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Tarabichi S, Lizcano JD, Abe EA, Goh GS, Baker CM, Parvizi J. Finding the Optimal Screening Test for Periprosthetic Joint Infection: A Prospective Study. J Arthroplasty 2024:S0883-5403(24)00129-3. [PMID: 38452860 DOI: 10.1016/j.arth.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Serological markers are often used as screening tools to avoid unnecessary joint aspiration in cases with a low probability of infection. This study aimed to determine the utility of standard-of-care serological tests as a screening tool for PJI in patients undergoing revision arthroplasty. METHODS This prospective study enrolled 502 patients undergoing revision hip or knee arthroplasty between May 2017 and August 2021. A PJI was defined using a modified definition of the 2018 International Consensus Meeting criteria. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. There were 82 patients undergoing reimplantation who were excluded. Additionally, 8 patients who had an inconclusive International Consensus Meeting score were also excluded. Of the 412 included patients, 317 (76.9%) underwent revision for aseptic failure, and 95 (23.1%) had PJI. Receiver operating characteristic curves were used to assess the diagnostic utility of each serological test. A pairwise comparison with Bonferroni correction was performed to determine whether the differences in areas under the curve (AUCs) between the tests were significant. Additional analyses were performed to find the threshold for each test that offered 100% sensitivity, allowing it to be the optimal screening test. RESULTS All 4 serological markers, D-dimer (AUC 0.860, sensitivity 81.3%, specificity 81.7%), CRP (AUC 0.862, sensitivity 90.4%, specificity 70.0%), ESR (AUC 0.833, sensitivity 73.9%, specificity 85.2%), and fibrinogen (AUC 0.798, sensitivity 74.7%, specificity 75.4%), demonstrated comparable accuracy for the diagnosis of PJI (all P > .05). When maximizing sensitivity to 100%, D-dimer demonstrated the highest specificity (AUC 0.860, specificity 40.2%), outperforming ESR (AUC 0.833, specificity 3.3%), fibrinogen (AUC 0.798, specificity 2.3%), and CRP (AUC 0.862, specificity 0%). A plasma D-dimer level of ≥ 244 ng/mL was identified as the optimal cutoff for use as a screening test. CONCLUSIONS Although plasma D-dimer demonstrated similar diagnostic accuracy as CRP, ESR, and fibrinogen, it outperformed all 3 aforementioned serological markers when used as a screening test for PJI. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Saad Tarabichi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Elizabeth A Abe
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts
| | - Colin M Baker
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Cleveland Clinic South Pointe, Cleveland, Ohio
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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Tsikopoulos K, Meroni G. Periprosthetic Joint Infection Diagnosis: A Narrative Review. Antibiotics (Basel) 2023; 12:1485. [PMID: 37887186 PMCID: PMC10604393 DOI: 10.3390/antibiotics12101485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/20/2023] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
Replacement of native joints aims to restore patients' quality of life by relieving pain and improving joint function. While periprosthetic joint infection (PJI) affects a small percentage of patients, with an estimated incidence of 1-9% following primary total joint replacement, this postoperative complication necessitates a lengthy hospitalisation, extended antibiotic treatment and further surgery. It is highlighted that establishing the correct diagnosis of periprosthetic infections is critical in order for clinicians to avoid unnecessary treatments in patients with aseptic failure. Of note, the PJI diagnosis could not purely rely upon clinical manifestations given the fact that heterogeneity in host factors (e.g., age and comorbidities), variability in infection period, difference in anatomical location of the involved joint and discrepancies in pathogenicity/virulence of the causative organisms may confound the clinical picture. Furthermore, intra-operative contamination is considered to be the main culprit that can result in early or delayed infection, with the hematogenous spread being the most prevalent mode. To elaborate, early and hematogenous infections often start suddenly, whereas chronic late infections are induced by less virulent bacteria and tend to manifest in a more quiescent manner. Last but not least, viruses and fungal microorganisms exert a role in PJI pathogenesis.
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Affiliation(s)
- Konstantinos Tsikopoulos
- 1st Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Gabriele Meroni
- One Health Unit, Department of Biomedical, Surgical and Dental Sciences, School of Medicine, University of Milan, 20133 Milan, Italy;
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Pannu TS, Villa JM, Jimenez D, Riesgo AM, Higuera CA. Does Performance of D-Dimer for Diagnosis of Periprosthetic Joint Infection Change with the Virulence of Infecting Organism? J Arthroplasty 2023:S0883-5403(23)00546-6. [PMID: 37209907 DOI: 10.1016/j.arth.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023] Open
Abstract
INTRODUCTION The impact of the organism virulence on diagnostic accuracy of D-Dimer for periprosthetic joint infection (PJI) is unknown. Our objective was to assess if the performance of D-Dimer in PJI diagnosis changes with the virulence of the organism(s). METHODS Retrospective review of 143 consecutive revision total hip/knee arthroplasties (THA/TKAs) with D-Dimer ordered preoperatively. Operations were performed by 3 surgeons at a single institution (November 2017 through September 2020). There were 141 revisions with complete 2013-International Consensus Meeting (ICM)-criteria initially included. This criteria was used to classify revisions as aseptic vs. septic. Culture-negative septic revisions (n=8) were excluded, and 133 revisions (47-hips/86-knees; 67-septic/66-aseptic) were analyzed. Based on culture results, septic-revisions were categorized into 'low-virulence (LV/n=40)' or 'high-virulence (HV/n=27)'. The D-Dimer threshold (850-ng/mL) was tested against 2013-ICM-criteria ("standard") in identifying septic-revisions (LV/HV) from aseptic-revisions. Sensitivity, specificity, and positive/negative-predictive-values (PPV/NPV) were determined. Receiver-operating-characteristic-curve-analyses were performed. RESULTS Plasma D-Dimer showed high sensitivity (97.5%) and NPV (95.4%) in LV septic cases, which appeared to reduce by about 5% in HV septic cases (sensitivity=92.5% and NPV=91.3%). However, this marker had poor overall accuracy (LV=57%; HV=49.4%), low specificity (LV and HV=31.8%), and PPV (LV=46.4%; HV=35.7%) to diagnose PJI. The area under the curve (AUC) was 0.647 and 0.622 in LV and HV vs. aseptic revisions, respectively. CONCLUSION D-Dimer performs poorly to identify septic from aseptic revisions in the setting of LV/HV infecting organisms alike. However, it shows high sensitivity for PJI diagnosis in cases of low virulence organisms which might be missed by most diagnostic tests.
