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Sun X, Li Y, Lv Y, Liu Y, Lai Z, Zeng Y, Zhang H. Diagnostic value of procalcitonin in patients with periprosthetic joint infection: a diagnostic meta-analysis. Front Surg 2024; 11:1211325. [PMID: 38660585 PMCID: PMC11039863 DOI: 10.3389/fsurg.2024.1211325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 03/22/2024] [Indexed: 04/26/2024] Open
Abstract
Background The success rate of periprosthetic joint infection (PJI) treatment is still low. Early diagnosis is the key to successful treatment. Therefore, it is necessary to find a biomarker with high sensitivity and specificity. The diagnostic value of serum procalcitonin (PCT) for PJI was systematically evaluated to provide the theoretical basis for clinical diagnosis and treatment in this study. Methods We searched the Web of Science, Embase, Cochrane Library, and PubMed for studies that evaluated the diagnostic value of serum PCT for PJI (from the inception of each database until September 2020). Two authors independently screened the literature according to the inclusion and exclusion criteria. The quality of each selected literature was evaluated by using the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) tool. RevMan 5.3 software was used for the quality evaluation. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were merged by using Meta-DiSc 1.4 software. The area under the curve (AUC) and Q index were calculated after the summary receiver operating characteristic (SROC) was generated. We also performed subgroup analysis. Results A total of 621 patients were enrolled in the nine studies. The pooled sensitivity of serum PCT for PJI diagnosis was 0.441 [95% confidence interval (CI), 0.384-0.500], the pooled specificity was 0.852 (95% CI, 0.811-0.888), the pooled PLR was 2.271 (95% CI, 1.808-2.853), the pooled NLR was 0.713 (95% CI, 0.646-0.786), and the pooled DOR was 5.756 (95% CI, 3.673-9.026). The area under SROC (the pooled AUC) was 0.76 (0.72-0.79). Q index was 0.6948. Conclusion This study showed that PCT detection of PJI had poor diagnostic accuracy. Hence, the serum PCT is not suitable as a serum marker for PJI diagnosis.
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Affiliation(s)
- Xiaobo Sun
- Department of Orthopaedics, Ganzhou Hospital of Traditional Chinese Medicine, Ganzhou, Jiangxi, China
| | - Yijin Li
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yan Lv
- Department of Cardiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuting Liu
- Academic Affairs Office, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Zhiwei Lai
- Department of Orthopaedics, Ganzhou Hospital of Traditional Chinese Medicine, Ganzhou, Jiangxi, China
| | - Yirong Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Haitao Zhang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Zampogna B, Laudisio A, Papalia GF, Vorini F, Zampoli A, Righini R, Fiore M, Vadalà G, Angeletti S, Ramella S, Papalia R. Heterotopic hip ossification resection: monocentric experiences of associated factors, outcomes, and complications. INTERNATIONAL ORTHOPAEDICS 2024; 48:699-704. [PMID: 37776348 DOI: 10.1007/s00264-023-05993-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/15/2023] [Indexed: 10/02/2023]
Abstract
PURPOSE The exponential increase in total hip arthroplasty (THA) has led to acute and chronic surgery-related complications. Common chronic and local complications are represented by hip ossification (HO). The aim of our study was to assess the clinical and radiological correlates of patients undergoing surgical removal of heterotopic ossifications after THA and the possible association between HO and prosthetic joint infection. METHODS Data of 26 patients who underwent surgical removal of periprosthetic calcifications after THA from 2000 to 2022 were analyzed and compared with characteristics of 156 subjects without HO. RESULTS The preoperative radiographs of patients showed a high-grade Brooker, 3 or 4, later reduced to 1 or 2 in the postoperative radiographs. Ten (38.5%) patients underwent radiotherapy prophylaxis, administered as a single dose 24 h before surgery. In 19 (73%) patients, pharmacological prophylaxis with indomethacin was added in the 30 postoperative days. Only one patient who underwent radiotherapy had a recurrence, while new ossifications were found in three patients without prophylaxis (11.5%). Intraoperative cultures were performed for suspected periprosthetic infection in 8 study group patients. In logistic regression, the presence of HO was significantly and inversely associated with the ASA score (OR = 0.27, 95% CI = 0.09-0.82; P = 0.021) after adjusting. CONCLUSION Surgical HO removal in symptomatic patients with high-grade disease produces good clinical and radiographic results. Radiotherapy was a good perioperative and preventive strategy for recurrence, also associated with NSAIDs and COX-2 inhibitors.
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Affiliation(s)
- B Zampogna
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - A Laudisio
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy.
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy.
- Research Unit of Geriatrics, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy.
| | - G F Papalia
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - F Vorini
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - A Zampoli
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - R Righini
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - M Fiore
- Operative Research Unit of Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Research Unit of Radiation Oncology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - G Vadalà
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - S Angeletti
- Operative Research Unit of Clinical Laboratory Science, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128, Rome, Italy
- Research Unit of Clinical Laboratory Science, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21 - 00128, Rome, Italy
| | - S Ramella
- Operative Research Unit of Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Research Unit of Radiation Oncology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - R Papalia
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy
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Sun X, Zhang H, Liu Y, Lai Z, Zeng Y. Serum procalcitonin has no significance in the diagnosis of periprosthesis joint infection before total hip and knee replacement. Front Surg 2023; 10:1216103. [PMID: 38026480 PMCID: PMC10657873 DOI: 10.3389/fsurg.2023.1216103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Background Currently, there is no "gold standard" for early diagnosing PJI. The diagnosis of periprosthetic joint infection (PJI) is a challenging problem in the clinic. As we know, many serum markers have been used in the early diagnosis of PJI. The aim of this study was to validate the value of PCT in the diagnosis of PJI. Methods A retrospective review of 77 patients with revision arthroplasties from January 2013 to July 2020 was conducted. PJI was defined using the modified Musculoskeletal Infection Society (MSIS) criteria combined with follow-up results. Besides medical history, clinical and laboratory data was gathered. Preoperative blood was taken for serum PCT and other biomarkers measurement. Receiver operating characteristic (ROC) curves were generated to evaluate the biomarkers' diagnostic performance and optimal cut-off value. Results Forty-one patients were identified as the PJI group (27 hips and 14 knees), while thirty-six patients were identified as the aseptic loosening (AL) group (33 hips and 3 knees). The AUCs for C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), Platelets (PLT), Fibrinogen (FIB), and Procalcitonin (PCT) were 0.845 (95% CI 0.755-0.936, p < 0.001), 0.817 (95% CI 0.718-0.916, p < 0.001), 0.728 (95% CI 0.613-0.843, p < 0.001), 0.810 (95% CI 0.710-0.910, p < 0.001) and 0.504 (95% CI 0.373-0.635, p = 0.950), respectively. Higher Area under the Curve (AUC) values were obtained for the combinations of PCT and CRP (AUC = 0.870) (95% CI, 0.774-0.936), PCT and ESR (AUC = 0.817) (95% CI, 0.712-0.896), PCT and PLT (AUC = 0.731) (95% CI, 0.617-0.825), PCT and FIB (AUC = 0.815) (95% CI, 0.710-0.894). The serum PCT indicated a sensitivity of 19.51% and a specificity of 83.33% for diagnosing PJI. When the optimal cut-off value for PCT was set as 0.05 ng/ml, its positive and negative likelihood ratios were 57.1% and 47.6%, respectively. Conclusion In conclusion, serum PCT appeared to be no reliable biomarker in differentiating PJI from aseptic loosening before revision arthroplasties. However, PCT combined with other biomarkers further increases the diagnostic accuracy.
