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Felstead A, Kundasamy P, Penfold G, Whiting K, Buck J, Sturridge S, Meda M. The combined measurement of synovial markers in the diagnosis of periprosthetic joint infection. Ann R Coll Surg Engl 2021; 104:334-339. [PMID: 34939833 DOI: 10.1308/rcsann.2021.0186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Currently there is no single test for periprosthetic joint infection (PJI) that demonstrates an acceptable level of sensitivity. The aim of this pilot study was to identify a combination of biomarkers that could exclude periprosthetic infection prior to revision surgery in hip and knee arthroplasty. This would help in equivocal cases of PJI, such as those with low-virulence organisms, chronic low-grade infection or 'aseptic' loosening. Current research has focused on measuring the levels of biomarkers in the patient's synovial fluid, and these can be combined to improve accuracy. METHODS We selected synovial white cell count (SF-WCC) and C-reactive protein (SF-CRP), as they demonstrated an acceptable level of sensitivity and specificity which could be measured using existing equipment. One hundred and sixty-one synovial fluid samples from 134 patients were collected and analysed prospectively using calculated cut-off values of 10mg/l for SF-CRP and 3,000×106/l for SF-WCC. Samples were deemed positive for infection when either of the SF-CRP or SF-WCC values were above the cut-off. RESULTS The combined test demonstrated a sensitivity greater than 98.5% and specificity above 80% in all samples analysed or looked at separately for total hip replacement and total knee replacement infections. All ten aspirates taken from chronically infected joints tested positive. CONCLUSIONS The combination of SF-CRP and SF-WCC measurement has been shown to have high sensitivity of over 99% in detecting both acute and chronic PJI in both hip and knee arthroplasty. This ability of the test to exclude infection with a high degree of certainty will help in preoperative planning of PJIs.
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Affiliation(s)
| | | | - G Penfold
- Frimley Health NHS Foundation Trust, UK
| | - K Whiting
- Frimley Health NHS Foundation Trust, UK
| | - J Buck
- Frimley Health NHS Foundation Trust, UK
| | | | - M Meda
- Frimley Health NHS Foundation Trust, UK
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Li C, Renz N, Trampuz A, Ojeda-Thies C. The value of conventional radiographs for diagnosing internal fixation-associated infection. BMC Musculoskelet Disord 2021; 22:411. [PMID: 33947369 PMCID: PMC8097790 DOI: 10.1186/s12891-021-04170-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/10/2021] [Indexed: 12/15/2022] Open
Abstract
Background The aim of the study is to assess the diagnostic value of preoperative conventional radiographs for diagnosing infection associated with internal fixation devices. Methods We prospectively collected data of patients undergoing removal of internal fixation devices for any reason. Infection was diagnosed in case of purulence, sinus tract, positive histopathology and/or positive peri-implant tissue or sonication fluid culture. In radiographs radiolucent lines, implant breakage or displacement, or periosteal reaction were assessed. White blood cell count (WBC) and serum C-reactive protein (CRP) were determined at admission. Results We included 421 surgeries in 380 patients (median age 53.6 years, range 11–98 years), mainly indicated for infection (24.9%), nonunion (20.0%) and symptomatic implants (13.5%). Radiologic signs of infection included radiolucent lines (11.4%); implant breakage (12.4%) or displacement (10.7%); and periosteal reaction (7.1%). Infection was confirmed in 116 cases (27.6%). Only radiolucent lines (OR = 1.86 [95%CI: 1.00–3.38]) and periosteal reaction (OR = 2.48 [95%CI: 1.17–5.26]) were associated with infection, with a low sensitivity (16.4 and 12.1%, respectively), and high specificity (90.5 and 94.8%, respectively). Preoperative WBC and CRP had a sensitivity of 23.0 and 35.3%, and specificity of 91.7 and 89.5%, respectively. Conclusions Radiological signs suggestive of infection were uncommon. Radiolucency and periosteal reaction were associated with infection, though with low sensitivity. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04170-3.
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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), Mittelallee 3, 13353, Berlin, Germany
| | - Nora Renz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Mittelallee 3, 13353, Berlin, Germany
| | - 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), Mittelallee 3, 13353, Berlin, Germany.
| | - Cristina Ojeda-Thies
- Department of Traumatology and Orthopedic Surgery, Hospital Universitario 12 de Octubre, Avda Córdoba s/n, 28041, Madrid, Spain
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Busch A, Jäger M, Engler H, Wasssenaar D, Bielefeld C, Wegner A. Diagnostic Accuracy of Synovial Neopterin, TNF-α and Presepsin in Periprosthetic Joint Infection: A Prospective Study. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2020; 160:299-306. [PMID: 33296945 DOI: 10.1055/a-1303-5105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Due to the lack of specificity of conventional diagnostic tools, the prediction of periprosthetic joint infections (PJI) remains challenging. The purpose of this study was to evaluate the accuracy of synovial fluid neopterin, presepsin, and TNF-α as diagnostic parameters and to compare it to the biomarkers recommended in the 2018 definition of periprosthetic hip and knee infection. METHODS Between August 2018 and July 2019, a prospective cohort study was conducted in 80 patients with painful hip, shoulder, and knee arthroplasty. In addition to medical history, clinical and laboratory data were gathered. PJI was diagnosed based on the 2018 definition of periprosthetic hip and knee infection. Synovial joint fluid was analyzed for biomarker measurement using standard quantitative enzyme immunoassay kits. RESULTS Fifty-three patients (66%) were classified as the aseptic group and twenty-seven patients (34%) as the PJI group. The mean levels of synovial fluid neopterin were significantly higher (p < 0.01) in the PJI group than those in the aseptic group (aseptic 8.3 ± 6.9 vs. PJI 20.9 ± 21.4 nmol/L). The average values of synovial fluid TNF-α and presepsin were not significantly higher in the PJI group than those in the aseptic group (presepsin: aseptic 0.13 ± 0.19 vs. PJI 0.11 ± 0.32 ng/mL, p = 0.08; TNF-α: aseptic 6.6 ± 7.3 vs. PJI 46.3 ± 123.2 pg/mL, p = 0.17). Synovial fluid neopterin was 59% specific and 74% sensitive with a cut-off value of 7.2 nmol/L. The sensitivity and specificity of synovial fluid TNF-α were 63 and 51% with a cut-off value of 3.9 pg/mL. Synovial fluid presepsin was 51% specific and 29% sensitive with a cut-off value above 0.06 ng/mL. CONCLUSION Synovial fluid neopterin appears to a reliable diagnostic marker for detection of PJI. In contrast, synovial fluid TNF-α and presepsin are not suitable to exclude or diagnose PJI.
