavage Reduces the Risk of Acute Postoperative Periprosthetic Joint Infection in Aseptic Revision Total Knee and Hip Arthroplasty: A Randomized Controlled Trial. Calkins TE, Culvern C, Nam D, Gerlinger TL, Levine BR, Sporer SM, Della Valle CJ. J Arthroplasty. 2019 Sep 12. pii: S0883-5403(19)30843-5. doi: 10.1016/j.arth.2019.09.011.

Summary by Dr Marjan Wouthuyzen-Bakker

Calkins et al. randomized 478 patients undergoing an aseptic revision of the hip or knee to receive either a 3-minute diluted betadine (povidone-iodine) lavage or normal saline lavage before wound closure. From the 457 analyzed patients, they observed an early PJI (i.e. <90 days of surgery) in 3.4% (8/234) cases lavaged with saline and in 0.4% (1/223) cases lavaged with betadine (p 0.04). There was no difference in wound complications between both groups. The authors conclude that the use of a diluted betadine lavage is a safe and effective way to reduce acute postoperative PJI in aseptic revisons of hip or knee.

Scarce data on the use of diluted betadine lavage in orthopaedic surgery is available. Two RCTs demonstrated an infection reduction when using betadine lavage in spine surgery [1-2]. However, no statistical difference was observed in an RCT performed by Kokavec et al., studying an orthopaedic population undergoing hip, femur or pelvis surgeries [3]. In joint arthroplasties, only one retrospective study has been performed in which the authors described a lower infection rate when using betadine compared to saline in a historical cohort of primary TJAs [4]. Due to this low quality evidence in orthopaedics, the WHO suggests ‘to consider the use of irrigation of the incisional wound with an aqueous povidone-iodine solution’ [5]. This paper of the week supports the use of diluted betadine lavage (0.35%) in revision arthroplasties in which the infection rate is generally much higher compared to primary arthroplasties, and adds to the much needed evidence in orthopaedic surgery on this topic.

References

  1. Chang FY, Chang MC, Wang ST et al. Can povidone-iodine solution be used safely in a spinal surgery? Eur Spine J 2006; 15(6): 1005-14.
  2. Cheng MT, Chang MC, Wang ST et al. Efficacy of dilute betadine solution irrigation in the prevention of postoperative infection of spinal surgery. Spine 2005: 30(15); 1689-93.
  3. Kokavec M and Fristáková M. Efficacy of antiseptics in the prevention of post-operative infections of the proximal femur, hip and pelvis regions in orthopedic pediatric patients. Analysis of the first results. Acta Chir Orthop Traumatol Cech. 2008;75(2):106-9.
  4. Brown NM, Cipriano CA, Moric M et al. Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty. 2012; 27(1):27-30.
  5. WHO, Global guidelines on the prevention of surgical site infection; second edition, 2018. ISBN: 978-92-4-155047-5.
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Paper of the week: Plasma Viscosity Has a Role in the Diagnosis of Prosthetic Joint Infection After Total Knee Arthroplasty.

Paper of the week: Plasma Viscosity Has a Role in the Diagnosis of Prosthetic Joint Infection After Total Knee Arthroplasty. Bajada S, Yoong AWH, Hourigan P, Koopmans PC, Phillips JRA, Toms AD. J Arthroplasty. 2019 Jul 30. pii: S0883-5403(19)30719-3. doi: 10.1016/j.arth.2019.07.035.

Summary by Dr Sreeram Penna

This retrospective study aimed to find out the clinical value of plasma viscosity in the diagnosis of periprosthetic joint infection (PJI) in painful total knee arthroplasty patients. Primarily researchers compared value of plasma viscosity with erythrocyte sedimentation rate (ESR) and c reactive protein (CRP). Patients with inflammatory arthropathies and lymphoproliferative disorders were excluded from the study. Researchers used MSIS criteria for diagnosing infection.

The results of the study showed that there is a strong correlation between plasma viscosity and ESR and CRP. Based on the study data, plasma viscosity value of 1.81 mPa.s. had the best efficacy. Utilizing this value sensitivity, specificity, positive likely hood ration, and negative likely hood ratio of plasma viscosity in PJI was 58.3%, 93.8%, 9.43, and 0.44, respectively. When comparing plasma viscosity to ESR in patients with both serum investigations available (107 patients), the area under the curve (AUC) was 0.814 for plasma viscosity while AUC for ESR was 0.812 — showing that PV is noninferior to ESR as a reliable screening test.

The advantages of plasma viscosity compared to ESR as suggested by authors include plasma viscosity not influenced by hematocrit (anemia, polycythemia), red blood cell aggregation, hemoglobinopathies, anti-inflammatory medication, or time to analysis, patients age. In addition, the authors mention that the plasma viscosity test is cheaper than ESR and CRP.  

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Paper of the week: The 2018 new definition of periprosthetic joint infection improves the diagnostic efficiency in the Chinese population.

Paper of the week:  The 2018 new definition of periprosthetic joint infection improves the diagnostic efficiency in the Chinese population. Haitao Guan, Jun Fu, Xiang Li, Wei Chai, Libo Hao, Rui Li, Jing Zhao, and Jiying Chen. J Orthop Surg Res. 2019; 14: 151. Published online 2019 May 24. doi: 10.1186/s13018-019-1185-y

Summary by Dr Sreeram Penna

The purpose of this retrospective study was to validate the 2018 ICM criteria on Chinese patients that underwent revision for total hip arthroplasty (THA) and total knee arthroplasty (TKA) for the periprosthetic joint infection (PJI) or aseptic loosening. This study excluded patients with antibiotic-loaded cement spacer in their joint at admission, patients who had a long antibiotic history prior to surgery, and those who had multiple prior surgical procedures. Patients were classified in PJI or not using major criteria in MSIS, 2013 ICM, and 2018 ICM criteria. Researchers then compared minor criteria between the 2018 ICM definition and the 2013 ICM and IDSA criteria.

The study cohort included 98 PJI cases and 168 aseptic revision patients. Statistical analysis showed that overall sensitivity, specificity, positive predictive value, and negative predictive value of 2018 ICM criteria was 94.9%, 95.2%, 92.1%, and 96.1% respectively. For 2013 ICM criteria the results were 53.1%, 98.4%, 96.3%, and 78.8% respectively. For IDSA criteria results were 72.4%, 86.7%, 76.3% and 84.1% respectively.

Overall researchers conclude that 2018 ICM criteria are applicable in the Chinese population. Also, the 2018 ICM criteria was shown to have higher sensitivity compared to the 2013 ICM criteria and IDSA criteria for the diagnosis of PJI.