Diagnostic Value of a PCR-Based Technique for Prosthetic Joint Infection
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CONTENT ALERTS
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Zonghuan Li and Aixi Yu J. Clin. Microbiol. 2014, 52(6):2281. DOI: 10.1128/JCM.00840-14.
LETTER TO THE EDITOR
Diagnostic Value of a PCR-Based Technique for Prosthetic Joint Infection Zonghuan Li, Aixi Yu
P
rosthetic joint infection (PJI) is a catastrophic complication for patients with arthroplasty. Culture is the most commonly used method to identify PJI. However, it may not be accurate enough because of contamination and false-negative results (1). A PCR-based technique has been developed and provides great value for PJI diagnosis. Thus, we read with great interest the study by Qu et al. (2) evaluating the diagnostic value of PCR-based diagnosis for PJI. In their study, 14 studies with 1,480 patients were finally included. However, according to the inclusion criteria, the study by Moojen et al. (3) should not be included. In this study, patients undergoing various orthopedic surgeries, including osteosynthesis, were included. Besides, two similar studies (4, 5) by Kobayashi et al. were performed during the same period. However, the authors included the study with a relatively smaller sample size (4) rather than the study with a larger sample size (5), resulting in the data loss of some patients. We then searched the databases (MEDLINE, EMBASE, Cochrane Library, and Google Scholar) from their establishment to March 2014. Reference lists and citations were also checked for
additional studies. Studies on the diagnostic value of a PCR-based technique were selected. Finally, 21 studies (5–25) with 2,619 patients met the inclusion criteria (2) and were included. True-positive, false-negative, false-positive, and true-negative values in all studies were extracted. The statistical analysis was performed with Meta-DiSc (version 1.4). The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the curve (AUC) were 0.79 (95% confidence interval [CI], 0.76 to 0.82), 0.86 (95% CI, 0.84 to 0.87), 8.22 (95% CI, 4.66 to 15.16), 0.25 (95% CI, 0.18 to
Editor: G. V. Doern Address correspondence to Aixi Yu, [email protected]. For the author reply, see doi:10.1128/JCM.00937-14. Copyright © 2014, American Society for Microbiology. All Rights Reserved. doi:10.1128/JCM.00840-14
FIG 1 Summary receiver operating characteristic (SROC) curves for PCR. SE, standard error.
June 2014 Volume 52 Number 6
Journal of Clinical Microbiology
p. 2281–2282
jcm.asm.org
2281
Downloaded from http://jcm.asm.org/ on June 6, 2014 by UNIVERSITY OF DAYTON LIBRARIES
Department of Orthopaedics, Zhongnan Hospital of Wuhan University, Wuhan, China
Letter to the Editor
TABLE 1 Statistical results of previous study by Qu et al. (2) and current studya 10.
Value (95% CI) for study: Study by Qu et al.
Current study
Sensitivity Specificity PLR NLR DOR AUC
0.86 (0.77–0.92) 0.91 (0.81–0.96) 9.1 (4.6–18.2) 0.16 (0.10–0.25) 59 (29–118) 0.94 (0.91–0.95)
0.79 (0.76–0.82) 0.86 (0.84–0.87) 8.22 (4.66–15.16) 0.25 (0.18–0.34) 49.03 (30.72–78.25) 0.93 (0.92–0.94)
11.
12.
a
Abbreviations: PLR, positive likelihood ratio; NLR, negative likelihood ratio; DOR, diagnostic odds ratio; AUC, area under the curve; CI, confidence interval.
13.
0.34), 49.03 (95% CI, 30.72 to 78.25), and 0.93 (95% CI, 0.92 to 0.94), respectively (Fig. 1 and Table 1). The results demonstrated that the diagnostic value of the PCRbased technique might have been overestimated in the previous study (2). With more studies and patients included, the results from the current study might be more accurate with a narrower 95% CI. Inevitably, as with the previous study (2), the statistical heterogeneity was still high. We hope that the enlarged sample size may minimize the bias. The results showed that the PCR-based technique has an adequate diagnostic value for PJI. It may be helpful for PJI diagnosis for patients in whom a low-grade infection is suspected.
