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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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Grzelecki D, Grajek A, Otworowski M, Paskal W, Fulin P, Kowalczewski J. The Diagnostic Utility of Fast Tests for Detecting C-Reactive Protein in Synovial Fluid in Periprosthetic Joint Infections. J Bone Joint Surg Am 2023; 105:1759-1767. [PMID: 37733911 DOI: 10.2106/jbjs.23.00252] [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] [Indexed: 09/23/2023]
Abstract
BACKGROUND Despite the fact that many synovial fluid biomarkers have found application in the routine diagnosis of periprosthetic joint infection (PJI), this process still remains a challenge for orthopaedic surgeons. To simplify this process, fast point-of-care (POC) tests can be used during ambulatory visits and in operating room conditions. However, before such tests can be routinely used in clinical practice, they require validation. The purpose of the present study was to evaluate the diagnostic accuracy of different fast POC tests for detecting C-reactive protein (CRP) in synovial fluid for the diagnosis of PJI. METHODS Synovial fluid samples were collected from 120 consecutive patients who underwent revision total joint arthroplasty (TJA). The patients were divided into 2 groups. The first group included 76 patients who underwent revision for reasons other than infection (the aseptic revision TJA [arTJA] group), and the second group included 44 patients who underwent revision because of periprosthetic joint infection (PJI). The diagnosis of infection was made according to the International Consensus Meeting (ICM) 2018 criteria. All patients were operatively treated at a single orthopaedic center from January 2022 to February 2023. Four fast CRP tests with different cutoff values (1 and 3 mg/L, ≥8 mg/L, ≥10 mg/L [cassette], ≥10 mg/L [strip]) were used off-label for synovial fluid testing. Tests were performed on the same synovial fluid samples, and the results of these tests were compared with those obtained with the laboratory method. RESULTS The cassette test with a minimum cutoff value of ≥8 mg/L demonstrated the best accuracy for the diagnosis of chronic PJI, with a sensitivity and specificity of 90.9% and 90.8%, respectively. For the cassette test with a cutoff value of >3 mg/L, the sensitivity and specificity were 68.2% and 77.6%, respectively. For the tests with a minimum cutoff value of ≥10 mg/L, the sensitivity and specificity were 77.3% and 94.7%, respectively, for the cassette test and 77.3% and 96.1%, respectively, for the strip test. The laboratory method with the statistically calculated threshold (2.7 mg/L) revealed the highest AUC (area under the receiver operating characteristic curve) value (0.95), with 90.9% sensitivity and 94.7% specificity. CONCLUSIONS The cassette POC test with the minimum cutoff value of ≥8 mg/L had very good accuracy for the diagnosis of chronic PJI. This test had comparable sensitivity and slightly lower specificity in comparison with the laboratory method with the calculated threshold of 2.7 mg/L. LEVEL OF EVIDENCE Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Dariusz Grzelecki
- Department of Orthopedics and Rheumoorthopedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Orthopedic and Trauma Teaching Hospital, Otwock, Poland
| | - Aleksandra Grajek
- Central Laboratory, Prof. Adam Gruca Orthopedic and Trauma Teaching Hospital, Otwock, Poland
| | - Maciej Otworowski
- Department of Orthopaedic Surgery and Traumatology, Southern Hospital, Warsaw, Poland
| | - Wiktor Paskal
- Department of Methodology, Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Petr Fulin
- 1st Department of Orthopaedics, First Faculty of Medicine of Charles University and Motol University Hospital, Prague, Czech Republic
| | - Jacek Kowalczewski
- Department of Orthopedics and Rheumoorthopedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Orthopedic and Trauma Teaching Hospital, Otwock, Poland
