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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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Diagnosis of prosthetic joint infection at the hip using the standard uptake value of three-phase 99mTc-hydroxymethylene diphosphonate SPECT/CT. Ann Nucl Med 2022; 36:634-642. [PMID: 35482179 DOI: 10.1007/s12149-022-01745-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/12/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE To retrospectively investigate whether the standard uptake value (SUV) of 99mTc-bone single-photon emission computed tomography (SPECT)/CT could be useful for predicting prosthetic joint infection (PJI) at the hip. PATIENTS AND METHODS We analyzed the cases of 37 patients with a suspected PJI at the hip who underwent 99mTc-bone SPECT/CT and surgical intervention with pathological and bacterial examinations. We divided the cases into those with and those without a causative bacterium detected in a surgical specimen, i.e., the positive bacterial culture (PBC) group (n = 17) and negative bacterial culture (NBC) group (n = 20). Cases with neutrophilic infiltration of surgical specimen comprised the positive neutrophilic infiltration (PINF) group (n = 18) and those without INF comprised the non-neutrophilic infiltration (NINF) group (n = 19). Quantitative analyses were performed using maximum SUVs and peak SUVs of blood-pool (BP) phase images (SUVmaxBP and SUVpeakBP) and late (LT)-phase images (SUVmaxLT and SUVpeakLT). RESULTS Regarding the bacterial cultures, there were significant differences between the PBC and NBC groups in SUVmaxBP (5.26 ± 1.49 vs. 4.21 ± 1.15, respectively; p = 0.019), SUVpeakBP (4.89 ± 1.32 vs. 3.87 ± 1.06, p = 0.012), SUVmaxLT (16.10 ± 6.36 vs. 11.67 ± 4.95, p = 0.026), and SUVpeakLT (14.58 ± 5.83 vs. 10.49 ± 4.31 p = 0.036). Regarding neutrophilic infiltration, there were significant differences between the PINF and NINF groups in SUVmaxBP (5.18 ± 1.48 vs. 4.24 ± 1.19, p = 0.047) and SUVpeakBP (4.78 ± 1.32 vs. 3.92 ± 1.10, p = 0.043). CONCLUSION An SUV analysis of 99mTc-bone SPECT/CT is a useful method to differentiate a PJI at the hip from non-infection.
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Goud A, Nützinger D, van der Bij A, Jenniskens K, Groenewold J, de Gast A, Bekkers JEJ. Synovial-Based Tests Outperform Serum Markers to Rule Out Infection in Total Knee Arthroplasty and Total Hip Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2022; 37:802-808.e5. [PMID: 34952165 DOI: 10.1016/j.arth.2021.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/22/2021] [Accepted: 12/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) provides successful results in most patients. Periprosthetic joint infection (PJI) accounts for up to 25% of failed TKAs needing revision. In clinical practice, consensus in diagnostic strategy for excluding or diagnosing PJI is still lacking. In this systematic review and meta-analysis, we aim to provide a simplified data-driven diagnostic strategy for aseptic knee and hip revision surgeons to rule out PJI in the outpatient clinic phase. METHODS A literature search in EMBASE, MEDLINE, PubMed, and Cochrane was conducted. Studies involving the diagnosis of PJI in patients with failed TKAs and total hip arthroplasties needing revision were identified. Only studies using the Musculoskeletal Infection Society criteria were included. Quality was assessed using MINORS criteria. Meta-analysis was performed for each diagnostic test identified in the included studies. Pooled estimates of diagnostic accuracy measures were calculated using a bivariate model and plotted in summary receiver-operator characteristic curves. Positive and negative predictive values were calculated in a hypothetical sample of patients with a given disease prevalence. RESULTS Twenty-four studies met the inclusion criteria, describing a total of 2974 patients. Quality scores ranged from 13 to 19. Meta-analysis could be performed on 7 unique diagnostic tests. Highest pooled sensitivity and specificity were demonstrated for α-defensin with values of 86% and 96.6%, respectively. α-defensin and white blood cell count in synovial fluid demonstrate highest negative predictive value values. CONCLUSIONS We recommend, in a clinical setting with low-intermediate prevalence of PJI, performing arthrocentesis and joint fluid analysis using α-defensin and/or white blood cell count before revision TKA and revision total hip arthroplasty surgery to rule out PJI.
