Department of Medicine, University of Illinois College of Medicine at Rockford, 1601 Parkview Avenue, Rockford, IL 61107, USA.
J Bone Joint Surg Am. 2012 Sep 19;94(18):1700-11. doi: 10.2106/JBJS.J.00756.
The accuracy of intraoperative periprosthetic frozen section histologic evaluation in predicting a diagnosis of periprosthetic joint infection prior to microbiologic culture results is unknown.
We performed a systematic review and meta-analysis of all longitudinal studies that compared frozen section histologic results with simultaneously obtained microbiologic culture at the time of revision total hip or total knee arthroplasty. The data sources were Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, ISI Web of Science, and SCOPUS, from the inception of each database to January 2010.
Twenty-six studies involving 3269 patients undergoing revision hip or knee arthroplasty met the inclusion criteria. A culture-positive periprosthetic joint infection was confirmed in 796 (24.3%) of the patients. Frozen section results, using any of the diagnostic criteria chosen by the investigating pathologist, had a pooled diagnostic odds ratio of 54.7 (95% confidence interval [CI], 31.2 to 95.7), a likelihood ratio of a positive test of 12.0 (95% CI, 8.4 to 17.2), and a likelihood ratio of a negative test of 0.23 (95% CI, 0.15 to 0.35) for the diagnosis of periprosthetic joint infection. Fifteen studies utilizing a threshold of five polymorphonuclear leukocytes (PMNs) per high-power field to define a positive frozen section had a diagnostic odds ratio of 52.6 (95% CI, 23.7 to 116.2), and six studies utilizing a diagnostic threshold of ten PMNs per high-power field had a diagnostic odds ratio of 69.8 (95% CI, 33.6 to 145.0). There was no significant difference between the diagnostic odds ratio or likelihood ratios associated with these thresholds. The moderate to high heterogeneity among the included studies was unexplained by variability in the study design, diagnostic criteria for acute inflammation, reference standard for periprosthetic joint infection, or prevalence of infection. This heterogeneity could be due to differences in the inclusion and exclusion criteria, tissue sampling error, experience or technique of the pathologists, number of microscopic fields visualized, and field diameter examined.
Intraoperative frozen sections of periprosthetic tissues performed well in predicting a diagnosis of culture-positive periprosthetic joint infection but had moderate accuracy in ruling out this diagnosis. Frozen section histopathology should therefore be considered a valuable part of the diagnostic work-up for patients undergoing revision arthroplasty, especially when the potential for infection remains after a thorough preoperative evaluation. The optimum diagnostic threshold (number of PMNs per high-power field) required to distinguish periprosthetic joint infection from aseptic failure could not be discerned from the included studies. There was no significant difference between the diagnostic accuracy of frozen section histopathology utilizing the most common thresholds of five or ten PMNs per high-power field.
在获得微生物培养结果之前，术中假体周围冰冻切片组织学评估预测假体周围关节感染的准确性尚不清楚。
我们对所有比较翻修全髋关节或全膝关节置换术时同时获得的冰冻切片组织学结果与微生物培养结果的前瞻性研究进行了系统回顾和荟萃分析。数据来源为 Ovid MEDLINE、Ovid EMBASE、Cochrane 图书馆、ISI Web of Science 和 SCOPUS，每个数据库的起始时间均为 2010 年 1 月之前。
26 项研究共纳入 3269 例接受翻修髋关节或膝关节置换术的患者，符合纳入标准。796 例（24.3%）患者的假体周围关节感染经培养证实。使用调查病理学家选择的任何诊断标准，冰冻切片结果的汇总诊断优势比为 54.7（95%置信区间[CI]，31.2 至 95.7），阳性试验的似然比为 12.0（95%CI，8.4 至 17.2），阴性试验的似然比为 0.23（95%CI，0.15 至 0.35）。15 项研究使用每高倍镜视野中 5 个多形核白细胞（PMN）定义为阳性冰冻切片，诊断优势比为 52.6（95%CI，23.7 至 116.2），6 项研究使用每高倍镜视野中 10 个 PMN 定义为阳性冰冻切片，诊断优势比为 69.8（95%CI，33.6 至 145.0）。这些阈值的诊断优势比或似然比之间没有显著差异。纳入研究的异质性较高，原因尚不清楚，可能与急性炎症的诊断标准、假体周围关节感染的参考标准或感染的流行率等方面的差异有关。这种异质性可能是由于纳入和排除标准、组织取样误差、病理学家的经验或技术、可视化的显微镜视野数量以及检查的视野直径不同造成的。
术中假体周围组织的冰冻切片在预测培养阳性的假体周围关节感染的诊断方面表现良好，但在排除该诊断方面的准确性中等。因此，冰冻切片组织病理学应被视为接受翻修关节置换术患者的诊断评估的一个有价值的部分，特别是在彻底的术前评估后仍然存在感染的可能性时。从纳入的研究中无法确定区分假体周围关节感染和无菌性失败所需的最佳诊断阈值（每高倍镜视野中的 PMN 数）。使用最常见的每高倍镜视野 5 或 10 个 PMN 的阈值，冰冻切片组织病理学的诊断准确性没有显著差异。
