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Background: The accuracy of intraoperative periprosthetic frozen section histologic evaluation in predicting a diagnosis of periprosthetic joint infection prior to microbiologic culture results is unknown.Methods: We performed a systematic review and meta-analysis of all longitudinal studies that compared frozen section histologic results with simultaneously obtained microbiologic culture at the time of revision total hip or total knee arthroplasty. The data sources were Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, ISI Web of Science, and SCOPUS, from the inception of each database to January 2010.Results: Twenty-six studies involving 3269 patients undergoing revision hip or knee arthroplasty met the inclusion criteria. A culture-positive periprosthetic joint infection was confirmed in 796 (24.3%) of the patients. Frozen section results, using any of the diagnostic criteria chosen by the investigating pathologist, had a pooled diagnostic odds ratio of 54.7 (95% confidence interval [CI], 31.2 to 95.7), a likelihood ratio of a positive test of 12.0 (95% CI, 8.4 to 17.2), and a likelihood ratio of a negative test of 0.23 (95% CI, 0.15 to 0.35) for the diagnosis of periprosthetic joint infection. Fifteen studies utilizing a threshold of five polymorphonuclear leukocytes (PMNs) per high-power field to define a positive frozen section had a diagnostic odds ratio of 52.6 (95% CI, 23.7 to 116.2), and six studies utilizing a diagnostic threshold of ten PMNs per high-power field had a diagnostic odds ratio of 69.8 (95% CI, 33.6 to 145.0). There was no significant difference between the diagnostic odds ratio or likelihood ratios associated with these thresholds. The moderate to high heterogeneity among the included studies was unexplained by variability in the study design, diagnostic criteria for acute inflammation, reference standard for periprosthetic joint infection, or prevalence of infection. This heterogeneity could be due to differences in the inclusion and exclusion criteria, tissue sampling error, experience or technique of the pathologists, number of microscopic fields visualized, and field diameter examined.Conclusions: Intraoperative frozen sections of periprosthetic tissues performed well in predicting a diagnosis of culture-positive periprosthetic joint infection but had moderate accuracy in ruling out this diagnosis. Frozen section histopathology should therefore be considered a valuable part of the diagnostic work-up for patients undergoing revision arthroplasty, especially when the potential for infection remains after a thorough preoperative evaluation. The optimum diagnostic threshold (number of PMNs per high-power field) required to distinguish periprosthetic joint infection from aseptic failure could not be discerned from the included studies. There was no significant difference between the diagnostic accuracy of frozen section histopathology utilizing the most common thresholds of five or ten PMNs per high-power field. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to review the results and complications of treatment of simultaneous infection of both knees after bilateral total knee arthroplasty.Methods: Between 1976 and 1999, twenty-one patients with a mean age of seventy-one years were treated for simultaneous infection of both knees after bilateral total knee arthroplasty. Two patients died within two years, and one patient was lost to follow-up after one year. The remaining eighteen patients were followed for a mean of five years. At the time of presentation, all twenty-one patients had had symptoms for less than three weeks. Eleven patients (twenty-two knees) were treated with attempts at prosthetic salvage with surgical débridement and administration of suppressive antibiotics. Resection arthroplasty was performed as the initial treatment in ten patients (twenty knees).Results: Of the ten patients treated with initial resection, seven patients (fourteen knees) underwent subsequent reimplantation. All fourteen knees were functioning well at the time of the latest follow-up, and none had been revised at a mean of two years after reimplantation. Of the eleven patients (twenty-two knees) who had been initially treated with prosthetic salvage, nine patients (eighteen knees) had a recurrence of the infection that required a reoperation (bilateral resection arthroplasty in seven patients, bilateral above-the-knee amputation in one patient, and repeat débridement of both knees in one patient). Two of the seven patients who had resection underwent reimplantation six weeks postoperatively, and the other five patients (ten knees) did not have reimplantation because of low functional demands and prohibitive medical comorbidity.Conclusion: We believe that treatment of simultaneous infection of both knees after bilateral total knee arthroplasty should consist of bilateral resection arthroplasty and delayed reimplantation after a period of intravenous administration of organism-specific antibiotics. [ABSTRACT FROM AUTHOR]