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Affiliation(s)
- Annemarie Goud
- Department of Orthopedic Surgery, Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands
| | - Don Nützinger
- Department of Orthopedic Surgery, Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands; Clinical Orthopedic Research Center Midden Nederland, Diakonessenhuis Utrecht/Zeist, Zeist, the Netherlands
| | - Akke van der Bij
- Department of Microbiology and Immunology, Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands
| | - Kevin Jenniskens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), University Utrecht, Utrecht, the Netherlands
| | - Joel Groenewold
- University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
| | - Arthur de Gast
- Clinical Orthopedic Research Center Midden Nederland, Diakonessenhuis Utrecht/Zeist, Zeist, the Netherlands
| | - Joris E J Bekkers
- Department of Orthopedic Surgery, Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands; Clinical Orthopedic Research Center Midden Nederland, Diakonessenhuis Utrecht/Zeist, Zeist, the Netherlands
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Abstract
Periprosthetic joint infection (PJI) is one of the most dreadful complications after THA and TKA. Though prevention is of utmost importance in PJI management, the last decade has seen many remarkable developments in PJI diagnosis, including the introduction of several standardized PJI diagnostic definitions and biomarkers. Depending on the specific clinical situation, a myriad of treatment options for PJI are offered. Our review aims to summarize the pertinent information on PJI diagnosis and synthesize literature on the different treatment methods currently used in clinical practice. One of the most accepted PJI diagnostic definitions was developed by the Musculoskeletal Infection Society (MSIS) in 2011, later modified in the 2013 International Consensus Meeting (ICM). After promising results from studies, alpha-defensins and D-dimer were recently incorporated into the 2018 ICM PJI definition. The management choices for PJI include irrigation and debridement (DAIR), one-stage exchange arthroplasty, or two-stage exchange arthroplasty, to name a few. While two-stage revision has traditionally been the treatment of choice in the United States, there has been a growing body of evidence framing one-stage revision as a comparable choice. One-stage revision should be offered in patients meeting strict selection criteria: no sinus tract, proper soft tissue available for wound closure, appropriate bone stock, a favorable identifiable organism with encouraging antibiotic sensitivities (for cement and oral suppression later), and robust immunological status. DAIR can be considered in case of early infections with sensitive infecting organisms. Patients with multiple unsuccessful revisions or those who refuse further surgical intervention for PJI can be offered antibiotic suppression. If nothing seems to work, salvage procedures (resection arthroplasty and arthrodesis) are available as a last resort. Further research is encouraged to improve on diagnostic capabilities and develop evidence on the best treatment of choice for PJI.
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Affiliation(s)
- Tejbir S. Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida 2950 Cleveland Clinic Blvd. Weston 33331 FL USA
| | - Jesus M. Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida 2950 Cleveland Clinic Blvd. Weston 33331 FL USA
| | - Carlos A. Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida 2950 Cleveland Clinic Blvd. Weston 33331 FL USA
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Mathis DT, Hirschmann MT. Why do knees after total knee arthroplasty fail in different parts of the world? J Orthop 2021; 23:52-59. [PMID: 33456216 PMCID: PMC7797486 DOI: 10.1016/j.jor.2020.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 02/09/2023] Open
Abstract
OBJECTIVE The aim of this narrative review was to provide an overview of failure modes after total knee arthroplasty in different parts of the world based on data from worldwide representative studies and National Joint Registries. METHODS A review of the available literature was performed using the keyword terms "total knee arthroplasty", "revision", "failure", "reasons", "causes", "complications", "epidemiology", "etiology"; "assessment", "painful knee", "registry" and "national" in several combinations. The following databases were assessed: Pubmed (https://pubmed.ncbi.nlm.nih.gov), Cochrane Reviews (https://www.cochrane.org), Google Scholar (https://scholar.google.com). In addition, registry data were obtained directly from national registry archives. Due to the heterogeneity of available data it was decided to present the review in a narrative manner. RESULTS Current literature report that infection has become the primary acute cause of TKA failure, while aseptic loosening and instability remain the overall most frequent reasons for revisions. Based on national registries certain tendencies can be deducted. The predominant overall failure mode of aseptic loosening is particularly found in Japan, United Kingdom, New Zealand and Switzerland. Leading early TKA failure mode represents infection with percentages of 20-30% in Sweden, Australia, New Zealand, Japan and the United States. Higher numbers could only be found in clinical studies on the Asian continent such as Korea (38%), China (53%), Iran (44%) and India (87%). CONCLUSION Although there are regional differences in TKA failure modes, TKA fails worldwide especially due to infections and aseptic loosening. It is important to diagnose these in good time and reliably using appropriate, standardized diagnostics in order to recommend the best possible therapy to the patient.
