Faculty Bibliography

We assessed the utility of culturing draining wounds or sinuses in evaluating periprosthetic joint infection (PJI). Fifty-five patients with a draining wound or sinus after total joint arthroplasty (28 knees, 27 hips) who had not received antibiotics for at least two weeks were prospectively studied. Superficial wound cultures were compared to intra-articular cultures to determine accuracy in isolating infecting organism(s). The superficial cultures were concordant with deep cultures in 26 of 55 cases (47.3%) and were more likely to generate polymicrobial results (27.3% vs. 10.9%; P=0.023). In 23 cases (41.8%), the superficial cultures would have led to a change in antibiotic regimen. Superficial cultures yielded bacterial growth in 8 of the 10 cases (80%) when deep cultures and further work-up suggested the absence of deep infection. Given the potential to misguide diagnosis and treatment, we recommend against obtainment of superficial cultures in patients with a draining wound or sinus following hip or knee arthroplasty.

Accurate and efficient diagnosis of periprosthetic joint infection remains one of the most challenging tasks for orthopedic surgeons. Currently, no widely used diagnostic test allows for quick and efficient performance, low cost, and high sensitivity and specificity. Aspiration of synovial fluid from a patient's joint can be done in the clinic both quickly and easily; oftentimes, the aspirate obtained is bloody, thus rendering the use of colorimetric strip testing impractical. We describe a simple, inexpensive, and effective protocol using centrifugation to allow for leukocyte esterase (LE) testing after bloody joint aspirations. In all cases, both septic and aseptic, there was a 100% concordance in LE enzyme test results. Although further validation may be necessary, these initial results demonstrate that accuracy of LE testing is not affected by centrifugation.

Periprosthetic joint infection (PJI) is one of the most devastating and costly complications following total joint arthroplasty (TJA). Diagnosis and management of PJI is challenging for surgeons. There is no "gold standard" for diagnosis of PJI, making distinction between septic and aseptic failures difficult. Additionally, some of the greatest difficulties and controversies involve choosing the optimal method to treat the infected joint. Currently, there is significant debate as to the ideal treatment strategy for PJI, and this has led to considerable international variation in both surgical and nonsurgical management of PJI. In this review, we will discuss diagnosis and management of PJI following TJA and highlight some recent advances in this field.

Infections with methicillin-resistant Staphylococcus aureus (MRSA) are an ever growing problem in the community, hospitals, and for orthopedic surgeons in particular. A conscious effort must be made to deal with this pathogen prior to total joint arthroplasty procedures. The drastic increase in prevalence of surgical-site infections (SSIs) after total joint replacement surgery has proved to be a major health care burden for both patients and surgeons from both a medical and financial standpoint. The development of screening techniques for detection of MRSA colonization in patients being admitted to hospitals is steadily increasing popularity. Particularly nasal swab rapid polymerase chain reaction detection of MRSA allows surgeons to identify patients at high risk for postoperative SSI. A variety of treatment regimens for eradication of MRSA colonization from the nares of surgical patients have surfaced, such as topical mupirocin prior to undergoing surgery. Decolonization of MRSA in patients undergoing joint arthroplasty procedures has demonstrated encouraging initial results in preventing SSIs and should be a serious focus of the future for orthopedic surgeons.