Complications - Infection
Leukocyte Esterase Strip Test Can Predict Subsequent Failure Following Reimplantation in Patients With Periprosthetic Joint Infection

https://doi.org/10.1016/j.arth.2017.01.031Get rights and content

Abstract

Background

Leukocyte esterase (LE) strip test is an accurate marker for diagnosing periprosthetic joint infection (PJI). This study aims to determine if LE is a good predictor of persistent infection and/or subsequent failure in patients undergoing reimplantation.

Methods

This single-institution study prospectively recruited and retrospectively analyzed 109 patients who underwent two-stage exchange treatment of PJI, from 2009-2016, and had an LE test performed at time of reimplantation. LE results of “2+” were considered positive. Ninety-five patients had 90-day minimum follow-up to assess treatment failure, defined by Delphi criteria. Eighteen patients were excluded due to blood contamination of LE test, resulting in a final cohort of 77 patients (mean follow-up 1.76 years).

Results

Of the final cohort, 19 patients (24.7%) experienced subsequent failure. At reimplantation, LE test was positive in 22.2% of culture-positive and 4.4% of culture-negative cases. The LE test was negative in all patients who had not failed at latest follow-up, yielding sensitivity, specificity, positive predictive value, negative predictive value, and AUC of 26.3%, 100%, 100%, 87.5%, and 0.632, respectively; in comparison, MSIS criteria respectively yielded 25.0%, 87.3%, 27.6%, 85.8%, and 0.562 (P = .01 for specificity). Kaplan-Meier curves revealed higher failure rate in patients who had a positive LE test at time of reimplantation (P < .001).

Conclusion

There is a dire need for an accurate diagnostic test to determine optimal timing of reimplantation in patients undergoing surgical treatment for PJI. The current study suggests that a positive LE test may be indicative of persistence of infection and results in a higher rate of subsequent failure.

Section snippets

Materials and Methods

This is a single-institution retrospective study of 109 prospectively collected patients who had undergone a prior resection arthroplasty and antibiotic-impregnated cement spacer, for treatment of chronic PJI, between January 2009 and January 2016, in whom an LE test was performed at the time of intended reimplantation. Of these, 96 patients had reimplantation while 13 patients received a spacer exchange. Diagnosis of PJI was made using the MSIS criteria [21]. During reimplantation, the status

Results

The rate of subsequent failure following reimplantation or the need for a spacer exchange at intended reimplantation in the overall cohort was 25.3% (24/95), and 24.7% in the final cohort (19/77). Thirteen patients had persistence of infection or reinfection as determined by at least one positive culture at the time of reimplantation; the LE test was positive in 2 of the 9 culture-positive cases at reimplantation (4 cases were excluded due to bloody aspiration) and in 3 of the 68

Discussion

PJI remains a major issue for our patients undergoing total joint arthroplasty 1, 2, 24, 25. The diagnosis of PJI is made using a combination of serological and synovial tests. As the preferred treatment for chronic PJI remains to be the 2-stage exchange arthroplasty, at least in North America, there is a dire need for a test or group of tests that can determine successful control of infection in patients who have undergone prior resection arthroplasty, and help determine the optimal timing of

Conclusion

This study provides encouraging data to support the use of the LE test in patients who have undergone prior resection arthroplasty and cement spacer insertion. The LE test is a simple, quick, and inexpensive test that appears to have utility for predicting the persistence of infection and a subsequent failure in patients undergoing reimplantation. Based on the findings of this study, we routinely utilize the LE test in patients undergoing reimplantation and allow the result of the test to guide

References (32)

  • J. Parvizi et al.

    Periprosthetic infection: are current treatment strategies adequate?

    Acta Orthop Belg

    (2008)
  • R.T. Goldman et al.

    2-Stage reimplantation for infected total knee replacement

    Clin Orthop Relat Res

    (1996)
  • Y. Mittal et al.

    Two-stage reimplantation for periprosthetic knee infection involving resistant organisms

    J Bone Joint Surg Am

    (2007)
  • S.J. Mortazavi et al.

    Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure

    Clin Orthop Relat Res

    (2011)
  • J.C. Sherrell et al.

    The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and débridement for periprosthetic knee infection

    Clin Orthop Relat Res

    (2011)
  • L. Font-Vizcarra et al.

    Blood culture flasks for culturing synovial fluid in prosthetic joint infections

    Clin Orthop Relat Res

    (2010)
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    Source of Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

    One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.01.031.

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