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Affiliation(s)
- André Busch
- Orthopaedic and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
| | - Marcus Jäger
- Orthopaedic and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
| | - Harald Engler
- Institute of Medical Psychology and Behavioral Immunobiology, University of Duisburg-Essen, Essen, Germany
| | - Dennis Wasssenaar
- Orthopaedic and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
| | - Charlotte Bielefeld
- Orthopaedic and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
| | - Alexander Wegner
- Orthopaedic and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
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4
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Chisari E, Parvizi J. Accuracy of blood-tests and synovial fluid-tests in the diagnosis of periprosthetic joint infections. Expert Rev Anti Infect Ther 2020; 18:1135-1142. [PMID: 32715785 DOI: 10.1080/14787210.2020.1792771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is one of the most complex complications following total joint arthroplasty. Despite significant progress in recent years, the use of blood and synovial biomarkers to diagnose PJI remains a challenge. AREAS COVERED A combination of serological, synovial, microbiological, histological, and radiological investigations is suggested by consensus and international guidelines. Novel biomarkers and molecular methods have shown promise in recent years. The purpose of this review is to provide an update about the biomarkers used to diagnose PJI and highlight their sensitivity and specificity. In addition, guidance on the diagnostic steps and clinical workflow will be included. EXPERT OPINION The diagnostic algorithm developed and validated by the international consensus meeting group is still the most valuable resource to approach PJI diagnosis. The current combination of blood and synovial biomarkers yield acceptable results and good performance. However, there is a need for new biomarkers and further research to understand the limitations of current tests better, as well as explore new options such as alpha-defensin, D-dimer, interleukin-6, and leukocyte esterase.
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Affiliation(s)
- Emanuele Chisari
- Rothman Orthopaedic Institute, Thomas Jefferson University , Philadelphia, PA, USA
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University , Philadelphia, PA, USA
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5
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Li C, Ojeda-Thies C, Xu C, Trampuz A. Meta-analysis in periprosthetic joint infection: a global bibliometric analysis. J Orthop Surg Res 2020; 15:251. [PMID: 32650802 PMCID: PMC7350679 DOI: 10.1186/s13018-020-01757-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/16/2020] [Indexed: 02/07/2023] Open
Abstract
Background Periprosthetic joint infection (PJI) is the most serious complication of joint replacement surgery. Further comorbidities include bedsore, deep vein thrombosis, reinfection, or even death. An increasing number of researchers are focusing on this challenging complication. The aim of the present study was to estimate global PJI research based on bibliometrics from meta-analysis studies. Methods A database search was performed in PubMed, Scopus, and Web of Science. Relevant studies were assessed using the bibliometric analysis. Results A total of 117 articles were included. The most relevant literature on PJI was found on Scopus. China made the highest contributions to global research, followed by the USA and the UK. The institution with the most contributions was the University of Bristol. The journal with the highest number of publications was The Journal of Arthroplasty, whereas the Journal of Clinical Medicine had the shortest acceptance time. Furthermore, the top three frequently used databases were Embase, MEDLINE, and Cochrane. The most frequent number of authors in meta-analysis studies was four. Most studies focused on the periprosthetic hip and knee. The alpha-defensin diagnostic test, preventive measures on antibiotics use, and risk factors of intra-articular steroid injections were the most popular topic in recent years. Conclusion Based on the results of the present study, we found that there was no single database that covered all relevant articles; the optimal method for bibliometric analysis is a combination of databases. The most popular research topics on PJI focused on alpha-defensin, antibiotic use, risk factors of intra-articular steroid injections, and the location of prosthetic hip and knee infection.
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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), Charitéplatz 1, D-10117, 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), Charitéplatz 1, D-10117, Berlin, Germany.
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6
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Ricciardi BF, Muthukrishnan G, Masters EA, Kaplan N, Daiss JL, Schwarz EM. New developments and future challenges in prevention, diagnosis, and treatment of prosthetic joint infection. J Orthop Res 2020; 38:1423-1435. [PMID: 31965585 PMCID: PMC7304545 DOI: 10.1002/jor.24595] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/03/2020] [Indexed: 02/04/2023]
Abstract
Prosthetic joint infection (PJI) is a devastating complication that results in substantial costs to society and patient morbidity. Advancements in our knowledge of this condition have focused on prevention, diagnosis, and treatment, in order to reduce rates of PJI and improve patient outcomes. Preventive measures such as optimization of patient comorbidities, and perioperative antibiotic usage are intensive areas of current clinical research to reduce the rate of PJI. Improved diagnostic tests such as synovial fluid (SF) α-defensin enzyme-linked immunosorbent assay, and nucleic acid-based tests for serum, SF, and tissue cultures, have improved diagnostic accuracy and organism identification. Increasing the diversity of available antibiotic therapy, immunotherapy, and alternative implant coatings remain promising treatments to improve infection eradication in the setting of PJI.