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Affiliation(s)
- Tejbir S Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida, 33331
| | - Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida, 33331
| | - Denise Jimenez
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida, 33331
| | - Aldo M Riesgo
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida, 33331
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida, 33331.
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Li Z, Maimaiti Z, Fu J, Li ZY, Hao LB, Xu C, Chen JY. The superiority of immune-inflammation summary index for diagnosing periprosthetic joint infection. Int Immunopharmacol 2023; 118:110073. [PMID: 36989888 DOI: 10.1016/j.intimp.2023.110073] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/07/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Accurate and rapid diagnosis of periprosthetic joint infections (PJI) is particularly challenging. This study aimed to evaluate the diagnostic value of a newly developed immune-inflammation summary index (IISI) for PJI. METHODS Our study enrolled 171 aseptic loosening (AL) and 172 PJI cases. Based on a biological-driven approach, the IISI was formulated as C-reaction protein (CRP) × globulin × neutrophil / [lymphocyte × albumin]. Receiver operating characteristic (ROC) curves were constructed to compare the diagnostic performance of IISI with other known serum markers. Subgroup analysis was also performed to explore the robustness of IISI. Restricted cubic splines were used to evaluate the dose-response association. Additionally, changes in IISI levels prior to reimplantation were investigated. RESULTS The levels of all tested biomarkers were significantly different between the PJI and AL groups (all P < 0.05). ROC analysis revealed that IISI outperformed any other marker in diagnosing PJI with an area under the curve (AUC) value of 0.890. The diagnostic performance of IISI was also optimal in the hip (0.898), knee (0.903), low-grade infection (0.841), and culture-negative (0.919) subgroups. The optimal cut-off value is stabilized at around 1.6. The nonlinear association between IISI scores and PJI was also confirmed (P < 0.001). The levels of IISI before reimplantation demonstrated a significant decrease (P < 0.001) and were comparable to those of the AL group (P = 0.143). CONCLUSION IISI can improve the utilization of serum indicators and is superior to other well-known biomarkers in diagnosing PJI. Further studies should evaluate its specific role in different infectious and inflammatory diseases.
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Cho J, Lee JH, Lee DH, Kim J, Uh Y. Performance Comparison of Procalcitonin, Delta Neutrophil Index, C-Reactive Protein, and Serum Amyloid A Levels in Patients with Hematologic Diseases. Diagnostics (Basel) 2023; 13:diagnostics13071213. [PMID: 37046430 PMCID: PMC10093706 DOI: 10.3390/diagnostics13071213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
(1) Background: We compared the diagnostic and prognostic performance of serum amyloid A (SAA), procalcitonin (PCT), delta neutrophil index (DNI), and C-reactive protein (CRP) in patients with hematologic diseases; (2) Methods: We retrospectively collected the remaining serum samples from patients with hematologic diseases, analyzed their clinical data, and measured the levels of PCT, DNI, CRP, and SAA. Performances for infection diagnosis were evaluated using a receiver operating characteristic curve analysis, and 90-day mortality was analyzed using Kaplan-Meier estimation; (3) Results: The levels of all markers were significantly higher in the infected group (N = 27) than those in the uninfected group (N = 100) (p < 0.0001 for all markers). The areas under the curve for diagnosing infection for PCT, DNI, CRP, and SAA were 0.770, 0.817, 0.870, and 0.904, respectively. Increased PCT levels were associated with higher mortality (p = 0.0250); this association was not observed with other examined markers; (4) Conclusions: CRP and SAA exhibited greater discriminative power for infection than PCT. However, only PCT levels were positively associated with 90-day mortality. Herein, we evaluated the diagnostic performance of the four markers. Additional studies are needed to confirm the findings of the present study and validate the potential of these markers in clinical practice.