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Affiliation(s)
- Xiaobo Sun
- Fourth Orthopedic Department, Ganzhou Hospital of Traditional Chinese Medicine, Ganzhou, China
| | - Haitao Zhang
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuting Liu
- Academic Affairs Office, Gannan Medical University, Ganzhou, China
| | - ZhiWei Lai
- Fourth Orthopedic Department, Ganzhou Hospital of Traditional Chinese Medicine, Ganzhou, China
| | - Yirong Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Cobra HADAB, Mozella AP, da Palma IM, Salim R, Leal AC. Cell-free Deoxyribonucleic Acid: A Potential Biomarker of Chronic Periprosthetic Knee Joint Infection. J Arthroplasty 2022; 37:2455-2459. [PMID: 35840076 DOI: 10.1016/j.arth.2022.07.002] [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: 02/18/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The correct diagnosis of a chronic periprosthetic joint infection (PJI) is a major challenge in clinical practice, with the "gold standard" for diagnosis yet to be established. Synovial fluid analysis has been proven to be a useful tool for that purpose. Cell-free DNA (cf-DNA) levels have been shown to be increased in several conditions such as cancer, trauma, and sepsis. Therefore, this study was designed to evaluate the potential of synovial fluid cf-DNA quantification for the diagnosis of chronic periprosthetic infections following total knee arthroplasty. METHODS A prospective study with patients undergoing total knee arthroplasty revision surgery for any indication was performed. PJI diagnosis was defined according to the Second International Consensus Meeting on Musculoskeletal Infection (2018) criteria. The study cohort consisted of 26 patients classified as infected and 40 as noninfected. Synovial fluid cf-DNA direct quantification by fluorescent staining was made. Sensitivity, specificity, and receiver operating characteristic curve were calculated. RESULTS The cf-DNA levels were significantly higher in patients who had PJIs (122.5 ± 57.2 versus 4.6 ± 2.8 ng/μL, P < .0001). With a cutoff of 15 ng/μL, the area under the receiver operating characteristic, sensitivity, and specificity of cf-DNA were 0.978, 96.2%, and 100%, respectively. CONCLUSION The present study has shown that cf-DNA is increased in synovial fluid of patients who have chronic PJIs. It is a promising biomarker for knee PJI diagnosis and further studies are needed to confirm its utility.
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Affiliation(s)
- Hugo A de A B Cobra
- Center for Surgery of Knee, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Alan P Mozella
- Center for Surgery of Knee, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Idemar M da Palma
- Rios D'or Hospital, Rio de Janeiro, Brazil; Montese Medical Center, Rio de Janeiro, Brazil
| | - Rodrigo Salim
- Department of Orthopaedics and Anaesthesiology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ana C Leal
- Teaching and Research Division, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
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Akcaalan S, Ozaslan HI, Caglar C, Şimşek ME, Citak M, Akkaya M. Role of Biomarkers in Periprosthetic Joint Infections. Diagnostics (Basel) 2022; 12:diagnostics12122958. [PMID: 36552965 PMCID: PMC9777153 DOI: 10.3390/diagnostics12122958] [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: 10/31/2022] [Revised: 11/10/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
Periprosthetic joint infection (PJI) is one of the most serious complications after joint arthroplasty. The incidence rate of PJI after total joint replacement is 1-3%. Although there are different guidelines and diagnostic criteria used to diagnose PJI, diagnosing PJI is a highly difficult process for orthopedists. The current Musculoskeletal Infection Society (MSIS) criteria are widely used for the diagnosis of PJI. These criteria include results from blood/synovial fluid tests, physical examination, and histological and microbiological analyses of intra-operative samples. However, there is currently no blood or synovial test that can definitively diagnose PJI. To make a more effective diagnosis of PJI, a large number of studies have explored and continue to investigate biomarkers. This review aims to provide general information about serum and synovial markers used for the diagnosis of PJI that may be used to create a database to guide researchers in new studies.
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Affiliation(s)
- Serhat Akcaalan
- Kırıkkale Yuksek Ihtısas Hospital, Kırıkkale 71300, Turkey
- Correspondence:
| | - Halil Ibrahim Ozaslan
- Department of Orthopedics and Traumatology, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara 06010, Turkey
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara 06800, Turkey
| | - Ceyhun Caglar
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara 06800, Turkey
| | - Mehmet Emin Şimşek
- Department of Orthopedics and Traumatology, Faculty of Medicine, Lokman Hekim University, Ankara 06230, Turkey
| | | | - Mustafa Akkaya
- Department of Orthopedics and Traumatology, Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara 06010, Turkey
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara 06800, Turkey
- Helios ENDO-Klinik Hamburg, 22767 Hamburg, Germany
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van Eck J, Liu WY, Goosen JHM, Rijnen WHC, van der Zwaard BC, Heesterbeek P, van der Weegen W. Higher 1-year risk of implant removal for culture-positive than for culture-negative DAIR patients following 359 primary hip or knee arthroplasties. J Bone Jt Infect 2022; 7:143-149. [PMID: 35937090 PMCID: PMC9350853 DOI: 10.5194/jbji-7-143-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/08/2022] [Indexed: 11/11/2022] Open
Abstract
Background and purpose: To date, the value of culture results after
debridement, antibiotics, and implant retention (DAIR) for early (suspected)
prosthetic joint infection (PJI) as risk indicators in terms of prosthesis
retention is not clear. At the 1-year follow-up, the relative risk of prosthesis
removal was determined for culture-positive and culture-negative DAIR patients
after primary total hip or knee arthroplasty. The secondary aim of this work was
to explore differences in patient characteristics, infection characteristics,
and outcomes between these two groups. Methods: A retrospective
regional registry study was performed in a group of 359 patients (positive
cultures: n=299; negative cultures: n=60) undergoing DAIR for high suspicion of early PJI in the period
from 2014 to 2019. Differences in patient characteristics, the number of
deceased patients, and the number of subsequent DAIR treatments between the
culture-positive and culture-negative DAIR groups were analysed using
independent t tests, Mann–Whitney U tests, Pearson's chi-square tests, and Fisher's exact tests.
