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Tarabichi S, Goh GS, Fraval A, Lizcano JD, Abe EA, Courtney PM, Namdari S, Parvizi J. Serum and Synovial Markers in the Diagnosis of Periprosthetic Joint Infection of the Hip, Knee, and Shoulder: An Algorithmic Approach. J Bone Joint Surg Am 2024; 106:1221-1230. [PMID: 38776388 DOI: 10.2106/jbjs.23.00669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
➤ No single test has demonstrated absolute accuracy for the diagnosis of periprosthetic joint infection (PJI).➤ Physicians rely on a combination of serological tests, synovial markers, and clinical findings plus clinical judgment to help to guide preoperative decision-making.➤ Several organizations have proposed criteria for the diagnosis of hip or knee PJI on which we now rely.➤ Given that shoulder arthroplasty has only recently become popular, it is possible that a shoulder-specific definition of PJI will be introduced in the coming years.➤ Although a number of serum and synovial markers have demonstrated high accuracy for the diagnosis of PJI of the hip and knee, further research is needed in order to identify markers that may be more suitable for the diagnosis of shoulder PJI and for the potential development and identification of specific serological tests as screening tools for PJI.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrew Fraval
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Elizabeth A Abe
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Surena Namdari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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Altsitzioglou P, Avgerinos K, Karampikas V, Gavriil P, Vlachos A, Soucacou F, Zafiris I, Kontogeorgakos V, Papagelopoulos PJ, Mavrogenis AF. Point of care testing for the diagnosis of periprosthetic joint infections: a review. SICOT J 2024; 10:24. [PMID: 38847648 PMCID: PMC11160401 DOI: 10.1051/sicotj/2024019] [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: 04/27/2024] [Accepted: 05/04/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) remains a major complication following total joint arthroplasties (TJA), significantly affecting patient outcomes and healthcare costs. Despite advances in diagnostic techniques, challenges persist in accurately diagnosing PJI, underscoring the need for effective point-of-care testing (POCT). METHODS This review examines the current literature and latest developments in POCT for diagnosing PJI, focusing on biomarkers such as alpha-defensin, leukocyte esterase, calprotectin, and C-reactive protein (CRP). Criteria from various societies like the Musculoskeletal Infection Society, Infectious Diseases Society of America, and the International Consensus Meeting were compared to evaluate the effectiveness of these biomarkers in a point-of-care setting. RESULTS POCT provides rapid results essential for the timely management of PJI, with alpha-defensin and leukocyte esterase showing high specificity and sensitivity. Recent advancements have introduced novel biomarkers like calprotectin, which demonstrate high diagnostic accuracy. However, challenges such as the variability in test performance and the need for validation under different clinical scenarios remain. DISCUSSION While POCT for PJI shows promising results, their integration into clinical practice requires standardized protocols and further validation. The evolution of these diagnostic tools offers a potential shift toward more personalized and immediate care, potentially improving outcomes for patients undergoing TJA.
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Affiliation(s)
- Pavlos Altsitzioglou
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Konstantinos Avgerinos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vasileios Karampikas
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis Gavriil
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Apostolos Vlachos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Fotini Soucacou
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Zafiris
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vasileios Kontogeorgakos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis J Papagelopoulos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas F Mavrogenis
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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de Sandes Kimura O, Mozella A, Cobra H, Maciel Saraiva AC, Carvalho de Almendra Freitas EH, Cury Fernandes MB, Matheus Guimarães JA, Defino H, Leal AC. Neutrophil Extracellular Trap-related Biomarkers Are Increased in the Synovial Fluid of Patients With Periprosthetic Joint Infections. Clin Orthop Relat Res 2024; 482:727-733. [PMID: 37882792 PMCID: PMC10937003 DOI: 10.1097/corr.0000000000002891] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 09/15/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The diagnosis of periprosthetic joint infection (PJI) is a major challenge in clinical practice. The role of neutrophils in fighting infection has been increasingly understood, and one mechanism of action of these cells is neutrophil extracellular traps. However, little is known about this process in PJI. QUESTIONS/PURPOSES (1) Are the biomarkers of neutrophil extracellular trap formation (citrullinated histone H3 [H3Cit], cell-free DNA [cf-DNA], and myeloperoxidase [MPO]) increased in the synovial fluid of patients with PJI? (2) What is the diagnostic accuracy of biomarkers of neutrophil extracellular trap formation for PJI? METHODS Between May 2020 and March 2021, 43 patients who underwent revision THA or TKA were enrolled in this study. Eleven patients were excluded and 32 patients were categorized into the PJI group (n = 16) or non-PJI group (n = 16) according to the 2018 Second International Consensus Meeting on Musculoskeletal Infection criteria. There were 15 men and 17 women in this study, with a median (range) age of 70 years (60 to 80 years). Twenty-seven patients had TKA and five had THA. We measured cf-DNA, MPO, and H3Cit in synovial fluid. The sensitivity, specificity, and receiver operating characteristic curve were calculated for each biomarker using the Musculoskeletal Infection Society criteria as the gold standard for diagnosis and considering a clinical surveillance of 2 years for patients in the non-PJI group. RESULTS Patients with PJI had higher levels of synovial fluid cf-DNA (median [range] 130 ng/µL [18 to 179] versus 2 ng/µL [0 to 6]; p < 0.001), MPO (1436 ng/µL [55 to 3996] versus 0 ng/µL [0 to 393]; p < 0.001), and H3Cit (2115 ng/µL [5 to 2885] versus 3 ng/µL [0 to 87]; p < 0.001) than those in the non-PJI group. In receiver operating characteristic curve analyses, we observed near-perfect performance for all biomarkers evaluated, with an area under the curve of 1 (95% CI 0.9 to 1), 0.98 (95% CI 0.9 to 1), and 0.94 (95% CI 0.8 to 0.99) for cf-DNA, MPO, and H3Cit, respectively. The sensitivity for detecting PJI using synovial fluid was 100% for cf-DNA, 94% for MPO, and 88% for H3Cit. The specificity was 100% for cf-DNA and MPO, and 88% for H3Cit. CONCLUSION Our results show that neutrophils in the periprosthetic microenvironment release neutrophil extracellular traps as part of the bactericidal arsenal to fight infection. These results allow a better understanding of the cellular and molecular processes that occur in this microenvironment, enabling the design of more assertive strategies for identifying new biomarkers and improving the available ones. Novel studies are needed to define whether and how neutrophil extracellular trap-related biomarkers can be useful for diagnosing PJI. LEVEL OF EVIDENCE Level II, diagnostic study.
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Affiliation(s)
- Osamu de Sandes Kimura
- Center for Surgery of Hip, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Alan Mozella
- Center for Surgery of Knee, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Hugo Cobra
- Center for Surgery of Knee, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | | | | | | | | | - Helton Defino
- Department of Orthopaedics and Anaesthesiology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ana Carolina Leal
- Teaching and Research Division, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
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Alkadhem MF, Wagenmakers-Huizenga LMF, Wouthuyzen-Bakker M, Muller Kobold AC. (Pre)analytical considerations concerning the analysis of synovial calprotectin. Clin Chem Lab Med 2024; 62:199-206. [PMID: 37529863 DOI: 10.1515/cclm-2023-0484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/26/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVES Several studies have demonstrated that synovial calprotectin is a highly accurate biomarker in diagnosing periprosthetic joint infections (PJI). Assuring reliability is of great importance and coincides with adequate preanalytical handling. This study focuses on potentially interfering factors. METHODS To assess the stability of synovial calprotectin, the effect of time, storage temperature, EDTA, freeze-thaw cycles, viscosity, and blood and lipid contamination was investigated. In the blood and lipid contamination experiments, hemolyzed and non-hemolyzed blood, homogenized adipose tissue, intralipid and chylomicrons were added. The effect of viscosity was investigated using freeze-thaw cycles, enzymatic pretreatment and sonification. RESULTS No effect on synovial calprotectin levels was observed in synovial samples kept at room temperature compared to samples kept at 4 °C for up to seven days of storage. Freeze-thaw cycles did not result in significantly different calprotectin levels, although samples without EDTA resulted in higher recoveries after 1 and 2 freeze-thaw cycles. Blood and lipid contamination did not interfere with accurate synovial calprotectin analysis. Sample pretreatment to reduce sample viscosity by pretreating samples with DNAse and/or hyaluronidase did not influence calprotectin analysis. Sonification, however, resulted in increased calprotectin values. CONCLUSIONS Synovial calprotectin is a stable biomarker and its analysis is not easily influenced by potential interfering factors.
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Affiliation(s)
- Mohammed F Alkadhem
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lucie M F Wagenmakers-Huizenga
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anneke C Muller Kobold
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Piuzzi NS, Klika AK, Lu Q, Higuera-Rueda CA, Stappenbeck T, Visperas A. Periprosthetic joint infection and immunity: Current understanding of host-microbe interplay. J Orthop Res 2024; 42:7-20. [PMID: 37874328 DOI: 10.1002/jor.25723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/19/2023] [Accepted: 10/17/2023] [Indexed: 10/25/2023]
Abstract
Periprosthetic joint infection (PJI) is a major complication of total joint arthroplasty. Even with current treatments, failure rates are unacceptably high with a 5-year mortality rate of 26%. Majority of the literature in the field has focused on development of better biomarkers for diagnostics and treatment strategies including innovate antibiotic delivery systems, antibiofilm agents, and bacteriophages. Nevertheless, the role of the immune system, our first line of defense during PJI, is not well understood. Evidence of infection in PJI patients is found within circulation, synovial fluid, and tissue and include numerous cytokines, metabolites, antimicrobial peptides, and soluble receptors that are part of the PJI diagnosis workup. Macrophages, neutrophils, and myeloid-derived suppressor cells (MDSCs) are initially recruited into the joint by chemokines and cytokines produced by immune cells and bacteria and are activated by pathogen-associated molecular patterns. While these cells are efficient killers of planktonic bacteria by phagocytosis, opsonization, degranulation, and recruitment of adaptive immune cells, biofilm-associated bacteria are troublesome. Biofilm is not only a physical barrier for the immune system but also elicits effector functions. Additionally, bacteria have developed mechanisms to evade the immune system by inactivating effector molecules, promoting killing or anti-inflammatory effector cell phenotypes, and intracellular persistence and dissemination. Understanding these shortcomings and the mechanisms by which bacteria can subvert the immune system may open new approaches to better prepare our own immune system to combat PJI. Furthermore, preoperative immune system assessment and screening for dysregulation may aid in developing preventative interventions to decrease PJI incidence.
