Intra-Operative Frozen Section
We recommend the use of frozen sections of peri-implant tissues in patients who are undergoing reoperation for whom the diagnosis of periprosthetic joint infection has not been established or excluded.
Rationale
Eight Level I studies were identified that evaluated the use of frozen sections to help diagnose peri-implant infection.3, 21, 30, 32, 54, 59, 75, 96 Three studies excluded patients with known underlying inflammatory arthropathy.30, 54, 96
Six of the eight studies used intraoperative cultures, while two studies used a combination of test results as the gold standard for diagnosis against which the frozen sections were compared. All studies based the histologic diagnosis of probable infection on the tissue concentration of acute inflammatory cells, usually defined by two variables: 1) the number of neutrophils in a high magnification (400X) microscopic field, and 2) the minimum number of fields containing that concentration of neutrophils. At least three studies excluded neutrophils entrapped in superficial fibrin.
Four studies used 10 or more neutrophils per high power field, and three of the four required 10 more neutrophils in at least 5 fields. The remaining study required 10 or more neutrophils in any given area. Our meta-analysis of these studies indicated that frozen section is a very good “rule in” test (i.e., a positive result has a high likelihood of infection; LR+: 23), but is a relatively low value “rule out” test (i.e. a negative result does not have a high likelihood of absent infection; LR-: 0.23).
Four other studies used 5 or more neutrophils per high power field; several of these specified at least 5 microscopic fields but the other studies did not. Meta-analysis indicated that when compared to a 10 PMN/HPF criterion this lower inflammation threshold may have similar sensitivity, but slightly lower specificity (i.e. a higher frequency of false positive results).
There is insufficient information to distinguish 5 from 10 neutrophils per high power field as the best threshold needed for diagnosis. Insufficient information is available to determine the efficacy of frozen sections in patients with an underlying inflammatory arthropathy.
Six of the eight studies used intraoperative cultures, while two studies used a combination of test results as the gold standard for diagnosis against which the frozen sections were compared. All studies based the histologic diagnosis of probable infection on the tissue concentration of acute inflammatory cells, usually defined by two variables: 1) the number of neutrophils in a high magnification (400X) microscopic field, and 2) the minimum number of fields containing that concentration of neutrophils. At least three studies excluded neutrophils entrapped in superficial fibrin.
Four studies used 10 or more neutrophils per high power field, and three of the four required 10 more neutrophils in at least 5 fields. The remaining study required 10 or more neutrophils in any given area. Our meta-analysis of these studies indicated that frozen section is a very good “rule in” test (i.e., a positive result has a high likelihood of infection; LR+: 23), but is a relatively low value “rule out” test (i.e. a negative result does not have a high likelihood of absent infection; LR-: 0.23).
Four other studies used 5 or more neutrophils per high power field; several of these specified at least 5 microscopic fields but the other studies did not. Meta-analysis indicated that when compared to a 10 PMN/HPF criterion this lower inflammation threshold may have similar sensitivity, but slightly lower specificity (i.e. a higher frequency of false positive results).
There is insufficient information to distinguish 5 from 10 neutrophils per high power field as the best threshold needed for diagnosis. Insufficient information is available to determine the efficacy of frozen sections in patients with an underlying inflammatory arthropathy.
- (21) Della Valle CJ, Sporer SM, Jacobs JJ, Berger RA, Rosenberg AG, Paprosky WG. Preoperative testing for sepsis before revision total knee arthroplasty. J Arthroplasty 2007;22(6 Suppl 2):90-93.
- (3) Banit DM, Kaufer H, Hartford JM. Intraoperative frozen section analysis in revision total joint arthroplasty. Clin Orthop Relat Res 2002;(401):230-238.
- (30) Fehring TK, McAlister JA, Jr. Frozen histologic section as a guide to sepsis in revision joint arthroplasty. Clin Orthop Relat Res 1994;(304):229-237.
- (32) Frances BA, Martinez FM, Cebrian Parra JL, Graneda DS, Crespo RG, Lopez-Duran SL. Diagnosis of infection in hip and knee revision surgery: intraoperative frozen section analysis. Int Orthop 2007;31(1):33-37.
- (54) Ko PS, Ip D, Chow KP, Cheung F, Lee OB, Lam JJ. The role of intraoperative frozen section in decision making in revision hip and knee arthroplasties in a local community hospital. J Arthroplasty 2005;20(2):189-195.
- (59) Lonner JH, Desai P, Dicesare PE, Steiner G, Zuckerman JD. The reliability of analysis of intraoperative frozen sections for identifying active infection during revision hip or knee arthroplasty. J Bone Joint Surg Am 1996;78(10):1553-1558.
- (75) Nunez LV, Buttaro MA, Morandi A, Pusso R, Piccaluga F. Frozen sections of samples taken intraoperatively for diagnosis of infection in revision hip surgery. Acta Orthop 2007;78(2):226-230.
- (96) Schinsky MF, la Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am 2008;90(9):1869-1875.