Background: Surgical site infection (SSI) is one of the most challenging and costly complications associated with total joint arthroplasty. Our primary aim in this case-controlled trial was to compare the risk of SSI within a year of surgery for patients undergoing primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) and revision TKA or THA under general anesthesia versus neuraxial anesthesia. Our secondary aim was to determine which patient, anesthetic, and surgical variables influence the risk of SSI. We hypothesized that patients who undergo neuraxial anesthesia may have a lesser risk of SSI compared with those who had a general anesthetic., Methods: We conducted a retrospective, case-control study of patients undergoing primary or revision TKA and THA between January 1, 1998, and December 31, 2008, who subsequently were diagnosed with an SSI. The cases were matched 1:2 with controls based on type of joint replacement (TKA versus THA), type of procedure (primary, bilateral, revision), sex, date of surgery (within 1 year), ASA physical status (I and II versus III, IV, and V), and operative time (<3 vs >3 hours)., Results: During the 11-year period, 202 SSIs were identified. Of the infections identified, 115 (57%) occurred within the first 30 days and 87 (43%) occurred between 31 and 365 days. From both univariate and multivariable analyses, no significant association was found between the use of central neuraxial anesthesia and the postoperative infection (univariate odds ratio [OR] = 0.92; 95% confidence interval [CI], 0.63-1.34; P = 0.651; multivariable OR = 1.10; 95% CI, 0.72-1.69; P = 0.664). The use of peripheral nerve block also was not found to influence the risk of postoperative infection (univariate OR = 1.41; 95% CI, 0.84-2.37; P = 0.193; multivariable OR = 1.35; 95% CI, 0.75-2.44; P = 0.312). The factors that were found to be associated with postoperative infection in multivariable analysis included current smoking (OR = 5.10; 95% CI, 2.30-11.33) and higher body mass index (BMI) (OR = 2.68; 95% CI, 1.42-5.06 for BMI ≥ 35 kg/m compared with those with BMI < 25 kg/m)., Conclusions: Recent studies using large databases have concluded that the use of neuraxial compared with general anesthesia is associated with a decreased incidence of SSI in patients undergoing total joint arthroplasty. In this retrospective, case-controlled study, we found no difference in the incidence of SSI in patients undergoing total joint arthroplasty under general versus neuraxial anesthesia. We also concluded that the use of peripheral nerve blocks does not influence the incidence of SSI. Increasing BMI and current smoking were found to significantly increase the incidence of SSI in patients undergoing lower extremity total joint arthroplasty.

Study Design: This is a prospective study comparing the diagnosis of spinal implant infection by conventional peri-implant tissue culture with a technique which uses a combination of vortexing and bath sonication to dislodge bacteria growing as a biofilm on the surface of retrieved spinal implants., Objective: We hypothesized that the biofilm-sampling technique would be more sensitive than peri-implant tissue culture., Summary of Background Data: Culture of peri-implant tissue is inaccurate for the diagnosis of orthopedic device-related infection; cultures taken from the implant may be more sensitive. We have developed a technique which uses vortexing-bath sonication to sample bacterial biofilms on the surface of retrieved hip and knee implants, and shown that it is more sensitive than peri-prosthetic tissue culture for the microbiologic diagnosis of prosthetic knee, hip, and shoulder infection., Methods: We compared peri-implant tissue culture to the vortexing-bath sonication technique which samples bacterial biofilm on the surface of retrieved spinal implants, for the diagnosis of spinal implant infection. In addition, we compared detection of Staphylococcus and Propionibacterium acnes by rapid cycle real-time polymerase chain reaction with culture of sonicate fluid., Results: A total of 112 subjects were studied; 22 had spinal implant infection. The sensitivities of peri-implant tissue and sonicate fluid culture were 73% and 91% (P = 0.046), and the specificities were 93% and 97%, respectively. P. acnes and coagulase-negative staphylococci were the most frequent microorganisms detected among subjects with spinal implant infection, with P. acnes detected in 56 and 45%, and coagulase-negative staphylococci detected in 31 and 40% of peri-implant tissue and sonicate fluid cultures, respectively. Compared with the culture of sonicate fluid, polymerase chain reaction was 100 and 67% sensitive for the detection of culture-positive Staphylococcus and P. acnes spinal implant infection, respectively., Conclusion: Implant sonication followed by culture is more sensitive than peri-implant tissue culture for the microbiologic diagnosis of spinal implant infection.