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Affiliation(s)
- Jooyoung Cho
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Jong-Han Lee
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Dong Hyun Lee
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Juwon Kim
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
- Center for Precision Medicine and Genomics, Wonju Severance Christian Hospital, Wonju 26426, Republic of Korea
| | - Young Uh
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
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Tarabichi S, Goh GS, Baker CM, Chisari E, Shahi A, Parvizi J. Plasma D-Dimer Is Noninferior to Serum C-Reactive Protein in the Diagnosis of Periprosthetic Joint Infection. J Bone Joint Surg Am 2023; 105:501-508. [PMID: 36758110 DOI: 10.2106/jbjs.22.00784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Serological markers are often used as screening tools in the workup of patients with suspected PJI. This study aimed to determine the diagnostic utility of plasma D-dimer for PJI in a variety of clinical scenarios. METHODS This prospective study enrolled 502 patients undergoing revision hip or knee arthroplasty. PJI was defined per a modified version of the 2018 International Consensus Meeting (ICM) criteria. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. Receiver operating characteristic curves were used to assess the utility of each biomarker in the diagnosis of PJI. Pairwise comparison with Bonferroni correction was performed to determine whether the differences in areas under the curve (AUCs) between the markers were significant. RESULTS Of the 412 patients included, 317 (76.9%) did not have an infection (aseptic group) and 95 (23.1%) had an infection (PJI group). All 4 serological markers, D-dimer (AUC, 0.860; sensitivity, 81.3%; specificity, 81.7%), CRP (AUC, 0.862; sensitivity, 90.4%; specificity, 70.0%), ESR (AUC, 0.833; sensitivity, 73.9%; specificity, 85.2%), and fibrinogen (AUC, 0.798; sensitivity, 74.7%; specificity, 75.4%), demonstrated comparable accuracy for the diagnosis of PJI (all p > 0.05). When examining the performance of the different inflammatory markers in diagnosing infection caused by indolent organisms, D-dimer demonstrated the highest sensitivity at 93.8%. CONCLUSIONS We found that plasma D-dimer was noninferior to serum CRP and ESR in the diagnosis of PJI and may be a useful adjunct when screening patients undergoing revision total joint arthroplasty. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Li Z, Maimaiti Z, Li ZY, Fu J, Hao LB, Xu C, Chen JY. Moderate-to-Severe Malnutrition Identified by the Controlling Nutritional Status (CONUT) Score Is Significantly Associated with Treatment Failure of Periprosthetic Joint Infection. Nutrients 2022; 14:nu14204433. [PMID: 36297116 PMCID: PMC9607573 DOI: 10.3390/nu14204433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/12/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
The prevalence and role of malnutrition in periprosthetic joint infection (PJI) remain unclear. This study aimed to use measurable nutritional screening tools to assess the prevalence of malnutrition in PJI patients during two-stage exchange arthroplasty and to explore the association between malnutrition and treatment failure. Our study retrospectively included 183 PJI cases who underwent 1st stage exchange arthroplasty and had available nutritional parameters, of which 167 proceeded with 2nd stage reimplantation. The recently proposed Musculoskeletal Infection Society (MSIS) Outcome Reporting Tool was used to determine clinical outcomes. The Controlling Nutritional Status (CONUT), Nutritional Risk Index (NRI), and Naples Prognostic Score (NPS) were used to identify malnutrition at 1st and 2nd stage exchange, respectively. Multivariate logistic regression analyses were performed to determine the association between malnutrition and treatment failure. Restricted cubic spline models were further used to explore the dose−response association. Additionally, risk factors for moderate-to-severe malnutrition were evaluated. Malnourished patients identified by CONUT, NPS, and NRI accounted for 48.1% (88/183), 98.9% (181/183), and 55.7% (102/183) of patients at 1st stage, and 9.0% (15/167), 41.9% (70/167), and 43.1% (72/167) at 2nd stage, indicating a significant improvement in nutritional status. We found that poorer nutritional status was a predictor of treatment failure, with CONUT performing best as a predictive tool. Moderate-to-severe malnutrition at 1st stage identified by CONUT was significantly related to treatment failure directly caused by PJI (odds ratio [OR] = 5.86), while the OR was raised to 12.15 at 2nd stage (OR = 12.15). The linear dose−response associations between them were also confirmed (P for nonlinearity at both 1st and 2nd stage > 0.05). As for total treatment failure, moderate-to-severe malnutrition as determined by CONUT was associated with a 1.96-fold and 8.99-fold elevated risk at the 1st and 2nd stages, respectively. Age ≥ 68 years (OR = 5.35) and an increased number of previous surgeries (OR = 2.04) may be risk factors for moderate-to-severe malnutrition. Overall, the prevalence of malnutrition in PJI patients is very high. Given the strong association between moderate-to-severe malnutrition identified by CONUT and PJI treatment failure, COUNT could be a promising tool to evaluate the nutritional status of PJI patients to optimize treatment outcomes.
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Affiliation(s)
- Zhuo Li
- School of Medicine, Nankai University, Tianjin 300071, China
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zulipikaer Maimaiti
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhi-Yuan Li
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Jun Fu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
| | - Li-Bo Hao
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
| | - Chi Xu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
- Correspondence: (C.X.); (J.-Y.C.)
| | - Ji-Ying Chen
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
- Correspondence: (C.X.); (J.-Y.C.)
