Üçüncü Basamak Merkeze Sevk Edilen Ağrılı Artroplasti Hastalarında Periprostetik Eklem Enfeksiyonu Tanı Süreci: Ortopedi ve Patoloji Perspektifi

Öz

Bu çalışmanın amacı, üçüncü basamak merkeze sevk edilen ağrılı artroplasti hastalarında periprostetik eklem enfeksiyonu (PEE) tanı sürecini incelemektir. Ocak 2021-Ocak 2024 tarihleri arasında ağrılı kalça ve diz artroplastisi nedeniyle sevk edilen 85 hasta retrospektif olarak değerlendirildi. Hastaların yaş ortancası 67 yıl olup, %58.8'ine total diz artroplastisi uygulanmıştı. Patolojik değerlendirmede, olguların %52.9'u non-enfeksiyöz, %29.4'ü enfeksiyöz ve %17.7'si belirsiz olarak raporlandı. Enfeksiyöz patoloji varlığı PEE tanısıyla güçlü ilişki gösterirken (OR:4.92, p=0.001), non-enfeksiyöz patoloji varlığı negatif ilişki gösterdi (OR:0.31, p=0.026). Nötrofil infiltrasyonu ve bakteriyel kolonizasyon, enfeksiyon tanısında bağımsız belirteçler olarak saptandı. Aseptik gevşeme olgularında fibrohistiyositik reaksiyon baskın bulgu olarak öne çıktı. Demografik faktörler kontrol edildikten sonra, patolojik değerlendirmenin tanısal katkısı istatistiksel olarak anlamlı bulundu. Sonuçlarımız, ağrılı artroplasti hastalarında patolojik incelemenin tanısal değerini ve multidisipliner yaklaşımın önemini vurgulamaktadır.

Anahtar Kelimeler

• Periprostetik Eklem Enfeksiyonu
• Tanısal Süreç
• Patolojik Değerlendirme
• Artroplasti Başarısızlığı
• Multidisipliner Yaklaşım

Diagnostic Process of Periprosthetic Joint Infection in Painful Arthroplasty Patients Referred to a Tertiary Care Center: Orthopedics and Pathology Perspective

Abstract

This study was aimed at determining the method of diagnosis of periprosthetic infection in the patients with painful joint arthroplasty referred to a tertiary center. Between January 2021 and January 2024, 85 patients referred for painful hip and knee arthroplasty were retrospectively evaluated. The median age of the patients was 67 years and 58.8% underwent total knee arthroplasty. Pathologically, 52.9% of the cases were reported as non-infectious, 29.4% as infectious and 17.7% as indeterminate. The presence of infectious pathology was strongly associated with the diagnosis of PEE (OR: 4.92, p=0.001), while the presence of non-infectious pathology was negatively associated (OR: 0.31, p=0.026). Neutrophil infiltration and bacterial colonization were independent markers for the diagnosis of infection. Fibrohistiocytic reaction was the dominant finding in cases of aseptic loosening. After controlling for demographic factors, the diagnostic contribution of pathologic evaluation was statistically significant. Our findings underscore the need for pathological assessment and highlight the importance of a team approach with different specializations in managing arthroplasty who complain of pain.

Keywords

• Periprosthetic Joint Infection
• Diagnostic Process
• Pathological Assessment
• Arthroplasty Failure
• Multidisciplinary Approach

