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Updated: Jan 1, 2026
Novel Diagnostics in Revision Arthroplasty: Implant Sonication and Multiplex Polymerase Chain Reaction
Published on: December 3, 2017
Multiple Cultures and Extended Incubation for Upper Extremity Revision Arthroplasty Affect Clinical Care: A Cohort
Jared Mahylis1, Alexander DeHaan1, Zachary B Domont1
1Specialty Physicians of Illinois, Olympia Fields, IL (Dr. Mahylis); the Orthopaedic + Fracture Specialists, Portland, OR (Dr. DeHaan); the Lincolnshire Orthopedics, Lincolnshire, IL (Dr. Domont); the Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR (Mr.Thompson, Dr. Orfaly, Dr. Mirarchi); and the Infectious Disease, PeaceHealth Medical Group-Whatcom, Bellingham, WA (Dr. Barnes).
Abstract:
Skin flora organisms (SFOs) isolated from 1 to 2 tissue samples during shoulder and elbow revision arthroplasty are difficult to distinguish as contamination or infection. We examined the change in clinical care after implementation of an Arthroplasty Infection Protocol by increasing the number of intraoperative samples held for 10-day incubation to a minimum of 5.
Methods:
Infection was defined as ≥3 cultures growing the same SFO or any one culture growing any other virulent organism. SFOs growing in 1 to 2 samples were defined as skin flora contaminant. All cases were compared with pre-Arthroplasty Infection Protocol institution standard to determine changes in microbiological diagnosis and resultant antibiotic treatment.
Results:
Forty cases fulfilled the inclusion criteria: 50% of these were culture negative, and 35% grew Propionibacteria. When compared with the standard of obtaining one sample, this protocol altered the microbiological diagnosis and subsequent antibiotic treatment in 45% of cases (95% confidence interval 29% to 62%). This protocol had a predictive value of joint sterility in 95% of culture-negative cases (95% confidence interval 74% to 99%).
Discussion:
The addition of 5 or more samples held for 10-day incubation reliably differentiated between joint infection, contamination, and sterility, which changed the course of care in 45% of surgical cases.
Insights
Increasing intraoperative samples to five for shoulder and elbow revision arthroplasty reliably differentiates infection from contamination. This protocol changed clinical care in 45% of cases, improving diagnosis for joint infections.
Area of Science:
- Orthopedic Surgery
- Infectious Disease Microbiology
Background:
- Distinguishing contamination from infection is challenging in shoulder and elbow revision arthroplasty due to skin flora organisms (SFOs).
- Current protocols may not adequately differentiate between true infection and superficial contamination.
Purpose of the Study:
- To evaluate the impact of an Arthroplasty Infection Protocol on differentiating SFOs in revision arthroplasty.
- To assess changes in microbiological diagnosis and antibiotic treatment following protocol implementation.
Main Methods:
- Implemented a protocol requiring a minimum of five intraoperative tissue samples for 10-day incubation.
- Defined infection as ≥3 cultures with the same SFO or any culture with a virulent organism.
- Defined SFOs in 1-2 samples as contamination.
Main Results:
- 50% of cases were culture-negative, and 35% grew Propionibacteria.
- The new protocol altered microbiological diagnosis and antibiotic treatment in 45% of cases compared to the standard single-sample method.
- The protocol demonstrated a 95% predictive value for joint sterility in culture-negative cases.
Conclusions:
- Collecting five or more intraoperative samples with extended incubation reliably differentiates joint infection, contamination, and sterility.
- This enhanced sampling strategy significantly impacted clinical care decisions in 45% of revision arthroplasty surgeries.
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