Why aspirate all total joints? A new study out of Germany pulled together data on 644 patients who have periprosthetic joint infections (PJI) in two or more joints – at the same time, and who’d recently undergone total joint arthroplasty. Of the enrolled patients, 26 had periprosthetic joint infections and 618 did not. The total number of prosthetic joints involved was 1,508.
Aspirate ALL Total Joints? Why?
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Their work, “Synchronous Periprosthetic Joint Infections: The Need for All Artificial Joints to Be Aspirated Routinely,” appears in the February 19, 2020 edition of The Journal of Bone and Joint Surgery.
Darius M. Thiesen, M.D., with the Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany, explained why he chose this particular topic to research. “We saw many patients that had a periprosthetic joint infections and had undergone multiple TJA developing a simultaneous, most likely hematogenous infection of the other-not primarily infected joint.”
After looking at their data, the research team concluded that “A suspicious clinical presentation of the non-primary joint had the strongest association with synchronous PJI. Additional associations with synchronous periprosthetic joint infections were detected for a history of neoplasia, the use of immune-modulating therapy, the presence of systemic inflammatory response syndrome or sepsis, and having ≥3 prosthetic joints.”
Dr. Thiesen: “We found that 4% of patients who had two or more TJAs and were suffering from periprosthetic joint infections developed a simultaneous or synchronous infection of the other joint, => 46 % of those without a suspicious clinical presentation ==> meaning that 1.8% of all patients with periprosthetic joint infections and more than two artificial joints had a periprosthetic joint infections in another joint without symptoms.”
“If you have a patient with the above-mentioned criteria (periprosthetic joint infections and more than one prosthetic joint) do an aspiration of ALL prosthetic joints regardless of symptoms. Maybe her or she is one of the nearly 2% who does not show symptoms.”
“You need to have the infrastructure to perform a joint aspiration in a very sterile OR-like setting. Otherwise it is not recommendable to set the bar to go for a joint aspiration as low as we do. But we think that if you want to treat periprosthetic joint infections you need to create that environment.”
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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