14.
15.
16.
REFERENCES 1. Parvizi J, Erkocak OF, Della Valle CJ. 2014. Culture-negative periprosthetic joint infection. J. Bone Joint Surg. Am. 96:430 – 436. http://dx.doi .org/10.2106/JBJS.L.01793. 2. Qu X, Zhai Z, Li H, Li H, Liu X, Zhu Z, Wang Y, Liu G, Dai K. 2013. PCR-based diagnosis of prosthetic joint infection. J. Clin. Microbiol. 51: 2742–2746. http://dx.doi.org/10.1128/JCM.00657-13. 3. Moojen DJ, Spijkers SN, Schot CS, Nijhof MW, Vogely HC, Fleer A, Verbout AJ, Castelein RM, Dhert WJ, Schouls LM. 2007. Identification of orthopaedic infections using broad-range polymerase chain reaction and reverse line blot hybridization. J. Bone Joint Surg. Am. 89:1298 –1305. http://dx.doi.org/10.2106/JBJS.F.00822. 4. Kobayashi N, Inaba Y, Choe H, Aoki C, Ike H, Ishida T, Iwamoto N, Yukizawa Y, Saito T. 2009. Simultaneous intraoperative detection of methicillin-resistant Staphylococcus and pan-bacterial infection during revision surgery: use of simple DNA release by ultrasonication and realtime polymerase chain reaction. J. Bone Joint Surg. Am. 91:2896 –2902. http://dx.doi.org/10.2106/JBJS.I.00119. 5. Kobayashi N, Inaba Y, Choe H, Iwamoto N, Ishida T, Yukizawa Y, Aoki C, Ike H, Saito T. 2009. Rapid and sensitive detection of methicillinresistant Staphylococcus periprosthetic infections using real-time polymerase chain reaction. Diagn. Microbiol. Infect. Dis. 64:172–176. http: //dx.doi.org/10.1016/j.diagmicrobio.2009.01.033. 6. Metso L, Mäki M, Tissari P, Remes V, Piiparinen P, Kirveskari J, Tarkka E, Anttila VJ, Vaara M, Huotari K. 2014. Efficacy of a novel PCR- and microarray-based method in diagnosis of a prosthetic joint infection. Acta Orthop. 85:165–170. http://dx.doi.org/10.3109/17453674 .2014.889978. 7. Greenwood-Quaintance KE, Uhl JR, Hanssen AD, Sampath R, Mandrekar JN, Patel R. 2014. Diagnosis of prosthetic joint infection by use of PCR-electrospray ionization mass spectrometry. J. Clin. Microbiol. 52: 642– 649. http://dx.doi.org/10.1128/JCM.03217-13. 8. Rak M, Barlicˇ-Maganja D, Kavcˇicˇ M, Trebše R, Co˝r A. 2013. Comparison of molecular and culture method in diagnosis of prosthetic joint infection. FEMS Microbiol. Lett. 343:42– 48. http://dx.doi.org/10.1111 /1574-6968.12125. 9. Cazanave C, Greenwood-Quaintance KE, Hanssen AD, Karau MJ, Schmidt SM, Urena EOG, Mandrekar JN, Osmon DR, Lough LE, Pritt BS, Steckelberg JM, Patel R. 2013. Rapid molecular microbiologic diag-
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18. 19.
20.
21. 22.
23.
24.
25.
