Enhancing Diagnostic Accuracy for Uncertain Periprosthetic Joint Infection: Combining Cultures with Intraoperative Multi-Site Sonication.

Abstract

Accurate diagnosis of periprosthetic joint infection (PJI) remains challenging, particularly in uncertain cases under the International Consensus Meeting (ICM) 2018 criteria. We explored whether combining cultures with intraoperative multi-site sonication could improve diagnostic performance, especially in ambiguous cases. We addressed the following questions: (1) Does multi-site sonication combined with standard culture reduce diagnostic uncertainty in PJI? (2) Does multi-site sonication improve intraoperative culture positivity? and (3) Do preoperative and intraoperative post-sonication bacterial profiles differ? A total of 375 patients who were undergoing revision surgery were enrolled, including 242 who had confirmed PJI and 133 who had aseptic loosening (AL). There were four diagnostic models established and compared: Model 1 applied the ICM 2018 criteria without histological data. Model 2 followed the standard ICM 2018 diagnostic criteria, which incorporate histological results and preoperative cultures. Model 3 employed the ICM 2018 criteria with non-sonicated, multi-site intraoperative cultures. Model 4 also adhered to the ICM 2018 criteria, but utilized intraoperative multi-site cultures with sonication. We calculated and compared the incidence rates of uncertain PJI diagnosis in specimens processed with and without intraoperative sonication. Additionally, we performed receiver operating characteristic curve analyses, examined bacterial spectra, and conducted Kaplan-Meier survival curve analyses. For uncertain PJI cases, integrating intraoperative multi-site sonication with standard cultures considerably reduced the uncertain case rate from 20.2% based on ICM 2018 criteria excluding histology and 13.6% using standard ICM 2018 criteria down to a final rate of 2.9%. With intraoperative sonication, the synovial fluid, tissue, and prosthesis culture positivity rates increased from 68.4, 64.1, and 57.3 to 72.5, 72.5, and 68.9%, respectively. Integrated culture using multiple sites with intraoperative sonication achieved a positive rate of 89.7%. Combining multi-site sonication with cultures improves diagnostic accuracy and reduces uncertainty in uncertain PJI cases. This integrated approach also provides more reliable pathogen identification, supporting more targeted and timely treatment decisions.