Abstract
The definition of peri-prosthetic joint infection (PJI) has a strong impact on the diagnostic pathway and on treatment decisions. In the last decade, at least five different definitions of peri-prosthetic joint infection (PJI) have been proposed, each one with intrinsic limitations. In order to move a step forward, the World Association against Infection in Orthopedics and Trauma (W.A.I.O.T.) has studied a possible alternative solution, based on three parameters: 1. the relative ability of each diagnostic test or procedure to Rule OUT and/or to Rule IN a PJI; 2. the clinical presentation; 3. the distinction between pre/intra-operative findings and post-operative confirmation. According to the WAIOT definition, any positive Rule IN test (a test with a specificity > 90%) scores +1, while a negative Rule OUT test (a test with a sensitivity > 90%) scores −1. When a minimum of two Rule IN and two Rule OUT tests are performed in a given patient, the balance between positive and negative tests, interpreted in the light of the clinical presentation and of the post-operative findings, allows to identify five different conditions: High-Grade PJI (score ≥ 1), Low-Grade PJI (≥0), Biofilm-related implant malfunction, Contamination and No infection (all scoring < 0). The proposed definition leaves the physician free to choose among different tests with similar sensitivity or specificity, on the basis of medical, logistical and economic considerations, while novel tests or diagnostic procedures can be implemented in the definition at any time, provided that they meet the required sensitivity and/or specificity thresholds. Key procedures to confirm or to exclude the diagnosis of PJI remain post-operative histological and microbiological analysis; in this regard, given the biofilm-related nature of PJI, microbiological investigations should be conducted with proper sampling, closed transport systems, antibiofilm processing of tissue samples and explanted biomaterials, and prolonged cultures. The proposed WAIOT definition is the result of an international, multidisciplinary effort. Next step will be a large scale, multicenter clinical validation trial.
Highlights
From a scientific point of view, the lack of a common definition of a clinical condition is a source of bias when comparing the results from different studies, weakening the power of systematic reviews and meta-analysis [2]
Through a multi-disciplinary and multi-national approach, in an effort to overcome some of the limitations of the existing score systems, we outlined here a novel approach to define peri-prosthetic joint infection
To the best of our knowledge, this is the only to distinguish between clinical presentations, including high- and low-grade infections, biofilm-related implant malfunction, contamination and no infection with a unique scoring system
Summary
“There is no single accepted set of diagnostic criteria for PJI. Various definitions have been proposed; none have been widely adopted. In spite of the MSIS declaration and the recognized need for a univocal and shared definition of PJI, since 2011 at least four more formulas have been published, all from highly respected scientific institutions, including the Infectious Disease Society of America (IDSA) [4], two International Consensus Meetings [5,6,7] and, more recently, the European Bone and Joint Infection Society (EBJIS) [8] To sum it up, in less than a decade at least five different definitions of PJI have been released, proposing a wide and heterogeneous set of criteria, scoring systems and reference values (Table 1). * “The presence of PJI is possible even if the above criteria are not met ( . . . )”
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