Kantonsspital St.Gallen

Implementation of an Algorithm for Prosthetic Joint Infection: Deviations and Problems

Heinrich M L Mühlhofer, Karl-Georg Kanz, Florian Pohlig, Ulrich Lenze, Florian Lenze, Andreas Toepfer, Ruediger Von Eisenhart-Rothe & Johannes Schauwecker


The outcome of revision surgery in arthroplasty is based on a precise diagnosis. In addition, the treatment varies based on whether the prosthetic failure is caused by aseptic or septic loosening. Algorithms can help to identify periprosthetic joint infections (PJI) and standardize diagnostic steps, however, algorithms tend to oversimplify the treatment of complex cases. We conducted a process analysis during the implementation of a PJI algorithm to determine problems and deviations associated with the implementation of this algorithm.

Fifty patients who were treated after implementing a standardized algorithm were monitored retrospectively. Their treatment plans and diagnostic cascades were analyzed for deviations from the implemented algorithm. Each diagnostic procedure was recorded, compared with the algorithm, and evaluated statistically.

We detected 52 deviations while treating 50 patients. In 25 cases, no discrepancy was observed. Synovial fluid aspiration was not performed in 31.8% of patients (95% confidence interval [CI], 18.1%-45.6%), while white blood cell counts (WBCs) and neutrophil differentiation were assessed in 54.5% of patients (95% CI, 39.8%-69.3%). We also observed that the prolonged incubation of cultures was not requested in 13.6% of patients (95% CI, 3.5%-23.8%). In seven of 13 cases (63.6%; 95% CI, 35.2%-92.1%), arthroscopic biopsy was performed; 6 arthroscopies were performed in discordance with the algorithm (12%; 95% CI, 3%-21%).

Self-critical analysis of diagnostic processes and monitoring of deviations using algorithms are important and could increase the quality of treatment by revealing recurring faults.
citation Mühlhofer H M L, Kanz K G, Pohlig F, Lenze U, Lenze F, Toepfer A, von Eisenhart-Rothe R, Schauwecker J. Implementation of an Algorithm for Prosthetic Joint Infection: Deviations and Problems. Surg Infect (Larchmt) 2016; 18:164-169.
type journal paper/review (English)
date of publishing 07-12-2016
journal title Surg Infect (Larchmt) (18/2)
ISSN electronic 1557-8674
pages 164-169
PubMed 27925502
DOI 10.1089/sur.2015.208