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Grünwald L, Schmidutz F, Döttger P, Erne F, Schreiner AJ, Hemmann P. Leukocyte esterase and alpha-defensin in periprosthetic joint infection: predictive quality and correlation in a prospective study. INTERNATIONAL ORTHOPAEDICS 2023; 47:2663-2668. [PMID: 37582980 PMCID: PMC10602937 DOI: 10.1007/s00264-023-05914-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/17/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE Periprosthetic joint infection (PJI) is a rare but serious complication of total joint arthroplasty (TJA). An accurate diagnosis of PJI preoperatively does not exist. Alpha-defensin (AD) is a proven and common indicator. The diagnostic marker of leukocyte esterase (LE) promises some advantages: feasibility, availability, and fast result reporting. The aim of this study was the evaluation of the predictive quality and correlation between both diagnostic tools in the diagnosis of PJI. METHODS A prospective study was conducted between April 2018 and August 2022. All patients with suspicion of PJI on hip and knee joint were included and underwent a routine and standardized joint punction. For laboratory diagnostics of AD, the synovial liquid was analyzed by ELISA. The sample was additionally applied to a LE test strip (Combur 10 Test, Roche Diagnostics, Mannheim, Germany). RESULTS A total of 249 patients were examined (mean age 67.12 ± 11.89; gender distribution man/woman 139 (55.8%)/110(44.2%), hip/knee 71(28.5%)/178 (71.5%). According to EBJIS criteria, PJI was diagnosed in 54 (21.7%) patients. AD showed excellent results with an AUC of 0.930 (sensitivity/specificity 0.870/0.990). LE yielded very good results with an AUC of 0.820 (sensitivity/specificity 0.722/0.918). Both parameters showed a strong positive correlation. CONCLUSION LE is a rapidly available alternative in PJI diagnostics. The simultaneous determination of both markers may enhance diagnostic reliability. A routine usage may shorten the time from diagnosis to treatment of PJI.
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Affiliation(s)
- Leonard Grünwald
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Schnarrenbergstrasse 95, 72076, Tuebingen, Germany
| | - Florian Schmidutz
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University of Munich (LMU), Munich, Germany
- Orthozentrum Rosenheim, Äußere Münchener Str. 94, 83026, Rosenheim, Germany
| | - Philipp Döttger
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Schnarrenbergstrasse 95, 72076, Tuebingen, Germany
| | - Felix Erne
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Schnarrenbergstrasse 95, 72076, Tuebingen, Germany.
- Siegfried Weller Institute for Trauma Research, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, 72076, Germany.
| | - Anna Janine Schreiner
- Siegfried Weller Institute for Trauma Research, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, 72076, Germany
| | - Philipp Hemmann
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Schnarrenbergstrasse 95, 72076, Tuebingen, Germany
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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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Grzelecki D, Grajek A, Walczak P, Kowalczewski J. What is the Accuracy of a Rapid Strip Test That Detects D-lactic Acid in Synovial Fluid for the Diagnosis of Periprosthetic Joint Infections? Clin Orthop Relat Res 2023; 481:120-129. [PMID: 35944072 PMCID: PMC9750661 DOI: 10.1097/corr.0000000000002328] [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: 03/04/2022] [Accepted: 06/28/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND D-lactic acid is a specific marker produced almost exclusively by bacterial species; thus, the appearance of this marker in synovial fluid may indicate periprosthetic joint infection (PJI). Recently, studies have investigated the accuracy of enzyme-linked laboratory tests that detect D-lactic acid in synovial fluid to diagnose PJI. However, to our knowledge, no studies have determined the usefulness of rapid strip tests that detect D-lactic acid in synovial fluid in the diagnosis of PJI. QUESTIONS/PURPOSES (1) What is the best cutoff value for the rapid D-lactic acid strip test for diagnosing PJI? (2) What are the diagnostic accuracies (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of the rapid D-lactic acid strip test and two different rapid leukocyte esterase (LE) strip tests? METHODS This prospective study enrolled 157 patients who underwent revision THA or TKA from May 2021 to February 2022 at a single orthopaedic center. Seventy percent (110 of 157) were eligible for analysis; 10% of these patients (15 of 157) were excluded based on the exclusion criteria (causes of revisions and additional comorbidities that may interfere with the results), and 20% (32 of 157) of the synovial fluid samples