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The role of intraoperative Gram stain in revision total joint arthroplasty
C J Della Valle1, D M Scher, Y H Kim
1Musculoskeletal Research Center, Department of Orthopaedic Surgery, New York University Medical Center-Hospital for Joint Diseases, New York 10003, USA.
Abstract:
The ability to identify intraoperatively patients with an infected prosthesis at the time of a revision procedure assists the surgeon in selecting appropriate management. The results of 413 intraoperative Gram stains were compared with the results of operative cultures, permanent histology, and the surgeon's intraoperative assessment to determine the ability of Gram stains to identify periprosthetic infection. Gram staining correctly identified the presence of infection in 10 of the 68 cases that met study criteria for infection (sensitivity of 14.7%). Four false-positive Gram stains were encountered. Intraoperative Gram stains do not have adequate sensitivity to be helpful in identifying periprosthetic infection and should not be performed on a routine basis. They may be helpful, however, in cases in which gross purulence is encountered to assist in the selection of initial antibiotic therapy. The use of intraoperative Gram staining alone is inadequate for ruling out infection at the time of revision total joint arthroplasty.
Insights
Intraoperative Gram stains lack the sensitivity to reliably detect periprosthetic joint infections during revision surgery. Routine use is not recommended, though they may aid antibiotic selection in cases with visible pus.
Area of Science:
- Orthopedic Surgery
- Infectious Disease Diagnostics
- Microbiology
Background:
- Accurate intraoperative diagnosis of infected prostheses is crucial for effective management during revision arthroplasty.
- Periprosthetic joint infection (PJI) diagnosis often relies on a combination of clinical, laboratory, and microbiological findings.
Purpose of the Study:
- To evaluate the diagnostic accuracy of intraoperative Gram stains for identifying periprosthetic joint infections.
- To determine if Gram stains can reliably guide surgical management and antibiotic choices in revision arthroplasty.
Main Methods:
- A retrospective analysis of 413 intraoperative Gram stains performed during revision arthroplasty procedures.
- Comparison of Gram stain results with operative cultures, permanent histology, and surgeon's intraoperative assessment.
- Calculation of sensitivity and specificity for Gram staining in diagnosing PJI.
Main Results:
- Gram staining demonstrated low sensitivity (14.7%) in detecting PJI, correctly identifying infection in only 10 of 68 cases.
- Four false-positive results were recorded.
- The test was inadequate for ruling out infection and not recommended for routine use.
Conclusions:
- Intraoperative Gram stains are not sufficiently sensitive for routine diagnosis of periprosthetic joint infection.
- Gram staining may offer limited utility in identifying infection when gross purulence is present, aiding initial antibiotic selection.
- Reliance on Gram stain alone is insufficient for excluding PJI in revision total joint arthroplasty.
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