Journal of Clinical Microbiology
Downloaded from http://jcm.asm.org/ on June 6, 2014 by UNIVERSITY OF DAYTON LIBRARIES
Estimate
nosis of prosthetic joint infection. J. Clin. Microbiol. 51:2280 –2287. http: //dx.doi.org/10.1128/JCM.00335-13. Miyamae Y, Inaba Y, Kobayashi N, Choe H, Yukizawa Y, Ike H, Saito T. 2013. Different diagnostic properties of C-reactive protein, real-time PCR, and histopathology of frozen and permanent sections in diagnosis of periprosthetic joint infection. Acta Orthop. 84:524 –529. http://dx.doi.org /10.3109/17453674.2013.862460. Bjerkan G, Witsø E, Nor A, Viset T, Løseth K, Lydersen S, Persen L, Bergh K. 2012. A comprehensive microbiological evaluation of fifty-four patients undergoing revision surgery due to prosthetic joint loosening. J. Med. Microbiol. 61:572–581. http://dx.doi.org/10.1099/jmm.0.036087-0. Portillo ME, Salvado M, Sorli L, Alier A, Martinez S, Trampuz A, Gomez J, Puig L, Horcajada JP. 2012. Multiplex PCR of sonication fluid accurately differentiates between prosthetic joint infection and aseptic failure. J. Infect. 65:541–548. http://dx.doi.org/10.1016/j.jinf.2012.08.018. Marin M, Garcia-Lechuz JM, Alonso P, Villanueva M, Alcala L, Gimeno M, Cercenado E, Sanchez-Somolinos M, Radice C, Bouza E. 2012. Role of universal 16S rRNA gene PCR and sequencing in diagnosis of prosthetic joint infection. J. Clin. Microbiol. 50:583–589. http://dx.doi.org/10.1128 /JCM.00170-11. Jacovides CL, Kreft R, Adeli B, Hozack B, Ehrlich GD, Parvizi J. 2012. Successful identification of pathogens by polymerase chain reaction (PCR)-based electron spray ionization time-of-flight mass spectrometry (ESI-TOF-MS) in culture-negative periprosthetic joint infection. J. Bone Joint Surg. Am. 94:2247–2254. http://dx.doi.org/10.2106/JBJS.L.00210. Gomez Cazanave C, Cunningham SA, Greenwood-Quaintance KE, Steckelberg JM, Uhl JR, Hanssen AD, Karau MJ, Schmidt SM, Osmon DR, Berbari EF, Mandrekar J, Patel R. 2012. Prosthetic joint infection diagnosis using broad-range PCR of biofilms dislodged from knee and hip arthroplasty surfaces using sonication. J. Clin. Microbiol. 50:3501–3508. http://dx.doi.org/10.1128/JCM.00834-12. Esteban J, Alonso-Rodriguez N, del-Prado G, Ortiz-Perez A, Molina Manso D, Cordero-Ampuero J, Sandoval E, Fernandez-Roblas R, Gomez-Barrena E. 2012. PCR-hybridization after sonication improves diagnosis of implant-related infection. Acta Orthop. 83:299 –304. http://dx .doi.org/10.3109/17453674.2012.693019. Bergin PF, Doppelt JD, Hamilton WG, Mirick GE, Jones AE, Sritulanondha S, Helm JM, Tuan RS. 2010. Detection of periprosthetic infections with use of ribosomal RNA-based polymerase chain reaction. J. Bone Joint Surg. Am. 92:654 – 663. http://dx.doi.org/10.2106/JBJS.I.00400. De Man FH, Graber P, Lüem M, Zimmerli W, Ochsner PE, Sendi P. 2009. Broad-range PCR in selected episodes of prosthetic joint infection. Infection 37:292–294. http://dx.doi.org/10.1007/s15010-008-8246-1. Piper KE, Jacobson MJ, Cofield RH, Sperling JW, Sanchez-Sotelo J, Osmon DR, McDowell A, Patrick S, Steckelberg JM, Mandrekar JN, Fernandez Sampedro M, Patel R. 2009. Microbiologic diagnosis of prosthetic shoulder infection by use of implant sonication. J. Clin. Microbiol. 47:1878 –1884. http://dx.doi.org/10.1128/JCM.01686-08. Kobayashi N, Procop GW, Krebs V, Kobayashi H, Bauer TW. 2008. Molecular identification of bacteria from aseptically loose implants. Clin. Orthop. Relat. Res. 466:1716 –1725. http://dx.doi.org/10.1007/s11999 -008-0263-y. Gallo J, Kolar M, Dendis M, Loveckova Y, Sauer P, Zapletalova J, Koukalova D. 2008. Culture and PCR analysis of joint fluid in the diagnosis of prosthetic joint infection. New Microbiol. 31:97–104. Panousis K, Grigoris P, Butcher I, Rana B, Reilly JH, Hamblen DL. 2005. Poor predictive value of broad-range PCR for the detection of arthroplasty infection in 92 cases. Acta Orthop. 