could not be tested (dry taps and blood-contaminated samples that could not be centrifuged). We performed the following off-label diagnostic tests on synovial fluid samples collected from all patients: the D-lactic acid strip test (QuantiQuick TM , BioAssay System), two different LE strip tests (10 EA from ARKRAY and BM 10 from BioMaxima). Differently colored strips were marked with symbols (from [-] to [++++] for D-lactic acid and from [-] to [+++] for LE tests) according to the manufacturers' instructions. For the LE tests, results were different for (++), which corresponds to a minimal value of 250 leu/mL for 10 EA and 125 leu/mL for BM 10 tests. The diagnostic standard for the presence or absence of PJI in this study was the International Consensus Meeting (ICM) 2018 criteria; based on these criteria (without the application of an LE test as a minor criterion), all patients were assessed and divided into two groups. Patients who did not meet the criteria for PJI and underwent revision for aseptic loosening, implant malposition, instability, or implant damage were included in the aseptic revision total joint arthroplasty group (68 patients). Patients with a fistula penetrating the joint, those with two positive culture results of the same pathogen, or those with ≥ 6 points according to ICM 2018 minor criteria were enrolled in the PJI group (42 patients). To ascertain the best cutoff value for the rapid D-lactic acid and both LE strip tests for diagnosing PJI, we used collected results, generated a receiver operating characteristic curve, and calculated the Youden index. To determine the accuracies of the diagnostic tests, we calculated their sensitivities, specificities, PPVs, and NPVs against the diagnostic standard (the ICM 2018 criteria). RESULTS The best cutoff value for D-lactic acid was 22.5 mg/L, which corresponded to a reading of (+) on the test strip. For D-lactic acid, in the diagnosis of PJI, the sensitivity was 83% (95% confidence interval [CI] 68% to 92%) and specificity was 100% (95% CI 93% to 100%). For both LE strip tests, the best cutoff value was the same as that proposed in the ICM 2018 criteria. For LE (10 EA), the sensitivity was 81% (95% CI 66% to 91%) and specificity was 99% (95% CI 91% to 100%); for LE (BM 10), sensitivity was 81% (95% CI 65% to 91%) and specificity was 97% (95% CI 89% to 100%). CONCLUSION A rapid off-label D-lactic acid strip test is valuable for diagnosing PJI. The results of this study indicate very good accuracy with comparable sensitivity and specificity for both LE strip tests. The usefulness of the test in a group of patients with chronic inflammatory diseases and the reproducibility of the reading by different researchers were not analyzed in this study and require further investigations. Before a rapid D-lactic strip test is routinely used for diagnosing PJI, multicenter studies on a larger group of patients should be conducted.Level of Evidence Level II, diagnostic study.
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Affiliation(s)
- Dariusz Grzelecki
- Department of Orthopedics and Rheumoorthopedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Orthopedic and Trauma Teaching Hospital, Otwock, Poland
| | - Aleksandra Grajek
- Central Laboratory of Prof. Adam Gruca Orthopedic and Trauma Teaching Hospital, Otwock, Poland
| | - Piotr Walczak
- Department of Orthopedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Orthopedic and Trauma Teaching Hospital, Otwock, Poland
| | - Jacek Kowalczewski
- Department of Orthopedics and Rheumoorthopedics, Centre of Postgraduate Medical Education, Prof. Adam Gruca Orthopedic and Trauma Teaching Hospital, Otwock, Poland
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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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7
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Tan TL. CORR Insights®: What Is the Optimal Timing for Reading the Leukocyte Esterase Strip for the Diagnosis of Periprosthetic Joint Infection? Clin Orthop Relat Res 2021; 479:1331-1332. [PMID: 33847602 PMCID: PMC8133130 DOI: 10.1097/corr.0000000000001683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/26/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Timothy L Tan
- T. L. Tan, University of California, San Francisco, Department of Orthopaedic Surgery, San Francisco, CA, USA
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8