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Affiliation(s)
- Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Adult Reconstruction Research (CCARR), Cleveland Clinic, Cleveland, Ohio, USA
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Adult Reconstruction Research (CCARR), Cleveland Clinic, Cleveland, Ohio, USA
| | - Qiuhe Lu
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Anabelle Visperas
- Department of Orthopaedic Surgery, Cleveland Clinic Adult Reconstruction Research (CCARR), Cleveland Clinic, Cleveland, Ohio, USA
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Balta O, Astan S, Altınayak H, Uçar C, Aytekin FY, Kurnaz R. Can C-Reactive Protein-Lymphocyte Ratio Be Used as a Screening Tool to Confirm the Diagnosis of Periprosthetic Joint Infection? Clin Orthop Surg 2023; 15:917-927. [PMID: 38045571 PMCID: PMC10689224 DOI: 10.4055/cios22313] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 08/13/2023] [Accepted: 08/13/2023] [Indexed: 12/05/2023] Open
Abstract
Background This study aimed to investigate whether periprosthetic joint infection (PJI) can be predicted by the C-reactive protein-to-lymphocyte ratio (CLR), whether this ratio increases the accuracy of PJI diagnosis, and whether it is more sensitive than other blood values and ratios. Methods The patients were divided into two groups: the septic revision (SR) group and the aseptic revision (AR) group. In cases of septic revision, the diagnosis of PJI was made based on the criteria proposed by the European Bone and Joint Infection Society (EBJIS). The groups were compared in terms of age, sex, body mass index, comorbidity, and preoperative laboratory results. The sensitivity, specificity, and diagnostic performance of the values and ratios were analyzed and compared. Results The receiver operating characteristic (ROC) analysis for the CLR gave a diagnostic value of 15.52, which provided a sensitivity of 91.1% and a specificity of 64.2% for PJI. The CLR gave lower specificity and higher sensitivity compared to the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values. The ROC analysis showed that the CLR had a similar area under the curve (AUC) with the ESR and CRP (0.808). The CLR had a higher specificity than other ratios (platelet volume ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and monocyte-to-lymphocyte ratio) and a higher value of the AUC. In the multivariate analysis, the CLR (hazard ratio, 1.088; 95% confidence interval, 1.063-1.113; p < 0.001) was found to be a significant risk factor. As CLR increased by one unit, the risk of PJI increased by 1.088 times, and it was statistically significant (p < 0.001). Conclusions The findings of this study suggest that CLR can serve as a valuable screening tool for diagnosing PJI. CLR demonstrated higher sensitivity in predicting PJI compared to ESR and CRP, and it exhibited greater specificity than other infection markers.
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Affiliation(s)
- Orhan Balta
- Department of Orthopaedics and Traumatology, Gaziosmanpasa University Hospital, Tokat, Türkiye
| | - Sezer Astan
- Department of Orthopaedics and Traumatology, Tokat State Hospital, Tokat, Türkiye
| | - Harun Altınayak
- Department of Orthopedics and Traumatology, Samsun Training and Research Hospital, Health Sciences University, Samsun, Türkiye
| | - Cihan Uçar
- Department of Orthopedics and Traumatology, Trabzon Kanuni Training and Research Hospital, Trabzon, Türkiye
| | - Feyza Yildiz Aytekin
- Department of Infectious Diseases and Clinical Microbiology, Ministry of Health Prof. Dr. A. Ilhan Özdemir State Hospital, Giresun, Türkiye
| | - Recep Kurnaz
- Department of Orthopaedics and Traumatology, Acıbadem State Hospital, Eskişehir, Türkiye
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Wang Y, Li G, Ji B, Xu B, Zhang X, Maimaitiyiming A, Cao L. Diagnosis of periprosthetic joint infections in patients who have rheumatoid arthritis. Bone Joint Res 2023; 12:559-570. [PMID: 37704202 PMCID: PMC10499527 DOI: 10.1302/2046-3758.129.bjr-2022-0432.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
Aims To investigate the optimal thresholds and diagnostic efficacy of commonly used serological and synovial fluid detection indexes for diagnosing periprosthetic joint infection (PJI) in patients who have rheumatoid arthritis (RA). Methods The data from 348 patients who had RA or osteoarthritis (OA) and had previously undergone a total knee (TKA) and/or a total hip arthroplasty (THA) (including RA-PJI: 60 cases, RA-non-PJI: 80 cases; OA-PJI: 104 cases, OA-non-PJI: 104 cases) were retrospectively analyzed. A receiver operating characteristic curve was used to determine the optimal thresholds of the CRP, ESR, synovial fluid white blood cell count (WBC), and polymorphonuclear neutrophil percentage (PMN%) for diagnosing RA-PJI and OA-PJI. The diagnostic efficacy was evaluated by comparing the area under the curve (AUC) of each index and applying the results of the combined index diagnostic test. Results For PJI prediction, the results of serological and synovial fluid indexes were different between the RA-PJI and OA-PJI groups. The optimal cutoff value of CRP for diagnosing RA-PJI was 12.5 mg/l, ESR was 39 mm/hour, synovial fluid WBC was 3,654/μl, and PMN% was 65.9%; and those of OA-PJI were 8.2 mg/l, 31 mm/hour, 2,673/μl, and 62.0%, respectively. In the RA-PJI group, the specificity (94.4%), positive predictive value (97.1%), and AUC (0.916) of synovial fluid WBC were higher than those of the other indexes. The optimal cutoff values of synovial fluid WBC and PMN% for diagnosing RA-PJI after THA were significantly higher than those of TKA. The specificity and positive predictive value of the combined index were 100%. Conclusion Serum inflammatory and synovial fluid indexes can be used for diagnosing RA-PJI, for which synovial fluid WBC is the best detection index. Combining multiple detection indexes can provide a reference basis for the early and accurate diagnosis of RA-PJI.
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Affiliation(s)
- Yulai Wang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Guoqing Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Baochao Ji
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Boyong Xu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaogang Zhang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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Baek YJ, Lee YJ, Lee JA, Kim JH, Kwon HM, Yeom JS, Park KK, Jeong SJ. Role of α-Defensin and the Microbiome in Prosthetic Joint Infection: A Prospective Cohort Study in Korea. J Clin Med 2023; 12:5964. [PMID: 37762905 PMCID: PMC10532201 DOI: 10.3390/jcm12185964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
The utility of α-defensin (AD), leukocyte esterase (LE) levels, and metagenomics sequencing as diagnostic tools for prosthetic joint infection (PJI) has been suggested, but there are few studies among the Asian population. This study aimed to evaluate the diagnostic performance of various biomarkers for PJI and the role of the microbiome in the synovial fluid of patients with prostheses. Patients with suspected knee PJI were enrolled, and their blood and synovial fluid were collected. The cases were classified into the PJI and non-PJI groups. Significant differences between the two groups were observed in the levels of AD (4698 µg/L vs. 296 µg/L, p < 0.001) and positivity for LE (62.5% vs. 21.1%, p = 0.01). AD had 94.4% sensitivity and 89.5% specificity for diagnosing PJI, whereas LE had 37.5% sensitivity and 100% specificity. Microbiome taxonomic profiling showed high sensitivity. The number of operational taxonomic units and the richness of the microbiome in the synovial fluid were higher in the non-PJI than in the PJI group. AD has shown encouraging results in the Asian population as a diagnostic biomarker for PJI, and LE can be used as a diagnostic adjunct. The bacterial richness of the synovial fluid is likely associated with infections.
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Affiliation(s)
- Yae Jee Baek
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul 04401, Republic of Korea;
| | - Youn-Jung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jung Ah Lee
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jung Ho Kim
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hyuck Min Kwon
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Joon-Sup Yeom
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Kwan Kyu Park
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Su Jin Jeong
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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Su X, Zhu B, Qin L, Yang J, Wei L, Xu Z, Wei K, Wang J, Chen L, Zhao C, Chen C, Huang W, Xiong Y, Hu N. Joint fluid interleukin-6 combined with the neutral polymorphonuclear leukocyte ratio (PMN%) as a diagnostic index for chronic periprosthesis infection after arthroplasty. J Orthop Traumatol 2023; 24:34. [PMID: 37402969 DOI: 10.1186/s10195-023-00712-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 06/02/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND The diagnosis of periprosthetic joint infection (PJI) remains a challenge in clinical practice. Many novel serum and joint fluid biomarkers have important implications for the diagnosis of PJI. The presented study evaluated the value of joint fluid interleukin-6 (IL-6) combined with the neutral polymorphonuclear leukocyte (PMN%) ratio for chronic PJI diagnosis after arthroplasty. MATERIALS AND METHODS Sixty patients with chronic PJI or aseptic failure who underwent hip or knee revision from January 2018 to January 2020 in our department were included in this retrospective study. According to the 2013 MSIS diagnostic criteria, the 60 patients were divided into a PJI group and a non-PJI group (30 patients per group). We collected the joint fluid before surgery and determined the level of IL-6 and the PMN% by ELISA, and the differences between the two groups were compared. The diagnostic efficacy of joint fluid IL-6 combined with PMN% in chronic PJI was analyzed using a receiver operating characteristic curve (ROC curve). RESULTS The diagnosis of PJI using joint fluid IL-6 combined with PMN% presented an area under the curve of 0.983, which was more accurate than the areas under the curve for diagnosis using IL-6 and PMN% individually (0.901 and 0.914, respectively). The optimal threshold values for IL-6 and PMN% were 662.50 pg/ml and 51.09%, respectively. Their sensitivity and specificity were 96.67% and 93.33%, respectively. The accuracy of the diagnosis of PJI was 95.00%. CONCLUSIONS Joint fluid IL-6 combined with PMN% can be used as an auxiliary method to detect chronic infection around the prosthesis after hip/knee arthroplasty. LEVEL OF EVIDENCE Patients who underwent hip/knee revision at the First Hospital of Chongqing Medical University for periprosthetic infection or aseptic failure of the prosthesis after hip/knee arthroplasty from January 2018 to January 2020 were included. Trial registration This study was approved by the ethics committee of the First Hospital of Chongqing Medical University on September 26, 2018 (local ethics committee number: 20187101) and registered with the China Clinical Trials Registry (registration number: ChiCTR1800020440) with an approval date of December 29, 2018.
