Diagnostic value of the CD 15 focus score in two-stage revision arthroplasty of periprosthetic joint infections : High specificity in diagnosing infect eradication.

INTRODUCTION: The purpose of this study is to use the CD15 focus score (FS) to determine the sensitivity and specificity of bacterial infection persistence in spacer-based two-stage revision arthroplasty. METHODS: The analysis comprises 112 cases that were subjected to revision due to the presence of infection upon replacement of a joint endoprosthesis. The histopathological data were collected in accordance with the synovial-like interface membrane (SLIM) classification and the CD15-FS and correlated with the microbiological data (MD). The quantifying evaluation of the CD15-FS was performed without knowledge regarding the microbiological data (MD). Correlation with the MD was performed after a 14-day cultivation period. RESULTS: With a single evaluation (1 focus, field area: 1.2 mm2) with a score value of 42, the CD15-FS showed a sensitivity for the eradication of infections of 0.64 and a specificity of 0.79 (PPV = 0.5; NPV = 0.87). With tenfold evaluation (10 foci, field area: 12 mm2) with a score value of 220, the sensitivity for the eradication was 0.68, the specificity 0.91 (PPV = 0.7; NPV = 0.89). No statistically significant correlation between the score values and the different infectious species could be detected. Based on the MD in 112 cases the rate of infection eradication was 75%. Polymethylmethacrylate-particles (PMMA) were detected in the perispacertissue in 64 cases (58%). No significant correlation could be established between microbiological pathogen detection and the presence of PMMA. CONCLUSION: In all cases (n = 112), periimplant synovial tissue (SLIM) with variable fibroblastic cellularity, capillary proliferation, leukocytic infiltration, fibrin deposition, new formation of woven bone and detection of PMMA particles was observed. These cases were classified as type IX perispacer synovialis/SLIM: type IX­A with histopathological infection eradication and type IX­B with histopathological infection persistence.

[Rheumatoid arthritis : These dermatoses lead you to the diagnosis]. / Rheumatoide Arthritis : Bei welchen Hautveränderungen sollte man daran denken?

BACKGROUND: Rheumatoid arthritis is one of the most common autoimmune disorders. In addition to chronic arthritis, rheumatoid arthritis may present a variety of extra-articular manifestations, most commonly of the skin. OBJECTIVES: Cutaneous manifestations associated with rheumatoid arthritis can be diverse, both specific and nonspecific. Which dermatoses should lead you to the diagnosis of an underlying rheumatoid arthritis? METHODS: Evaluation of exemplary overviews, case presentations and relevant textbook articles. RESULTS: Rheumatoid arthritis presents various specific and nonspecific skin manifestations. Besides visual diagnosis like classic rheumatoid nodules a histopathologic correlation or an interdisciplinary approach is often needed, such as for diagnosis of pyoderma gangrenosum. CONCLUSIONS: The early detection and correct classification of cutaneous manifestations associated with rheumatoid arthritis can be groundbreaking for a successful therapy and a consequently better prognosis for patients with rheumatoid arthritis. Therefore dermatologists bear responsibility in the patient-centered care.

[Complications in orthopedic rheumatology-characteristics of operative procedures]. / Komplikationen in der orthopädischen Rheumatologie ­ Besonderheiten operativer Verfahren.

The introduction of biologics has led to a great improvement in the treatment options for inflammatory rheumatic diseases. Nevertheless, surgical interventions are still necessary in many patients but a change in surgical indications could be observed. The previously predominant synovectomy of inflamed rheumatic joints is now reduced to a few so-called rebellious joints with persistent inflammation. Joint-preservation and tenoplasty are standard surgical procedures requiring a specific approach including potential complications. The basic immunosuppressive medication has to be considered for all rheumatological interventions. Recommendations extensively evaluate the risk profile of immunosuppressants. The available clinical data are difficult to assess and incomplete. Advances in modern joint replacement procedures have increased the quality of life of patients. Compared to degenerative osteoarthritis, patients with rheumatism tend to present at a lower age, with poorer bone quality and have an increased risk for bacterial joint infections. In cases of a multilocular rheumatoid manifestation including all joints of the extremities, joint replacement specifics need to be taken into account. In patients with rheumatic diseases the mechanical stability of joint replacements, revision options, potential risk of joint infections and periprosthetic fractures vary sometimes considerably from patients with degenerative osteoarthritis. Missing clinical signs of joint infection despite a life-threatening, possibly multilocular dissemination of the disease due to immunosuppressants represents a particular challenge with respect to the diagnostics and treatment. The confusion of this with a rheumatic exacerbation might lead to general septicemia with a high mortality.

[Arthur Vick Prize 2017 of the German Society of Orthopaedic Rheumatology]. / Arthur-Vick-Preis der Deutschen Gesellschaft für Orthopädische Rheumatologie 2017.

The German Society of Orthopaedic Rheumatology (DGORh) honored Prof. Dr. med. Veit Krenn (MVZ-ZHZMD-Trier) with the Arthur Vick Prize 2017. With this award, scientific results with high impact on the diagnosis, therapy and pathogenetic understanding of rheumatic diseases are honored. In cooperation with pathologists and colleagues from various clinical disciplines Prof. Dr. med. Veit Krenn developed several histopathologic scoring systems which contribute to the diagnosis and pathogenetic understanding of degenerative and rheumatic diseases. These scores include the synovitis score, the meniscal degeneration score, the classification of periprosthetic tissues (SLIM classification), the arthrofibrosis score, the particle score and the CD15 focus score. Of highest relevance for orthopedic rheumatology is the synovitis score which is a semiquantitative score for evaluating immunological and inflammatory changes of synovitis in a graded manner. Based on this score, it is possible to divide results into low-grade synovitis and high-grade synovitis: a synovitis score of 1-4 is called low-grade synovitis and occurs for example in association with osteoarthritis (OA), post-trauma, with meniscal lesions and hemochromatosis. A synovitis score of 5-9 is called high-grade synovitis, e.g. rheumatoid arthritis, psoriatic arthritis, Lyme arthritis, postinfection and reactive arthritis as well as peripheral arthritis with Bechterew's disease (sensitivity 61.7%, specificity 96.1%). The first publication (2002) and an associated subsequent publication (2006) of the synovitis score has led to national and international acceptance of this score as the standard for histopathological assessment of synovitis. The synovitis score provides a diagnostic, standardized and reproducible histopathological evaluation method for joint diseases, particularly when this score is applied in the context with the joint pathology algorithm.