76:341–346. http://dx.doi .org/10.1080/00016470510030805. Kordelle J, Hossain H, Stahl U, Schleicher I, Haas H. 2004. Usefulness of 16S rDNA polymerase-chain-reaction (PCR) in the intraoperative detection of infection in revision of failed arthroplasties. Z. Orthop. Ihre Grenzgeb. 142:571–576. (In German.) http://dx.doi.org/10.1055/s-2004 -832343. Tunney MM, Patrick S, Curran MD, Ramage G, Hanna D, Nixon JR, Gorman SP, Davis RI, Anderson N. 1999. Detection of prosthetic hip infection at revision arthroplasty by immunofluorescence microscopy and PCR amplification of the bacterial 16S rRNA gene. J. Clin. Microbiol. 37:3281–3290. Mariani BD, Martin DS, Levine MJ, Booth RE, Jr, Tuan RS. 1996. The Coventry Award. Polymerase chain reaction detection of bacterial infection in total knee arthroplasty. Clin. Orthop. Relat. Res. 311:11–22.
Updated information and services can be found at: http://jcm.asm.org/content/52/6/2281 These include: REFERENCES
CONTENT ALERTS
This article cites 25 articles, 13 of which can be accessed free at: http://jcm.asm.org/content/52/6/2281#ref-list-1 Receive: RSS Feeds, eTOCs, free email alerts (when new articles cite this article), more»
Information about commercial reprint orders: http://journals.asm.org/site/misc/reprints.xhtml To subscribe to to another ASM Journal go to: http://journals.asm.org/site/subscriptions/
Downloaded from http://jcm.asm.org/ on June 6, 2014 by UNIVERSITY OF DAYTON LIBRARIES
Zonghuan Li and Aixi Yu J. Clin. Microbiol. 2014, 52(6):2281. DOI: 10.1128/JCM.00840-14.
LETTER TO THE EDITOR
Diagnostic Value of a PCR-Based Technique for Prosthetic Joint Infection Zonghuan Li, Aixi Yu
P
rosthetic joint infection (PJI) is a catastrophic complication for patients with arthroplasty. Culture is the most commonly used method to identify PJI. However, it may not be accurate enough because of contamination and false-negative results (1). A PCR-based technique has been developed and provides great value for PJI diagnosis. Thus, we read with great interest the study by Qu et al. (2) evaluating the diagnostic value of PCR-based diagnosis for PJI. In their study, 14 studies with 1,480 patients were finally included. However, according to the inclusion criteria, the study by Moojen et al. (3) should not be included. In this study, patients undergoing various orthopedic surgeries, including osteosynthesis, were included. Besides, two similar studies (4, 5) by Kobayashi et al. were performed during the same period. However, the authors included the study with a relatively smaller sample size (4) rather than the study with a larger sample size (5), resulting in the data loss of some patients. We then searched the databases (MEDLINE, EMBASE, Cochrane Library, and Google Scholar) from their establishment to March 2014. Reference lists and citations were also checked for
additional studies. Studies on the diagnostic value of a PCR-based technique were selected. Finally, 21 studies (5–25) with 2,619 patients met the inclusion criteria (2) and were included. True-positive, false-negative, false-positive, and true-negative values in all studies were extracted. The statistical analysis was performed with Meta-DiSc (version 1.4). The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the curve (AUC) were 0.79 (95% confidence interval [CI], 0.76 to 0.82), 0.86 (95% CI, 0.84 to 0.87), 8.22 (95% CI, 4.66 to 15.16), 0.25 (95% CI, 0.18 to
Editor: G. V. Doern Address correspondence to Aixi Yu, [email protected]. For the author reply, see doi:10.1128/JCM.00937-14. Copyright © 2014, American Society for Microbiology. All Rights Reserved. doi:10.1128/JCM.00840-14
FIG 1 Summary receiver operating characteristic (SROC) curves for PCR. SE, standard error.