Results: The overall implant survival rate following DAIR was
89 %. The relative risk of prosthesis removal was 7.4 times higher (95 %
confidence interval (CI) 1.0–53.1) in the culture-positive DAIR group (37 of
299, 12.4 %) compared with the culture-negative DAIR group (1 of 60, 1.7 %). The
culture-positive group had a higher body mass index (p=0.034), a rate of wound leakage of >10 d (p=0.016), and more subsequent DAIR treatments (p=0.006). Interpretation: As implant survival results
after DAIR are favourable, the threshold to perform a DAIR procedure for early
(suspected) PJI should be low in order to retain the prosthesis. A DAIR
procedure in the case of negative cultures does not seem to have unfavourable
results in terms of prosthesis retention.
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Synovial fluid calprotectin in diagnosing periprosthetic joint infection: A meta-analysis. INTERNATIONAL ORTHOPAEDICS 2022; 46:971-981. [PMID: 35233711 PMCID: PMC9001224 DOI: 10.1007/s00264-022-05357-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/22/2022] [Indexed: 11/08/2022]
Abstract
Purpose Periprosthetic joint infection (PJI) is one of the most debilitating complications following joint replacement surgery. Synovial biomarkers, such as Calprotectin, have become valuable in the diagnosis of PJI. This meta-analysis aimed to investigate the role of synovial Calprotectin as a diagnostic test in PJI. Methods This meta-analysis was conducted with adherence to PRISMA guidelines. PubMed, Cochrane, Web of Science, and Google Scholar were searched until February 2022. Inclusion criteria were as follows: all studies in which the patients with joint replacements were evaluated for PJI; synovial Calprotectin was the biomarker of choice to diagnose PJI; standardized guidelines were used as the gold standard for the diagnosis; and a comparison between the guidelines and Calprotectin results was made. Diagnostic parameters such as sensitivity, specificity, diagnostic odds ratio (DOR), positive predictive value, negative predictive value, and area under the curve (AUC) were calculated for the included studies to evaluate synovial Calprotectin for PJI diagnosis. Results The total number of the included patients was 618 from eight studies. The pooled sensitivity, specificity, and diagnostic odds ratio of Calprotectin test were 92% (95%CI: 84%-98%), 93% (95%CI: 84%-99%), and 187.61 (95%CI: 20.21–1741.18), respectively. The results showed that the negative and positive likelihood ratios of the Calprotectin test were 0.07 (95%CI: 0.02–0.22) and 9.91 (95%CI: 4.11–23.93), respectively. The SROC showed that the area under the curve for Calprotectin test was 0.935. Conclusion Synovial Calprotectin is a valuable biomarker as it provides a reliable and rapid diagnosis of PJI. It has the potential to be used in clinical practice due to its high sensitivity and specificity that are comparable to the other utilized biomarkers. Another advantage is its low cost relative to other biomarkers.
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Synovial Complement Factors in Patients with Periprosthetic Joint Infection after Undergoing Revision Arthroplasty of the Hip or Knee Joint. Diagnostics (Basel) 2021; 11:diagnostics11030434. [PMID: 33806309 PMCID: PMC8002017 DOI: 10.3390/diagnostics11030434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 11/16/2022] Open
Abstract
The role and diagnostic value of the synovial complement system in patients with low-grade periprosthetic joint infection (PJI) are unclear. We sought to evaluate, for the first time, the usefulness of synovial complement factors in these patients by measuring the individual synovial fluid levels of complement factors (C1q, C3b/iC3b, C4b, C5, C5a, C9, factor B, factor D, factor H, factor I, properdin, and mannose-binding lectin [MBL]). The patients (n = 74) were classified into septic (n = 28) and aseptic (n = 46). Receiver-operator characteristic curves and a multiple regression model to determine the feasibility of a combination of the tested cytokines to determine the infection status were calculated. The synovial fluid levels of C1q, C3b/C3i, C4b, C5, C5a, MBL, and properdin were significantly elevated in the PJI group. The best sensitivity and specificity was found for C1q. The multiple regression models revealed that the combination of C1q, C3b/C3i, C4b, C5, C5a, and MBL was associated with the best sensitivity (83.3%) and specificity (79.2%) for a cutoff value of 0.62 (likelihood ratio: 4.0; area under the curve: 0.853). Nevertheless, only a combined model showed acceptable results. The expression patterns of the complement factors suggested that PJI activates all three pathways of the complement system.
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Wang K, Li W, Liu H, Yang Y, Lv L. Progress in Prevention, Diagnosis, and Treatment of Periprosthetic Joint Infection. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2021; 2021:3023047. [PMID: 33542741 PMCID: PMC7840269 DOI: 10.1155/2021/3023047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/02/2021] [Accepted: 01/11/2021] [Indexed: 12/24/2022]
Abstract
Periprosthetic joint infection (PJI) after joint replacement surgery is a severe complication associated with high morbidity and increased treatment costs. More than 25% of joint implant failures are attributed to PJI. PJI diagnosis and treatment methods have substantially improved in recent years. However, the prevalence of PJI remains high, primarily due to the increased prevalences of obesity, diabetes, and other underlying conditions. Moreover, increasing elderly prefers to total joint replacement surgery. However, due to frailty and comorbidities, most are at increased risk of infectious arthritis and artificial joint infection (PJI). Therefore, PJI management for the elderly requires multilevel and multiangle intervention. In this review, we summarize the risk factors and diagnostic methods currently available for PJI and discuss the current PJI prevention and treatment interventions, especially the management in older adults.