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Affiliation(s)
- Xudong Su
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China
| | - Bo Zhu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China
| | - Leilei Qin
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China
| | - Jianye Yang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China
| | - Li Wei
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China
| | - Zhenghao Xu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China
| | - Keyu Wei
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China
| | - Jiayi Wang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China
| | - Li Chen
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China
| | - Chen Zhao
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China
| | - Cheng Chen
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China
| | - Wei Huang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China
| | - Yan Xiong
- Department of Orthopedics, Daping Hospital, Army Medical University, Chongqing, China.
| | - Ning Hu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing, 400016, China.
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10
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Yilmaz MK, Abbaszadeh A, Tarabichi S, Azboy I, Parvizi J. Diagnosis of Periprosthetic Joint Infection: The Utility of Biomarkers in 2023. Antibiotics (Basel) 2023; 12:1054. [PMID: 37370373 DOI: 10.3390/antibiotics12061054] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a rare yet devastating complication following total joint arthroplasty (TJA). Early and accurate diagnosis of PJI is paramount in order to maximize the chances of successful treatment. However, we are yet to identify a single "gold standard" test for the diagnosis of PJI. As a result, the diagnosis of PJI is often challenging. Currently, the 2018 ICM definition of PJI is the only validated diagnostic criteria available. This article will review the importance of serum and synovial biomarkers in the diagnosis of PJI. In addition, it will provide a brief overview of the emerging modalities for the identification of infections in this setting.
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Affiliation(s)
- Mehmet Kursat Yilmaz
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Department of Orthopaedics and Traumatology, School of Medicine, Istanbul Medipol University, Istanbul 34810, Turkey
| | - Ahmad Abbaszadeh
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Saad Tarabichi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Ibrahim Azboy
- Department of Orthopaedics and Traumatology, School of Medicine, Istanbul Medipol University, Istanbul 34810, Turkey
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
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11
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Evaluation of Serum Albumin and Globulin in Combination With C-Reactive Protein Improves Serum Diagnostic Accuracy for Low-Grade Periprosthetic Joint Infection. J Arthroplasty 2023; 38:555-561. [PMID: 36115535 DOI: 10.1016/j.arth.2022.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Serum immune markers can be useful in the diagnosis of periprosthetic joint infection (PJI) by detecting long-lasting abnormal immunological conditions. The purpose of this study was to examine whether serum immune markers can improve the diagnostic accuracy of PJI. METHODS We enrolled 51 PJI, 45 aseptic loosening, and 334 osteoarthritis patients for assessment of the discriminatory accuracy of serum markers including white blood cell count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and D-dimer, total protein, albumin (Alb), globulin (Glb), neutrophil-lymphocyte ratio, lymphocyte-monocyte ratio, platelet-lymphocyte ratio, albumin-globulin ratio (AGR), CRP-albumin ratio (CAR), and CRP-AGR ratio (CAGR). These diagnostic accuracies for low-grade PJI were also calculated in patients who had serum CRP levels < 10 mg/L. RESULTS Among serum markers, Alb, Glb, AGR, CRP, ESR, CAR, and CAGR had highly accurate diagnostic accuracy for PJI, with area under the curve of 0.92, 0.90, 0.96, 0.97, 0.92, 0.97, and 0.98, respectively. In low-grade PJI patients, area under the curve of CRP, ESR, CAR, and CAGR (0.69, 0.80, 0.65, and 0.82, respectively) was decreased but that of Alb, Glb, and AGR (0.90, 0.88, and 0.95, respectively) remained high, indicating the diagnostic utility of these immune markers. The sensitivity and specificity of AGR with cutoff value of 1.1 were demonstrated as 0.92 and 0.89, respectively, and with cutoff value of 1.2, 1.00, and 0.79, respectively, in the diagnosis of low-grade infection. CONCLUSION Our results demonstrate the potential value of Alb, Glb, AGR, and combination indices of these immune makers with CRP in improving preoperative serum diagnosis for PJI, especially in low-grade PJI. LEVEL OF EVIDENCE Diagnostic- Level II.
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12
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Vrancianu CO, Serban B, Gheorghe-Barbu I, Czobor Barbu I, Cristian RE, Chifiriuc MC, Cirstoiu C. The Challenge of Periprosthetic Joint Infection Diagnosis: From Current Methods to Emerging Biomarkers. Int J Mol Sci 2023; 24:ijms24054320. [PMID: 36901750 PMCID: PMC10002145 DOI: 10.3390/ijms24054320] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023] Open
Abstract
Due to the increase in the life span and mobility at older ages, the number of implanted prosthetic joints is constantly increasing. However, the number of periprosthetic joint infections (PJIs), one of the most severe complications after total joint arthroplasty, also shows an increasing trend. PJI has an incidence of 1-2% in the case of primary arthroplasties and up to 4% in the case of revision operations. The development of efficient protocols for managing periprosthetic infections can lead to the establishment of preventive measures and effective diagnostic methods based on the results obtained after the laboratory tests. In this review, we will briefly present the current methods used in PJI diagnosis and the current and emerging synovial biomarkers used for the prognosis, prophylaxis, and early diagnosis of periprosthetic infections. We will discuss treatment failure that may result from patient factors, microbiological factors, or factors related to errors during diagnosis.
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Affiliation(s)
- Corneliu Ovidiu Vrancianu
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
| | - Bogdan Serban
- University Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence: (B.S.); (I.G.-B.)
| | - Irina Gheorghe-Barbu
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
- Correspondence: (B.S.); (I.G.-B.)
| | - Ilda Czobor Barbu
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
| | - Roxana Elena Cristian
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
- Department of Biochemistry and Molecular Biology, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania
| | - Mariana Carmen Chifiriuc
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
- Romanian Academy, 010071 Bucharest, Romania
| | - Catalin Cirstoiu
- University Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
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13
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Zheng QY, Ren P, Cheng L, Liu H, Zhao R, Lv Y, Geng Z, Lu K, Ni M, Zhang GQ. Leukocyte Esterase Strip Quantitative Detection Based on RGB Photometry is a Probable Method to Diagnose Periprosthetic Joint Infection: An Exploratory Study. Orthop Surg 2023; 15:983-992. [PMID: 36782275 PMCID: PMC10102294 DOI: 10.1111/os.13667] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 02/15/2023] Open
Abstract
OBJECTIVE Leucocyte esterase (LE) strip test is the most rapid, convenient, and cheap method to diagnose chronic periprosthesis joint infection (PJI). However, the determination of LE strip mainly relies on colorimetric method with strong subjectivity, which leads to low diagnostic accuracy. Therefore, we try to convert LE strip images into digital data through the RGB photometric system to achieve objective diagnosis. This method will greatly improve the accuracy of LE strip detection and diagnosis of PJI. METHODS From January 2021 to September 2021, 46 patients with suspected PJI after total hip and knee arthroplasty underwent diagnostic joint puncture. After effective joint fluid samples were harvested, they were divided into original fluid and centrifuged fluid for LE strip detection. Real-time images of LE strip were taken at 90 s, 3 min, 5 min, 10 min, and 15 min after sampling, and their brightness (Y) was obtained after they were input into an RGB photometric system. Grouping was based on centrifugation, infection, and time points, and then the differences in brightness among groups were compared. The correlation between LE strip image brightness and WBC count was evaluated. Student t-test was used for the parametric data and chi-square test for qualitative data. Simple linear regression was utilized to analyze the correlation between brightness and WBC count in each group. RESULTS Included were 19 cases of PJI and 27 Non-PJI subjects diagnosed against ICM2018 diagnostic criteria. The brightness was lower in the PJI group than in Non-PJI group (p < 0.05). The brightness of the uncentrifuged group was lower than that of the centrifuged group (p < 0.05). Irrespective of centrifugation or infection, the brightness of LE strip decreased with the exposure time after sampling. The brightness of LE strip was correlated with WBC count at different time points, with the correlation being strongest 5 min after sampling (R2 (5 min) = 0.86, p < 0.0001). The correlation between LE strip brightness and WBC count was also found in the centrifugation group, with the correlation being most robust 15 min after sampling (R2 (15 min) = 0.73, p < 0.0001). CONCLUSION A remarkable correlation was found between LE strip brightness and the WBC count. It is feasible to directly quantify LE strip image on a RGB photometer to achieve quantitative detection of LE strip to diagnose PJI.
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Affiliation(s)
- Qing-Yuan Zheng
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Peng Ren
- Department of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Long Cheng
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Hao Liu
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Runkai Zhao
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yicun Lv
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zongjie Geng
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Kuan Lu
- Department of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ming Ni
- Department of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing, China.,Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Guo-Qiang Zhang
- Department of Orthopedics, the First Medical Center, Chinese PLA General Hospital, Beijing, China.,Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
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14
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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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15
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Patel M, Gazendam A, Wood TJ, Tushinski D, Bali K. The quality of diagnostic studies used for the diagnostic criteria of periprosthetic joint infections. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03386-w. [PMID: 36121542 DOI: 10.1007/s00590-022-03386-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Although periprosthetic joint infection (PJI) is a serious complication following a total joint arthroplasty procedure, there remains uncertainty regarding the diagnosis of PJI due to the lack of a globally accepted, standardized definition. The goal of this review is to critically analyze the quality of the evidence used for the novel 2018 MSIS PJI definition and identify gaps and limitations with using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. METHODS References from the modified 2018 MSIS definition for PJI by Parvizi et al. were retrieved and manually reviewed. A total of 11 studies were assessed using a validated QUADAS-2 tool. RESULTS Many included studies had an unclear or high risk of bias for the Index Test domain due to a lack of blinding and lack of prespecified thresholds. A majority of studies utilized Youden's J statistic to optimize the thresholds which may diminish external validity. Likewise, several studies were assessed to have an unclear and high risk of bias for the Flow and Timing domain primarily due to a lack of reporting and a large number of exclusions. Overall, there was a low risk of bias for the choice of reference standard, its conduct and interpretation, as well as for the Patient Selection domain. CONCLUSION Although the literature used for the MSIS 2018 PJI definition is fraught with potential sources of bias, there may be a trend toward an improvement in the quality of evidence when compared to the earlier definition of PJI.