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Affiliation(s)
- Benjamin F Ricciardi
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine,Corresponding author: Benjamin Ricciardi, MD, Center for Musculoskeletal Research, University of Rochester School of Medicine, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, Telephone: 585-341-9763 / Fax: 585-341-9865,
| | - Gowrishankar Muthukrishnan
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - Elysia A Masters
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - Nathan Kaplan
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - John L Daiss
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
| | - Edward M Schwarz
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester School of Medicine
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Busch A, Jäger M, Dittrich F, Wegner A, Landgraeber S, Haversath M. Synovial bone sialoprotein indicates aseptic failure in total joint arthroplasty. J Orthop Surg Res 2020; 15:193. [PMID: 32460850 PMCID: PMC7254687 DOI: 10.1186/s13018-020-01718-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/20/2020] [Indexed: 11/10/2022] Open
Abstract
Background Until today, a reliable diagnostic discrimination between periprosthetic joint infections (PJI) and aseptic failure (AF) after total joint arthroplasty (TJA) remains challenging. Nearly all recent research focused on synovial markers to be elevated in PJI rather than in AF patients. In this study, synovial bone sialoprotein (sBSP) was investigated in PJI and AF arthroplasty patients before revision surgery. Methods sBSP and C-reactive protein (CRP) were determined in synovial fluid samples of PJI (n = 13) patients fulfilling the MSIS criteria and AF (n = 25) patients. Beside descriptive analysis and comparison, computed statistics determined the area under the receiver operating characteristics curve (AUC) to evaluate the discrimination ability of the tested synovial markers. Results In patients with PJI according to the MSIS criteria, mean sBSP was significantly lower: 14.8 ng/ml (95% CI 5.5-24.1) vs. 38.2 ng/ml in the AF group (95% CI 31.1-45.3), p ≤ 0.001. Conversely, mean sCRP was significantly higher in PJI patients: 8.4 μg/ml (95% CI 0-17.2) vs. 1.8 μg/ml in the AF group (95% CI 0.9-2.8), p = 0.032. The AUC of sCRP in PJI patients was 0.71. The AUC of sBSP in AF revision arthroplasty patients was 0.83. The detection of osteolyses was not associated with higher sBSP concentrations. Conclusions Considering the MSIS criteria, significantly higher sBSP concentrations were found in synovial fluid samples of AF compared to PJI patients. sCRP showed only fair, sBSP good discrimination potential. If it is not clear whether PJI is present or not, sBSP may be considered as an add-on synovial marker.
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Affiliation(s)
- André Busch
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien-Hospital Mülheim a.d. Ruhr, 45468, Mülheim an der Ruhr, Germany.,Orthopaedics and Trauma Surgery, University of Duisburg - Essen, 47057, Duisburg, Germany
| | - Marcus Jäger
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien-Hospital Mülheim a.d. Ruhr, 45468, Mülheim an der Ruhr, Germany.,Orthopaedics and Trauma Surgery, University of Duisburg - Essen, 47057, Duisburg, Germany
| | - Florian Dittrich
- Department of Orthopaedics, University of Saarland, 66123, Saarbrücken, Germany
| | - Alexander Wegner
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien-Hospital Mülheim a.d. Ruhr, 45468, Mülheim an der Ruhr, Germany.,Orthopaedics and Trauma Surgery, University of Duisburg - Essen, 47057, Duisburg, Germany
| | - Stefan Landgraeber
- Department of Orthopaedics, University of Saarland, 66123, Saarbrücken, Germany
| | - Marcel Haversath
- Department of Orthopaedics, St. Vinzenz-Krankenhaus, Schloßstraße 85, 40477, Düsseldorf, Germany.
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Busch A, Jäger M, Engler H, Haversath M, Bielefeld C, Landgraeber S, Wegner A. Is Procalcitonin (PCT) a reliable biomarker for preoperative diagnosing of low grade periprosthetic joint infection? A prospective study. BMC Musculoskelet Disord 2020; 21:257. [PMID: 32312264 PMCID: PMC7171844 DOI: 10.1186/s12891-020-03266-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 04/03/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Since a "gold-standard" is missing, diagnosing periprosthetic joint infection (PJI) remains a challenge in orthopedic surgery. The purpose of this study was to evaluate the accuracy of serum and synovial fluid Procalcitonin (S-PCT and SF-PCT) as a diagnostic parameter and to compare it to the biomarkers recommended in the 2018 Definition of periprosthetic hip and knee infection. METHODS Between August 2018 and July 2019, a prospective cohort study was conducted in 70 patients with painful hip, shoulder and knee arthroplasty. Besides medical history, clinical and laboratory data was gathered. PJI was diagnosed based on the 2018 Definition of periprosthetic hip and knee infection. Preoperative blood and synovial joint fluid were taken for PCT measurement. S-PCT and SF-PCT levels were measured using standard quantitative PCT enzyme immunoassays. RESULTS Twenty three patients (33%) were classified as the PJI group and fourty seven patient (67%) as the aseptic group. The mean levels of S-PCT were significantly (p < 0.001) higher in the PJI group than those in the aseptic group (PJI 0.05 ± 0.21 ng/mL (0.0-1.03) vs. aseptic 0.02 ± 0.03 ng/mL (0.0-0.18)). In synovial fluid, the mean PCT values in the aseptic group were significantly higher (p < 0.001) than those of PJI group (PJI 2.7 ± 1.4 ng/mL (0.53-9.7) vs. aseptic 8.7 ± 2.5 ng/mL (0.25-87.9)). S- PCT, with a cut-off level of 0.5 ng/mL, had a sensitivity of 13.0% and a specificity of 91.0%. SF-PCT, with a cut-off level of 5.0 ng/mL, had a sensitivity of 13.0% and a specificity of 52.0%. CONCLUSION S-PCT and SF-PCT appeared to be no reliable biomarkers in the differential diagnosis of PJI from aseptic loosening in total joint arthroplasty.