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Affiliation(s)
- Kai Wang
- International Medicine Center, Tianjin Hospital, 406 Jiefang South Road, Hexi District, Tianjin 300211, China
| | - Wei Li
- College of Light Industry Science and Engineering, Tianjin University of Science and Technology, Tianjin 30045, China
| | - Huayu Liu
- College of Light Industry Science and Engineering, Tianjin University of Science and Technology, Tianjin 30045, China
| | - Yang Yang
- International Medicine Center, Tianjin Hospital, 406 Jiefang South Road, Hexi District, Tianjin 300211, China
| | - Lingyun Lv
- Department of Otorhinolaryngology-Head and Neck Surgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian 223300, China
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Analysis of synovial biomarkers with a multiplex protein microarray in patients with PJI undergoing revision arthroplasty of the hip or knee joint. Arch Orthop Trauma Surg 2020; 140:1883-1890. [PMID: 32133538 DOI: 10.1007/s00402-020-03388-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Diagnosing a (low-grade) periprosthetic joint infection (PJI) after hip or knee arthroplasty remains a diagnostic challenge. The aim of this study was to evaluate the utility of using a novel multiplex protein microarray system for synovial biomarkers in determining PJI in patients undergoing revision knee or hip arthroplasty. MATERIALS AND METHODS The individual synovial fluid levels of 12 cytokines (IL-1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, IL-17, GM-CSF, TNF-α, and INF-γ) were analysed with a novel multiplex protein microarray system in 32 patients undergoing revision hip (n = 22) or knee (n = 10) arthroplasty. Cases were classified into septic and aseptic groups on basis of pre- and interoperative findings: [PJI (n = 14) vs. non-PJI (n = 18)]. Receiver operator characteristic (ROC) curves were calculated to assess the discriminatory strength of the individual parameters. A multiple regression model was used to determine the utility of using a combination of the tested cytokines to determine the infection status. RESULTS The levels of all of the evaluated cytokines were significantly elevated in the PJI-group. Best sensitivity and specificity were found for IL-6, followed by IL-1b, IL-10, and IL-17. The multiple regression models revealed a combination of IL-2, IL-4, IL-5, IL6, lL-12, and GM-CSF to be associated with the best sensitivity (100%) and specificity (88.9%) for a cut-off value of 0.41, with a likelihood ratio of 9.0. CONCLUSION Analysis of individual synovial fluid cytokine levels showed both high sensitivity and high specificity in diagnosing PJI. A combined model using several cytokines showed even higher sensitivity and specificity in diagnosing PJI and could thus be a useful predictive tool to determine the probability of PJI in patients with a painful prosthesis. LEVEL OF EVIDENCE Diagnostic IV.
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Banke IJ, Stade N, Prodinger PM, Tübel J, Hapfelmeier A, von Eisenhart-Rothe R, van Griensven M, Gollwitzer H, Burgkart R. Antimicrobial peptides in human synovial membrane as (low-grade) periprosthetic joint infection biomarkers. Eur J Med Res 2020; 25:33. [PMID: 32799924 PMCID: PMC7429885 DOI: 10.1186/s40001-020-00434-1] [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] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/30/2020] [Indexed: 12/16/2022] Open
Abstract
Background Safe diagnosis of periprosthetic joint infection (PJI) is of utmost importance for successful exchange arthroplasty. However, current diagnostic tools show insufficient accuracy in the clinically common and challenging chronic low-grade infections. To close this diagnostic gap, reliable (bio)markers display the most promising candidates. Antimicrobial peptides (AMPs) are part of the innate immune response towards microbial growth. Recently we could show significant intraarticular levels of human cathelicidin LL-37 and β-defensin-3 (HBD-3) with high diagnostic accuracy in PJI synovial fluid. Consequently, these promising biomarkers were evaluated in PJI synovial membrane and synoviocytes, which may significantly facilitate histological diagnosis of PJI to improve outcome of septic joint replacement. Methods In this prospective single-center controlled clinical study (diagnostic level II), consecutive patients with total hip (THR) and knee (TKR) replacements were included undergoing primary arthroplasty (n = 8), surgical revision due to aseptic loosening (n = 9) and septic arthroplasty with coagulase-negative staphylococci (n = 8) according to the criteria of the Musculoskeletal Infection Society (MSIS). Semiquantitative immunohistochemical (IHC) analysis of LL-37, HBD-3 and HBD-2 in synovial membrane and isolated synoviocytes based on Total Allred Score (TS) and Immunoreactive Remmele and Stegner score (IRS) was performed. For statistical analysis, SPSS 26.0/R3.6.3 (p < 0.05) was used. Results The AMPs LL-37 and HBD-3 were significantly elevated (up to 20×) in synovial membranes from PJI compared to aseptic loosening or primary arthroplasty. The area under the curve (AUC) in a receiver operating characteristic curve analysis was equal to 1.0 for both scores revealing excellent diagnostic accuracy. Isolated synoviocytes as cellular AMP source showed comparable results with a significant LL-37/HBD-3-increase up to 3 × in PJI. In contrast, local HBD-2 levels were negligible (p > 0.23) upon PJI with a lower diagnostic accuracy (AUC = 0.65) in analogy to our previous findings with synovial fluid. Conclusions Our results implicate AMPs as promising and specific biomarkers for the histological diagnosis of PJI.
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Affiliation(s)
- Ingo J Banke
- Clinic of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - Niko Stade
- Clinic of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Peter M Prodinger
- Clinic of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Jutta Tübel
- Clinic of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Clinic of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Martijn van Griensven
- Department of Experimental Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany.,Department cBITE, MERLN Institute, Maastricht University, Maastricht, The Netherlands
| | - Hans Gollwitzer
- Clinic of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany.,ECOM-Excellent Center of Medicine, Arabellastrasse 17, 81925, Munich, Germany
| | - Rainer Burgkart
- Clinic of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
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Zhang Z, Cai Y, Bai G, Zhang C, Li W, Yang B, Zhang W. The value of calprotectin in synovial fluid for the diagnosis of chronic prosthetic joint infection. Bone Joint Res 2020; 9:450-457. [PMID: 32832073 PMCID: PMC7418777 DOI: 10.1302/2046-3758.98.bjr-2019-0329.r2] [Citation(s) in RCA: 14] [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] [Indexed: 01/18/2023] Open
Abstract
Aims This study aimed to evaluate calprotectin in synovial fluid for diagnosing chronic prosthetic joint infection (PJI) . Methods A total of 63 patients who were suspected of PJI were enrolled. The synovial fluid calprotectin was tested by an enzyme-linked immunosorbent assay (ELISA). Laboratory test data, such as ESR, CRP, synovial fluid white blood cells (SF-WBCs), and synovial fluid polymorphonuclear cells (SF-PMNs), were documented. Chi-squared tests were used to compare the sensitivity and specificity of calprotectin and laboratory tests. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve was calculated to determine diagnostic efficacy. Results The median calprotectin level was 776 μg/ml (interquartile range (IQR) 536.5 to 1132) in the PJI group and 54.5 μg/ml (IQR, 38.75 to 78.25) in the aseptic failure (AF) group (p < 0.05). Using a threshold of 173 ug/ml, the sensitivity was 95.2%, with a 97.6% specificity, and the AUC was 0.993. The sensitivity of calprotectin of the antibiotic-treated PJI group was 100% versus 90.9% of the non-antibiotic-treated PJI group. Although 47.6% (ten cases) of the patients in the PJI group received antibiotics before aspiration, the diagnostic efficacy of calprotectin was not affected. The sensitivity and specificity of ESR, CRP, SF-WBCs, and SF-PMNs ranged from 76.2% to 90.5% and 64.3% to 85.7%, respectively. Conclusion Calprotectin in synovial fluid has great diagnostic efficacy for PJI diagnosisand outperformed ESR, CRP, SF-WBCs, and SF-PMNs. Cite this article: Bone Joint Res 2020;9(8):450–457.