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Affiliation(s)
- Mansi Patel
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Aaron Gazendam
- Division of Orthopaedic, Department of Surgery, St. Joseph's Hospital, McMaster University, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
| | - Thomas J Wood
- Division of Orthopaedic, Department of Surgery, St. Joseph's Hospital, McMaster University, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - Daniel Tushinski
- Division of Orthopaedic, Department of Surgery, St. Joseph's Hospital, McMaster University, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
| | - Kamal Bali
- Division of Orthopaedic, Department of Surgery, St. Joseph's Hospital, McMaster University, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
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16
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Mian HM, Lyons JG, Perrin J, Froehle AW, Krishnamurthy AB. A review of current practices in periprosthetic joint infection debridement and revision arthroplasty. ARTHROPLASTY 2022; 4:31. [PMID: 36045436 PMCID: PMC9434893 DOI: 10.1186/s42836-022-00136-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Periprosthetic joint infection remains a significant challenge for arthroplasty surgeons globally. Over the last few decades, there has been much advancement in terms of treatment and diagnosis, however, the fight rages on. As management of periprosthetic joint infections continues to evolve, it is critical to reflect back on current debridement practices to establish common ground as well as identify areas for future research and improvement. BODY: In order to understand the debridement techniques of periprosthetic joint infections, one must also understand how to diagnose a periprosthetic joint infection. Multiple definitions have been elucidated over the years with no single consensus established but rather sets of criteria. Once a diagnosis has been established the decision of debridement method becomes whether to proceed with single vs two-stage revision based on the probability of infection as well as individual patient factors. After much study, two-stage revision has emerged as the gold standard in the management of periprosthetic infections but single-stage remains prominent with further and further research. CONCLUSION Despite decades of data, there is no single treatment algorithm for periprosthetic joint infections and subsequent debridement technique. Our review touches on the goals of debridement while providing a perspective as to diagnosis and the particulars of how intraoperative factors such as intraarticular irrigation can play pivotal roles in infection eradication. By providing a perspective on current debridement practices, we hope to encourage future study and debate on how to address periprosthetic joint infections best.
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Affiliation(s)
- Humza M Mian
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA.
| | - Joseph G Lyons
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA
| | - Joshua Perrin
- Wright State University Boonshoft School of Medicine, Wright State Physicians Bldg, 725 University Blvd., Dayton, OH, 45435, USA
| | - Andrew W Froehle
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA
- School of Nursing, Kinesiology and Health, Wright State University, 3640 Colonel Glenn Hwy., Dayton, OH, 45435, USA
| | - Anil B Krishnamurthy
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA
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17
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Gazendam A, Wood TJ, Tushinski D, Bali K. Diagnosing Periprosthetic Joint Infection: a Scoping Review. Curr Rev Musculoskelet Med 2022; 15:219-229. [PMID: 35368214 DOI: 10.1007/s12178-022-09751-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to provide an up to date understanding of the utility and limitations of the current tests utilized in the diagnosis of periprosthetic joint infection (PJI) in total knee and hip arthroplasty. RECENT FINDINGS Despite the growth in literature surrounding PJI diagnosis, there remains challenges in establishing a diagnosis of PJI. A combination of clinical, serum, and synovial tests and microbiologic and histologic examinations can yield a diagnosis in the majority of cases. Novel molecular and imaging studies may be beneficial for indeterminant cases. A number of emerging diagnostic tests have been proposed and may be incorporated into diagnostic algorithms in the future. Recently proposed stepwise diagnostic algorithms have shown high sensitivity and specificity. The diagnosis of PJI remains challenging due to a lack of tests that can definitively rule out infection. Diagnosis and investigations should occur in a stepwise fashion. There has been a plethora of new diagnostic tests introduced in attempts to improve the accuracy of diagnostic algorithms. The definition and algorithms for the diagnoses of PJI will continue to evolve as new techniques and tests are introduced.
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Affiliation(s)
- Aaron Gazendam
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Thomas J Wood
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Tushinski
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kamal Bali
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada. .,Juravinski Hospital, 711 Concession St, Hamilton, Ontario, L8V 1C3, Canada.
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18
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Abstract
Accurate diagnosis of orthopedic infection is crucial in guiding both antimicrobial therapy and surgical management in order to optimize patient outcomes. A variety of microbiological and nonmicrobiological methods are used to establish the presence of a musculoskeletal infection. In this minireview, we examine traditional culture-based and newer molecular methodologies for pathogen detection, as well as systemic and localized assays to assess host response to maximize diagnostic yield.
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19
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Chisari E, Yacovelli S, Goswami K, Shohat N, Woloszyn P, Parvizi J. Leukocyte Esterase Versus ICM 2018 Criteria in the Diagnosis of Periprosthetic Joint Infection. J Arthroplasty 2021; 36:2942-2945.e1. [PMID: 33812714 DOI: 10.1016/j.arth.2021.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/23/2021] [Accepted: 03/01/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND A leukocyte esterase (LE) test is inexpensive and provides real-time information about patients suspected of periprosthetic joint infections (PJIs). The 2018 International Consensus Meeting (ICM) recommends it as a diagnostic tool with a 2+ cutoff. There is still a lack of data revealing LE utility versus the ICM 2018 criteria for PJI. METHODS This is a retrospective study of patients who underwent revision total hip and total knee arthroplasty at a single institution between March 2009 and December 2019. All patients underwent joint aspiration before the arthrotomy, and the LE strip test was performed on aspirated joint fluid. PJI was defined using the 2018 ICM criteria. RESULTS As per the 2018 ICM criteria, 78 patients were diagnosed with chronic PJI and 181 were not infected. An LE test with a cutoff of ≥1+ had a sensitivity of 0.744, a specificity of 0.906, a positive predictive value of 0.773, an accuracy of 0.825 (95% confidence interval 0.772-0.878), and a negative predictive value of 0.891. The positive likelihood ratio (LR+) was 7.917. Using an LE cutoff of 2 + had a sensitivity of 0.513, a specificity of 1.000, and an accuracy of 0.756 (95% confidence interval-0.812). CONCLUSION LE is a rapid and inexpensive test which can be performed at the bedside. Its performance is valuable as per ICM criteria. Based on the findings of this study and the given cohort, we suggest using the cutoff of LE1+ (result = negative or trace) as a point of care test to exclude infection, whereas LE at 2 + threshold has near absolute specificity for the diagnosis.
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Affiliation(s)
- Emanuele Chisari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Steven Yacovelli
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Noam Shohat
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Paul Woloszyn
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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20
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Liu X, Jiang N, Wang T, Yu B. Serum and Synovial Biomarkers for the Diagnosis of Implant-Associated Infection After Orthopedic Surgery. Orthopedics 2021; 44:e158-e166. [PMID: 33416900 DOI: 10.3928/01477447-20210104-07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Implant-associated infection is one of the most devastating complications following orthopedic surgery. Early identification is crucial for treatment. Currently, however, a reliable diagnostic tool is lacking, partly due to disparate bacteria colonies (virulent vs non-virulent), difficulty in distinguishing infection from inflammatory disease, and highly diverse diagnostic thresholds and testing methods. Given the importance of biomarkers in the initial screening for the infection, an extensive effort has been made to develop serum and synovial biomarkers. In this review, the authors summarize the results from the most relevant studies to provide comprehensive information on biomarkers for the diagnosis of implant-associated infection. [Orthopedics. 2021;44(2):e158-e166.].
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21
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Indelli PF, Ghirardelli S, Violante B, Amanatullah DF. Next generation sequencing for pathogen detection in periprosthetic joint infections. EFORT Open Rev 2021; 6:236-244. [PMID: 34040801 PMCID: PMC8142595 DOI: 10.1302/2058-5241.6.200099] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Periprosthetic joint infections (PJI) represent one of the most catastrophic complications following total joint arthroplasty (TJA). The lack of standardized diagnostic tests and protocols for PJI is a challenge for arthroplasty surgeons.Next generation sequencing (NGS) is an innovative diagnostic tool that can sequence microbial deoxyribonucleic acids (DNA) from a synovial fluid sample: all DNA present in a specimen is sequenced in parallel, generating millions of reads. It has been shown to be extremely useful in a culture-negative PJI setting.Metagenomic NGS (mNGS) allows for universal pathogen detection, regardless of microbe type, in a 24-48-hour timeframe: in its nanopore-base variation, mNGS also allows for antimicrobial resistance characterization.Cell-free DNA (cfDNA) NGS, characterized by lack of the cell lysis step, has a fast run-time (hours) and, together with a high sensitivity and specificity in microorganism isolation, may provide information on the presence of antimicrobial resistance genes.Metagenomics and cfDNA testing have reduced the time needed to detect infecting bacteria and represent very promising technologies for fast PJI diagnosis.NGS technologies are revolutionary methods that could disrupt the diagnostic paradigm of PJI, but a comprehensive collection of clinical evidence is still needed before they become widely used diagnostic tools. Cite this article: EFORT Open Rev 2021;6:236-244. DOI: 10.1302/2058-5241.6.200099.