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Tang H, Xu J, Yuan W, Wang Y, Yue B, Qu X. Reliable Diagnostic Tests and Thresholds for Preoperative Diagnosis of Non-Inflammatory Arthritis Periprosthetic Joint Infection: A Meta-analysis and Systematic Review. Orthop Surg 2022; 14:2822-2836. [PMID: 36181336 PMCID: PMC9627080 DOI: 10.1111/os.13500] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 02/06/2023] Open
Abstract
Objective The current diagnostic criteria for periprosthetic joint infection (PJI) are diverse and controversial, leading to delayed diagnosis. This study aimed to evaluate and unify their diagnostic accuracy and the threshold selection of serum and synovial routine tests for PJI at an early stage. Methods We searched the MEDLINE and Embase databases for retrospective or prospective studies which reported preoperative‐available assays (serum, synovial, or culture tests) for the diagnosis of chronic PJI among inflammatory arthritis (IA) or non‐IA populations from January 1, 2000 to June 30, 2022. Threshold effective analysis was performed on synovial polymorphonuclear neutrophils (PMN%), synovial white blood cell (WBC), serum C‐reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to find the relevant cut‐offs. Results Two hundred and sixteen studies and information from 45,316 individuals were included in the final analysis. Synovial laboratory‐based α‐defensin and calprotectin had the best comprehensive sensitivity (0.91 [0.86–0.94], 0.95 [0.88–0.98]) and specificity (0.96 [0.94‐0.97], 0.95 [0.89–0.98]) values. According to the threshold effect analysis, the recommended cut‐offs are 70% (sensitivity 0.89 [0.85–0.92], specificity 0.90 [0.87–0.93]), 4100/μL (sensitivity 0.90 [0.87–0.93], specificity 0.97 [0.93–0.98]), 13.5 mg/L (sensitivity 0.84 [0.78–0.89], specificity 0.83 [0.73–0.89]), and 30 mm/h (sensitivity 0.79 [0.74–0.83], specificity 0.78 [0.72–0.83]) for synovial PMN%, synovial WBC, serum CRP, and ESR, respectively, and tests seem to be more reliable among non‐IA patients. Conclusions The laboratory‐based synovial α‐defensin and synovial calprotectin are the two best independent preoperative diagnostic tests for PJI. A cut off of 70% for synovial PMN% and tighter cut‐offs for synovial WBC and serum CRP could have a better diagnostic accuracy for non‐IA patients with chronic PJI.
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Affiliation(s)
- Haozheng Tang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jialian Xu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei'en Yuan
- Ministry of Education Engineering Research Center of Cell & Therapeutic Antibody, School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - You Wang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Yue
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Xu H, Xie J, Zhang S, Wang D, Huang Z, Zhou Z. Potential Blood Biomarkers for Diagnosing Periprosthetic Joint Infection: A Single-Center, Retrospective Study. Antibiotics (Basel) 2022; 11:antibiotics11040505. [PMID: 35453256 PMCID: PMC9030667 DOI: 10.3390/antibiotics11040505] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/30/2022] [Accepted: 04/06/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Blood biomarkers are first-line tools for identifying periprosthetic joint infection (PJI). C-reactive protein (CRP) is currently recognized as the standard biomarker for PJI diagnosis. Other recently reported novel biomarkers, including plasma fibrinogen, platelet count, monocyte/lymphocyte ratio (MLR), neutrophil/lymphocyte ratio (NLR), and platelet count/lymphocyte ratio (PLR), have also shown promise in diagnosing PJI. This study aimed to evaluate whether these biomarkers were superior to CRP for identifying PJI. Methods: Patients who underwent revision hip or knee arthroplasty at our hospital from January 2008 to September 2020 were included consecutively and divided into infected and non-infected groups according to the 2013 International Consensus Meeting Criteria. Blood samples were collected preoperatively, and erythrocyte sedimentation rate (ESR), CRP, interleukin-6, fibrinogen, platelet count, MLR, NLR, and PLR were analyzed. The diagnostic values of the tested biomarkers and their combinations were compared with CRP based on the area under the receiver operating characteristic curve (AUC) using the z-test. Classification trees were constructed to explore more accurate combinations of the tested markers for identifying PJI. Results: A total of 543 patients were included, of whom 245 had PJI. Among the tested biomarkers, CRP with a cutoff of 7.39 mg/L showed the highest AUC, which gave a sensitivity of 79.1% and specificity of 86.0%. The AUCs of pairwise combinations of tested markers including CRP also were inferior to CRP itself, as were combinations derived from classification trees. Conclusions: Preoperative serum CRP with a low cutoff may be the best reliable blood biomarker for identifying PJI, and those traditional or novel available blood biomarkers could not further improve the diagnostic ability on the basis of CRP.
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Affiliation(s)
- Hong Xu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu 610000, China; (H.X.); (J.X.); (S.Z.); (D.W.); (Z.H.)
| | - Jinwei Xie
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu 610000, China; (H.X.); (J.X.); (S.Z.); (D.W.); (Z.H.)
| | - Shaoyun Zhang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu 610000, China; (H.X.); (J.X.); (S.Z.); (D.W.); (Z.H.)
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang 621000, China
| | - Duan Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu 610000, China; (H.X.); (J.X.); (S.Z.); (D.W.); (Z.H.)
| | - Zeyu Huang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu 610000, China; (H.X.); (J.X.); (S.Z.); (D.W.); (Z.H.)
| | - Zongke Zhou
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu 610000, China; (H.X.); (J.X.); (S.Z.); (D.W.); (Z.H.)
