Pre-operative biopsies in the revision setting - helpful or harmful?

There is no clear consensus as to whether pre-operative biopsies (arthroscopic or open) should be routinely obtained to confirm absence of infection in presumed aseptic revision cases, and practice widely varies.

Consecutive patients over a 4-year period from a single centre undergoing a revision shoulder or elbow procedure without evidence or suspicion of infection were included. Electronic patient records were utilised to determine biopsy results, revision procedure and clinical outcome.

Of 81 patients undergoing a revision shoulder or elbow procedure for presumed aseptic cause, 40 had biopsies taken prior to the revision procedure, with seven positive results (defined as ≥3/5 positive samples). These were treated with oral antibiotics before undergoing revision. At revision, intra-operative biopsies showed that infection had been cleared in 4/7 cases, and new infection was identified in six cases that were previously negative. Of the 41 patients who did not have pre-revision biopsies, 13 were positive at the time of definitive procedure and subsequently successfully treated with oral antibiotics.

Pre-revision biopsy has a low sensitivity (54%) for identifying bacteria in presumed aseptic cases and is not necessarily a benign procedure, with potential risk of introducing infection. Pre-revision antibiotic treatment may not result in negative biopsies at the time of definitive revision.