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Affiliation(s)
- Pier F Indelli
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | | | | | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
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Soluble Pecam-1 as a Biomarker in Periprosthetic Joint Infection. J Clin Med 2021; 10:jcm10040612. [PMID: 33562828 PMCID: PMC7914675 DOI: 10.3390/jcm10040612] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/24/2021] [Accepted: 01/29/2021] [Indexed: 02/07/2023] Open
Abstract
A reliable workup with regard to a single diagnostic marker indicating periprosthetic joint infection (PJI) with sufficient sensitivity and specificity is still missing. The immunologically reactive molecule Pecam-1 is shed from the T-cell surface upon activation via proinflammatory signaling, e.g., triggered by specific pathogens. We hypothesized that soluble Pecam-1 (sPecam-1) can hence function as a biomarker of PJI. Fifty-eight patients were prospectively enrolled and assigned to one of the respective treatment groups (native knees prior to surgery, aseptic, and septic total knee arthroplasty (TKA) revision surgeries). Via synovial sample acquisition and ELISA testing, a database on local sPecam-1 levels was established. We observed a significantly larger quantity of sPecam-1 in septic (n = 22) compared to aseptic TKA revision surgeries (n = 20, p ≤ 0.001). Furthermore, a significantly larger amount of sPecam-1 was found in septic and aseptic revisions compared to native joints (n = 16, p ≤ 0.001). Benchmarking it to the gold standard showed a high predictive power for the detection of PJI. Local sPecam-1 levels correlated to the infection status of the implant, and thus bear a strong potential to act as a biomarker of PJI. While a clear role of sPecam-1 in infection could be demonstrated, the underlying mechanism of the molecule’s natural function needs to be further unraveled.
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Goh GS, Parvizi J. Think Twice before Prescribing Antibiotics for That Swollen Knee: The Influence of Antibiotics on the Diagnosis of Periprosthetic Joint Infection. Antibiotics (Basel) 2021; 10:antibiotics10020114. [PMID: 33530305 PMCID: PMC7911292 DOI: 10.3390/antibiotics10020114] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 12/23/2022] Open
Abstract
Periprosthetic joint infection (PJI) is a rare but devastating complication after total joint arthroplasty. An estimated 7-12% of patients have negative cultures despite clear clinical evidence of infection. One oft-cited reason for this occurrence is the administration of antibiotics in the weeks prior to obtaining cultures. This article reviews the influence of antibiotics on the diagnosis of PJI. Specifically, we examine the effect of prophylactic and therapeutic antibiotic administration on the diagnostic accuracy of microbiological cultures as well as serum and synovial biomarkers. We also explore the potential of molecular techniques in overcoming these limitations in patients who have received antibiotics before specimen collection and propose areas for future research.
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McNally M, Sousa R, Wouthuyzen-Bakker M, Chen AF, Soriano A, Vogely HC, Clauss M, Higuera CA, Trebše R. The EBJIS definition of periprosthetic joint infection. Bone Joint J 2021; 103-B:18-25. [PMID: 33380199 PMCID: PMC7954183 DOI: 10.1302/0301-620x.103b1.bjj-2020-1381.r1] [Citation(s) in RCA: 269] [Impact Index Per Article: 89.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition. Methods This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance. Results This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI. Conclusion The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice. Cite this article: Bone Joint J 2021;103-B(1):18–25.
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Affiliation(s)
- Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Ricardo Sousa
- Porto Bone Infection Group (GRIP), Orthopaedic Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Antonia F Chen
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - H Charles Vogely
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martin Clauss
- Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic, Florida, USA
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Tirumala V, Klemt C, Xiong L, Chen W, van den Kieboom J, Kwon YM. Diagnostic Utility of Platelet Count/Lymphocyte Count Ratio and Platelet Count/Mean Platelet Volume Ratio in Periprosthetic Joint Infection Following Total Knee Arthroplasty. J Arthroplasty 2021; 36:291-297. [PMID: 32773272 DOI: 10.1016/j.arth.2020.07.038] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Diagnosing a periprosthetic joint infection (PJI) can be challenging and often requires a combination of clinical and laboratory findings. Monocyte/lymphocyte ratio, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio (PLR), and platelet/mean platelet volume ratio (PVR) are simple predictors for inflammation that can be readily obtained from complete blood count. The aim of this study is to evaluate the diagnostic utility of these markers in predicting PJI in total knee arthroplasty (TKA) patients. METHODS A total of 538 patients who underwent revision TKA with calculable marker ratios prerevision in 2 groups were evaluated: (1) 206 patients with a preoperative diagnosis of PJI (group I) and (2) 332 patients treated for revision TKA for aseptic failures (group II). The diagnostic abilities of the markers were assessed via receiver operator characteristic curve analysis. RESULTS The optimal threshold of PVR at 30.82 had the highest sensitivity of 87.7%, while the optimal threshold of PLR at 234.13 had the highest specificity of 82.5%. Both PLR and PVR, when combined with Musculoskeletal Infection Society thresholds for erythrocyte sedimentation rate, C-reactive protein, synovial WBC, and PMN%, achieve significantly higher sensitivity and specificity rates for PJI at or above 97% (PLR: 99.03%; 98.80%; PVR: 98.54%;97.89%). CONCLUSION Our study demonstrates that PVR and PLR, which are readily available and inexpensive to obtain from complete blood counts, when combined with serum and synovial fluid markers have increased sensitivity and specificity comparable to that of alpha defensin. This suggests that PVR and PLR can be used together with other hematologic and aspirate markers to increase the accuracy of PJI diagnosis in TKA patients.
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Affiliation(s)
- Venkatsaiakhil Tirumala
- 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
| | - Liang Xiong
- Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA
| | - Wenhao Chen
- Department of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA
| | - Janna van den Kieboom
- 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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Li Z, Zhang Q, Shi L, Gao F, Sun W, Li Z. Alpha-Defensin versus Leukocyte Esterase in Periprosthetic Joint Infection: An Updated Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3704285. [PMID: 33294439 PMCID: PMC7688361 DOI: 10.1155/2020/3704285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/22/2020] [Accepted: 10/26/2020] [Indexed: 12/21/2022]
Abstract
Periprosthetic joint infection (PJI) is a devastating complication after arthroplasty. Prompt establishment of an infection diagnosis is critical but can be very challenging at present. In order to evaluate the diagnostic accuracy of alpha-defensin or leukocyte esterase for PJI, we performed systematic research in PubMed, Embase, and Cochrane Library to retrieve relevant studies. Data extraction and quality assessment were performed by two reviewers independently. A total of thirty-one eligible studies were finally included in the quantitative analysis. The pooled sensitivity and specificity of alpha-defensin (21 studies) for the diagnosis of PJI were 0.89 (95% confidence interval (CI), 0.83 to 0.93) and 0.96 (95% CI, 0.95 to 0.97), respectively. The value of the pooled diagnostic odds ratios (DOR) of alpha-defensin for PJI was 209.14 (95% CI, 97.31 to 449.50), and the area under the curve (AUC) was 0.98 (95% CI, 0.96 to 0.99). The pooled sensitivity and specificity of leukocyte esterase (17 studies) for the diagnosis of PJI were 0.90 (95% CI, 0.84 to 0.95) and 0.96 (95% CI, 0.93 to 0.97), respectively. The value of the DOR of leukocyte esterase for PJI was 203.23 (95% CI, 96.14 to 429.61), and the AUC was 0.98 (95% CI, 0.96 to 0.99). Based on the results of our meta-analysis, we can conclude that alpha-defensin and leukocyte esterase are valuable synovial fluid markers for identifying PJI with comparable high diagnostic accuracy.
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Affiliation(s)
- Zhizhuo Li
- Department of Orthopedics, Peking University China-Japan Friendship School of Clinical Medicine, 2 Yinghuadong Road, Chaoyang District, Beijing 100029, China
| | - Qingyu Zhang
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong University, No. 324, Road Jing Wu Wei Qi, Jinan, 250021 Shandong, China
| | - Lijun Shi
- Department of Orthopedics, Graduate School of Peking Union Medical College, China-Japan Friendship Institute of Clinical Medicine, 2 Yinghuadong Road, Chaoyang District, Beijing 100029, China
| | - Fuqiang Gao
- Beijing Key Laboratory of Immune Inflammatory Disease, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing 100029, China
| | - Wei Sun
- Beijing Key Laboratory of Immune Inflammatory Disease, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing 100029, China
| | - Zirong Li
- Beijing Key Laboratory of Immune Inflammatory Disease, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing 100029, China
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27
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Zheng QY, Zhang GQ. Application of leukocyte esterase strip test in the screening of periprosthetic joint infections and prospects of high-precision strips. ARTHROPLASTY 2020; 2:34. [PMID: 35236471 PMCID: PMC8796411 DOI: 10.1186/s42836-020-00053-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/12/2020] [Indexed: 12/19/2022] Open
Abstract
Periprosthetic joint infection (PJI) represents one of the most challenging complications after total joint arthroplasty (TJA). Despite the availability of a variety of diagnostic techniques, the diagnosis of PJI remains a challenge due to the lack of well-established diagnostic criteria. The leucocyte esterase (LE) strips test has been proved to be a valuable diagnostic tool for PJI, and its weight in PJI diagnostic criteria has gradually increased. Characterized by its convenience, speed and immediacy, leucocyte esterase strips test has a prospect of broad application in PJI diagnosis. Admittedly, the leucocyte esterase strips test has some limitations, such as imprecision and liability to interference. Thanks to the application of new technologies, such as machine reading, quantitative detection and artificial intelligence, the LE strips test is expected to overcome the limitations and improve its accuracy.