- Correspondence:
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10
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Choi YS, Oh JB, Chang MJ, Kim TW, Kang KS, Kang SB. Delayed normalization of C-Reactive protein and erythrocyte sedimentation rate was not associated with inferior clinical outcomes after total knee arthroplasty. J Orthop Sci 2022; 28:589-596. [PMID: 35331605 DOI: 10.1016/j.jos.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/06/2022] [Accepted: 02/16/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND The purpose of this study aimed to identify the proportion of patients with delayed normalization of C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) after TKA, to determine postoperative thresholds predictive of prolonged elevation. Further, we aimed to determine if the clinical outcomes of patients with prolonged elevation were inferior to those without prolonged elevation. METHODS The records of 211 unilateral and 320 bilateral TKA were reviewed. Patients were divided into the normal and elevation group based on CRP and ESR levels at 6 weeks and 3 months. The temporal pattern of CRP and ESR change in both groups was compared, and thresholds predictive of elevation at 6 weeks and 3 months were identified. Further, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and Tegner activity scale of both groups at 6 months, 1 year, and 2 years after TKA were compared. RESULTS The proportion of patients with elevated CRP and ESR at 6 weeks and 3 months was CRP: 24.2%, 10%, ESR: 51.6%, 29.9% in unilateral and CRP: 31.5%, 10.6%, ESR: 58.1%, 42.7% in bilateral TKA. The thresholds for elevation at 6 weeks and 3 months were 9.5 mg/dL, 11.4 mg/dL (CRP at 6 weeks) and 81.5 mm/h, 74.5 mm/h (ESR at 3 months). There was no difference in the WOMAC score and Tegner activity scale between both groups. CONCLUSIONS CRP and ESR are often elevated for a prolonged period even in the absence of infection after TKA. Such cases show distinct temporal patterns, which are predictable, and do not appear to have a significant effect on clinical outcome.
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Affiliation(s)
- Yun Seong Choi
- Department of Orthopedic Surgery, Veterans Health Service Medical Center, Seoul, Korea.
| | - Jong Byung Oh
- Department of Orthopedic Surgery, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, 5 Gil 20, Boramae-road, Dongjak-gu, Seoul, 07061, South Korea.
| | - Moon Jong Chang
- Department of Orthopedic Surgery, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, 5 Gil 20, Boramae-road, Dongjak-gu, Seoul, 07061, South Korea.
| | - Tae Woo Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, 5 Gil 20, Boramae-road, Dongjak-gu, Seoul, 07061, South Korea.
| | - Kee Soo Kang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea.
| | - Seung-Baik Kang
- Department of Orthopedic Surgery, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, 5 Gil 20, Boramae-road, Dongjak-gu, Seoul, 07061, South Korea.
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11
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Long B, Carlson J, Montrief T, Koyfman A. High risk and low prevalence diseases: Spinal epidural abscess. Am J Emerg Med 2022; 53:168-172. [DOI: 10.1016/j.ajem.2022.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/31/2021] [Accepted: 01/04/2022] [Indexed: 02/07/2023] Open
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12
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Kopechek KJ, Cvetanovich GL, Everhart JS, Frantz TL, Samade R, Bishop JY, Neviaser AS. Factors Associated With Elevated Inflammatory Markers Prior to Shoulder Arthroplasty. HSS J 2022; 18:70-77. [PMID: 35087335 PMCID: PMC8753553 DOI: 10.1177/1556331621998662] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/09/2020] [Indexed: 02/03/2023]
Abstract
Background: Preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) ranges for several shoulder arthroplasty indications are not well understood. Purpose: We sought to compare preoperative ESR and CRP values for a variety of shoulder arthroplasty indications and evaluate risk factors for elevated preoperative ESR and CRP values. Methods: We conducted a retrospective cohort study of shoulder arthroplasty cases performed at a single academic medical institution from 2013 to 2018. Preoperative ESR and CRP values for 235 shoulder arthroplasties with various indications were recorded. Independent risk factors for elevated values (CRP > 10.0 mg/L and ESR > 30.0 mm/h) were determined via multiple variable logistic regression. Results: Patients undergoing shoulder arthroplasty for osteoarthritis had an ESR (mean ± SD) of 22.6 ± 17.8, with 29.8% of patients elevated, and a CRP of 6.5 ± 6.4, with 25.5% of patients elevated. Arthroplasty for acute fracture and prosthetic joint infection (PJI) had higher preoperative ESR and CRP values. Multivariate analysis identified several predictors of elevated ESR, including infection, acute fracture, diabetes, and female sex. It also identified predictors of elevated CRP, including infection, acute fracture, and younger age. Conclusions: Preoperative ESR and CRP values may be elevated in 25% to 30% of patients undergoing primary shoulder arthroplasty. Arthroplasty for both acute fracture and PJI, along with several other patient factors, was associated with elevated preoperative ESR and CRP. Thus, routine collection of ESR and CRP preoperatively may not be of benefit, as elevated values are common. Further study is warranted.
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Affiliation(s)
- Kyle J. Kopechek
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gregory L. Cvetanovich
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua S. Everhart
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Travis L. Frantz
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Richard Samade
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Julie Y. Bishop
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Andrew S. Neviaser
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA,Andrew S. Neviaser, MD, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.