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Affiliation(s)
- André Busch
- Department of Orthopaedics and Trauma Surgery, University of Duisburg - Essen, Hufelandstr 55, 45147, Essen, Germany.
| | - Marcus Jäger
- Department of Orthopaedics and Trauma Surgery, University of Duisburg - Essen, Hufelandstr 55, 45147, Essen, Germany
| | - Harald Engler
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Marcel Haversath
- Department of Orthopaedics and Trauma Surgery, University of Duisburg - Essen, Hufelandstr 55, 45147, Essen, Germany
| | - Charlotte Bielefeld
- Department of Orthopaedics and Trauma Surgery, University of Duisburg - Essen, Hufelandstr 55, 45147, Essen, Germany
| | - Stefan Landgraeber
- Department of Orthopaedics and Trauma Surgery, University of Duisburg - Essen, Hufelandstr 55, 45147, Essen, Germany.,Department of Orthopaedics, University of Saarland, Saarbrücken, Germany
| | - Alexander Wegner
- Department of Orthopaedics and Trauma Surgery, University of Duisburg - Essen, Hufelandstr 55, 45147, Essen, Germany
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Lapić I, Padoan A, Bozzato D, Plebani M. Erythrocyte Sedimentation Rate and C-Reactive Protein in Acute Inflammation. Am J Clin Pathol 2020; 153:14-29. [PMID: 31598629 DOI: 10.1093/ajcp/aqz142] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess the diagnostic accuracy of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in acute inflammation. METHODS PubMed and Scopus were searched and eligible articles were screened for methodologic quality using the Quality Assessment of the Diagnostic Accuracy Studies-Revised. Meta-analysis with calculation of pooled sensitivity (Se), specificity (Sp), and summary area under the curve (SAUC) was performed. RESULTS Twenty-nine studies were eligible. Se and Sp were 0.78 and 0.68 (SAUC = 0.80) for ESR in orthopedic infections and 0.79 and 0.70 (SAUC = 0.81) for CRP. For the diagnosis of other various inflammatory conditions, CRP had a superior diagnostic accuracy, with a Se of 0.86, Sp of 0.67, and SAUC of 0.86 compared with a Se of 0.77, Sp of 0.59, and SAUC of 0.75 for ESR. Heterogeneity among studies was elevated. Combined use of ESR and CRP yielded higher diagnostic accuracy. CONCLUSIONS Despite observed heterogeneity among studies, ESR and CRP have a similar diagnostic accuracy in assessment of inflammation, especially in orthopedic conditions.
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Affiliation(s)
- Ivana Lapić
- Department of Laboratory Diagnostics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Andrea Padoan
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
- Department of Medicine–DIMED, University of Padova, Padova, Italy
| | - Dania Bozzato
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
- Department of Medicine–DIMED, University of Padova, Padova, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
- Department of Medicine–DIMED, University of Padova, Padova, Italy
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10
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Han X, Xie K, Jiang X, Wang L, Wu H, Qu X, Yan M. Synovial fluid α-defensin in the diagnosis of periprosthetic joint infection: the lateral flow test is an effective intraoperative detection method. J Orthop Surg Res 2019; 14:274. [PMID: 31455372 PMCID: PMC6712677 DOI: 10.1186/s13018-019-1320-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 08/16/2019] [Indexed: 12/29/2022] Open
Abstract
Background Synovial fluid α-defensin is a valuable biomarker for periprosthetic joint infection (PJI). Its diagnostic value for PJI has been widely evaluated recently, but results are inconsistent, especially for different test methods. The objective of this study was to evaluate the diagnostic value of laboratory-based immunoassay and lateral flow testing for the detection of α-defensin against hip and knee PJI. Methods We systematically searched MEDLINE and EMBASE for articles on the diagnostic accuracy of α-defensin for PJI published up to September 2018. The pooled sensitivity, specificity, area under the curve (AUC), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were calculated for the evaluation of the diagnostic value of α-defensin for PJI. Results Nineteen studies were included. Eleven evaluated laboratory-based immunoassay, and 10 evaluated the lateral flow test results. The pooled sensitivity, specificity, AUC, PLR, NLR, and DOR of laboratory-based immunoassays were 0.96 (95% confidence interval [CI] 0.90–0.98), 0.97 (95% CI 0.95–0.99), 0.99 (95% CI 0.98–1.00), 35.0 (95% CI 18.5–66.2), 0.04 (95% CI 0.02–0.11), and 811 (95% CI 220–2990), respectively. The pooled sensitivity, specificity, AUC, PLR, NLR, and DOR of the lateral flow test were 0.86 (95% CI 0.81–0.91), 0.96 (95% CI 0.93–0.98), 0.95 (95% CI 0.93–0.97), 21.2 (95% CI 11.7–38.5), 0.14 (95% CI 0.10–0.21), and 148 (95% CI 64–343), respectively. Conclusions Laboratory-based immunoassay of α-defensin is highly accurate for the diagnosis of hip and knee PJI. The lateral flow test is less sensitive but still a useful intraoperative detection tool for PJI.
