Accuracy of Preoperative Hip Aspiration in Diagnosing Infection before Conversion to Total Hip Arthroplasty after Failed Fixation for Hip Fracture: A Retrospective Study

Document Type : RESEARCH PAPER

Authors

Joint Reconstruction Research Center, Tehran University of Medical Sciences

10.22038/abjs.2025.82044.3732

Abstract

Objectives: 1.What is the accuracy of preoperative hip aspiration in diagnosing infections in patients scheduled for conversion of failed hip fixation to total hip arthroplasty (cTHA)? 2. What is the clinically significant cutoff value for inflammatory markers that may assist in diagnosing hip infections before cTHA? 3. What is the concordance between preoperative hip aspiration and intraoperative cultures?
Methods: A retrospective study was conducted at Imam Khomeini Hospital Complex, Tehran (2017–2021), including candidates for cTHA following failed open reduction and internal fixation (ORIF). Exclusions were dry tap (failed aspiration), recent antibiotic therapy, or insufficient synovial fluid. Patients underwent erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) testing, joint aspiration, and intraoperative cultures, with the latter serving as the gold standard for diagnosis.
Results: The study involved 38 patients (mean age 50 ± 16.4 years). Preoperative hip aspiration demonstrated low sensitivity (17.7%) but high specificity (81.0%). C-reactive protein (CRP) demonstrated moderate diagnostic value (AUC = 0.643) with an optimal cutoff of 8.8 mg/L (sensitivity, 64.3%; specificity, 64.7%). Erythrocyte sedimentation rate (ESR) had limited diagnostic value (AUC = 0.577).
Conclusion: Preoperative hip aspiration for diagnosing infection in patients with total hip arthroplasties (THA) demonstrated poor sensitivity but high specificity. C-reactive protein (CRP) demonstrated moderate potential, whereas erythrocyte sedimentation rate (ESR) had limited value. These findings underscore the need for improved diagnostic methods, potentially combining multiple tests. Future research should focus on developing more accurate diagnostic approaches for infections in patients with chronic total hip arthroplasty (cTHA).
        Level of evidence: II