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13
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Christopher ZK, McQuivey KS, Deckey DG, Haglin J, Spangehl MJ, Bingham JS. Acute or chronic periprosthetic joint infection? Using the ESR ∕ CRP ratio to aid in determining the acuity of periprosthetic joint infections. J Bone Jt Infect 2021; 6:229-234. [PMID: 34159047 PMCID: PMC8209584 DOI: 10.5194/jbji-6-229-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/31/2021] [Indexed: 01/15/2023] Open
Abstract
Introduction: The gold standard for determining the duration of periprosthetic joint infection (PJI) is a thorough history. Currently, there are no well-defined objective criteria to determine the duration of PJI, and little evidence exists regarding the ratio between ESR (mm/h) and CRP (mg/L) in joint arthroplasty. This study suggests the ESR / CRP ratio will help differentiate acute from chronic PJI. Methods: Retrospective review of patients with PJI was performed. Inclusion criteria: patients > 18 years old who underwent surgical revision for PJI and had documented ESR and CRP values. Subjects were divided into two groups: PJI for greater (chronic) or less than (acute) 4 weeks and the ESR / CRP ratio was compared between them. Receiver-operating characteristic (ROC) curves were evaluated to determine the utility of the ESR / CRP ratio in characterizing the duration of PJI. Results: 147 patients were included in the study (81 acute and 66 chronic). The mean ESR / CRP ratio in acute patients was 0.48 compared to 2.87 in chronic patients ( p < 0.001 ). The ESR / CRP ROC curve demonstrated an excellent area under the curve (AUC) of 0.899. The ideal cutoff value was 0.96 for ESR / CRP to predict a chronic ( > 0.96 ) vs. acute ( < 0.96 ) PJI. The sensitivity at this value was 0.74 (95 % CI 0.62-0.83) and the specificity was 0.90 (95 % CI 0.81-0.94). Conclusions: The ESR / CRP ratio may help determine the duration of PJI in uncertain cases. This metric may give arthroplasty surgeons more confidence in defining the duration of the PJI and therefore aid in treatment selection.
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Affiliation(s)
| | - Kade S McQuivey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Jack Haglin
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
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14
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Watanabe S, Kobayashi N, Tomoyama A, Choe H, Yamazaki E, Inaba Y. Clinical characteristics and risk factors for culture-negative periprosthetic joint infections. J Orthop Surg Res 2021; 16:292. [PMID: 33941220 PMCID: PMC8091510 DOI: 10.1186/s13018-021-02450-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/26/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Culture-negative periprosthetic joint infections (PJIs) can complicate diagnosis and management of PJI. This study aimed to identify risk factors for culture-negative PJI and differences in clinical characteristics between culture-positive and culture-negative PJI group. METHODS This retrospective, cross-sectional study evaluated PJI cases obtained between January 2013 and October 2019 at our institution. These PJI cases were divided into culture-positive and culture-negative groups and then compared. The demographics, laboratory findings, and details of patient's clinical characteristics were investigated. Univariate and multivariate logistic regression analysis were performed to investigate risk factors for culture-negative PJI. RESULTS A total of 109 PJI cases were included in the analysis: 82 (75%) culture-positive and 27 (25%) culture-negative. The mean serum white blood cell (WBC) count, C-reactive protein level, and erythrocyte sedimentation rate in the culture-negative group were significantly lower than those in the culture-positive group (p < 0.05). There were no significant differences between the two groups regarding history of prior antibacterial administration or treatment success rates. Multivariate analysis identified a low serum WBC count as a risk factor for culture-negative PJI (odds ratio = 0.78; 95% confidence interval [CI] = 0.63-0.97; p = 0.027). CONCLUSIONS A low serum WBC count is a risk factor for culture-negative PJI, but prior antimicrobial therapy is not. The results suggest that PJI cases with lower levels of systemic inflammation are likely to be culture-negative; therefore, the possibility of a culture-negative result should be considered in suspected cases of PJI with low inflammatory markers, regardless of prior antibiotic exposure.
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Affiliation(s)
- Shintaro Watanabe
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City, Kanagawa Japan
| | - Naomi Kobayashi
- Department of Orthopedic Surgery, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama City, Kanagawa Japan
| | - Akito Tomoyama
- Department of Clinical Laboratory Center, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City, Kanagawa Japan
| | - Hyonmin Choe
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City, Kanagawa Japan
| | - Etsuko Yamazaki
- Department of Clinical Laboratory Center, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City, Kanagawa Japan
| | - Yutaka Inaba
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City, Kanagawa Japan
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15
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Xu H, Xie JW, Yang JL, Huang ZY, Pei FX. Role of D-dimer and Fibrinogen in the Diagnosis of Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis. Orthop Surg 2021; 13:692-700. [PMID: 33682337 PMCID: PMC8126916 DOI: 10.1111/os.12969] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/15/2021] [Accepted: 01/28/2021] [Indexed: 02/05/2023] Open
Abstract
