Routine Intraoperative Cultures

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Authors: Greber E, Barnes C L, Bushmiaer M, Brewer B, Edwards P. Arkansas Specialty Orthopaedics and St. Vincents Infirmary, Little Rock, AR 

Title: Is There a Role for Routine Intraoperative Cultures to Diagnose Subclinical Periprosthetic Joint Infection During Revision Total Hip And Knee Arthroplasty?

Background: Periprosthetic joint infections (PJI) continue to be a diagnostic challenge for orthopedic surgeons. Chronic PJI are sometimes difficult to diagnose and occasionally present in a subclinical fashion with normal CRP/ESR and/or normal joint aspiration.  Some institutions advocate for routine use of intraoperative culture swabs at the time of all revision surgeries to definitively rule out infection. 

Hypothesis/Purpose: The purpose of this study is to determine whether routine intraoperative cultures is an appropriate and cost effective method of diagnosing subclinical chronic PJI in revision joint replacement patients with a low clinical suspicion for infection.

Methods: We performed a retrospective chart review and identified 33 patients that underwent revision hip or knee replacement from a single surgeon over a five-month period.  The AAOS guidelines for preoperative PJI workup were followed.  13 patients were diagnosed preoperatively with infection and excluded from the study.  20 patients underwent revision joint replacement and three separate cultures swabs were taken for each patient to help in determining true-positive cultures.  Infectious Disease was consulted for all patients with any positive culture.  Culture results were reviewed.  At our hospital, the cost billed to insurance for a single culture is $1,458.58.   We did not calculate the cost of the consultant fee. 

Results: Three (15%) of the 20 revision arthroplasty patients had a single positive culture.  Infectious Disease consultants diagnosed all three of these positive cultures as contaminants.  None of the patients had a true-positive intraoperative culture.  The total cost billed by the hospital to obtain these cultures in all 20 patients was $87,514.80

Discussion: In our study, obtaining a set of three intraoperative cultures for those patients with a negative preoperative infection workup was not only cost prohibitive but did not diagnose a single subclinical infection.  Studies to find other more reliable, accurate, and cost effective alternatives to diagnose PJI are warranted. 

Conclusion: In patients undergoing revision hip or knee arthroplasty with a low preoperative clinical suspicion for infection, it does not seem that routine intraoperative culture swabs are necessary or cost effective method for diagnosing subclinical periprosthetic joint infection.