Keywords

Main Subjects

References

  1. Hemmann P, Schmidutz F, Ahrend MD, Yan SG, Stöckle U, Schreiner AJ. Single-stage total hip arthroplasty after failed fixation of proximal femoral fractures: an increased risk for periprosthetic joint infections? Arch Orthop Trauma Surg. 2022;142(10):2911-7. doi:10.1007/s00402-021-04119-0.
  2. Kanis JA, Odén A, McCloskey EV, Johansson H, Wahl DA, Cooper C. A systematic review of hip fracture incidence and probability of fracture worldwide. Osteoporos Int. 2012;23(9):2239-56. doi:10.1007/s00198-012-1964-3.
  3. Koyuncu Ş, Altay T, Kayalı C, Ozan F, Yamak K. Mechanical failures after fixation with proximal femoral nail and risk factors. Clin Interv Aging. 2015;10:1959-65. doi:10.2147/cia.S96852.
  4. Petrie J, Sassoon A, Haidukewych GJ. When femoral fracture fixation fails: salvage options. Bone Joint J. 2013;95-B(11 Suppl A):7-10. doi: 10.1302/0301-620X.95B11.32896.
  5. Archibeck MJ, Carothers JT, Tripuraneni KR, White RE, Jr. Total hip arthroplasty after failed internal fixation of proximal femoral fractures. J Arthroplasty. 2013;28(1):168-71. doi:10.1016/j.arth.2012.04.003.
  6. D'Arrigo C, Perugia D, Carcangiu A, Monaco E, Speranza A, Ferretti A. Hip arthroplasty for failed treatment of proximal femoral fractures. Int Orthop. 2010;34(7):939-42. doi:10.1007/s00264-009-0834-x.
  7. Gjertsen JE, Fevang JM, Matre K, Vinje T, Engesæter LB. Clinical outcome after undisplaced femoral neck fractures. Acta Orthop. 2011;82(3):268-74.doi:10.3109/17453674.2011.588857.
  8. Kain MS, Marcantonio AJ, Iorio R. Revision surgery occurs frequently after percutaneous fixation of stable femoral neck fractures in elderly patients. Clin Orthop Relat Res. 2014;472(12):4010-4. doi:10.1007/s11999-014-3957-3.
  9. O'Toole RV, Hui E, Chandra A, Nascone JW. How often does open reduction and internal fixation of geriatric acetabular fractures lead to hip arthroplasty? J Orthop Trauma. 2014;28(3):148-53.doi:10.1097/BOT.0b013e31829c739a.
  10. Zardi EM, Franceschi F. Prosthetic joint infection. A relevant public health issue. J Infect Public Health. 2020;13(12):1888-91. doi:10.1016/j.jiph.2020.09.006.
  11. Kelmer G, Stone AH, Turcotte J, King PJ. Reasons for Revision: Primary Total Hip Arthroplasty Mechanisms of Failure. J Am Acad Orthop Surg. 2021;29(2):78-87.doi:10.5435/jaaos-d-19-00860.
  12. Gittings DJ, Courtney PM, Ashley BS, Hesketh PJ, Donegan DJ, Sheth NP. Diagnosing Infection in Patients Undergoing Conversion of Prior Internal Fixation to Total Hip Arthroplasty. J Arthroplasty. 2017;32(1):241-5.doi:10.1016/j.arth.2016.06.047.
  13. Ali F, Wilkinson JM, Cooper JR, et al. Accuracy of joint aspiration for the preoperative diagnosis of infection in total hip arthroplasty. J Arthroplasty. 2006;21(2):221-6.doi:10.1016/j.arth.2005.05.027.
  14. Williams JL, Norman P, Stockley I. The value of hip aspiration versus tissue biopsy in diagnosing infection before exchange hip arthroplasty surgery. J Arthroplasty. 2004;19(5):582-6.doi:10.1016/j.arth.2003.11.011.
  15. Kanthawang T, Bodden J, Joseph GB, et al. Diagnostic value of fluoroscopy-guided hip aspiration for periprosthetic joint infection. Skeletal Radiol. 2021;50(11):2245-54. doi:10.1007/s00256-021-03795-8.
  16. Li R, Li X, Ni M, Zheng QY, Zhang GQ, Chen JY. Anatomic Landmark-Guided Hip Aspiration in the Diagnosis of Periprosthetic Joint Infection. Orthopedics. 2021;44(1):e85-e90. doi:10.3928/01477447-20201007-04.
  17. Isern-Kebschull J, Tomas X, García-Díez AI, Morata L, Ríos J, Soriano A. Accuracy of Computed Tomography-Guided Joint Aspiration and Computed Tomography Findings for Prediction of Infected Hip Prosthesis. J Arthroplasty. 2019;34(8):1776-82. doi:10.1016/j.arth.2019.04.018.
  18. Duck H, Tanner S, Zillmer D, Osmon D, Perry K. Value of ultrasound-guided aspiration of hip arthroplasties performed in an orthopedic clinic by orthopedic surgeons. J Bone Jt Infect. 2021;6(9):393-403. doi:10.5194/jbji-6-393-2021.
  19. Christensen TH, Ong J, Lin D, Aggarwal VK, Schwarzkopf R, Rozell JC. How Does a "Dry Tap" Impact the Accuracy of Preoperative Aspiration Results in Predicting Chronic Periprosthetic Joint Infection? J Arthroplasty. 2022;37(5):925-9. doi:10.1016/j.arth.2022.01.066.
  20. van den Kieboom J, Bosch P, Plate JDJ, et al. Diagnostic accuracy of serum inflammatory markers in late fracture-related infection: a systematic review and meta-analysis. Bone Joint J. 2018;100-b(12):1542-50.doi:10.1302/0301-620x.100b12.Bjj-2018-0586.R1.
  21. CCichos KH, Christie MC, Heatherly AR, McGwin Jr G, Quade JH, Ghanem ES. The Value of Serological Screening Prior to Conversion Total Hip Arthroplasty. J Arthroplasty. 2020;35(6):S319-s24.doi:10.1016/j.arth.2020.02.035.