June 2014 Volume 52 Number 6
Journal of Clinical Microbiology
p. 2281–2282
jcm.asm.org
2281
Downloaded from http://jcm.asm.org/ on June 6, 2014 by UNIVERSITY OF DAYTON LIBRARIES
Department of Orthopaedics, Zhongnan Hospital of Wuhan University, Wuhan, China
Letter to the Editor
TABLE 1 Statistical results of previous study by Qu et al. (2) and current studya 10.
Value (95% CI) for study: Study by Qu et al.
Current study
Sensitivity Specificity PLR NLR DOR AUC
0.86 (0.77–0.92) 0.91 (0.81–0.96) 9.1 (4.6–18.2) 0.16 (0.10–0.25) 59 (29–118) 0.94 (0.91–0.95)
0.79 (0.76–0.82) 0.86 (0.84–0.87) 8.22 (4.66–15.16) 0.25 (0.18–0.34) 49.03 (30.72–78.25) 0.93 (0.92–0.94)
11.
12.
a
Abbreviations: PLR, positive likelihood ratio; NLR, negative likelihood ratio; DOR, diagnostic odds ratio; AUC, area under the curve; CI, confidence interval.
13.
0.34), 49.03 (95% CI, 30.72 to 78.25), and 0.93 (95% CI, 0.92 to 0.94), respectively (Fig. 1 and Table 1). The results demonstrated that the diagnostic value of the PCRbased technique might have been overestimated in the previous study (2). With more studies and patients included, the results from the current study might be more accurate with a narrower 95% CI. Inevitably, as with the previous study (2), the statistical heterogeneity was still high. We hope that the enlarged sample size may minimize the bias. The results showed that the PCR-based technique has an adequate diagnostic value for PJI. It may be helpful for PJI diagnosis for patients in whom a low-grade infection is suspected.
14.
15.
16.
REFERENCES 1. Parvizi J, Erkocak OF, Della Valle CJ. 2014. Culture-negative periprosthetic joint infection. J. Bone Joint Surg. Am. 96:430 – 436. http://dx.doi .org/10.2106/JBJS.L.01793. 2. Qu X, Zhai Z, Li H, Li H, Liu X, Zhu Z, Wang Y, Liu G, Dai K. 2013. PCR-based diagnosis of prosthetic joint infection. J. Clin. Microbiol. 51: 2742–2746. http://dx.doi.org/10.1128/JCM.00657-13. 3. Moojen DJ, Spijkers SN, Schot CS, Nijhof MW, Vogely HC, Fleer A, Verbout AJ, Castelein RM, Dhert WJ, Schouls LM. 2007. Identification of orthopaedic infections using broad-range polymerase chain reaction and reverse line blot hybridization. J. Bone Joint Surg. Am. 89:1298 –1305. http://dx.doi.org/10.2106/JBJS.F.00822. 4. Kobayashi N, Inaba Y, Choe H, Aoki C, Ike H, Ishida T, Iwamoto N, Yukizawa Y, Saito T. 2009. Simultaneous intraoperative detection of methicillin-resistant Staphylococcus and pan-bacterial infection during revision surgery: use of simple DNA release by ultrasonication and realtime polymerase chain reaction. J. Bone Joint Surg. Am. 91:2896 –2902. http://dx.doi.org/10.2106/JBJS.I.00119. 5. Kobayashi N, Inaba Y, Choe H, Iwamoto N, Ishida T, Yukizawa Y, Aoki C, Ike H, Saito T. 2009. Rapid and sensitive detection of methicillinresistant Staphylococcus periprosthetic infections using real-time polymerase chain reaction. Diagn. Microbiol. Infect. Dis. 64:172–176. http: //dx.doi.org/10.1016/j.diagmicrobio.2009.01.033. 