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Zheng QY, Li R, Ni M, Ren P, Ji QB, Sun JY, Li JC, Chen JY, Zhang GQ. What Is the Optimal Timing for Reading the Leukocyte Esterase Strip for the Diagnosis of Periprosthetic Joint Infection? Clin Orthop Relat Res 2021; 479:1323-1330. [PMID: 33492869 PMCID: PMC8133206 DOI: 10.1097/corr.0000000000001609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/24/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The leucocyte esterase (LE) strip test often is used to diagnose periprosthetic joint infection (PJI). In accordance with the manufacturer's directions, the LE strip test result is read 3 minutes after exposing it to joint fluid, but this has not been supported by robust research. Moreover, we have noted that the results of the LE strip test might change over time, and our previous studies have found that centrifugation causes the results of the LE strip test to degrade. Still, there is no evidence-based recommendation as to when to read the LE strip test to maximize diagnostic accuracy, in general, and the best reading times for the LE strip test before and after centrifugation need to be determined separately, in particular. QUESTIONS/PURPOSES (1) What is the optimal timing for reading LE strip test results before centrifugation to diagnose PJI? (2) What is the optimal timing for reading LE strip test results after centrifugation to diagnose PJI? METHODS This study was a prospective diagnostic trial. In all, 120 patients who were scheduled for revision arthroplasty and had signs of infection underwent joint aspiration in the outpatient operating room between July 2018 and July 2019 and were enrolled in this single-center study. For inclusion, patients must have had a diagnosis of PJI or nonPJI, valid synovial fluid samples, and must not have received antibiotics within 2 weeks before arthrocentesis. As such, 36 patients were excluded; 84 patients were included for analysis, and all 84 patients agreed to participate. The 2018 International Consensus Meeting Criteria (ICM 2018) was used for the classification of 49 patients with PJI (score ≥ 6) and 35 without PJI (score ≤ 2). The classification was used as the standard against which the different timings for reading LE strips were compared. All patients without PJI were followed for more than 1 year, during which they did not report the occurrence of PJI. All patients were graded against the diagnostic criteria regardless of their LE strip test results. In 83 patients, one drop of synovial fluid (50 μL) was applied to LE strips before and after centrifugation, and in one patient (without PJI), the sample was not centrifuged because the sample volume was less than 1.5 mL. The results of the strip test were read on an automated colorimeter. Starting from 1 minute after centrifugation, these strips were automatically read once every minute, 15 times (over a period of 16 minutes), and the results were independently recorded by two observers. Results were rated as negative, ±, 1+, and 2+ upon the machine reading. Grade 2+ (dark purple) was used as the threshold for a positive result. An investigator who was blinded to the study performed the statistics. Optimal timing for reading the LE strip before and after centrifugation was determined by using receiver operative characteristic (ROC) analysis. The specificity, sensitivity, and positive predictive and negative predictive values were calculated for key timepoints. RESULTS Before centrifugation, the area under the curve was the highest when the results were read at 5 minutes (0.90 [95% CI 0.83 to 0.98]; sensitivity 0.88 [95% CI 0.75 to 0.95]; specificity 0.89 [95% CI 0.72 to 0.96]). After centrifugation, the area under the curve was the highest when the results were read at 10 minutes (0.92 [95% CI 0.86 to 0.98]; sensitivity 0.65 [95% CI 0.50 to 0.78]; specificity 0.97 [95% CI 0.83 to 1.00]). CONCLUSION The LE strip test results are affected by time and centrifugation. For samples without centrifugation, we found that 5 minutes after application was the best time to read LE strips. We cannot deny the use of centrifuges because this is an effective way to solve the sample-mingling problem at present. We recommend 10 minutes postapplication as the most appropriate time to read LE strips after centrifugation. Multicenter and large-sample size studies are warranted to further verify our conclusion. LEVEL OF EVIDENCE Level II, diagnostic study.
