Pre-operative biopsies in the revision setting - helpful or harmful?

Abstract

Background: There is no clear consensus as to whether pre-operative biopsies (arthroscopic or open) should be routinely obtained to confirm absence of infection in presumed aseptic revision cases, and practice widely varies.

Methods: Consecutive patients over a 4-year period from a single centre undergoing a revision shoulder or elbow procedure without evidence or suspicion of infection were included. Electronic patient records were utilised to determine biopsy results, revision procedure and clinical outcome.

Results: Of 81 patients undergoing a revision shoulder or elbow procedure for presumed aseptic cause, 40 had biopsies taken prior to the revision procedure, with seven positive results (defined as ≥3/5 positive samples). These were treated with oral antibiotics before undergoing revision. At revision, intra-operative biopsies showed that infection had been cleared in 4/7 cases, and new infection was identified in six cases that were previously negative. Of the 41 patients who did not have pre-revision biopsies, 13 were positive at the time of definitive procedure and subsequently successfully treated with oral antibiotics.

Discussion: Pre-revision biopsy has a low sensitivity (54%) for identifying bacteria in presumed aseptic cases and is not necessarily a benign procedure, with potential risk of introducing infection. Pre-revision antibiotic treatment may not result in negative biopsies at the time of definitive revision.