6. Metso L, Mäki M, Tissari P, Remes V, Piiparinen P, Kirveskari J, Tarkka E, Anttila VJ, Vaara M, Huotari K. 2014. Efficacy of a novel PCR- and microarray-based method in diagnosis of a prosthetic joint infection. Acta Orthop. 85:165–170. http://dx.doi.org/10.3109/17453674 .2014.889978. 7. Greenwood-Quaintance KE, Uhl JR, Hanssen AD, Sampath R, Mandrekar JN, Patel R. 2014. Diagnosis of prosthetic joint infection by use of PCR-electrospray ionization mass spectrometry. J. Clin. Microbiol. 52: 642– 649. http://dx.doi.org/10.1128/JCM.03217-13. 8. Rak M, Barlicˇ-Maganja D, Kavcˇicˇ M, Trebše R, Co˝r A. 2013. Comparison of molecular and culture method in diagnosis of prosthetic joint infection. FEMS Microbiol. Lett. 343:42– 48. http://dx.doi.org/10.1111 /1574-6968.12125. 9. Cazanave C, Greenwood-Quaintance KE, Hanssen AD, Karau MJ, Schmidt SM, Urena EOG, Mandrekar JN, Osmon DR, Lough LE, Pritt BS, Steckelberg JM, Patel R. 2013. Rapid molecular microbiologic diag-
2282
jcm.asm.org
17.
18. 19.
20.
21. 22.
23.
24.
25.
Journal of Clinical Microbiology
Downloaded from http://jcm.asm.org/ on June 6, 2014 by UNIVERSITY OF DAYTON LIBRARIES
Estimate
nosis of prosthetic joint infection. J. Clin. Microbiol. 51:2280 –2287. http: //dx.doi.org/10.1128/JCM.00335-13. Miyamae Y, Inaba Y, Kobayashi N, Choe H, Yukizawa Y, Ike H, Saito T. 2013. Different diagnostic properties of C-reactive protein, real-time PCR, and histopathology of frozen and permanent sections in diagnosis of periprosthetic joint infection. Acta Orthop. 84:524 –529. http://dx.doi.org /10.3109/17453674.2013.862460. Bjerkan G, Witsø E, Nor A, Viset T, Løseth K, Lydersen S, Persen L, Bergh K. 2012. A comprehensive microbiological evaluation of fifty-four patients undergoing revision surgery due to prosthetic joint loosening. J. Med. Microbiol. 61:572–581. http://dx.doi.org/10.1099/jmm.0.036087-0. Portillo ME, Salvado M, Sorli L, Alier A, Martinez S, Trampuz A, Gomez J, Puig L, Horcajada JP. 2012. Multiplex PCR of sonication fluid accurately differentiates between prosthetic joint infection and aseptic failure. J. Infect. 65:541–548. http://dx.doi.org/10.1016/j.jinf.2012.08.018. Marin M, Garcia-Lechuz JM, Alonso P, Villanueva M, Alcala L, Gimeno M, Cercenado E, Sanchez-Somolinos M, Radice C, Bouza E. 2012. Role of universal 16S rRNA gene PCR and sequencing in diagnosis of prosthetic joint infection. J. Clin. Microbiol. 50:583–589. http://dx.doi.org/10.1128 /JCM.00170-11. Jacovides CL, Kreft R, Adeli B, Hozack B, Ehrlich GD, Parvizi J. 2012. Successful identification of pathogens by polymerase chain reaction (PCR)-based electron spray ionization time-of-flight mass spectrometry (ESI-TOF-MS) in culture-negative periprosthetic joint infection. J. Bone Joint Surg. Am. 94:2247–2254. http://dx.doi.org/10.2106/JBJS.L.00210. Gomez Cazanave C, Cunningham SA, Greenwood-Quaintance KE, Steckelberg JM, Uhl JR, Hanssen AD, Karau MJ, Schmidt SM, Osmon DR, Berbari EF, Mandrekar J, Patel R. 2012. Prosthetic joint infection diagnosis using broad-range PCR of biofilms dislodged from knee and hip arthroplasty surfaces using sonication. J. Clin. Microbiol. 