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Affiliation(s)
- Zeyu Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yuanqing Cai
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Guochang Bai
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Chaofan Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wenbo Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Bin Yang
- Department of Laboratory Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wenming Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
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13
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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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14
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Development of a Novel and Rapid Antibody-Based Diagnostic for Chronic Staphylococcus aureus Infections Based on Biofilm Antigens. J Clin Microbiol 2020; 58:JCM.01414-19. [PMID: 32051263 DOI: 10.1128/jcm.01414-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 02/10/2020] [Indexed: 12/15/2022] Open
Abstract
Prosthetic joint infections are difficult to diagnose and treat due to biofilm formation by the causative pathogens. Pathogen identification relies on microbial culture that requires days to weeks, and in the case of chronic biofilm infections, lacks sensitivity. Diagnosis of infection is often delayed past the point of effective treatment such that only the removal of the implant is curative. Early diagnosis of an infection based on antibody detection might lead to less invasive, early interventions. Our study examined antibody-based assays against the Staphylococcus aureus biofilm-upregulated antigens SAOCOL0486 (a lipoprotein), glucosaminidase (a domain of SACOL1062), and SACOL0688 (the manganese transporter MntC) for detection of chronic S. aureus infection. We evaluated these antigens by enzyme-linked immunosorbent assay (ELISA) using sera from naive rabbits and rabbits with S. aureus-mediated osteomyelitis, and then we validated a proof of concept for the lateral flow assay (LFA). The SACOL0688 LFA demonstrated 100% specificity and 100% sensitivity. We demonstrated the clinical diagnostic utility of the SACOL0688 antigen using synovial fluid (SF) from humans with orthopedic implant infections. Elevated antibody levels to SACOL0688 in clinical SF specimens correlated with 91% sensitivity and 100% specificity for the diagnosis of S. aureus infection by ELISA. We found measuring antibodies levels to SACOL0688 in SF using ELISA or LFA provides a tool for the sensitive and specific diagnosis of S. aureus prosthetic joint infection. Development of the LFA diagnostic modality is a desirable, cost-effective option, potentially providing rapid readout in minutes for chronic biofilm infections.
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15
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Ding BT, Tan KG, Kau CY, Chan HYH, Mohd Fadil MFB. Accuracy of the α-defensin lateral flow assay for diagnosing periprosthetic joint infection in Asians. J Orthop Surg (Hong Kong) 2020; 27:2309499019828459. [PMID: 30744473 DOI: 10.1177/2309499019828459] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE This study aimed to test the accuracy of the Synovasure®, α-defensin lateral flow test kit, in diagnosing periprosthetic joint infections (PJIs) in a predominantly Asian population and to evaluate whether other patient or disease factors may affect its results. METHODS 61 Asian patients comprising 70 hip or knee prosthetic joints, performed between November 2015 and November 2018, were retrospectively evaluated. Cases were categorized as infected or not infected using Musculoskeletal Infection Society (MSIS) Criteria. Synovial fluid was tested for α-defensin using a commercially available kit. . RESULTS The Synovasure test had a sensitivity of 73.7% (95% confidence interval (CI): 48.8-90.9%) and specificity of 92.2% (95% CI: 81.1-97.8%) in an Asian population, which was slightly lower compared to previously reported studies in a predominantly Caucasian population. The positive predictive value was 77.8% (95% CI: 56.8-90.3%) and the negative predictive value was 90.4% (95% CI: 81.5-95.2%). The test had an area under curve (AUC) of the receiver operating characteristic (ROC) graph of 0.938, which represents an accuracy that is similar to synovial white blood cells (WBCs) and almost equivalent to that of synovial polymorphonuclear cells (PMNs). The presence of diabetes ( p = 0.26), systemic inflammatory joint disease ( p = 0.33), other metallic implants ( p = 0.53), immunosuppression ( p = 0.13), prior antibiotic usage ( p = 0.99), and chronicity of symptoms ( p = 0.34) was not significantly associated with a positive test in patients with PJI. CONCLUSION The α-defensin lateral flow test kit is highly accurate in the diagnosis of PJI but with slightly lower sensitivity and specificity in an Asian population when compared with previous studies. The test should be used in conjunction with other MSIS criteria to provide clinically relevant and meaningful results for the diagnosis of PJI.
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Affiliation(s)
- Benjamin Tk Ding
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Chung Yuan Kau
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
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Di Benedetto P, Dalla Vecchia G, Dante F, Gisonni R, Cainero V, Causero A. Leukocyte esterase strip test as a reliable intraoperative PJIs biomarker. Our experience. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:43-47. [PMID: 31821283 PMCID: PMC7233717 DOI: 10.23750/abm.v90i12-s.8993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Indexed: 11/23/2022]
Abstract
Backgroud and aim of work: Prosthetic joint infection (PJI) is the most common cause of total knee replacement failure and the third most common cause of total hip replacement failure, accounting for 16.8% of all knee revisions and 14.8% of the hip revisions; nevertheless, the diagnosis of PJI is often a challenge for the orthopaedic surgeon. The aim of these study was to evaluate the reliability of the LE strip test for diagnosis of PJI. Materials and Methods: From December 2016 to January 2019, we enrolled 50 patients with suspected PJI; 32 females and 18 males, the average age at the time of the surgery was 76 years. Twenty-four patients underwent knee revision surgery and twenty-six hip revision surgery. In all patients during the surgery, the synovial fluid was aspirated and used for leukocyte esterase strip test. The result of the tests was compared to periprosthetic tissues culture, histological examination and sonication fluid culture for PJI. Results: Comparing the results obtained from the LE test with the results obtained from the other diagnostic methods, we found that the concordance between the results of the leukocyte-esterase test and those of the culture test with peri-prosthetic tissue or synovial fluid was shown to be 93%, between LE and histological examinations, the concordance was 93% and finally with the culture of the sonicated fluid the concordance was 86% of the cases. Conclusions: The results of our serie show a good intraoperative diagnostic accuracy of the LE test, especially in its ability to exclude the hypothesis of periprosthetic infection in case of a negative result. (www.actabiomedica.it)
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17
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Teo BJX, Yeo W, Chong HC, Tan AHC. Surgical site infection after primary total knee arthroplasty is associated with a longer duration of surgery. J Orthop Surg (Hong Kong) 2019; 26:2309499018785647. [PMID: 30010488 DOI: 10.1177/2309499018785647] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Surgical site infection (SSI) is a serious complication following total knee arthroplasty (TKA) leading to considerable morbidity. The incidence is reported to be up to 2%. Risk factors continue to be an area of intense debate. Our study aims to report the incidence of SSI and identify possible risk factors in our patients undergoing TKA. METHODS Prospectively collected data for 905 patients who underwent elective unilateral TKA by a single surgeon from February 2004 to July 2014 were reviewed. Patient demographics and relevant co-morbidities such as diabetes and heart disease were analysed. The presence of superficial wound infections and/or prosthetic joint infections was included. RESULTS The overall infection rate was 1.10% (10 of 905 patients). Six patients (0.66%) were diagnosed with superficial infections and four with PJI (0.44%). The mean operative duration for TKA with SSI was significantly longer at 90.5 ± 28.2 min, compared to 72.2 ± 20.3 min in TKA without SSI ( p = 0.03). All superficial infections occurred within the first month post-surgery and were self-limiting with oral antibiotics. The four patients with PJI required repeated procedures following TKA, including debridement, implant removal and/or revision arthroplasty. None of the 10 patients had a history of diabetes. There were no significant differences in demographics and co-morbidities between those who developed infection after TKA and those who did not. CONCLUSION An overwhelming majority had good outcomes with only four deep infections resulting in revision surgery. We report that the risk of infection in TKA was significantly associated with a longer operative duration.