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Affiliation(s)
- Qing-yuan Zheng
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Rui Li
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Ming Ni
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Peng Ren
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Quan-bo Ji
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Jing-yang Sun
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Jun-cheng Li
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Ji-ying Chen
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Guo-qiang Zhang
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
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9
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The Graphical Representation of Cell Count Representation: A New Procedure for the Diagnosis of Periprosthetic Joint Infections. Antibiotics (Basel) 2021; 10:antibiotics10040346. [PMID: 33804988 PMCID: PMC8063952 DOI: 10.3390/antibiotics10040346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 11/19/2022] Open
Abstract
Aim: This study was designed to answer the question whether a graphical representation increase the diagnostic value of automated leucocyte counting of the synovial fluid in the diagnosis of periprosthetic joint infections (PJI). Material and methods: Synovial aspirates from 322 patients (162 women, 160 men) with revisions of 192 total knee and 130 hip arthroplasties were analysed with microbiological cultivation, determination of cell counts and assay of the biomarker alpha-defensin (170 cases). In addition, microbiological and histological analysis of the periprosthetic tissue obtained during the revision surgery was carried out using the ICM classification and the histological classification of Morawietz and Krenn. The synovial aspirates were additionally analysed to produce dot plot representations (LMNE matrices) of the cells and particles in the aspirates using the hematology analyser ABX Pentra XL 80. Results: 112 patients (34.8%) had an infection according to the ICM criteria. When analysing the graphical LMNE matrices from synovia cell counting, four types could be differentiated: the type “wear particles” (I) in 28.3%, the type “infection” (II) in 24.8%, the “combined” type (III) in 15.5% and “indeterminate” type (IV) in 31.4%. There was a significant correlation between the graphical LMNE-types and the histological types of Morawietz and Krenn (p < 0.001 and Cramer test V value of 0.529). The addition of the LMNE-Matrix assessment increased the diagnostic value of the cell count and the cut-off value of the WBC count could be set lower by adding the LMNE-Matrix to the diagnostic procedure. Conclusion: The graphical representation of the cell count analysis of synovial aspirates is a new and helpful method for differentiating between real periprosthetic infections with an increased leukocyte count and false positive data resulting from wear particles. This new approach helps to increase the diagnostic value of cell count analysis in the diagnosis of PJI.
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10
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Yu BZ, Li R, Fu J, Chai W, Hao LB, Chen JY. Leukocyte esterase test and alpha-defensin test have similar accuracy for the diagnosis of periprosthetic joint infection. INTERNATIONAL ORTHOPAEDICS 2021; 45:1677-1682. [PMID: 33576866 DOI: 10.1007/s00264-020-04903-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 12/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The diagnosis of periprosthetic joint infection (PJI) after total joint replacement remains challenging. Synovial biomarkers are recommended as the major diagnostic criteria for PJI. The purpose of this study was to test the accuracy of the alpha-defensin test and compare it with that of the leukocyte esterase (LE) test for the diagnosis of PJI. METHODS We obtained 130 hip or knee aspirates from May 2015 to September 2018. PJI was defined according to the European Bone and Joint Infection Society (EBJIS) criteria. Synovial fluid samples were tested with the alpha-defensin ELISA and a LE strip. For the LE strip test, besides using the traditional threshold 500 (equal to ++), we are also using an improved one, with 500 (equal to ++) serving as the threshold for the tests before centrifugation and both 250 and 500 indicating positive results after centrifugation. The receiver operating characteristic (ROC) curves, sensitivity, specificity, positive predictive value, negative predictive value, and Cohen's Kappa value were calculated for the LE and alpha-defensin tests. RESULTS The area under the curve (AUC) of alpha-defensin, LE strip test with traditional, and improved interpretation strategy were 0.875, 0.854, and 0.877, respectively. The Cohen's Kappa value for the alpha-defensin tests was 0.826 with the traditional LE interpretation strategy and 0.875 with the improved strategy. CONCLUSION The present study shows that the use of the LE strip to test synovial fluid yielded an accuracy similar to that of the alpha-defensin immunoassay for the diagnosis of PJI; this finding supports the 2018 ICM PJI definition, which considers positive alpha-defensin and LE test results to be equivalent.