50:3501–3508. http://dx.doi.org/10.1128/JCM.00834-12. Esteban J, Alonso-Rodriguez N, del-Prado G, Ortiz-Perez A, Molina Manso D, Cordero-Ampuero J, Sandoval E, Fernandez-Roblas R, Gomez-Barrena E. 2012. PCR-hybridization after sonication improves diagnosis of implant-related infection. Acta Orthop. 83:299 –304. http://dx .doi.org/10.3109/17453674.2012.693019. Bergin PF, Doppelt JD, Hamilton WG, Mirick GE, Jones AE, Sritulanondha S, Helm JM, Tuan RS. 2010. Detection of periprosthetic infections with use of ribosomal RNA-based polymerase chain reaction. J. Bone Joint Surg. Am. 92:654 – 663. http://dx.doi.org/10.2106/JBJS.I.00400. De Man FH, Graber P, Lüem M, Zimmerli W, Ochsner PE, Sendi P. 2009. Broad-range PCR in selected episodes of prosthetic joint infection. Infection 37:292–294. http://dx.doi.org/10.1007/s15010-008-8246-1. Piper KE, Jacobson MJ, Cofield RH, Sperling JW, Sanchez-Sotelo J, Osmon DR, McDowell A, Patrick S, Steckelberg JM, Mandrekar JN, Fernandez Sampedro M, Patel R. 2009. Microbiologic diagnosis of prosthetic shoulder infection by use of implant sonication. J. Clin. Microbiol. 47:1878 –1884. http://dx.doi.org/10.1128/JCM.01686-08. Kobayashi N, Procop GW, Krebs V, Kobayashi H, Bauer TW. 2008. Molecular identification of bacteria from aseptically loose implants. Clin. Orthop. Relat. Res. 466:1716 –1725. http://dx.doi.org/10.1007/s11999 -008-0263-y. Gallo J, Kolar M, Dendis M, Loveckova Y, Sauer P, Zapletalova J, Koukalova D. 2008. Culture and PCR analysis of joint fluid in the diagnosis of prosthetic joint infection. New Microbiol. 31:97–104. Panousis K, Grigoris P, Butcher I, Rana B, Reilly JH, Hamblen DL. 2005. Poor predictive value of broad-range PCR for the detection of arthroplasty infection in 92 cases. Acta Orthop. 76:341–346. http://dx.doi .org/10.1080/00016470510030805. Kordelle J, Hossain H, Stahl U, Schleicher I, Haas H. 2004. Usefulness of 16S rDNA polymerase-chain-reaction (PCR) in the intraoperative detection of infection in revision of failed arthroplasties. Z. Orthop. Ihre Grenzgeb. 142:571–576. (In German.) http://dx.doi.org/10.1055/s-2004 -832343. Tunney MM, Patrick S, Curran MD, Ramage G, Hanna D, Nixon JR, Gorman SP, Davis RI, Anderson N. 1999. Detection of prosthetic hip infection at revision arthroplasty by immunofluorescence microscopy and PCR amplification of the bacterial 16S rRNA gene. J. Clin. Microbiol. 37:3281–3290. Mariani BD, Martin DS, Levine MJ, Booth RE, Jr, Tuan RS. 1996. The Coventry Award. Polymerase chain reaction detection of bacterial infection in total knee arthroplasty. Clin. Orthop. Relat. Res. 311:11–22.
