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Does Change in ESR and CRP Guide the Timing of Two-stage Arthroplasty Reimplantation?

Stambough, Jeffrey B., MD; Curtin, Brian M., MD; Odum, Susan M., PhD; Cross, Michael B., MD, MS; Martin, J. Ryan, MD; Fehring, Thomas K., MD

Clinical Orthopaedics and Related Research®: February 2019 - Volume 477 - Issue 2 - p 364–371
doi: 10.1097/01.blo.0000533618.31937.45

Background Two-stage reimplantation arthroplasty is a commonly used approach for treating chronic periprosthetic joint infections. A prereimplantation threshold value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to determine infection eradication and the proper timing of reimplantation remains ill defined. We theorized that rather than a specific numeric threshold, a percentage of improvement in these serology markers might improve diagnostic accuracy in determining the timing of reimplantation.

Question/purposes We investigated if (1) the percent, or delta, change in ESR and CRP values from preresection to prereimplantation ([INCREMENT]ESR, [INCREMENT]CRP) is a useful marker of infection eradication and (2) whether the initial PJI causative organism (resistant, nonresistant, or culture-negative) is associated with serum ESR and CRP values before and after treatment with an antibiotic spacer and parenteral antibiotic therapy.

Methods We retrospectively reviewed 300 patients, nine of whom were lost to followup, treated with a two-stage revision THA or TKA protocol between 2005 and 2014 from two separate institutional arthroplasty registries. Serum ESR and CRP values were recorded at two designated points: (1) preresection and (2) after 6 weeks of intravenous antibiotic therapy with a drug-eluting spacer and completion of an organism-specific intravenous antibiotic regimen. Patient records were reviewed electronically for causative species of infection, revision surgeries, and recurrent/persistent infection based on Musculoskeletal Infection Society criteria for a minimum of 2 years. Forty-eight of 291 patients (16%) underwent a revision procedure for recurrent or persistent infection, whereas 31 patients (10%) were revised for noninfectious reasons. The [INCREMENT]ESR, [INCREMENT]CRP, culture results, and patient demographics were recorded and analyzed with receiver operator curves controlling for American Society of Anesthesiologists (ASA) class.

Results Receiver operator characteristic area under the curves (AUC) demonstrated that both the [INCREMENT]ESR (AUC = 0.581) and [INCREMENT]CRP (AUC = 0.539) percentages were poor markers of recurrent or persistent infection. When comparing preresection with prereimplantation values, the median percent [INCREMENT]ESR was 50% (interquartile range [IQR], 17%-77%) for those patients who remained infection-free versus 59% (IQR, 29%-78%) for those who developed reinfection (p = 0.540). The median percent [INCREMENT]CRP was 77% (IQR, 47%-92%) for those patients who remained infection-free versus 79% (IQR, 46%-95%) for those who experienced reinfection (p = 0.634). Although no significant differences were found between organism type and CRP values at the two time points, the preresection ESR level was higher in patients infected with resistant bacteria (median, 69; IQR, 60%-85%) compared with nonresistant organisms (median, 55; IQR, 33%-83%; p = 0.020).

Conclusions The percent change in serum ESR and CRP inflammatory markers before and after two-stage reimplantation for PJI was not associated with reinfection risk when controlling for ASA class. Although a return to normal serology infrequently occurs before reimplantation, [INCREMENT]ESR and [INCREMENT]CRP provide no additional diagnostic accuracy to determine the timing of reimplantation. Furthermore, the pre- and postresection serology values have no meaningful relationship to resistant or nonresistant pathogens. Decisions for reimplantation must take into account multiple variables rather than a specific threshold change in serum inflammatory markers.

Level of Evidence Level III, diagnostic study.

J. B. Stambough, B. M. Curtin, J. R. Martin, T. K. Fehring, OrthoCarolina, Hip & Knee Center, Charlotte, NC, USA

S. M. Odum, OrthoCarolina Research Institute, Charlotte, NC, USA

M. B. Cross, Hospital for Special Surgery, Department of Orthopaedic Surgery, New York, NY, USA

J. B. Stambough, OrthoCarolina Hip & Knee Center, 2001 Vail Avenue, Suite 200a, Charlotte, NC 28207, USA, email:

One or more of the authors (BMC, MBC, TKF) have received consultant and royalty fees from DePuy (Warsaw, IN, USA; BMC USD 10,000 to USD 100,000, TKF more than USD 1,000,001), Stryker (Mahwah, NJ, USA; BMC USD 10,000 to USD 100,000), Zimmer-Biomet (Warsaw, IN, USA; BMC USD 10,000 to USD 100,000, MBC less than USD 10,000), LINK (Hamburg, Germany; MBC less than USD 10,000), Smith & Nephew (Memphis, TN, USA; MBC less than USD 10,000), Exactech (Gainesville, FL, USA; MBC USD 10,000 to USD 100,000), and Acelity (San Antonio, TX, USA; MBC less than USD 10,000), all outside the submitted work.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at OrthoCarolina Hip & Knee Center, Charlotte, NC, USA.

Received October 17, 2017

Received in revised form March 26, 2018

Accepted April 02, 2018

© 2019 Lippincott Williams & Wilkins LWW
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