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Affiliation(s)
- Bryon Jun Xiong Teo
- 1 Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
| | - William Yeo
- 2 Department of Physiotherapy, Singapore General Hospital, Singapore, Singapore
| | - Hwei-Chi Chong
- 2 Department of Physiotherapy, Singapore General Hospital, Singapore, Singapore
| | - Andrew Hwee Chye Tan
- 1 Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
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18
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Taneja A, El-Bakoury A, Khong H, Railton P, Sharma R, Johnston KD, Puloski S, Smith C, Powell J. Association between Allogeneic Blood Transfusion and Wound Infection after Total Hip or Knee Arthroplasty: A Retrospective Case-Control Study. J Bone Jt Infect 2019; 4:99-105. [PMID: 31192107 PMCID: PMC6536767 DOI: 10.7150/jbji.30636] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 04/01/2019] [Indexed: 02/06/2023] Open
Abstract
Background: To assess using a retrospective case control study, whether patients undergoing primary, elective total hip or knee arthroplasty who receive blood transfusion have a higher rate of post-operative infection compared to those who do not. Materials and Methods: Data on elective primary total hip or knee arthroplasty patients, including patient characteristics, co-morbidities, type and duration of surgery, blood transfusion, deep and superficial infection was extracted from the Alberta Bone and Joint Health Institute (ABJHI). Logistic regression analysis was used to compare deep infection and superficial infection in blood-transfused and non-transfused cohorts. Results: Of the 27892 patients identified, 3098 (11.1%) received blood transfusion (TKA 9.7%; THA 13.1%). Overall, the rate of superficial infection (SI) was 0.5% and deep infection (DI) was 1.1%. The infection rates in the transfused cohort were SI 1.0% and DI 1.6%, and in the non-transfused cohort were SI 0.5% and DI 1.0%. The transfused cohort had an increased risk of superficial infection (adjusted odds ratio (OR) 1.9 [95% CI 1.2-2.9, p-value 0.005]) as well as deep infection (adjusted OR 1.6 [95% CI 1.1-2.2, p-value 0.008]). Conclusion: The odds of superficial and deep wound infection are significantly increased in primary, elective total hip and knee arthroplasty patients who receive blood transfusion compared to those who did not. This study can potentially help in reducing periprosthetic hip or knee infections.
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Affiliation(s)
- Ashish Taneja
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Ahmed El-Bakoury
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada.,University of Alexandria, Egypt
| | - Hoa Khong
- Alberta Bone and Joint Health Institute, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Pam Railton
- Alberta Health Services, Calgary, Alberta, Canada
| | - Rajrishi Sharma
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada.,McCaig Institute for Bone and Joint Health
| | - Kelly Dean Johnston
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Shannon Puloski
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Christopher Smith
- Alberta Bone and Joint Health Institute, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - James Powell
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
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Barrack R, Bhimani S, Blevins JL, Blevins K, Demetres M, Figgie M, Fillingham Y, Goodman S, Huddleston J, Kahlenberg C, Lautenbach C, Lin J, Lonner J, Lynch M, Malkani A, Martin L, Mirza S, Rahim Najjad MK, Penna S, Richardson S, Sculco P, Shahi A, Szymonifka J, Wang Q. General Assembly, Diagnosis, Laboratory Test: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S187-S195. [PMID: 30348554 DOI: 10.1016/j.arth.2018.09.070] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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20
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Zahar A, Lausmann C, Cavalheiro C, Dhamangaonkar AC, Bonanzinga T, Gehrke T, Citak M. How Reliable Is the Cell Count Analysis in the Diagnosis of Prosthetic Joint Infection? J Arthroplasty 2018; 33:3257-3262. [PMID: 29887359 DOI: 10.1016/j.arth.2018.05.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/27/2018] [Accepted: 05/11/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Synovial analysis of joint aspirates is a key diagnostic tool; all major diagnostic algorithms include cell count (CC) and polymorphonuclear percentage (PMN%) as important criteria to make the diagnosis. In this context, we conducted this study to analyze the overall accuracy of CC and PMN%. METHODS A single-center retrospective analysis was performed with clinical data of included patients, with a total of 524 preoperative joint aspirations (255 hips, 269 knees). From the aspirated synovial fluid, we tested the leukocyte esterase activity, leukocyte CC, and PMN%, and sent specimens for aerobic and anaerobic bacterial culture. Depending on the clinical results in accordance with the Musculoskeletal Infection Society criteria for prosthetic joint infection (PJI), 203 patients were then admitted for aseptic revision and 134 patients for septic exchange. RESULTS In 337 cases (64.3% of the study patients), it was possible to measure the CC. The best cutoff level for PJI of all study patients was 2582 leukocytes/μL (sensitivity [SE] 80.6%, specificity [SP] 85.2%) and a PMN% of 66.1% (SE 80.6%, SP 83.3%). The chosen cutoff levels for PJI of total knee and total hip arthroplasty were 1630 leukocytes/μL (SE 83.6%, SP 82.2%) and a PMN% of 60.5% (SE 80.3%, SP 77.1%) and 3063 leukocytes/μL (SE 78.1%, SP 80.0%) and a PMN% of 66.1% (SE 82.2%, SP 82.4%), respectively. CONCLUSIONS CC and PMN% are sensitive methods for diagnosing PJI of total hip and total knee arthroplasty. However, there are differences in cutoff levels between knees and hips. International guidelines and diagnostic criteria need revisions in terms of these parameters.