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Affiliation(s)
- Xuequan Han
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Kai Xie
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Xu Jiang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Liao Wang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Haishan Wu
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, 145 Middle Shandong Road, Shanghai, China
| | - Mengning Yan
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China.
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11
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Unter Ecker N, Suero EM, Gehrke T, Haasper C, Zahar A, Lausmann C, Hawi N, Citak M. Serum C-reactive protein relationship in high- versus low-virulence pathogens in the diagnosis of periprosthetic joint infection. J Med Microbiol 2019; 68:910-917. [DOI: 10.1099/jmm.0.000958] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Niklas Unter Ecker
- 1 Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
| | - Eduardo M. Suero
- 2 Trauma Department, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany
| | - Thorsten Gehrke
- 1 Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
| | - Carl Haasper
- 3 Department of Orthopaedic Surgery, AMEOS Klinikum Seepark Geestland, Langener Str. 66, 27607 Geestland, Germany
| | - Akos Zahar
- 1 Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
| | - Christian Lausmann
- 1 Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
| | - Nael Hawi
- 2 Trauma Department, Hannover Medical School, Carl-Neuberg Strasse 1, 30625 Hannover, Germany
| | - Mustafa Citak
- 1 Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
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12
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Carli AV, Abdelbary H, Ahmadzai N, Cheng W, Shea B, Hutton B, Sniderman J, Philip Sanders BS, Esmaeilisaraji L, Skidmore B, Gauthier-Kwan OY, Bunting AC, Gauthier P, Crnic A, Logishetty K, Moher D, Fergusson D, Beaulé PE. Diagnostic Accuracy of Serum, Synovial, and Tissue Testing for Chronic Periprosthetic Joint Infection After Hip and Knee Replacements: A Systematic Review. J Bone Joint Surg Am 2019; 101:635-649. [PMID: 30946198 DOI: 10.2106/jbjs.18.00632] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint replacement. Patients with chronic PJI report a substantially lower quality of life and face a higher risk of short-term mortality. Establishing a diagnosis of chronic PJI is challenging because of conflicting guidelines, numerous tests, and limited evidence. Delays in diagnosing PJI are associated with poorer outcomes and morbid revision surgery. The purpose of this systematic review was to compare the diagnostic accuracy of serum, synovial, and tissue-based tests for chronic PJI. METHODS This review adheres to the Cochrane Collaboration's diagnostic test accuracy methods for evidence searching and syntheses. A detailed search of MEDLINE, Embase, the Cochrane Library, and the grey literature was performed to identify studies involving the diagnosis of chronic PJI in patients with hip or knee replacement. Eligible studies were assessed for quality and bias using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Meta-analyses were performed on tests with sufficient data points. Summary estimates and hierarchical summary receiver operating characteristic (HSROC) curves were obtained using a bivariate model. RESULTS A total of 12,616 citations were identified, and 203 studies met the inclusion criteria. Of these 203 studies, 170 had a high risk of bias. Eighty-three unique PJI diagnostic tests were identified, and 17 underwent meta-analyses. Laboratory-based synovial alpha-defensin tests and leukocyte esterase reagent (LER) strips (2+) had the best performance, followed by white blood-cell (WBC) count, measurement of synovial C-reactive protein (CRP) level, measurement of the polymorphonuclear neutrophil percentage (PMN%), and the alpha-defensin lateral flow test kit (Youden index ranging from 0.78 to 0.94). Tissue-based tests and 3 serum tests (measurement of interleukin-6 [IL-6] level, CRP level, and erythrocyte sedimentation rate [ESR]) had a Youden index between 0.61 to 0.75 but exhibited poorer performance compared with the synovial tests mentioned above. CONCLUSIONS The quality of the literature pertaining to chronic PJI diagnostic tests is heterogeneous, and the studies are at a high risk for bias. We believe that greater transparency and more complete reporting in studies of diagnostic test results should be mandated by peer-reviewed journals. The available literature suggests that several synovial fluid-based tests perform well for diagnosing chronic PJI and their use is recommended in the work-up of any suspected case of chronic PJI. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alberto V Carli
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Nadera Ahmadzai
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Beverley Shea
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jhase Sniderman
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Leila Esmaeilisaraji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Becky Skidmore
- Independent Information Specialist, Ottawa, Ontario, Canada
| | | | | | - Paul Gauthier
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Agnes Crnic
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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13
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Barrack R, Bhimani S, Blevins JL, Blevins K, Demetres M, Figgie M, Fillingham Y, Goodman S, Huddleston J, Kahlenberg C, Lautenbach C, Lin J, Lonner J, Lynch M, Malkani A, Martin L, Mirza S, Rahim Najjad MK, Penna S, Richardson S, Sculco P, Shahi A, Szymonifka J, Wang Q. General Assembly, Diagnosis, Laboratory Test: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S187-S195. [PMID: 30348554 DOI: 10.1016/j.arth.2018.09.070] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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14
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Marson BA, Deshmukh SR, Grindlay DJC, Scammell BE. Alpha-defensin and the Synovasure lateral flow device for the diagnosis of prosthetic joint infection: a systematic review and meta-analysis. Bone Joint J 2018; 100-B:703-711. [PMID: 29855233 DOI: 10.1302/0301-620x.100b6.bjj-2017-1563.r1] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims The aim of this review was to evaluate the available literature and to calculate the pooled sensitivity and specificity for the different alpha-defensin test systems that may be used to diagnose prosthetic joint infection (PJI). Materials and Methods Studies using alpha-defensin or Synovasure (Zimmer Biomet, Warsaw, Indiana) to diagnose PJI were identified from systematic searches of electronic databases. The quality of the studies was evaluated using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) tool. Meta-analysis was completed using a bivariate model. Results A total of 11 eligible studies were included. The median QUADAS score was 13 (interquartile range 13 to 13) out of 14. Significant conflicts of interest were identified in five studies. The pooled sensitivity for the laboratory alpha-defensin test was 0.95 (95% confidence interval (CI) 0.91 to 0.98) and the pooled specificity was 0.97 (95% CI 0.95 to 0.98) for four studies with a threshold level of 5.2 mgl-1 The pooled sensitivity for the lateral flow cassette test was 0.85 (95% CI 0.74 to 0.92) and the pooled specificity was 0.90 (95% CI 0.91 to 0.98). There was a statistically significant difference in sensitivity (p = 0.019), but not specificity (p = 0.47). Conclusion Laboratory-based alpha-defensin testing remains a promising tool for diagnosing PJI. The lateral flow cassette has a significantly lower performance and pooled results are comparable to the leucocyte esterase test. Further studies are required before the widespread adoption of the lateral flow cassette alpha-defensin test. Cite this article: Bone Joint J 2018;100-B:703-11.