[Periprosthetic infections in systemic inflammatory rheumatic disease. Review article on diagnostics and therapy]. / Periprothetische Infekte bei rheumatisch-entzündlicher Systemerkrankung. Übersichtsartikel zu Diagnostik und Therapie.

BACKGROUND: Patients with an inflammatory disease have an elevated risk for periprosthetic joint infections due to impairment of the immune system caused by the disease itself in combination with disease-modifying antirheumatic drugs (DMARD). These infections can cause life-threatening sepsis. Unfortunately recommendations on the diagnostics and treatment are mostly based on studies with a level of evidence grade IV or V. OBJECTIVES: This article gives an overview of recent publications evaluating the level of evidence of recommendations on diagnostics and treatment of periprosthetic joint infections in patients with inflammatory diseases. METHODS: A systematic literature search was performed in the Medline database in January and February 2014. The search included all articles on diagnostic and/or treatment of periprosthetic joint infections in patients with inflammatory diseases. Articles in languages other than English or German were excluded, as well as case reports, studies with less than 20 patients and articles only referring to patients with inflammatory diseases without periprosthetic infections. RESULTS: Nearly all recommendations are based on retrospective studies or expert opinions (level of evidence IV or V). Conflicting results are common but there is good evidence on preoperative aspiration of joint fluid (level of evidence I) and a doubled risk of joint infections under treatment with anti-tumor necrosis factor (level of evidence II). An increased mortality has been reported in multiple studies. Two-stage revision seems to have a slightly better outcome than retention of prosthesis or one-stage revision. Generally, therapeutic recommendations for periprosthetic joint infections lack a good level of evidence. Future studies are urgently needed.

[Histopathology and microbiology of joint infections: extension of diagnostic safety in patients with chronic polyarthritis]. / Histopathologie und Mikrobiologie bei Gelenkinfekten : Erweiterung der Diagnostiksicherheit bei Patienten mit chronischer Polyarthritis.

BACKGROUND: It can be difficult to distinguish between synovitis due to rheumatism and synovitis due to a bacterial infection. Microbiological detection of bacteria is not always successful and the clinical significance of low virulent bacteria often remains uncertain. Therefore, the histopathological finding of inflammatory reactions is very important. STUDY DESIGN AND METHODS: From patients with clinically clear signs of infections and rheumatoid arthritis who underwent surgery between April and August 2011, samples were taken during surgery. Histopathological diagnosis was carried out by conventional enzyme and immunohistochemical techniques based on defined criteria of bacterial infection in tissues, synovial tissue and bone. RESULTS: A total of 20 patients were included, 10 males and 10 females with a mean age of 61.7 years. Staphylococcus aureus was the most commonly detected bacteria and in 4 cases bacteria could not be demonstrated. The correlation between the histopathological signs of an infection and microbiological detection of bacteria was 93.3 %. CONCLUSIONS: In patients with rheumatoid arthritis the combination of histopathology and microbiology significantly increased the safety of detecting an infection or contamination.

[Purulent gonarthritis resulting from H1N1 viral pneumonia]. / Eitrige Gonarthritis im Rahmen einer H1N1-Viruspneumonie.

No articles on orthopedic complications of pneumonia due to influenza A H1N1 virus have yet been published. A 44-year-old male patient was hospitalized due to the suspicion of an infected knee. During arthroscopy beta-hemolytic Streptococcus group A and Acinetobacter were found and the histopathological diagnosis of an infectious bacterial synovialitis was made. Despite resistance-oriented antibiotic treatment the patient's general condition worsened. Influenza A H1N1 virus was detected in a nasal sample and was successfully treated with Tamiflu®. If fever and elevated infection markers persist a search for the focus has to be performed including unlikely diseases such as influenza A H1N1 virus.

[Joint endoprosthesis pathology. Histopathological diagnostics and classification]. / Gelenkendoprothesenpathologie. Histopathologische Diagnostik und Klassifikation.

Prosthesis durability has steadily increased with high 10-year rates of 88-95%. However, four pathogenetic groups of diseases can decrease prosthesis durability: (1) periprosthetic wear particle disease (aseptic loosening) (2) bacterial infection (septic loosening) (3) periprosthetic ossification, and (4) arthrofibrosis. The histopathological "extended consensus classification of periprosthetic membranes" includes four types of membranes, arthrofibrosis, and osseous diseases of endoprosthetics: The four types of neosynovia are: wear particle-induced type (type I), mean prosthesis durability (MPD) in years 12.0; infectious type (type II), MPD 2.5; combined type (type III) MPD 4.2; and indeterminate type (type IV), MPD 5.5. Arthrofibrosis can be determined in three grades: grade 1 needs clinical information to be differentiated from a type IV membrane, and grades 2 & 3 can be diagnosed histopathologically. Periprosthetic ossification, osteopenia-induced fractures, and aseptic osteonecrosis can be histopathologically diagnosed safely with clinical information. The extended consensus classification of periprosthetic membranes may be a diagnostic groundwork for a future national endoprosthesis register.