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Affiliation(s)
- Bao-Zhan Yu
- Department of Orthopaedics, Chinese PLA General Hospital (301 Hospital), 28 Fuxing Rd., Beijing, 100853, People's Republic of China.,Department of Orthopaedics, Bao Ding Gem Flower Eastern Hospital, Bao Ding, Hebei, People's Republic of China
| | - Rui Li
- Department of Orthopaedics, Chinese PLA General Hospital (301 Hospital), 28 Fuxing Rd., Beijing, 100853, People's Republic of China.
| | - Jun Fu
- Department of Orthopaedics, Chinese PLA General Hospital (301 Hospital), 28 Fuxing Rd., Beijing, 100853, People's Republic of China
| | - Wei Chai
- Department of Orthopaedics, Chinese PLA General Hospital (301 Hospital), 28 Fuxing Rd., Beijing, 100853, People's Republic of China
| | - Li-Bo Hao
- Department of Orthopaedics, Chinese PLA General Hospital (301 Hospital), 28 Fuxing Rd., Beijing, 100853, People's Republic of China
| | - Ji-Ying Chen
- Department of Orthopaedics, Chinese PLA General Hospital (301 Hospital), 28 Fuxing Rd., Beijing, 100853, People's Republic of China.
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11
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Sharma K, Ivy M, Block DR, Abdel MP, Hanssen AD, Beauchamp C, Perry KI, Rosemark CL, Greenwood-Quaintance KE, Mandrekar J, Patel R. Comparative analysis of 23 synovial fluid biomarkers for hip and knee periprosthetic joint infection detection. J Orthop Res 2020; 38:2664-2674. [PMID: 32485031 DOI: 10.1002/jor.24766] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/30/2020] [Accepted: 05/25/2020] [Indexed: 02/04/2023]
Abstract
There is interest in novel synovial fluid biomarkers for the detection of periprosthetic joint infection (PJI). Here, we assessed the diagnostic accuracy of 23 simple or sophisticated synovial fluid biomarkers for periprosthetic hip or knee infection detection. One hundred seven subjects were studied, 57 of whom had aseptic failure (AF) and 50 PJI. The following synovial fluid biomarkers were tested using spectrophotometric assays, immunoassays, lateral flow tests, or test strips: leukocyte count, monocyte percentage, lymphocyte percentage, neutrophil percentage, C-reactive protein (CRP), glucose, lactate, granulocyte-macrophage colony-stimulating factor, interferon-γ, interleukin-1β (IL-1β), IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-17A, IL-23, tumor necrosis factor-α, α-defensin, and leukocyte esterase. The best-performing synovial fluid biomarkers to differentiate PJI from AF-that is, those with highest area under the curve compared to all other biomarkers-were leukocyte count, percent neutrophils and percent monocytes, CRP, and α-defensin (P < .0001).
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Affiliation(s)
- Katyayini Sharma
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota
| | - Morgan Ivy
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota
| | - Darci R Block
- Clinical Core Laboratory Services, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arlen D Hanssen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin I Perry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Jay Mandrekar
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota
| | - Robin Patel
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota.,Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
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12
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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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13
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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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14
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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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15
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Li R, Wang C, Ji XJ, Zheng QY, Li X, Ni M, Zhang GQ, Chen JY. Centrifugation may eliminate false-positive leucocyte esterase strip test results caused by inflammatory arthritis in the diagnosis of knee infection: A pilot study. Bone Joint Res 2020; 9:236-241. [PMID: 32566145 PMCID: PMC7284292 DOI: 10.1302/2046-3758.95.bjr-2019-0245.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims The purpose of this study was to validate our hypothesis that centrifugation may eliminate false-positive leucocyte esterase (LE) strip test results caused by autoimmune diseases in the diagnosis of knee infection. Methods Between January 2016 and May 2019, 83 cases, including 33 cases of septic arthritis and 50 cases of aseptic arthritis, were enrolled in this study. To further validate our hypothesis, another 34 cases of inflammatory arthritis from the Department of Rheumatology of our institution were also included. After aspiration, one drop of synovial fluid was applied to LE strips before and after centrifugation. The results were recorded after approximately three minutes according to the different colour grades on the colour chart. The differences of LE results between each cohort were analyzed. Results Before centrifugation, 46% (23/50) of the LE strip tests in the aseptic arthritis group were false-positives. Most of the false-positive results were due to inflammatory arthritis; after centrifugation, 78.3% (18/23) of the tests yielded negative results. Similar results were observed in cases from the Department of Rheumatology. The sensitivity of the centrifuged LE strip test was 0.818 (0.639 to 0.924), which is still an acceptable level compared with the uncentrifuged results, which yielded a sensitivity of 0.909 (0.745 to 0.976). However, the specificity was increased from 0.540 (0.395 to 0.679) to 0.900 (0.774 to 0.963) after centrifugation. Conclusion Although inflammatory arthritis can yield a false-positive LE strip test result in the diagnosis of knee infection, centrifugation may eliminate these false-positive results. Cite this article: Bone Joint Res. 2020;9(5):236–241.