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Affiliation(s)
- B A Marson
- Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - S R Deshmukh
- Nottingham Elective Orthopaedic Service, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK
| | - D J C Grindlay
- Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - B E Scammell
- Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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Screening for Infection Before Revision Hip Arthroplasty: A Meta-analysis of Likelihood Ratios of Erythrocyte Sedimentation Rate and Serum C-reactive Protein Levels. J Am Acad Orthop Surg 2017; 25:809-817. [PMID: 29176504 DOI: 10.5435/jaaos-d-16-00642] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Diagnosing periprosthetic joint infection (PJI) before revision hip arthroplasty is critical to ensure effective treatment of patients undergoing surgery for reasons other than infection. The main objective of our study is to determine whether the erythrocyte sedimentation rate (ESR) and the serum C-reactive protein (CRP) level are sufficient to use for testing to rule out infection in patients undergoing revision hip surgery. METHODS We performed a systematic review of the literature in the MEDLINE, Ovid, and Embase databases. We included studies in which the investigators used the ESR (>30 mm/h) and serum CRP level (>10 mg/L) for the diagnosis of PJI of the hip. We obtained meta-estimates of sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-). RESULTS From 511 articles, we analyzed 12 studies in which the investigators reported data on 2,736 patients. Sensitivity and specificity for the ESR were 0.860 (95% confidence interval [CI], 0.825 to 0.890) and 0.723 (95% CI, 0.704 to 0.742), respectively, and for the CRP level were 0.869 (95% CI, 0.835 to 0.899) and 0.786 (95% CI, 0.769 to 0.803), respectively. For the ESR, LR+ was 3.42 (95% CI, 2.55 to 4.59) and LR- was 0.22 (95% CI, 0.12 to 0.41). For the CRP level, LR+ was 4.18 (95% CI, 3.42 to 5.11) and LR- was 0.20 (95% CI, 0.12 to 0.32). DISCUSSION With a low pretest probability of PJI, a negative test result for either the ESR or CRP level is enough to rule out infection before revision hip arthroplasty. LEVEL OF EVIDENCE III.
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16
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The Diagnostic Utility of Synovial Fluid Markers in Periprosthetic Joint Infection: A Systematic Review and Meta-analysis. J Am Acad Orthop Surg 2017; 25:763-772. [PMID: 29059113 DOI: 10.5435/jaaos-d-16-00548] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION This study is a systematic review of all reported synovial fluid markers for the diagnosis of periprosthetic joint infection and a meta-analysis of the most frequently reported markers to identify those of greatest diagnostic utility. METHODS A search of six databases was conducted to identify all studies evaluating the utility of synovial fluid markers in the diagnosis of periprosthetic joint infection. Two observers assessed methodologic quality and extracted data independently. A meta-analysis of the most frequently reported markers was performed. RESULTS Twenty-three studies were included in the meta-analysis. The most common markers (and their respective area under the curve) were interleukin-17 (0.974), leukocyte esterase (0.968), α-defensin (0.958), interleukin-6 (0.956), interleukin-1β (0.948), and C-reactive protein (0.927). Among these markers, α-defensin had the highest diagnostic odds ratio but did not achieve statistically significant superiority. CONCLUSION The most frequently studied synovial fluid markers for the diagnosis of periprosthetic joint infection are C-reactive protein, leukocyte esterase, interleukin-6, interleukin-1β, α-defensin, and interleukin-17, all of which have high diagnostic utility. LEVEL OF EVIDENCE Level II.
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17
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Serum and Synovial Fluid Interleukin-6 for the Diagnosis of Periprosthetic Joint Infection. Sci Rep 2017; 7:1496. [PMID: 28473693 PMCID: PMC5431429 DOI: 10.1038/s41598-017-01713-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 03/31/2017] [Indexed: 01/29/2023] Open
Abstract
A gold standard for diagnosis of periprosthetic joint infection (PJI) has not yet been established. The objective of this study was to evaluate the diagnostic value of serum and synovial fluid interleukin (IL)-6 levels for PJI. The MEDLINE and EMBASE databases were searched for studies describing PJI diagnosis using serum and synovial fluid IL-6 and published between January 1990 and October 2016. Seventeen studies were included in the analysis. The pooled sensitivities of serum and synovial fluid IL-6 were 0.72 (95% confidence interval [CI]: 0.63–0.80) and 0.91 (95% CI: 0.82–0.96), respectively. The pooled specificities of serum and synovial fluid IL-6 were 0.89 (95% CI: 0.77–0.95) and 0.90 (95% CI: 0.84–0.95), respectively. The pooled diagnostic odds ratios (DORs) of serum and synovial fluid IL-6 were 20 (95% CI: 7–58) and 101 (95% CI: 28–358), respectively, and the pooled areas under the curve (AUCs) were 0.83 (95% CI: 0.79–0.86) and 0.96 (95% CI: 0.94–0.98), respectively. Synovial fluid IL-6 had high diagnostic value for PJI. Although serum IL-6 test was less sensitive than synovial fluid IL-6 test, it may be regularly prescribed for patients with prosthetic failure owing to its high specificity.