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Qin L, Li X, Wang J, Gong X, Hu N, Huang W. Improved diagnosis of chronic hip and knee prosthetic joint infection using combined serum and synovial IL-6 tests. Bone Joint Res 2020; 9:587-592. [PMID: 33005398 PMCID: PMC7502257 DOI: 10.1302/2046-3758.99.bjr-2020-0095.r1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Aims This study aimed to explore whether serum combined with synovial interleukin-6 (IL-6) measurement can improve the accuracy of prosthetic joint infection (PJI) diagnosis, and to establish the cut-off values of IL-6 in serum and synovial fluid in detecting chronic PJI. Methods Patients scheduled to have a revision surgery for indications of chronic infection of knee and hip arthroplasties or aseptic loosening of an implant were prospectively screened before being enrolled into this study. The Musculoskeletal Infection Society (MSIS) definition of PJI was used for the classification of cases as aseptic or infected. Serum CRP, ESR, IL-6, and percentage of polymorphonuclear neutrophils (PMN%) and IL-6 in synovial fluid were analyzed. Statistical tests were performed to compare these biomarkers in the two groups, and receiver operating characteristic (ROC) curves and area under the curve (AUC) were analyzed for each biomarker. Results A total of 93 patients were enrolled. There was no difference in demographic data between both groups. Synovial fluid IL-6, with a threshold of 1,855.36 pg/ml, demonstrated a mean sensitivity of 94.59% (95% confidence interval (CI) 81.8% to 99.3%) and a mean specificity of 92.86% (95% CI 82.7 to 98.0) for detecting chronic PJI. Then 6.7 pg/ml was determined to be the optimal threshold value of serum IL-6 for the diagnosis of chronic PJI, with a mean sensitivity of 97.30% (95% CI 85.8% to 99.9%) and a mean specificity of 76.79% (95% CI 63.6% to 87.0%). The combination of synovial IL-6 and serum IL-6 led to improved accuracy of 96.77% in diagnosing chronic PJI. Conclusion The present study identified that a combination of IL-6 in serum and synovial IL-6 has the potential for further improvement of the diagnosis of PJI.Cite this article: Bone Joint Res 2020;9(9):587-592.
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Affiliation(s)
- Leilei Qin
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xinyu Li
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiawei Wang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuan Gong
- Outpatient Department, Chongqing First People's Hospital, Chongqing, China
| | - Ning Hu
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Wasterlain AS, Goswami K, Ghasemi SA, Parvizi J. Diagnosis of Periprosthetic Infection: Recent Developments. J Bone Joint Surg Am 2020; 102:1366-1375. [PMID: 32769605 DOI: 10.2106/jbjs.19.00598] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ There is no absolute test for the preoperative diagnosis of periprosthetic joint infection (PJI); thus, clinical practice relies on a combination of supportive tests and criteria.➤ Novel serum and synovial tests have improved our ability to diagnose PJI. The 2018 evidence-based algorithm for PJI diagnosis provides weighted scores for serum markers, as well as synovial markers, to facilitate diagnosis when major criteria such as positive cultures or a sinus tract are not present.➤ Culture-independent technologies such as next-generation sequencing can facilitate pathogen identification, particularly in the setting of culture-negative PJI.➤ Despite recent developments, PJI diagnosis remains challenging and warrants further innovation.
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Affiliation(s)
- Amy S Wasterlain
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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30
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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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Abstract
PURPOSE OF REVIEW Prosthetic joint infections (PJIs) represent one of the most disastrous complications in prosthetic surgery, requiring long hospitalization, prolonged antimicrobial treatment and repeated surgical interventions. No gold standard test to formulate diagnosis exist. A combination of high index of suspicion, physical examination, microbiological and biohumoral investigations is required. Therapeutical approach should be based on a multidisciplinary team. In our center, a two-stage approach is preferred. As regards the choice of the empirical antibiotic backbone, individual risk factors for multiple-drug resistant (MDR) pathogens should be considered. Several studies enhance the possibility to shorten the length of antibiotic couses. RECENT FINDINGS Some interesting improvements have been made in the setting of PJIs management. As regards diagnosis, novel biomarkers and nuclear imaging are acquiring more importance. Molecular biology techniques also offer the possibility to formulate rapid microbiological identification. The pattern of PJIs is evolving towards higher rates of MDR causes. During the last decade, a number of new antibiotic molecules with activity against MDRs have been approved. Some of them are also available either in oral formulation or as long-acting compounds, offering the opportunity for early patient's discharge, with expected healthcare costs saving. SUMMARY Management of PJIs still represents a major threat for clinicians. Improvements in surgical techniques and antibiotic pipeline promise to revolutionize the approach in next years. Despite data from our experience confirm the efficacy of shorter antibiotic courses and the value of new molecules, randomized clinical trials are lacking. More data are needed in order to modify the routine clinical practice.
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Qin L, Hu N, Li X, Chen Y, Wang J, Huang W. Evaluation of synovial fluid neutrophil CD64 index as a screening biomarker of prosthetic joint infection. Bone Joint J 2020; 102-B:463-469. [PMID: 32228083 DOI: 10.1302/0301-620x.102b4.bjj-2019-1271.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIMS Prosthetic joint infection (PJI) remains a major clinical challenge. Neutrophil CD64 index, Fc-gamma receptor 1 (FcγR1), plays an important role in mediating inflammation of bacterial infections and therefore could be a valuable biomarker for PJI. The aim of this study is to compare the neutrophil CD64 index in synovial and blood diagnostic ability with the standard clinical tests for discrimination PJI and aseptic implant failure. METHODS A total of 50 patients undergoing revision hip and knee arthroplasty were enrolled into a prospective study. According to Musculoskeletal Infection Society (MSIS) criteria, 25 patients were classified as infected and 25 as not infected. In all patients, neutrophil CD64 index and percentage of polymorphonuclear neutrophils (PMN%) in synovial fluid, serum CRP, ESR, and serum CD64 index levels were measured preoperatively. Receiver operating characteristic (ROC) curves and the area under the curve (AUC) were analyzed for each biomarker. RESULTS Serum CD64 index showed no significant difference between the two groups (p = 0.091). Synovial fluid CD64 index and PMN% discriminated good differentiation between groups of PJI and aseptic failure with AUC of 0.946 (95% confidence interval (CI) 0.842 to 0.990) and 0.938 (95% CI 0.832 to 0.987) separately. The optimal threshold value of synovial CD64 index for the diagnosis of PJI was 0.85, with a sensitivity of 92.00%, a specificity of 96.00%, and diagnostic odds ratio (DOR) of 227.11. CONCLUSION The present study demonstrates that CD64 index in synovial fluid could be a promising laboratory marker for screening PJI. The cut-off values of 0.85 for synovial CD64 index has the potential to distinguish aseptic failure from PJI. Cite this article: Bone Joint J 2020;102-B(4):463-469.
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Affiliation(s)
- Leilei Qin
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ning Hu
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xinyu Li
- Department of pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuelong Chen
- Department of Respiratory and critical care medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiawei Wang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Abstract
BACKGROUND Most tests used to diagnose pediatric septic arthritis are either not accurate or do not produce rapid results. A leukocyte esterase (LE) strip test has previously been validated for the diagnosis of adult native and periprosthetic joint infections. The purpose of this prospective study was to: (1) evaluate the performance characteristics of the LE strip test in the diagnosis of pediatric septic arthritis and (2) determine the false positive rate of LE strip test on the aseptic synovial fluid (SF). METHODS Between May 2016 and November 2018, SF was obtained from children who were hospitalized at our tertiary referral center on the basis of suspicion of septic arthritis. All patients underwent arthrocentesis, and the aspirate was tested with LE strip test, leukocyte count, and culture. Twenty-five patients satisfied the inclusion criteria. For the second part of the study, SF from 25 children undergoing surgery for developmental dysplasia of the hip was collected and tested with LE strip test, leukocyte count, and culture. RESULTS In the first part of this study, 19 joints were classified as septic and 6 as aseptic. Considering a positive LE strip test ("++" and "+++" readings) indicative of septic arthritis yielded a sensitivity of 100%, specificity of 83%, positive predictive value of 95%, and negative predictive value of 100%. In the second part, all 25 patients with an aseptic SF had a negative test result ("-" and "+" readings). CONCLUSIONS The LE strip test seems to be a valuable additional tool in the diagnosis of pediatric septic arthritis. The LE strip test has the advantages of being inexpensive and simple, providing real-time results and having a perfect negative predictive value to rule out the diagnosis of septic arthritis. LEVEL OF EVIDENCE Level II-diagnostic.
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Abstract
The discovery of infection enzyme leukocyte esterase (LE) hydrolyzing a mitochondrial substrate methyl pyruvate (MP) was explored in the development of electroanalytical methods for LE in human biofluids. The LE + MP reaction was coupled with alcohol oxidase to produce hydrogen peroxide, which was then reduced at a nitrogen-doped carbon nanotube electrode at -0.20 V, yielding current proportional to the LE content in a sample. The kinetic assays revealed a fast turnover (kcat = 15 s-1) and high specificity constant (kcatKm-1 = 2.3 × 106 M-1 s-1) for the LE-triggered hydrolysis of MP. The analytical assays were short (5 min) and the quantified LE was in the clinically relevant range of 22-300 μg L-1 (R2, 0.985). The immuno-electroanalysis could detect the picomole quantity of LE and yielded linear calibration plots up to 150 μg L-1 of LE with the same slope regardless of the sample matrix (urine, saliva, and phosphate buffer). The spike-and-recovery experiments displayed an LE recovery of 99-104%. The amperometric immunoassay of LE was less laborious than traditional enzyme-linked immunosorbent assay (ELISA) for LE and reduced the required sample incubation time from 4 h (sandwich ELISA) to 30 min (immuno-electroanalysis). The proposed combination of immunosorption with internally calibrated amperometry can also be used for a selective determination of other enzymes, which form enzymatically active immune complexes.
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Affiliation(s)
- Michael Bekhit
- Department of Chemistry, University of Texas at San Antonio, One UTSA Circle, San Antonio, Texas 78249, United States
| | - Waldemar Gorski
- Department of Chemistry, University of Texas at San Antonio, One UTSA Circle, San Antonio, Texas 78249, United States
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35
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Combined Measurement of D-Dimer and C-Reactive Protein Levels: Highly Accurate for Diagnosing Chronic Periprosthetic Joint Infection. J Arthroplasty 2020; 35:229-234. [PMID: 31526698 DOI: 10.1016/j.arth.2019.08.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/29/2019] [Accepted: 08/04/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Diagnosis of chronic periprosthetic joint infection (PJI) can be challenging and elusive in the absence of a gold standard. D-dimer plays an important role in inflammation that occurs during infections and therefore could be a valuable biomarker for PJI. This study aims to investigate the sensitivity and specificity of D-dimer in detecting chronic PJI and to improve the accuracy of chronic PJI diagnosis through combined measurement of serum D-dimer with C-reactive protein (CRP)/erythrocyte sedimentation rate. METHODS One hundred twenty-two patients presenting with a painful knee or hip after total hip or total knee arthroplasty for surgical revision were included in this prospective trial. Our cohort consisted of 55 patients undergoing revision for chronic PJI and 67 patients undergoing revision for aseptic failure. PJI was defined using the Musculoskeletal Infection Society criteria. Receiver operating characteristic curves and area under the curve were analyzed for each biomarker. RESULTS The area under the curve for D-dimer was 0.915 and was more accurate than serum erythrocyte sedimentation rate 0.719 and CRP 0.761. 1170 ng/mL was determined to be the optimal threshold value of D-dimer for the diagnosis of chronic PJI, with a sensitivity of 92.73% and a specificity of 74.63% in the diagnosis of chronic PJI. The combination of D-dimer and CRP tests demonstrated a sensitivity of 98.11% and negative predictive value of 96.55% for the diagnosis of chronic PJI. CONCLUSION The present study identified the D-dimer is a valuable biomarker in detecting chronic PJI. The combinations of serum D-dimer and CRP led to the improvement of sensitivity compared with those of the single-index test.