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Affiliation(s)
- Dominic T. Mathis
- University of Basel, CH-4051, Basel, Switzerland
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101, Bruderholz, Switzerland
| | - Michael T. Hirschmann
- University of Basel, CH-4051, Basel, Switzerland
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), CH-4101, Bruderholz, Switzerland
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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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Berns E, Barrett C, Gardezi M, Spake C, Glasser J, Antoci V, Born CT, Garcia DR. Current Clinical Methods for Detection of Peri-Prosthetic Joint Infection. Surg Infect (Larchmt) 2020; 21:645-653. [PMID: 32043924 PMCID: PMC9639237 DOI: 10.1089/sur.2019.314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Currently, one of the most pressing problems in the field of orthopedic surgery is peri-prosthetic joint infection [PJI]. While there are numerous ways to detect PJI, current clinical detection methods differ across institutions and have varying criteria and protocols. Some of these methods include the Modified Musculoskeletal Infection Society system, culturing, polymerase chain reaction, the determination of the presence of certain biomarkers, testing for the presence of alpha defensin peptides, and leukocyte level testing. Methods: This review summarizes the most recent publications in the field of PJI detection to highlight current strengths as well as provide future directions to find the system for the quickest, cost-effective, and most accurate way to diagnose these types of infections. Results: The results of this literature review suggest that, while each method of diagnosis has its advantages, each has various drawbacks as well. Current methods can be expensive, take days to weeks to complete, be prone to contamination, and can produce ambiguous results. Conclusions: The findings in this review emphasize the need for a more comprehensive and accurate system for diagnosing PJI. In addition, the specific comparison of advantages and drawbacks can be useful for researchers and clinicians with goals of creating new diagnostic tests for PJIs, as well as in clinical scenarios to determine the correct treatment for patients.
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Affiliation(s)
- Ellis Berns
- Warren Alpert Medical School of Brown University, Brown University, Providence, Rhode Island, USA
| | | | | | - Carole Spake
- Warren Alpert Medical School of Brown University, Brown University, Providence, Rhode Island, USA
| | | | - Valentin Antoci
- Warren Alpert Medical School of Brown University, Brown University, Providence, Rhode Island, USA
- Brown University and Department of Orthopaedic Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Christopher T. Born
- Warren Alpert Medical School of Brown University, Brown University, Providence, Rhode Island, USA
- Brown University and Department of Orthopaedic Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Dioscaris R. Garcia
- Brown University, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Brown University, Providence, Rhode Island, USA
- Brown University and Department of Orthopaedic Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
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Lausmann C, Kolle KN, Citak M, Abdelaziz H, Schulmeyer J, Delgado GD, Gehrke T, Gebauer M, Zahar A. How reliable is the next generation of multiplex-PCR for diagnosing prosthetic joint infection compared to the MSIS criteria? Still missing the ideal test. Hip Int 2020; 30:72-77. [PMID: 32907419 DOI: 10.1177/1120700020938576] [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: 02/04/2023]
Abstract
INTRODUCTION Identification of the pathogen in case of a periprosthetic joint infection (PJI) remains 1 of the greatest challenges in septic surgery. Rapid germ identification enables timely, specific, antimicrobial therapy. The first multiplex PCR (polymerase chain reaction) generation (Unyvero-i60) enables germ detection within 5 hours with a sensitivity of 78.8% and a specificity of 100%. The aim of this study is to investigate the performance of the new generation of cartridges (Unyvero-ITI) of multiplex PCR in the case of a PJI. METHODS In a prospective study, intraoperatively aspirated synovial fluid from 97 patients with aseptic or septic hip or knee revision surgery (49 aseptic, 48 septic) was examined with the multiplex PCR system (Unyvero-ITI) and the results were compared with the MSIS criteria. In addition, the time until the microbiological result was obtained in the event of a germ detection was documented. RESULTS The multiplex PCR showed a germ detection with a sensitivity of 85.1% and a specificity of 98.0%. In 7 cases a false negative result was found and in one patient a false positive result was found. The general accuracy of this test procedure was 91.8%. The detection of germs was carried out within 5 hours with the multiplex PCR compared to 4.9 days in conventional microbiological diagnostics. CONCLUSIONS The new generation of multiplex-PCR was able to improve germ detection. The possibility of prompt detection of germs offers the option of faster, targeted antimicrobial therapy. This diagnostic tool offers significant advantages, particularly in the context of an acute periprosthetic infection.