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18
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Xie K, Qu X, Yan M. Procalcitonin and α-Defensin for Diagnosis of Periprosthetic Joint Infections. J Arthroplasty 2017; 32:1387-1394. [PMID: 27817992 DOI: 10.1016/j.arth.2016.10.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 09/27/2016] [Accepted: 10/03/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Current methods to diagnose periprosthetic joint infection (PJI) before revision surgery have limited diagnostic accuracy. This meta-analysis was performed to estimate the accuracy of procalcitonin (PCT) and α-defensin for the diagnosis of PJI. METHODS Articles on the diagnostic value of PCT or α-defensin for PJI diagnosis were searched in the PubMed database. Sensitivity, specificity, diagnostic odds ratio, the area under the curve of summary receiver operating characteristic curves (AUC), the positive likelihood ratio, and the negative likelihood ratio were calculated to evaluate the diagnostic ability of PCT and the α-defensin test for the diagnosis of PJI. RESULTS The pooled sensitivities for detecting PJI using PCT and α-defensin were 0.53 (95% confidence interval [CI], 0.24-0.80) and 0.96 (95% CI, 0.85-0.99), respectively. The pooled specificities for detecting PJI using PCT and α-defensin were 0.92 (95% CI, 0.45-0.99) and 0.95 (95% CI, 0.89-0.98), respectively. The pooled diagnostic odds ratios for detecting PJI using PCT and α-defensin were 13 (95% CI, 3-70) and 496 (95% CI, 71-3456), respectively. The pooled AUCs for PCT and α-defensin were 0.76 (95% CI, 0.72-0.80) and 0.99 (95% CI, 0.97-0.99), respectively. The positive likelihood ratio and the negative likelihood ratio of PCT were 6.8 (95% CI, 1.0-48.1) and 0.51 (95% CI, 0.31-0.84), respectively, whereas those of α-defensin were 19.6 (95% CI, 8.2-46.8) and 0.04 (95% CI, 0.01-0.17), respectively. CONCLUSION Synovial fluid α-defensin has a great potential to diagnose PJI.
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Affiliation(s)
- Kai Xie
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Xinhua Qu
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Mengning Yan
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
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Wang C, Wang Q, Li R, Duan JY, Wang CB. Synovial Fluid C-reactive Protein as a Diagnostic Marker for Periprosthetic Joint Infection: A Systematic Review and Meta-analysis. Chin Med J (Engl) 2017; 129:1987-93. [PMID: 27503025 PMCID: PMC4989431 DOI: 10.4103/0366-6999.187857] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Periprosthetic joint infection (PJI) is the main cause of failure following total joint arthroplasty. Until now, the diagnosis of PJI is still confronted with technical limitations, and the question of whether synovial fluid biomarker, C-reactive protein (CRP), can provide high value in the diagnosis of PJI remains unanswered and, therefore, was the aim of the study. Methods: First, we conducted a systematic review on CRP in the diagnosis of PJI by searching online databases using keywords such as “periprosthetic joint infection”, “synovial fluid”, and “C-reactive protein”. Eligible studies providing sufficient data to construct 2 × 2 contingency tables were then selected based on the list of criteria and the quality of included studies was assessed subsequently. Finally, the reported sensitivity, specificity, diagnostic odds ratio (DOR), summary receiver operating characteristic (SROC) curve, and the area under the SROC (AUSROC) were pooled together and used to evaluate overall diagnostic performance. Results: Seven studies were included in our review, six of which comprising a total of 456 participants were further investigated in our meta-analysis. The pooled sensitivity, specificity, and DOR were 0.92 (95% confidence interval [CI]: 0.86–0.96), 0.90 (95% CI: 0.87–0.93), and 101.40 (95% CI: 48.07–213.93), respectively. The AUSROC was 0.9663 (standard error, 0.0113). Conclusions: Synovial fluid CRP is a good biomarker for the diagnosis of PJI with high sensitivity and specificity.
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Affiliation(s)
- Chi Wang
- Department of Clinical Laboratory, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Qi Wang
- Outpatient Department of Chinese People's Liberation Army, Beijing, 101123, China
| | - Rui Li
- Department of Orthopedics, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Jin-Yan Duan
- Department of Clinical Laboratory, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Cheng-Bin Wang
- Department of Clinical Laboratory, Chinese People's Liberation Army General Hospital, Beijing 100853, China
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20
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Accuracy of diagnostic tests for prosthetic joint infection: a systematic review. Knee Surg Sports Traumatol Arthrosc 2016; 24:3064-3074. [PMID: 27377905 DOI: 10.1007/s00167-016-4230-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 06/22/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE There are few evidence-based recommendations on the most effective methods for diagnosing prosthetic joint infections (PJIs), and the potency of tests in relation to each other also remains vague. This systematic review aimed to (1) identify systematic reviews reporting accuracies of available approaches for diagnosing PJI, (2) critically appraise their quality and bias, and (3) compare the available approaches in terms of accuracy for diagnosing PJI. METHODS PubMed and EMBASE databases were searched for meta-analyses reporting accuracies of different diagnostic modalities for PJIs. Thirteen systematic reviews met the inclusion and exclusion criteria, and their data were extracted and tabulated by two reviewers in duplicate and independent manners. RESULTS The 13 articles reported diagnostic accuracy from 278 clinical studies comprising 27,754 patients and evaluating 13 diagnostic tests grouped into 7 broad categories. Implant sonication had the highest positive likelihood ratio (17.2), followed by bacteriology (15.3) and synovial fluid differentiated cytology (13.3). The highest negative likelihood ratio was for interleukin (IL)-6 serum marker (0.03) followed by synovial fluid cytology and differentiation (0.12 and 0.13, respectively). CONCLUSION The diagnostic tests that are most likely to rule out PJI include serum IL-6, serum C-reactive protein, and synovial fluid cytology. On the other hand, the diagnostic test that is most likely to confirm PJI is implant sonication. Nuclear imaging showed low overall accuracy as diagnostic tests for PJI. The findings of this study could enable clinicians to confirm or rule out PJIs using the most accurate, rapid, least invasive, and cost-effective tools available, thereby enabling fast treatment before formation of resistant biofilms and degradation of patient conditions. LEVEL OF EVIDENCE Systematic review, Level IV.