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Affiliation(s)
- Akos Zahar
- Joint Replacement Department, Helios ENDO-Klinik, Hamburg, Germany
| | | | - Camila Cavalheiro
- Joint Replacement Department, Helios ENDO-Klinik, Hamburg, Germany; Department of Orthopedics, Hospital das Clínicas Faculdade de Medicina da Universidade de São Paulo, São Paolo, Brazil
| | - Anoop C Dhamangaonkar
- Joint Replacement Department, Helios ENDO-Klinik, Hamburg, Germany; Department of Orthopedic and Trauma Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | | | - Thorsten Gehrke
- Joint Replacement Department, Helios ENDO-Klinik, Hamburg, Germany
| | - Mustafa Citak
- Joint Replacement Department, Helios ENDO-Klinik, Hamburg, Germany
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21
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Wang C, Li R, Wang Q, Wang C. Synovial Fluid Leukocyte Esterase in the Diagnosis of Peri-Prosthetic Joint Infection: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2017; 19:245-253. [PMID: 29099342 DOI: 10.1089/sur.2017.192] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Peri-prosthetic joint infection (PJI) is a serious and frequent complication of total joint arthroplasty (TJA). Recently, synovial fluid leukocyte esterase (LE), measurement of which is convenient and fast, has been examined as a marker of PJI. We summarized the articles describing synovial fluid LE as a biomarker for the diagnosis of PJI and assessed its diagnostic value in patients suspected of having PJI. METHODS We searched with appropriate key words in PubMed, Embase, Web of Science, the Cochrane database, and Science Direct. Eligible studies providing sufficient data to construct 2 × 2 contingency tables were chosen on the basis of several criteria, and the quality of the chosen studies was assessed. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated for those studies. The summary receiver operating characteristic (SROC) curve and the area under the SROC (AUSROC) were used to evaluate the overall diagnostic performance of LE. RESULTS Eleven studies were found suitable for this systematic review. Among them, eight articles with a total of 1,011 participants qualified for meta-analysis. The pooled sensitivity, specificity, and DOR were 0.90 (95% confidence interval [CI] 0.76-0.96), 0.97 (95% CI 0.95-0.98), and 310.76 (95% CI 103.86-929.88), respectively. The SROC was 0.98 (95% CI 0.96-0.99). Sub-group analysis indicated that the sample inclusion criteria might be the main source of heterogeneity. Publication bias was suggested by an asymmetrical funnel plot (p = 0.144). CONCLUSION Although the result of synovial fluid LE assay can be influenced by sample-related factors, it is more specific as a means to exclude PJI.
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Affiliation(s)
- Chi Wang
- 1 Department of Clinical Laboratory Diagnosis, PLA General Hospital , Beijing, China
| | - Rui Li
- 2 Department of Orthopedics, PLA General Hospital , Beijing, China
| | - Qi Wang
- 2 Department of Orthopedics, PLA General Hospital , Beijing, China
| | - Chengbin Wang
- 1 Department of Clinical Laboratory Diagnosis, PLA General Hospital , Beijing, China
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22
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Villa F, Toscano M, De Vecchi E, Bortolin M, Drago L. Reliability of a multiplex PCR system for diagnosis of early and late prosthetic joint infections before and after broth enrichment. Int J Med Microbiol 2017; 307:363-370. [DOI: 10.1016/j.ijmm.2017.07.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 07/13/2017] [Accepted: 07/14/2017] [Indexed: 12/27/2022] Open
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Excellent Diagnostic Characteristics for Ultrafast Gene Profiling of DEFA1-IL1B-LTF in Detection of Prosthetic Joint Infections. J Clin Microbiol 2017. [PMID: 28637910 PMCID: PMC5648706 DOI: 10.1128/jcm.00558-17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The timely and exact diagnosis of prosthetic joint infection (PJI) is crucial for surgical decision-making. Intraoperatively, delivery of the result within an hour is required. Alpha-defensin lateral immunoassay of joint fluid (JF) is precise for the intraoperative exclusion of PJI; however, for patients with a limited amount of JF and/or in cases where the JF is bloody, this test is unhelpful. Important information is hidden in periprosthetic tissues that may much better reflect the current status of implant pathology. We therefore investigated the utility of the gene expression patterns of 12 candidate genes (TLR1, -2, -4, -6, and 10, DEFA1, LTF, IL1B, BPI, CRP, IFNG, and DEFB4A) previously associated with infection for detection of PJI in periprosthetic tissues of patients with total joint arthroplasty (TJA) (n = 76) reoperated for PJI (n = 38) or aseptic failure (n = 38), using the ultrafast quantitative reverse transcription-PCR (RT-PCR) Xxpress system (BJS Biotechnologies Ltd.). Advanced data-mining algorithms were applied for data analysis. For PJI, we detected elevated mRNA expression levels of DEFA1 (P < 0.0001), IL1B (P < 0.0001), LTF (P < 0.0001), TLR1 (P = 0.02), and BPI (P = 0.01) in comparison to those in tissues from aseptic cases. A feature selection algorithm revealed that the DEFA1-IL1B-LTF pattern was the most appropriate for detection/exclusion of PJI, achieving 94.5% sensitivity and 95.7% specificity, with likelihood ratios (LRs) for positive and negative results of 16.3 and 0.06, respectively. Taken together, the results show that DEFA1-IL1B-LTF gene expression detection by use of ultrafast qRT-PCR linked to an electronic calculator allows detection of patients with a high probability of PJI within 45 min after sampling. Further testing on a larger cohort of patients is needed.
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Bibbo C. Groundhog Day Again? You Be the Judge: Commentary on an article by Carlos A. Higuera, MD, et al.: "Synovial Fluid Cell Count for Diagnosis of Chronic Periprosthetic Hip Infection". J Bone Joint Surg Am 2017; 99:e48. [PMID: 28463930 DOI: 10.2106/jbjs.16.01579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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25
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Definition of periprosthetic joint infection of the hip and new tools for diagnosis. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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C-reactive protein may misdiagnose prosthetic joint infections, particularly chronic and low-grade infections. INTERNATIONAL ORTHOPAEDICS 2017; 41:1315-1319. [DOI: 10.1007/s00264-017-3430-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/12/2017] [Indexed: 02/08/2023]
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Birt MC, Anderson DW, Toby EB, Wang J. Osteomyelitis: Recent advances in pathophysiology and therapeutic strategies. J Orthop 2017; 14:45-52. [PMID: 27822001 PMCID: PMC5090239 DOI: 10.1016/j.jor.2016.10.004] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/13/2016] [Indexed: 01/29/2023] Open
Abstract
This review article summarizes the recent advances in pathogenic mechanisms and novel therapeutic strategies for osteomyelitis, covering both periprosthetic joint infections and fracture-associated bone infections. A better understanding of the pathophysiology including the mechanisms for biofilm formation has led to new therapeutic strategies for this devastating disease. Research on novel local delivery materials with appropriate mechanical properties, lower exothermicity, controlled release of antibiotics, and absorbable scaffolding for bone regeneration is progressing rapidly. Emerging strategies for prevention, early diagnosis of low-grade infections, and innovative treatments of osteomyelitis such as biofilm disruptors and immunotherapy are highlighted in this review.