The diagnostic potential of D-dimer and fibrinogen to detect periprosthetic joint infection (PJI) of the hip and knee is not well-understood. The aim of this study was to determine whether D-Dimer and fibrinogen can be used as effective biomarkers to screen PJI. A systematic review of the literature indexed in Web of Science, PubMed, Cochrane Library, Embase, and Google Scholar databases was performed. All studies using D-dimer levels in serum or plasma, or fibrinogen levels in plasma, for the diagnosis of PJI were included. Meta-analysis estimates, including sensitivity, specificity, diagnostic odds ratios (DOR), and the area under the summary receiver operating characteristic curve (AUSROC), were calculated using a random-effects model, and used to assess the diagnostic accuracy of these biomarkers. A total of nine studies were analyzed, and their quality was considered to be acceptable. D-dimer gave a limited diagnostic value if serum and plasma combined: sensitivity (0.77, 95% confidence interval [CI] [0.63 to 0.87]), specificity (0.67, 95% CI [0.54 to 0.78]), DOR (6.81, 95% CI [2.67 to 17.37]), and AUSROC (0.78, 95% CI [0.74 to 0.82]). Plasma D-dimer levels were associated with less satisfactory sensitivity (0.65, 95% CI 0.57 to 0.71), specificity (0.58, 95% CI 0.50 to 0.66), DOR (2.52, 95% CI 1.64 to 3.90), and AUSROC (0.65, 95% CI 0.61 to 0.69). Serum D-dimer levels showed higher corresponding values of 0.89 (95% CI 0.79 to 0.94), 0.76 (95% CI 0.55 to 0.89), 24.24 (95% CI 10.07 to 58.32), and 0.91 (95% CI 0.88 to 0.93). Plasma fibrinogen showed acceptable corresponding values of 0.79 (95% CI 0.70 to 0.85), 0.73 (95% CI 0.57 to 0.85), 10.14 (95% CI 6.16 to 16.70), and 0.83 (95% CI 0.79 to 0.86). Serum D-dimer may be an effective marker for the diagnosis of PJI in hip and knee arthroplasty patients, and it may show higher diagnostic potential than plasma fibrinogen. Plasma D-dimer may have limited diagnostic potential.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Jin-Wei Xie
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Jing-Li Yang
- College of Earth and Environmental Sciences, School of Public Health, Lanzhou University, Lanzhou, China
| | - Ze-Yu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fu-Xing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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16
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C-reactive protein in spinal surgery: more predictive than prehistoric. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:1261-1269. [PMID: 33682035 DOI: 10.1007/s00586-021-06782-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/10/2021] [Accepted: 02/18/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE In spinal surgery, surgical site infections (SSI) after dorsal spondylodesis lead to severe short- and long-term complications. Despite various clinical and serological evidence, the detection of a postoperative SSI remains crucial. In this retrospective cohort study, we determined the prognostic value of C-reactive protein (CRP) kinetics after open reduction and dorsal spondylodesis in the development of a SSI. METHODS We retrospectively analyzed 192 patients from 2016 to 2018 undergoing open reduction and dorsal spondylodesis with and without SSI for 20 days at a level-I trauma center and assessed their serological and clinical characteristics. RESULTS On day 7 and 8 after surgery, patients who developed a SSI displayed significantly higher CRP levels. A second peak after the initial maximum of CRP and a restricted failure to decline as well as a maximum CRP of more than 225 mg/l predict an infectious complication with a sensitivity of 92.9%, and a specificity of 78.2%. A binary logistic regression leads to 85.7% and 69.7%, respectively. A one-phase decay exponential regression can predict 75.6% of the variance after the initial peak of CRP. CONCLUSION Our study demonstrates a high value of postoperative CRP kinetics in SSI detection after dorsal spondylodesis. Moreover, we observed typical CRP levels with a specific course as indicative predictors that may facilitate an early SSI detection in clinical practice.
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17
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Yin H, Xu D, Wang D. Diagnostic value of next-generation sequencing to detect periprosthetic joint infection. BMC Musculoskelet Disord 2021; 22:252. [PMID: 33676477 PMCID: PMC7937267 DOI: 10.1186/s12891-021-04116-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/19/2021] [Indexed: 12/27/2022] Open
Abstract
Background We herein compared the diagnostic value of next-generation sequencing (NGS), bacterial culture, and serological biomarkers to detect periprosthetic joint infection (PJI) after joint replacement. Methods According to the diagnostic criteria of the Musculoskeletal Infection Society, 35 patients who underwent joint revision surgery were divided into infection (15 cases) and non-infection (20 cases) groups, and were routinely examined preoperatively for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6), and D-dimer levels. All patients underwent arthrocentesis preoperatively. Synovial fluid was used for white blood cell count, white blood cell classification, bacterial culture, and NGS. Furthermore, we calculated the area under the curve (AUC) of the receiver operating characteristic curve (ROC) for ESR, CRP, PCT, IL-6, and D-dimer. Data were assessed by comparing diagnostic accuracy, sensitivity, and specificity. Results Fourteen patients showed positive results by NGS and seven showed positive bacterial culture results in the infection group; further, 18 showed negative results by NGS in the non-infection group. The AUC of ESR, D-dimer, CRP, IL-6, and PCT was 0.667, 0.572, 0.827, 0.767, and 0.808, respectively. The accuracy of NGS, bacterial culture, CRP, IL-6, and PCT was 0.91, 0.74, 0.77, 0.74, and 0.83, respectively. When comparing NGS with CRP, IL-6, PCT, and bacterial culture, differences in overall test results and those in sensitivity were statistically significant, and compared with CRP, differences in specificity were also statistically significant. In comparison with IL-6, PCT, and bacterial culture, the specificity of NGS was statistically insignificant. Conclusions Our results indicated that NGS had higher accuracy and sensitivity than the bacterial culture method and commonly used serological biomarkers for diagnosing PJI.
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Affiliation(s)
- Han Yin
- Department of Orthopaedics, Liaocheng People's Hospital and Liaocheng Clinical School of Taishan Medical University, No. 67, Dongchang Road, Liaocheng, Shandong, China
| | - Duliang Xu
- Department of Orthopaedics, Liaocheng People's Hospital and Liaocheng Clinical School of Taishan Medical University, No. 67, Dongchang Road, Liaocheng, Shandong, China
| | - Dawei Wang
- Department of Orthopaedics, Liaocheng People's Hospital and Liaocheng Clinical School of Taishan Medical University, No. 67, Dongchang Road, Liaocheng, Shandong, China.