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Yan CH, Arciola CR, Soriano A, Levin LS, Bauer TW, Parvizi J. Team Approach: The Management of Infection After Total Knee Replacement. JBJS Rev 2019; 6:e9. [PMID: 29664872 DOI: 10.2106/jbjs.rvw.17.00058] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Chun Hoi Yan
- Department of Orthopaedics & Traumatology, The University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Carla Renata Arciola
- Research Unit on Implant Infections, Rizzoli Orthopaedic Institute, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Spain
| | - L Scott Levin
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Thomas W Bauer
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, NY
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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The Quality of Diagnostic Studies in Periprosthetic Joint Infections: Can We Do Better? J Arthroplasty 2019; 34:2737-2743. [PMID: 31324355 DOI: 10.1016/j.arth.2019.06.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The diagnosis of periprosthetic joint infections (PJIs) continues to be a subject of extensive debate. This is in part due to the lack of a single "gold standard" test, and the marked heterogeneity in the design of studies evaluating the accuracy of different diagnostic modalities. The goal of this review is to critically analyze the evidence cited by the proceedings of the 2013 International Consensus Meeting (ICM) on PJI with regards to the diagnosis of PJI. METHODS References from the Proceedings of the ICM on PJI related to PJI minor criteria were retrieved and manually reviewed. A total of 25 studies were analyzed using a Validated Quality Assessment of Diagnostic Accuracy Studies tool. RESULTS A large number of studies were determined to have a high risk of bias for flow and timing domains due to the large numbers of exclusions. Studies of synovial white blood cells count and polymorphonuclear neutrophils percentage suffered from threshold optimization and lack of internal validity. Furthermore, due to the lack of homogeneity across studies, index test and reference standard domains showed high risk of bias for white blood cell/polymorphonuclear neutrophil percentage and the utility histological analysis, respectively. Leukocyte esterase testing lacked standardization with regard to the strip reagent used, and the exclusion of bloody samples limited sample sizes. CONCLUSION The 2013 ICM minor criteria were based on studies with a low quality of evidence. As the committee continues to adjust these guidelines, they should encourage future studies with sound clinical design, patient selection, and testing procedures.
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Thiesen DM, Koniker A, Gehrke T, Linke P, Ohlmeier M, Salber J, Citak M. The Impact of α-Defensin Test in Diagnosing Periprosthetic Infection After Total Ankle Arthroplasty. J Foot Ankle Surg 2019; 58:1125-1128. [PMID: 31679665 DOI: 10.1053/j.jfas.2019.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/21/2018] [Accepted: 03/11/2019] [Indexed: 02/03/2023]
Abstract
Periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a serious complication, and a reliable diagnostic test to identify PJI is needed. The purpose of this study was to investigate the use of synovial α-defensin levels in identifying PJI of the ankle. Data from 33 patients were retrospectively collected between September 2015 and May 2018. Patients who had pain or suspected loosening after TAA and who had undergone joint aspiration were included in the study. Aspiration was performed in a semisterile theatre. Synovial fluid was processed in descending order for microbiological cultures, α-defensin, leukocyte esterase strip test, and cell count. A periprosthetic infection was defined by Musculoskeletal Infection Society criteria. The sensitivity, specificity, and overall accuracy were calculated, and based on a receiver operating characteristic curve, the quality of the α-defensin test was determined. The calculated area under the curve was 0.97 ± 0.32. Two of 33 patients fulfilled the 2014 Musculoskeletal Infection Society criteria and were scheduled for septic revision arthroplasty. Sensitivity, specificity, and overall accuracy of the α-defensin test were 100% (95% confidence interval [CI], 15.8% to 100%), 93.5% (95% CI, 78.6% to 99.2%), and 93.9% (95% CI, 79.8% to 99.3%), respectively. The positive predictive value was 50% (95% CI, 20.7% to 79.3%), and the negative predictive value was 100%. The α-defensin test seems to be the best available synovial test to detect a late-onset PJI after total ankle arthroplasty. Further prospective studies with a larger number of patients are required.
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Affiliation(s)
- Darius M Thiesen
- Associate Registrar, Department of Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Associate Registrar, Department of Orthopaedic and Joint Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany.
| | - Alina Koniker
- Medical Student, Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Thorsten Gehrke
- Professor and Chief, Orthopaedic Surgery, Department of Orthopaedic and Joint Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Philipp Linke
- Medical Student, Department of Orthopaedic and Joint Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Malte Ohlmeier
- Associate Registrar, Department of Orthopaedic and Joint Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Jochen Salber
- Surgeon, Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Mustafa Citak
- Surgeon and Head of Research, Department of Orthopaedic and Joint Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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Abstract
Infection can be a devastating complication of surgically inserted prosthetic implants and intramedullary rods, plates and pins. About 2 million implants were inserted in the United States in 2004, and, despite appropriate perioperative antibiotics, approximately 5% of internal fixation devices became infected. Infection rates in fractures that pierce the skin can be as high as 22.7%. Complications of infection include excessive antibiotic use, implant removal, reoperation, and potential amputation. Infections caused by colonized prosthetic implants are often difficult to predict, diagnose, and treat, because they form biofilms. This article explores the approach to infected implants.
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Affiliation(s)
- Dena El-Sayed
- Internal Medicine Clinic, Infectious Diseases Clinic, Ventura County Medical Center, Ventura, CA, USA
| | - Aksone Nouvong
- Department of Surgery, Division of Vascular Surgery, David Geffen School of Medicine at UCLA, 200 Medical Plaza, Suite 526, Los Angeles, CA 90095, USA.
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Ellington K, Raikin S, Bemenderfer TB. What Strategies Can Be Implemented to Help Isolate the Causative Organism in Patients With Infection of the Foot and Ankle? Foot Ankle Int 2019; 40:33S-38S. [PMID: 31322940 DOI: 10.1177/1071100719859887] [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: 02/01/2023]
Abstract
RECOMMENDATION Transfer of synovial aspirate in blood culture bottles, obtaining deep biopsy of tissues and bone, obtaining multiple samples, increasing incubation period of cultures, and the use of molecular techniques for culture negative cases are some of the strategies that can help improve the ability to isolate the causative organism(s) in infections of foot and ankle. LEVEL OF EVIDENCE Moderate. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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Affiliation(s)
- Kent Ellington
- 1 OrthoCarolina, Foot and Ankle Institute, AtriumHealth, Charlotte, NC, USA
| | - Steven Raikin
- 2 Sydney Kimmel Medical College, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Emara K, Embil JM. Is There a Role for Measuring Synovial Biomarkers for Diagnosis of Infected Total Ankle Arthroplasty (TAA)? Foot Ankle Int 2019; 40:27S-29S. [PMID: 31322931 DOI: 10.1177/1071100719859570] [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: 02/01/2023]
Abstract
RECOMMENDATION Based on the hip and knee arthroplasty literature, measuring synovial biomarkers may play a role in the diagnosis of infected total ankle arthroplasty (TAA). The diagnosis of periprosthetic joint infection (PJI) in the setting of a TAA can be confirmed with cultures, provided that a plausible pathogen is recovered in the context of a compatible clinical picture. In the absence of a positive culture, synovial biomarker analysis may help in establishing the diagnosis. LEVEL OF EVIDENCE Moderate. DELEGATE VOTE Agree: 92%, Disagree: 8%, Abstain: 0% (Super Majority, Strong Consensus).
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Sconfienza LM, Signore A, Cassar-Pullicino V, Cataldo MA, Gheysens O, Borens O, Trampuz A, Wörtler K, Petrosillo N, Winkler H, Vanhoenacker FMHM, Jutte PC, Glaudemans AWJM. Diagnosis of peripheral bone and prosthetic joint infections: overview on the consensus documents by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur Radiol 2019; 29:6425-6438. [PMID: 31250170 DOI: 10.1007/s00330-019-06326-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/27/2019] [Accepted: 06/12/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Peripheral bone infection (PBI) and prosthetic joint infection (PJI) are two different infectious conditions of the musculoskeletal system. They have in common to be quite challenging to be diagnosed and no clear diagnostic flowchart has been established. Thus, a conjoined initiative on these two topics has been initiated by the European Society of Radiology (ESR), the European Association of Nuclear Medicine (EANM), the European Bone and Joint Infection Society (EBJIS), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). The purpose of this work is to provide an overview on the two consensus documents on PBI and PJI that originated by the conjoined work of the ESR, EANM, and EBJIS (with ESCMID endorsement). METHODS AND RESULTS After literature search, a list of 18 statements for PBI and 25 statements for PJI were drafted in consensus on the most debated diagnostic challenges on these two topics, with emphasis on imaging. CONCLUSIONS Overall, white blood cell scintigraphy and magnetic resonance imaging have individually demonstrated the highest diagnostic performance over other imaging modalities for the diagnosis of PBI and PJI. However, the choice of which advanced diagnostic modality to use first depends on several factors, such as the benefit for the patient, local experience of imaging specialists, costs, and availability. Since robust, comparative studies among most tests do not exist, the proposed flowcharts are based not only on existing literature but also on the opinion of multiple experts involved on these topics. KEY POINTS • For peripheral bone infection and prosthetic joint infection, white blood cell and magnetic resonance imaging have individually demonstrated the highest diagnostic performance over other imaging modalities. • Two evidence- and expert-based diagnostic flowcharts involving variable combination of laboratory tests, biopsy methods, and radiological and nuclear medicine imaging modalities are proposed by a multi-society expert panel. • Clinical application of these flowcharts depends on several factors, such as the benefit for the patient, local experience, costs, and availability.