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Affiliation(s)
- Christian Lausmann
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Kim Niklas Kolle
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Hussein Abdelaziz
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Juan Schulmeyer
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany.,Department of Orthopaedic Surgery, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Gio D Delgado
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany.,Department of Orthopaedics, Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Matthias Gebauer
- Department of Orthopaedic Surgery, Roland Klinik, Bremen, Germany
| | - Akos Zahar
- Department of Orthopaedic Surgery and Traumatology, Helios Klinikum Emil von Behring, Berlin, Germany
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Hu Q, Fu Y, Tang L. Serum D-dimer as a diagnostic index of PJI and retrospective analysis of etiology in patients with PJI. Clin Chim Acta 2020; 506:67-71. [DOI: 10.1016/j.cca.2020.03.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 02/29/2020] [Accepted: 03/12/2020] [Indexed: 01/03/2023]
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Kuiper JWP, Verberne SJ, Vos SJ, van Egmond PW. Does the Alpha Defensin ELISA Test Perform Better Than the Alpha Defensin Lateral Flow Test for PJI Diagnosis? A Systematic Review and Meta-analysis of Prospective Studies. Clin Orthop Relat Res 2020; 478:1333-1344. [PMID: 32324670 PMCID: PMC7319381 DOI: 10.1097/corr.0000000000001225] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/28/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) following total joint arthroplasty is a serious complication that causes severe morbidity and adds a major financial burden to the healthcare system. Although there is plenty of research on the alpha-defensin (AD) test, a meta-analysis consisting of only prospective studies investigating AD's diagnostic efficacy has not been performed. Additionally, some important subgroups such as THA and TKA have not been separately analyzed, particularly regarding two commonly used versions of the AD test, the laboratory-based (ELISA) and lateral-flow (LF). QUESTIONS/PURPOSES (1) Does the AD ELISA test perform better in the detection of PJI than the AD LF test, in terms of pooled sensitivity and specificity, when including prospective studies only? (2) Are there differences in sensitivity or specificity when using AD ELISA and AD LF tests for PJI diagnosis of THA or TKA PJI separately? METHODS Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we included prospective studies describing the use of either AD test in the workup of pain after total joint arthroplasty (primary or revision, but not after resection arthroplasty). Fifteen studies (AD ELISA: 4; AD LF: 11) were included, with 1592 procedures. Subgroup data on THA and TKA could be retrieved for 1163 procedures (ELISA THA: 123; LF THA: 257; ELISA TKA: 228; LF TKA: 555). Studies not describing THA or TKA, those not using Musculoskeletal Infection Society (MSIS) criteria as the standard for determining the presence or absence of PJI, those not clearly reporting data for the AD test for the total cohort, and those describing data published in another study were excluded. Studies were not excluded based on follow-up duration; the MSIS criteria could be used within a few weeks, when test results were available. Quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 criteria. Study quality was generally good. The most frequent sources of bias were related to patient selection (such as unclear inclusion and exclusion criteria) and flow and timing (uncertainty in place and time of aspiration, for example). Heterogeneity was moderate to high; a bivariate random-effects model therefore was used. To answer both research questions, sensitivity and specificity were calculated for AD ELISA and LF test groups and THA and TKA subgroups, and were compared using z-test statistics and meta-regression analysis. RESULTS No differences were found between the AD ELISA and the AD LF for PJI diagnosis in the pooled cohorts (THA and TKA combined), in terms of sensitivity (90% versus 86%; p = 0.43) and specificity (97% versus 96%; p = 0.39). Differences in sensitivity for PJI diagnosis were found between the THA and TKA groups for the AD ELISA test (70% versus 94%; p = 0.008); pooled AD LF test sensitivity did not differ between THA and TKA (80% versus 87%; p = 0.20). No differences in specificity were found in either subgroup. CONCLUSIONS Both the AD ELISA and AD LF test can be used in clinical practice because both have high sensitivity and very high specificity for PJI diagnosis. The lower sensitivity found for diagnosis of PJI in THA for the AD ELISA test must be carefully interpreted because the pooled data were heterogenous and only two studies for this group were included. Future research should analyze TKAs and THAs separately to confirm or disprove this finding. LEVEL OF EVIDENCE Level II diagnostic study.