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21
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Bozhkova S, Tikhilov R, Labutin D, Denisov A, Shubnyakov I, Razorenov V, Artyukh V, Rukina A. Failure of the first step of two-stage revision due to polymicrobial prosthetic joint infection of the hip. J Orthop Traumatol 2016; 17:369-376. [PMID: 27387172 PMCID: PMC5071240 DOI: 10.1007/s10195-016-0417-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 06/26/2016] [Indexed: 12/16/2022] Open
Abstract
Background The unsuccessful treatment of prosthetic joint infection (PJI) with two-stage revision leads to infection recurrence. The objectives of the study were to assess the clinical and demographic characteristics of patients with polymicrobial PJI, and to evaluate the role of the microbial profile involved in PJI in the risk of infection recurrence after the first step of two-stage revision surgery. Materials and methods A retrospective analysis of 189 cases of culture-positive PJI following total hip replacement over a 5-year period was performed. The demographic characteristics of patients, clinical symptoms, microbiology cultures of intraoperative biopsies, laboratory values of C-reactive protein (CRP), white blood cell count and erythrocyte sedimentation rate were analyzed. Patients were divided into two groups—135 with monomicrobial and 54 with polymicrobial infection. Results Of all patients, 68.9 % in the monomicrobial and 83.3 % in the polymicrobial group had a body mass index >25 kg/m2 (p = 0.05). The median CRP values were 5.7 mg/L (IQR 4.0–10.0 mg/L) in the monomicrobial compared to 8.8 mg/L (IQR 5.0–27 mg/L) in the polymicrobial group (p = 0.01). The percentage of successful outcomes was 27.8 % in patients with microbial associations (p < 0.0001). Gram-negative pathogens caused polymicrobial PJI in 61.5 % of cases with infection recurrence (OR 4.4; 95 % CI 1.18–16.37; p = 0.03). Conclusions Overweight and obese patients or those with elevated CRP had a greater risk of polymicrobial PJI. They were predisposed to recurrence of infection after the first step of two-stage revision. An unsuccessful outcome was more likely in cases with polymicrobial infection compared to those with monomicrobial infection. In addition, the presence of multidrug-resistant strains of Gram-negative bacteria substantially increased the risk of PJI treatment being unsuccessful. Level of evidence Level III, therapeutic study.
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Affiliation(s)
- Svetlana Bozhkova
- Vreden Russian Research Institute of Traumatology and Orthopaedics, Akademika Baikova Str., 8, 195427, St. Petersburg, Russian Federation.
| | - Rashid Tikhilov
- Vreden Russian Research Institute of Traumatology and Orthopaedics, Akademika Baikova Str., 8, 195427, St. Petersburg, Russian Federation.,Mechnikov North-Western State Medical University, St. Petersburg, Russian Federation
| | - Dmitry Labutin
- Vreden Russian Research Institute of Traumatology and Orthopaedics, Akademika Baikova Str., 8, 195427, St. Petersburg, Russian Federation
| | - Alexey Denisov
- Vreden Russian Research Institute of Traumatology and Orthopaedics, Akademika Baikova Str., 8, 195427, St. Petersburg, Russian Federation
| | - Igor Shubnyakov
- Vreden Russian Research Institute of Traumatology and Orthopaedics, Akademika Baikova Str., 8, 195427, St. Petersburg, Russian Federation
| | - Vadim Razorenov
- Vreden Russian Research Institute of Traumatology and Orthopaedics, Akademika Baikova Str., 8, 195427, St. Petersburg, Russian Federation
| | - Vasilii Artyukh
- Vreden Russian Research Institute of Traumatology and Orthopaedics, Akademika Baikova Str., 8, 195427, St. Petersburg, Russian Federation
| | - Anna Rukina
- Vreden Russian Research Institute of Traumatology and Orthopaedics, Akademika Baikova Str., 8, 195427, St. Petersburg, Russian Federation
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22
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Abstract
Periprosthetic joint infection (PJI) is one of the most feared and challenging complications following total knee arthroplasty. We provide a detailed description of our current understanding regarding the management of PJI of the knee, including diagnostic aids, pre-operative planning, surgical treatment, and outcome.
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Affiliation(s)
- T Gehrke
- Helios Endo-Klinik, Holstenstr.2, 22767 Hamburg, Germany
| | - P Alijanipour
- Rothman Institute, 125 S 9th St Ste 1000, Philadelphia, PA 19107, USA
| | - J Parvizi
- Rothman Institute, 125 S 9th St Ste 1000, Philadelphia, PA 19107, USA
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