Painful Hip Re-evaluation
In the absence of reliable evidence, it is the opinion of the work group that patients judged to be at lower probability for periprostheic hip infection and without planned reoperation who have abnormal erythrocyte sedimentation rates OR abnormal C-reactive protein levels be re-evaluated within three months. We are unable to recommend specific diagnostic tests at the time of this follow-up.
CONSENSUS RECOMMENDATION Rationale
In the opinion of the work group, the possible harms associated with performing hip aspiration need to be weighed when conflicting erythrocyte sedimentation rates OR abnormal C-reactive protein levels are found in the patient. Lower probability hip arthroplasty patients without planned reoperation who have an abnormal ESR OR CRP are to be re-evaluated within three months. If the patient is asymptomatic, further testing may not be necessary.
Hip aspiration is a useful test to diagnose periprosthetic hip infection in patients who have a higher probability of infection and abnormal ESR or CRP as referenced in Recommendation 4.
However, possible harms of joint aspiration include the possibility of false positive results, the possibility of the introduction of bacteria into the joint during the procedure and patient pain and/or discomfort while undergoing the procedure.4 There are also concerns about the cost of the procedure.4 Lower probability hip arthroplasty patients without planned reoperation who have an abnormal ESR OR CRP are to be re-evaluated within three months.
There is insufficient evidence to address whether further observation alone, diagnostic testing, or both can be recommended based on lack of available evidence to address the recommendation.
Hip arthroplasty patients at a lower probability of infection who have an isolated elevation in ESR OR CRP levels but without other objective or subjective evidence of periprosthetic infection include patients who have a known unrelated cause for this elevation. Such patients may not require future observation. However, this patient group also includes the low-grade subclinical infection or early onset periprosthetic infection that has not fully declared itself.
Because of the often insidious nature of periprosthetic infection, the orthopedic surgeon will need to use clinical judgment in each individual case. Options to consider include simple future observation with repeat ESR and CRP testing and reentering the patient into the diagnostic algorithm versus attempting to immediately establish the presence or absence of periprosthetic infection with additional testing. Discussion of available diagnostic procedures applicable to the individual patient relies on mutual communication between the patient and physician, weighing the potential risks and benefits for that patient. The ultimate judgment regarding any specific procedure or treatment must be made in light of all circumstances presented by the patient.
Hip aspiration is a useful test to diagnose periprosthetic hip infection in patients who have a higher probability of infection and abnormal ESR or CRP as referenced in Recommendation 4.
However, possible harms of joint aspiration include the possibility of false positive results, the possibility of the introduction of bacteria into the joint during the procedure and patient pain and/or discomfort while undergoing the procedure.4 There are also concerns about the cost of the procedure.4 Lower probability hip arthroplasty patients without planned reoperation who have an abnormal ESR OR CRP are to be re-evaluated within three months.
There is insufficient evidence to address whether further observation alone, diagnostic testing, or both can be recommended based on lack of available evidence to address the recommendation.
Hip arthroplasty patients at a lower probability of infection who have an isolated elevation in ESR OR CRP levels but without other objective or subjective evidence of periprosthetic infection include patients who have a known unrelated cause for this elevation. Such patients may not require future observation. However, this patient group also includes the low-grade subclinical infection or early onset periprosthetic infection that has not fully declared itself.
Because of the often insidious nature of periprosthetic infection, the orthopedic surgeon will need to use clinical judgment in each individual case. Options to consider include simple future observation with repeat ESR and CRP testing and reentering the patient into the diagnostic algorithm versus attempting to immediately establish the presence or absence of periprosthetic infection with additional testing. Discussion of available diagnostic procedures applicable to the individual patient relies on mutual communication between the patient and physician, weighing the potential risks and benefits for that patient. The ultimate judgment regarding any specific procedure or treatment must be made in light of all circumstances presented by the patient.