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Affiliation(s)
- Jesse W P Kuiper
- J. W. P. Kuiper, S. J. Verberne, S. J. Vos, Department of Orthopaedics and Centre for Orthopaedic Research Alkmaar (CORAL) Noordwest Ziekenhuisgroep Alkmaar, Alkmaar, the Netherlands
| | - Steven J Verberne
- J. W. P. Kuiper, S. J. Verberne, S. J. Vos, Department of Orthopaedics and Centre for Orthopaedic Research Alkmaar (CORAL) Noordwest Ziekenhuisgroep Alkmaar, Alkmaar, the Netherlands
| | - Stan J Vos
- J. W. P. Kuiper, S. J. Verberne, S. J. Vos, Department of Orthopaedics and Centre for Orthopaedic Research Alkmaar (CORAL) Noordwest Ziekenhuisgroep Alkmaar, Alkmaar, the Netherlands
| | - Pim W van Egmond
- P. W. van Egmond, Department of Orthopaedics, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands
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Palmer JR, Pannu TS, Villa JM, Manrique J, Riesgo AM, Higuera CA. The treatment of periprosthetic joint infection: safety and efficacy of two stage versus one stage exchange arthroplasty. Expert Rev Med Devices 2020; 17:245-252. [DOI: 10.1080/17434440.2020.1733971] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Joseph R. Palmer
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Tejbir S. Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Jesus M. Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Jorge Manrique
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Aldo M. Riesgo
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Carlos A. Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
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High-Performance Liquid Chromatography as a Novel Method for the Determination of α-Defensins in Synovial Fluid for Diagnosis of Orthopedic Infections. Diagnostics (Basel) 2020; 10:diagnostics10010033. [PMID: 31936486 PMCID: PMC7167866 DOI: 10.3390/diagnostics10010033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 11/18/2022] Open
Abstract
The α-defensins (AD) present in synovial fluid have been regarded as constituting the most accurate periprosthetic joint infection (PJI) biomarker. The methods most commonly used for estimating AD as a biomarker are the qualitative Synovasure® PJI tests, based on the technique of lateral flow, and quantitative enzyme-linked immunosorbent assay (ELISA). Here, we propose a novel test based on detecting α-defensins in synovial fluid by high-performance liquid chromatography (HPLC). Synovial fluid was collected from 157 patients diagnosed with PJI, infectious arthritis (IA), arthrosis, reactive arthritis, and rheumatoid arthritis. AD concentrations in the fluid were determined by HPLC, and these same samples were used for additional diagnostic analyses. The results were statistically processed to calculate cutoff concentrations for PJI and IA. HPLC testing showed a sensitivity of 94% and a specificity of 92% for diagnosis of PJI, and a sensitivity of 97% and a specificity of 87% for diagnosis of IA. Using HPLC, we detected in synovial fluid a combination of three α-defensins: human neutrophil peptides HNP1, HNP2, and HNP3. All measured AD concentration values shown in this work refer to the sum of these three individual concentrations. Our study shows that the HPLC method meets the conditions for measuring precise concentrations of the sum of AD and can be recommended as part of a diagnostic array for PJI and IA diagnostics. By this method, we have verified that higher levels of AD in synovial fluid can also be seen in rheumatoid illnesses, crystal arthropathies, and reactive arthritis.