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18
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van den Kieboom J, Tirumala V, Xiong L, Klemt C, Kwon YM. Concomitant Hip and Knee Periprosthetic Joint Infection in Periprosthetic Fracture: Diagnostic Utility of Serum and Synovial Fluid Markers. J Arthroplasty 2021; 36:722-727. [PMID: 32893059 DOI: 10.1016/j.arth.2020.08.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Diagnosing periprosthetic joint infection (PJI) in patients with a periprosthetic fracture can be challenging due to concerns regarding the reliability of commonly used serum and synovial fluid markers. This study aimed at determining the diagnostic performance of serum and synovial fluid markers for diagnosing PJI in patients with a periprosthetic fracture of a total joint arthroplasty. METHODS A total of 144 consecutive patients were included: (1) 41 patients with concomitant PJI and periprosthetic fracture and (2) 103 patients with periprosthetic fracture alone. Serum markers erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and synovial markers white blood cell (WBC) count and polymorphonuclear percentage were assessed. RESULTS ESR demonstrated 87% sensitivity and 48% specificity at the Musculoskeletal Infection Society threshold, area under the curve (AUC) of 0.74, and optimal threshold of 45.5 mm/h (76% sensitivity, 68% specificity). CRP showed 94% sensitivity and 40% specificity, AUC of 0.68 with optimal threshold of 16.7 mg/L (84% sensitivity, 51% specificity). Synovial WBC count demonstrated 87% sensitivity and 78% specificity, AUC of 0.90 with optimal threshold of 4552 cells/μL (86% sensitivity, 85% specificity). Polymorphonuclear percentage showed 79% sensitivity and 63% specificity, AUC of 0.70 with optimal threshold of 79.5% (74% sensitivity, 63% specificity). The AUC of all combined markers was 0.90 with 84% sensitivity and 79% specificity. CONCLUSION The diagnostic utility of the serum and synovial markers for diagnosing PJI was lower in the setting of concomitant periprosthetic fracture compared to PJI alone. Using the Musculoskeletal Infection Society thresholds, ESR, CRP, and WBC count showed high sensitivity, yet low specificity, thus higher thresholds and utilizing all serum and synovial markers in combination should be considered.
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Affiliation(s)
- Janna van den Kieboom
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Venkatsaiakhil Tirumala
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Liang Xiong
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christian Klemt
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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19
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Li C, Ojeda Thies C, Xu C, Trampuz A. Is combining serum interleukin-6 and C-reactive protein a reliable diagnostic tool in periprosthetic joint infections? J Orthop Surg Res 2020; 15:450. [PMID: 33008442 PMCID: PMC7532114 DOI: 10.1186/s13018-020-01864-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 08/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Because there is no single gold standard method for the diagnosis of periprosthetic joint infection (PJI), the combination of valuable methods to evaluate infection appears to achieve a better diagnostic result. The objective of the present study was to evaluate the diagnostic value of serum interleukin (IL)-6 and C-reactive protein (CRP) for the diagnosis of PJI. METHODS PubMed, Embase, and the Web of Science databases were searched for articles describing PJI diagnosis using serum IL-6 and CRP published between January 1990 and December 2019. RESULTS Eight studies were included in the meta-analysis. The pooled sensitivity was 0.84 (95% confidence interval [CI], 0.80-0.88) for the combined method (serum IL-6 and CRP) in series and parallel approaches, 0.87 (95% CI, 0.82-0.90) for IL-6, and 0.84 (95% CI, 0.79-0.88) for CRP. The pooled specificity was 0.85 (95% CI, 0.82-0.88) for the combined method, 0.83 (95% CI, 0.79-0.87) for IL-6, and 0.83 (95% CI, 0.79-0.87) for CRP. The combined method had the highest value for the area under the curve (0.9453), followed by IL-6 (0.9237) and CRP (0.9074). Subgroup analyses showed that the sensitivity of the combined method in parallel tests was higher than that in IL-6 or CRP (94% vs. 89% and 84%, respectively). Serial testing of the combined method showed increased specificity compared to a single indicator (96% vs. 83% and 80%). CONCLUSION The combination of serum IL-6 and CRP was a reliable tool for the diagnosis of periprosthetic hip and knee infection, demonstrating a better diagnostic accuracy than single marker analysis.
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Affiliation(s)
- Cheng Li
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | | | - Chi Xu
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, People's Republic of China
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany.
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20
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Sharfman ZT, Gelfand Y, Shah P, Holtzman AJ, Mendelis JR, Kinon MD, Krystal JD, Brook A, Yassari R, Kramer DC. Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications. Asian Spine J 2020; 14:742-759. [PMID: 32718133 PMCID: PMC7595828 DOI: 10.31616/asj.2019.0369] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/17/2020] [Indexed: 12/18/2022] Open
Abstract
Spinal epidural abscess (SEA) is a rare condition associated with significant morbidity and mortality. Despite advances in diagnostic medicine, early recognition of SEAs remains elusive. The vague presentation of the disease, coupled with its numerous risk factors, the diagnostic requirement for obtaining advanced imaging, and the necessity of specialized care constitute extraordinary challenges to both diagnosis and treatment of SEA. Once diagnosed, SEAs require urgent or emergent medical and/or surgical management. As SEAs are a relatively rare pathology, high-quality data are limited and there is no consensus on their optimal management. This paper focuses on presenting the treatment modalities that have been successful in the management of SEAs and providing a critical assessment of how specific SEA characteristics may render one infection more amenable to primary surgical or medical interventions. This paper reviews the relevant history, epidemiology, clinical presentation, radiology, microbiology, and treatment of SEAs and concludes by addressing the medicolegal implications of delayed treatment of the disease.
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Affiliation(s)
- Zachary Tuvya Sharfman
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yaroslav Gelfand
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pryiam Shah
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ari Jacob Holtzman
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Joseph Roy Mendelis
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Merritt Drew Kinon
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jonathan David Krystal
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Allan Brook
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Reza Yassari
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David Claude Kramer
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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