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Affiliation(s)
- Rui Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Chi Wang
- Medical Laboratory Center, Chinese PLA General Hospital, Beijing, China
| | - Xiao-Jian Ji
- Department of Rheumatology, Chinese PLA General Hospital, Beijing, China
| | - Qing-Yuan Zheng
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Xiang Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Ming Ni
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Guo-Qiang Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Ji-Ying Chen
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
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16
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Guan H, Xu C, Fu J, Ni M, Li X, Chai W, Hao L, Zhou Y, Chen J. Diagnostic criteria of periprosthetic joint infection: a prospective study protocol to validate the feasibility of the 2018 new definition for Chinese patients. BMC Musculoskelet Disord 2019; 20:552. [PMID: 31747958 PMCID: PMC6868824 DOI: 10.1186/s12891-019-2941-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/12/2019] [Indexed: 12/29/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is a challenging complication following total joint arthroplasty (TJA), and the diagnostic criteria remains controversial. The 2018 new definition proposed in May 2018 consists of new diagnostic criteria for PJI. We conducted a retrospective study and demonstrated that the new definition could improve the diagnostic efficiency in Chinese patients. However, missing data led to bias in the previous retrospective study. Therefore, this prospective study is designed to further validate the feasibility of 2018 new definition (and its modified version) for Chinese patients. Methods/design This is a single-centre, prospective diagnostic study with 1 year of follow-up. The patients enrolled in the trial will be divided into a PJI group and an Aseptic group based on the eligibility criteria. We will recruit at least 70 patients for each group from October 2019 to October 2020. Blood samples, synovial fluid samples and intraoperative variables of all the included patients will be collected to assess various indicators. We will integrate the results of the various tests and examine the diagnostic efficiency (sensitivity and specificity) of five diagnostic criteria. Discussion We design the prospective study in the hope of reducing the bias caused by missing data. Therefore, the prospective study will further support the conclusion of our preceding retrospective study. The results of this study will be submitted to a peer-reviewed journal for publication. Conclusion Through this prospective study, we will validate the feasibility of the 2018 new PJI definition (and its modified version) for Chinese patients and determine the optimal method of PJI diagnosis. Trial registration Chinese Clinical Trial Registry, ChiCTR1900025395. Registered on 25 August 2019.
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Affiliation(s)
- Haitao Guan
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China.,Medical School of Nankai University, Tianjin, China
| | - Chi Xu
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Jun Fu
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Ming Ni
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Xiang Li
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Wei Chai
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Libo Hao
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Yonggang Zhou
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Jiying Chen
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China.
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17
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Abstract
Culture-negative periprosthetic joint infections (CN-PJI) pose a significant challenge in terms of diagnosis and management. The reported incidence of CN-PJI is reported to be between 7% and 15%. Fungi and mycobacterium are thought to be responsible for over 85% of such cases with more fastidious bacteria accounting for the rest. With the advent of polymerase chain reaction, mass spectrometry and next generation sequencing, identifying the causative organism(s) may become easier but such techniques are not readily available and are very costly. There are a number of more straightforward and relatively low-cost methods to help surgeons maximize the chances of diagnosing a PJI and identify the organisms responsible. This review article summarizes the main diagnostic tests currently available as well as providing a simple diagnostic clinical algorithm for CN-PJI.
Cite this article: EFORT Open Rev 2019;4:585-594. DOI: 10.1302/2058-5241.4.180067
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Affiliation(s)
- Jeya Palan
- Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Ciaran Nolan
- Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Kostas Sarantos
- Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Richard Westerman
- Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Richard King
- Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Pedro Foguet
- Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
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18
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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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