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Affiliation(s)
- Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy. .,Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy.
| | - Alberto Signore
- Nuclear Medicine Unit, Faculty of Medicine and Psychology, Department of Medical-Surgical Sciences and Translational Medicine, "Sapienza" University, Rome, Italy
| | - Victor Cassar-Pullicino
- Department of Diagnostic Imaging, The Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Oswestry, Shropshire, UK
| | - Maria Adriana Cataldo
- Infectious Disease Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS, Rome, Italy
| | - Olivier Gheysens
- Department of Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Olivier Borens
- Division of Orthopaedic Surgery and Traumatology, Septic surgical unit, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Klaus Wörtler
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Munich, Germany
| | - Nicola Petrosillo
- Infectious Disease Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS, Rome, Italy
| | - Heinz Winkler
- Osteitis-Centre, Privatklinik Döbling, Vienna, Austria
| | - Filip M H M Vanhoenacker
- Department of Radiology, Antwerp University Hospital and Antwerp University, Antwerp, Belgium.,AZ Sint-Maarten, Belgium, Mechelen, Belgium.,University of Ghent, Ghent, Belgium
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Shahi A, Alvand A, Ghanem E, Restrepo C, Parvizi J. The Leukocyte Esterase Test for Periprosthetic Joint Infection Is Not Affected by Prior Antibiotic Administration. J Bone Joint Surg Am 2019; 101:739-744. [PMID: 30994592 DOI: 10.2106/jbjs.18.00615] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND It has been demonstrated that administration of antibiotics prior to performing diagnostic testing for periprosthetic joint infection can interfere with the accuracy of the standard diagnostic tests. Therefore, the purpose of this study was to evaluate the effects of antibiotic administration prior to performing the synovial leukocyte esterase strip test for periprosthetic joint infection. METHODS We identified 121 patients who underwent revision hip or knee arthroplasty for a Musculoskeletal Infection Society (MSIS)-confirmed periprosthetic joint infection. All patients also had a leukocyte esterase strip test performed. Patients in one group (32%) took antibiotics prior to the diagnostic workup, whereas patients in another group (68%) did not receive antibiotics within 2 weeks of the diagnostic workup. The leukocyte esterase strip test, erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), synovial white blood-cell (WBC) count, and polymorphonuclear neutrophil (PMN) percentage were collected and were compared between the 2 groups. RESULTS The median serum ESR (85 compared with 67 mm/hr for patients who did not and did receive antibiotics; p = 0.009), CRP (16.5 compared with 12.9 mg/L; p = 0.032), synovial WBC count (45,675 compared with 9,650 cells/µL; p < 0.0001), and PMN percentage (93% compared with 88%; p = 0.004) were all significantly lower for patients receiving antibiotics. Furthermore, the administration of antibiotics resulted in a significant decrease in the sensitivity of all tests, except leukocyte esterase: ESR (79.5% in the antibiotics cohort compared with 92.7% in the no-antibiotics cohort [relative risk (RR) for false-negative results, 2.8; p = 0.04]), CRP (64.2% compared with 81.8% [RR, 1.9; p = 0.03]), WBC count (69.3% compared with 93.4% [RR, 5.0; p = 0.001]), PMN percentage (74.4% compared with 91.5% [RR, 3.0; p = 0.01]), and leukocyte esterase (78% compared with 83% [RR, 1.6; p = 0.17]). The rate of negative cultures was higher in the antibiotics group at 30.7% compared with the no-antibiotics group at 12.1% (p = 0.015). CONCLUSIONS This current study and previous studies have demonstrated that the administration of premature antibiotics can compromise the results of standard diagnostic tests for periprosthetic joint infection, causing significant increases in false-negative results. However, in this study, the leukocyte esterase strip test maintained its performance even in the setting of antibiotic administration. Antibiotic administration prior to diagnostic workups for periprosthetic joint infection stands to interfere with diagnosis. The leukocyte esterase strip test can be used as a reliable diagnostic marker for diagnosing periprosthetic joint infection even when prior antibiotics are administered. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alisina Shahi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Abtin Alvand
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom
| | - Elie Ghanem
- Department of Orthopaedic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Camilo Restrepo
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Zagra L, Villa F, Cappelletti L, Gallazzi E, Materazzi G, De Vecchi E. Can leucocyte esterase replace frozen sections in the intraoperative diagnosis of prosthetic hip infection? Bone Joint J 2019; 101-B:372-377. [PMID: 30929495 DOI: 10.1302/0301-620x.101b4.bjj-2018-0752.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Leucocyte esterase (LE) has been shown to be an accurate marker of prosthetic joint infection (PJI), and has been proposed as an alternative to frozen section (FS) histology for intraoperative diagnosis. In this study, the intraoperative assessment of LE was compared with FS histology for the diagnosis of prosthetic hip infection. PATIENTS AND METHODS A total of 119 patients undergoing revision total hip arthroplasty (THA) between June 2015 and December 2017 were included in the study. There were 56 men and 63 women with a mean age of 66.2 years (27 to 88). Synovial fluid was collected before arthrotomy for the assessment of LE using enzymatic colourimetric strips. Between five and six samples were stained with haematoxylin and eosin for FS histology, and considered suggestive of infection when at least five polymorphonuclear leucocytes were found in five high-power fields. RESULTS The sensitivity and specificity of the LE assay were 100% and 93.8%, respectively; the positive (PPV) and the negative (NPV) predictive values were 79.3% and 100%, respectively. The mean time between the collection of the sample and the result being known was 20.1 minutes (sd 4.4). The sensitivity and specificity of FS histology were 78.3% and 96.9%, respectively; the PPV and the NPV were 85.7% and 94.9%, respectively. The mean time between the collection of the sample and the result being known was 27.2 minutes (sd 6.9). CONCLUSION The sensitivity of LE assay was higher, with similar specificity and diagnostic accuracy, compared with FS histology. The faster turnaround time, its ease of use, and low costs make LE assay a valuable alternative to FS histology. We now use it routinely for the intraoperative diagnosis of PJI. Cite this article: Bone Joint J 2019;101-B:372-377.
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Affiliation(s)
- L Zagra
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - F Villa
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - L Cappelletti
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - E Gallazzi
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - G Materazzi
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - E De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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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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Aalirezaie A, Bauer TW, Fayaz H, Griffin W, Higuera CA, Krenn V, Krenn V, Molano M, Moojen DJ, Restrepo C, Shahi A, Shubnyakov I, Sporer S, Tanavalee A, Teloken M, Velázquez Moreno JD. Hip and Knee Section, Diagnosis, Reimplantation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S369-S379. [PMID: 30343965 DOI: 10.1016/j.arth.2018.09.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Abdel Karim M, Andrawis J, Bengoa F, Bracho C, Compagnoni R, Cross M, Danoff J, Della Valle CJ, Foguet P, Fraguas T, Gehrke T, Goswami K, Guerra E, Ha YC, Klaber I, Komnos G, Lachiewicz P, Lausmann C, Levine B, Leyton-Mange A, McArthur BA, Mihalič R, Neyt J, Nuñez J, Nunziato C, Parvizi J, Perka C, Reisener MJ, Rocha CH, Schweitzer D, Shivji F, Shohat N, Sierra RJ, Suleiman L, Tan TL, Vasquez J, Ward D, Wolf M, Zahar A. Hip and Knee Section, Diagnosis, Algorithm: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S339-S350. [PMID: 30348566 DOI: 10.1016/j.arth.2018.09.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [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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Consensus document for the diagnosis of prosthetic joint infections: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur J Nucl Med Mol Imaging 2019; 46:971-988. [PMID: 30683987 PMCID: PMC6450843 DOI: 10.1007/s00259-019-4263-9] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/02/2019] [Indexed: 12/13/2022]
Abstract
Background For the diagnosis of prosthetic joint infection, real evidence-based guidelines to aid clinicians in choosing the most accurate diagnostic strategy are lacking. Aim and Methods To address this need, we performed a multidisciplinary systematic review of relevant nuclear medicine, radiological, orthopaedic, infectious, and microbiological literature to define the diagnostic accuracy of each diagnostic technique and to address and provide evidence-based answers on uniform statements for each topic that was found to be important to develop a commonly agreed upon diagnostic flowchart. Results and Conclusion The approach used to prepare this set of multidisciplinary guidelines was to define statements of interest and follow the procedure indicated by the Oxford Centre for Evidence-based Medicine (OCEBM). Electronic supplementary material The online version of this article (10.1007/s00259-019-4263-9) contains supplementary material, which is available to authorized users.
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Mercuri LG. Prevention and detection of prosthetic temporomandibular joint infections-update. Int J Oral Maxillofac Surg 2018; 48:217-224. [PMID: 30316660 DOI: 10.1016/j.ijom.2018.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/25/2018] [Indexed: 10/28/2022]
Abstract
Prosthetic joint infections are not only distressing complications for patients and surgeons, but also have an enormous financial impact on healthcare systems. The reported incidence of prosthetic joint infection is likely underestimated due to difficulties in their diagnosis. This unfortunate complication has challenged joint replacement surgeons for years, despite all the advances made in this surgical discipline. Since eradication of these infections can be very difficult, prevention remains the primary objective. Identifying recipient risk factors, adopting a proper surgical technique, appropriate wound care, optimizing the operating room environment, and appropriate postoperative care have become some of the core elements that can help to minimize the overall incidence of this complication. The purpose of this article is to provide the temporomandibular joint replacement surgeon with an update on the prevention and detection of prosthetic joint infections based on a review of the most recent information published in the orthopedic and surgical literature.
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Affiliation(s)
- L G Mercuri
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA.
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