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Han X, Xie K, Jiang X, Wang L, Wu H, Qu X, Yan M. Synovial fluid α-defensin in the diagnosis of periprosthetic joint infection: the lateral flow test is an effective intraoperative detection method. J Orthop Surg Res 2019; 14:274. [PMID: 31455372 PMCID: PMC6712677 DOI: 10.1186/s13018-019-1320-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 08/16/2019] [Indexed: 12/29/2022] Open
Abstract
Background Synovial fluid α-defensin is a valuable biomarker for periprosthetic joint infection (PJI). Its diagnostic value for PJI has been widely evaluated recently, but results are inconsistent, especially for different test methods. The objective of this study was to evaluate the diagnostic value of laboratory-based immunoassay and lateral flow testing for the detection of α-defensin against hip and knee PJI. Methods We systematically searched MEDLINE and EMBASE for articles on the diagnostic accuracy of α-defensin for PJI published up to September 2018. The pooled sensitivity, specificity, area under the curve (AUC), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were calculated for the evaluation of the diagnostic value of α-defensin for PJI. Results Nineteen studies were included. Eleven evaluated laboratory-based immunoassay, and 10 evaluated the lateral flow test results. The pooled sensitivity, specificity, AUC, PLR, NLR, and DOR of laboratory-based immunoassays were 0.96 (95% confidence interval [CI] 0.90–0.98), 0.97 (95% CI 0.95–0.99), 0.99 (95% CI 0.98–1.00), 35.0 (95% CI 18.5–66.2), 0.04 (95% CI 0.02–0.11), and 811 (95% CI 220–2990), respectively. The pooled sensitivity, specificity, AUC, PLR, NLR, and DOR of the lateral flow test were 0.86 (95% CI 0.81–0.91), 0.96 (95% CI 0.93–0.98), 0.95 (95% CI 0.93–0.97), 21.2 (95% CI 11.7–38.5), 0.14 (95% CI 0.10–0.21), and 148 (95% CI 64–343), respectively. Conclusions Laboratory-based immunoassay of α-defensin is highly accurate for the diagnosis of hip and knee PJI. The lateral flow test is less sensitive but still a useful intraoperative detection tool for PJI.
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Affiliation(s)
- Xuequan Han
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Kai Xie
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Xu Jiang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Liao Wang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Haishan Wu
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, 145 Middle Shandong Road, Shanghai, China
| | - Mengning Yan
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China.
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Fehring TK, Fehring KA, Hewlett A, Higuera CA, Otero JE, Tande A. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2019; 101:1237-1244. [PMID: 31318802 DOI: 10.2106/jbjs.19.00403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | | | | | | | - Jesse E Otero
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina
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CORR Insights®: Does Change in ESR and CRP Guide the Timing of Two-stage Arthroplasty Reimplantation? Clin Orthop Relat Res 2019; 477:372-373. [PMID: 29863530 PMCID: PMC6370085 DOI: 10.1097/corr.0000000000000373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Bauer TW, Bedair H, Creech JD, Deirmengian C, Eriksson H, Fillingham Y, Grigoryan G, Hickok N, Krenn V, Krenn V, Lazarinis S, Lidgren L, Lonner J, Odum S, Shah J, Shahi A, Shohat N, Tarabichi M, W-Dahl A, Wongworawat MD. Hip and Knee Section, Diagnosis, Laboratory Tests: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S351-S359. [PMID: 30343973 DOI: 10.1016/j.arth.2018.09.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Significant increase of pathogen detection rate by dry arthroscopic biopsies at suspected low-grade infection following total knee arthroplasty: a prospective observational study. Arch Orthop Trauma Surg 2018; 138:1583-1590. [PMID: 30182141 DOI: 10.1007/s00402-018-3032-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The differentiation between stiff-knee and low-grade periprosthetic joint infection (PJI) is the current diagnostic challenge in total knee (TKA) revision arthroplasty. The aim of this study was to investigate the additional value of dry biopsies, compared to wet biopsies, in patients presenting with knee stiffness following primary TKA. MATERIALS AND METHODS Single center, prospective observational study. Consecutive patients with joint stiffness of unknown origin following primary TKA were enrolled. Patient assessment followed the diagnostic standard algorithm. During diagnostic arthroscopy, synovial fluid (synovial WBC, PMN%) and five dry biopsies (dry) were collected. Then fluid was infused and another five microbiology (wet) and five histological biopsies gathered, all from identical locations. The primary outcome parameter was the difference between the pathogens in wet and dry biopsies. RESULTS 71 patients (61% females, 67 ± 10 years) were eligible. Preoperative blood serology mean CRP (0.7 ± 1.5 mg/dl; p = 0.852), WBC (6.6 ± 1.7 G/l; p = 0.056), and synovial fluid mean WBC (1639 ± 2111; p = 0.602), PMN% (38 ± 28; p = 0.738) did not differ between patients with negative, positive wet or dry biopsies. The histology was in 11% positive (p = 0.058). In 32% at least one pathogen was detected, 48% from wet, 44% from dry biopsies. An inhomogeneous distribution was found. Cutibacterium acnes (100%) was solely found in wet, Micrococcus luteus (75%), Staphylococcus capitis (67%), and Micrococcus lylae (100%) were predominantly found in dry biopsies. Additional dry biopsies increased the pathogen detection rate by 49%. CONCLUSION The addition of dry biopsies to the current standard diagnostic algorithm for PJI increased the pathogen detection rate by 49%.
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