  22. Xu H, Xie JW, Liu L, Wang D, Huang ZY, Zhou ZK. Combination of CRP with NLR is a sensitive tool for screening fixation-related infection in patients undergoing conversion total hip arthroplasty after failed internal fixation for femoral neck fracture. Bone Joint J. 2021;103(9):1534-40.doi:10.1302/0301-620x.103b.Bjj-2021-0105.R1.
  23. Anderson PM, Rudert M, Holzapfel BM, Meyer JS, Weißenberger M, Bölch SP. Conversion total hip arthroplasty following proximal femur fracture: A retrospective analysis. Technol Health Care. 2023;31(2):507-516. doi: 10.3233/THC-220136.
  24. Hemmann P, Schmidutz F, Ahrend MD, Yan SG, Stöckle U, Schreiner AJ. Single-stage total hip arthroplasty after failed fixation of proximal femoral fractures: an increased risk for periprosthetic joint infections? Arch Orthop Trauma Surg. 2022;142(10):2911-2917. doi: 10.1007/s00402-021-04119-0.
  25. Xu H, Liu L, Xie J, et al. The Screening of Fixation-Related Infection in Patients Undergoing Conversion Total Hip Arthroplasty after Failed Internal Fixation of Hip Fractures: A Single-Central Retrospective Study. Orthop Surg. 2022;14(6):1167-74.doi:10.1111/os.13225.
  26. Poursalehian M, Lotfi M, Mortazavi SMJ. Latent infections in conversion total hip arthroplasty following internal fixation of femoral neck fractures: a systematic review and meta-analysis of diagnostic methods. Arch Orthop Trauma Surg. 2024;144(12):5079-5087. doi: 10.1007/s00402-024-05216-6.
  27. Poursalehian M, Bahmani M, Ghorbanzadeh M, Mortazavi SMJ. Conversion Total Hip Arthroplasty in Patients With Osteopetrosis: Insights From Two Unique Cases. JBJS Case Connect. 2024;14(2). doi: 10.2106/JBJS.CC.23.00583.
  28. Abrishami R, Aghili SH, Afshar C, Farhang Ranjbar M, Nasrollahizadeh A, Poursalehian M. Long-term outcomes of converting fused hips to total hip arthroplasty are satisfactory: a systematic review and meta-analysis. Ann Med Surg (Lond). 2024;86(6):3391-9. doi:10.1097/ms9.0000000000002024.
  29. Poursalehian M, Hassanzadeh A, Lotfi M, Mortazavi SMJ. Conversion of a Failed Hip Hemiarthroplasty to Total Hip Arthroplasty: A Systematic Review and Meta-Analysis. Arthroplast Today. 2024;28:101459. doi:10.1016/j.artd.2024.101459.
  30. Metsemakers WJ, Kuehl R, Moriarty TF, et al. Infection after fracture fixation: Current surgical and microbiological concepts. Injury. 2018;49(3):511-22. doi:10.1016/j.injury.2016.09.019.
  31. Lapić I, Padoan A, Bozzato D, Plebani M. Erythrocyte Sedimentation Rate and C-Reactive Protein in Acute Inflammation. Am J Clin Pathol. 2020;153(1):14 29.doi:10.1093/ajcp/aqz142.
  32. Alende-Castro V, Alonso-Sampedro M, Vazquez-Temprano N, et al. Factors influencing erythrocyte sedimentation rate in adults: New evidence for an old test. Medicine (Baltimore). 2019;98(34):e16816.doi:10.1097/md.0000000000016816.
  33. van Schaik TJA, de Jong LD, van Meer MPA, Goosen JHM, Somford MP. The concordance between preoperative synovial fluid culture and intraoperative tissue cultures in periprosthetic joint infection: a systematic review. J Bone Jt Infect. 2022;7(6):259-67. doi:10.5194/jbji-7-259-2022.
  34. Li H, Xu C, Hao L, Chai W, Jun F, Chen J. The concordance between preoperative aspiration and intraoperative synovial fluid culture results: intraoperative synovial fluid re-cultures are necessary whether the preoperative aspiration culture is positive or not. BMC Infect Dis. 2021;21(1):1018. doi:10.1186/s12879-021-06721-4.
  35. Wang Y, Leng V, Patel V, Phillips KS. Injections through skin colonized with Staphylococcus aureus biofilm introduce contamination despite standard antimicrobial preparation procedures. Sci Rep. 2017;7:45070. doi:10.1038/srep45070.
  36. Xie BL, Guo RS, Yang XW, et al. Epidemiology and Drug Resistance Analysis of Mixed Infection in Orthopedic Surgical Sites. Surg Infect (Larchmt). 2020;21(5):465-71. doi:10.1089/sur.2019.276.
  37. Sharma S, Mohler J, Mahajan SD, Schwartz SA, Bruggemann L, Aalinkeel R. Microbial Biofilm: A Review on Formation, Infection, Antibiotic Resistance, Control Measures, and Innovative Treatment. Microorganisms. 2023;11(6). doi:10.3390/microorganisms11061614.
  38. Filipović U, Dahmane RG, Ghannouchi S, Zore A, Bohinc K. Bacterial adhesion on orthopedic implants. Adv Colloid Interface Sci. 2020;283:102228. doi:10.1016/j.cis.2020.102228.

 

 

 

 

The Archives of Bone and Joint Surgery
Volume 14, Issue 3
March 2026
Pages 193-200

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History

  • Receive Date: 25 September 2024
  • Revise Date: 16 November 2025
  • Accept Date: 13 April 2025

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