Kaynakça

1. Zagra L, Maccario C, Mondini A, et al. Treatment of failures related to articulation material in THA. A comprehensive algorithm of surgical options and open questions. Hip Int. 2014;24(Suppl 10)–S57.
2. Bieger R, Kappe T, Fraitzl CR, et al. The aetiology of total knee arthroplasty failure influences the improvement in knee function. Arch Orthop Trauma Surg. 2013;133(2):237–241.
3. Margulies BS, DeBoyace SD, Parsons AM, et al. Functionally deficient mesenchymal stem cells reside in the bone marrow niche with M2-macrophages and amyloid-beta protein adjacent to loose total joint implants. J Orthop Res. 2015;33(5):615–624.
4. Miller DD, Yaar R, Posnik O, et al. Reactive granular histiocytosis secondary to arthroplasty prosthesis: a novel reaction pattern. J Cutan Pathol. 2012;39(5):558–561.
5. Eftekhar NS, Doty SB, Johnston AD, et al. Prosthetic synovitis. Hip. 1985;1:169–183.
6. Zysk SP, Gebhard H, Plitz W, et al. Influence of orthopedic particulate biomaterials on inflammation and synovial microcirculation in the murine knee joint. J Biomed Mater Res B Appl Biomater. 2004;71(1):108–115.
7. Xu J, Yang J, Chen J, et al. Activation of synovial fibroblasts from patients at revision of their metal-on-metal total hip arthroplasty. Part Fibre Toxicol. 2020;17(1):42.
8. Kwon YM, Thomas P, Summer B, et al. Lymphocyte proliferation responses in patients with pseudotumors following metal-on-metal hip resurfacing arthroplasty. J Orthop Res. 2010;28(4):444–450.

9. Bémer P, Léger J, Milin S, et al. Histopathological diagnosis of prosthetic joint infection: does a threshold of 23 neutrophils do better than classification of the periprosthetic membrane in a prospective multicenter study? J Clin Microbiol. 2018;56(9).
10. Bori G, Muñoz-Mahamud E, Garcia S, et al. Interface membrane is the best sample for histological study to diagnose prosthetic joint infection. Mod Pathol. 2011;24(4):579–584.
11. Kumar VA, Abbas A, Aster J. Robbins and Cotran pathologic basis for disease (ed. V Kumar). Philadelphia, PA: Elsevier; 2015.
12. Hasegawa M, Yoshida K, Wakabayashi H, et al. Pseudotumor with dominant B-lymphocyte infiltration after metal-on-metal total hip arthroplasty with a modular cup. J Arthroplasty. 2012;27(3):493.e5–e7.
13. Watters TS, Cardona DM, Menon KS, et al. Aseptic lymphocyte-dominated vasculitis-associated lesion. Am J Clin Pathol. 2010;134(6):886–893.
14. Kurmis AP, Herman A, McIntyre AR, et al. Pseudotumors and high-grade aseptic lymphocyte-dominated vasculitis-associated lesions around total knee replacements identified at aseptic revision surgery: findings of a large-scale histologic review. J Arthroplasty. 2019;34(10):2434–2438.
15. Calliess T, Ettinger M, Hülsmann N, et al. Update on the etiology of revision TKA—evident trends in a retrospective survey of 1449 cases. Knee. 2015;22(3):174–179.
16. Randelli F, Brioschi M, Randelli P, Ambrogi F, Sdao S, Aliprandi A (2018) Fluoroscopy- vs ultrasound-guided aspiration techniques in the management of periprosthetic joint infection: which is the best? Radiol Med 123(1):28–35. https://doi.org/10.1007/s11547-017-0811-1
17. Fritz J, Lurie B, Miller TT (2013) Imaging of hip arthroplasty. Semin Musculoskelet Radiol 17(3):316–327. https://doi.org/10.1055/s-0033-1348098
18. Hargunani R, Madani H, Khoo M, Fotiadou A, Pressney I, Calleja M, O'Donnell P (2016) Imaging of the painful hip arthroplasty. Can Assoc Radiol J 67(4):345–355. https://doi.org/10.1016/j.carj.2015.11.003
19. Dinneen A, Guyot A, Clements J, Bradley N (2013) Synovial fluid white cell and differential count in the diagnosis or exclusion of prosthetic joint infection. Bone Jt J 95:554–557. https://doi.org/10.1302/0301-620X.95B4.30388
20. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG (2008) Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am 90(9):1869–1875. https://doi.org/10.2106/JBJS.G.01255
21. Cipriano CA, Brown NM, Michael AM, Moric M, Sporer SM, Della Valle CJ (2012) Serum and synovial fluid analysis for diagnosing chronic periprosthetic infection in patients with inflammatory arthritis. J Bone Joint Surg Am 94(7):594–600. https://doi.org/10.2106/JBJS.J.01318