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Affiliation(s)
| | | | | | - Jinxi Wang
- Department of Orthopedic Surgery, University of Kansas Medical Center,
Kansas City, KS 66160, USA
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Sousa R, Serrano P, Gomes Dias J, Oliveira JC, Oliveira A. Improving the accuracy of synovial fluid analysis in the diagnosis of prosthetic joint infection with simple and inexpensive biomarkers. Bone Joint J 2017; 99-B:351-357. [DOI: 10.1302/0301-620x.99b3.bjj-2016-0684.r1] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 11/25/2016] [Indexed: 12/16/2022]
Abstract
Aims The aims of this study were to increase the diagnostic accuracy of the analysis of synovial fluid in the differentiation of prosthetic joint infection (PJI) by the addition of inexpensive biomarkers such as the levels of C-reactive protein (CRP), adenosine deaminase (ADA), alpha-2-macrogloblulin (α2M) and procalcitonin. Patients and Methods Between January 2013 and December 2015, synovial fluid and removed implants were requested from 143 revision total joint arthroplasties. A total of 55 patients met inclusion criteria of the receipt of sufficient synovial fluid, tissue samples and removed implants for analysis. The diagnosis of PJI followed the definition from a recent International Consensus Meeting to create two groups of patients; septic and aseptic. Using receiver operating characteristic curves we determined the cutoff values and diagnostic accuracy for each marker. Results There were 23 PJIs and 32 patients with aseptic loosening. The levels of total leucocyte count, proportion of polymorphonuclear leucocytes (PMNs), CRP, ADA and α2M in the synovial fluid were all significantly higher in those with a PJI than in those with aseptic loosening. The levels of procalcitonin were comparable in the two groups. Cutoff values for the optimal performance in the diagnosis of infection were: total leucocyte count > 1463 cells/μL (sensitivity (Sens) 100%, specificity (Spec) 71.9%, positive predictive value (PPV) 71.9%, negative predictive value (NPV) 100%); proportion of PMNs > 81% (Sens 78.3%, Spec 75.0%, PPV 69.2%, NPV 82.8%); CRP > 6.7mg/L (Sens 78.3%, Spec 93.8%, PPV 90.0%, NPV 85.7%); ADA > 61U/L (Sens 78.3%, Spec 96.9%, PPV 94.7%, NPV 86.1%) and α2M > 958 mg/L (Sens 47.8%, Spec 96.9%, PPV 91.7%, NPV 72.1%). The addition of a raised level of CRP or ADA to the total leukocyte count increased the specificity: total leukocyte count > 1463 cells/μL and CRP > 6.7mg/L (Sens 78.3%, Spec 100%, PPV 100%, NPV 86.5%) or with ADA > 61U/L (Sens 78.3%, Spec 96.9%, PPV 94.7%, NPV 86.1%). Conclusion The total leucocyte count in the synovial fluid offers great negative predictive value in the diagnosis of PJI and the addition of more specific markers such as CRP and ADA improves the positive predictive value. Thus the addition of simple and inexpensive markers to the measurement of the leucocyte count in the synovial fluid may reduce the number of equivocal results which demand more expensive investigation. Cite this article: Bone Joint J 2017;99-B:351–7.
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Affiliation(s)
- R. Sousa
- Centro Hospitalar do Porto, Hospital de
Santo António, Largo Professor Abel Salazar; 4099-001
Porto, Portugal
| | - P. Serrano
- Centro Hospitalar do Porto, Hospital de
Santo António, Largo Professor Abel Salazar; 4099-001
Porto, Portugal
| | - J. Gomes Dias
- Administração Regional de Saúde do
Norte, Rua Anselmo Braancamp, 144;
4000-078 Porto, Portugal
| | - J. C. Oliveira
- Centro Hospitalar do Porto, Hospital de
Santo António, Largo Professor Abel Salazar; 4099-001
Porto, Portugal
| | - A. Oliveira
- Centro Hospitalar do Porto, Hospital de
Santo António, Largo Professor Abel Salazar; 4099-001
Porto, Portugal
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Wang C, Wang Q, Li R, Duan JY, Wang CB. Synovial Fluid C-reactive Protein as a Diagnostic Marker for Periprosthetic Joint Infection: A Systematic Review and Meta-analysis. Chin Med J (Engl) 2017; 129:1987-93. [PMID: 27503025 PMCID: PMC4989431 DOI: 10.4103/0366-6999.187857] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Periprosthetic joint infection (PJI) is the main cause of failure following total joint arthroplasty. Until now, the diagnosis of PJI is still confronted with technical limitations, and the question of whether synovial fluid biomarker, C-reactive protein (CRP), can provide high value in the diagnosis of PJI remains unanswered and, therefore, was the aim of the study. Methods: First, we conducted a systematic review on CRP in the diagnosis of PJI by searching online databases using keywords such as “periprosthetic joint infection”, “synovial fluid”, and “C-reactive protein”. Eligible studies providing sufficient data to construct 2 × 2 contingency tables were then selected based on the list of criteria and the quality of included studies was assessed subsequently. Finally, the reported sensitivity, specificity, diagnostic odds ratio (DOR), summary receiver operating characteristic (SROC) curve, and the area under the SROC (AUSROC) were pooled together and used to evaluate overall diagnostic performance. Results: Seven studies were included in our review, six of which comprising a total of 456 participants were further investigated in our meta-analysis. The pooled sensitivity, specificity, and DOR were 0.92 (95% confidence interval [CI]: 0.86–0.96), 0.90 (95% CI: 0.87–0.93), and 101.40 (95% CI: 48.07–213.93), respectively. The AUSROC was 0.9663 (standard error, 0.0113). Conclusions: Synovial fluid CRP is a good biomarker for the diagnosis of PJI with high sensitivity and specificity.
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Affiliation(s)
- Chi Wang
- Department of Clinical Laboratory, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Qi Wang
- Outpatient Department of Chinese People's Liberation Army, Beijing, 101123, China
| | - Rui Li
- Department of Orthopedics, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Jin-Yan Duan
- Department of Clinical Laboratory, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Cheng-Bin Wang
- Department of Clinical Laboratory, Chinese People's Liberation Army General Hospital, Beijing 100853, China
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Alpha-defensin—novel synovial fluid biomarker for the diagnosis of periprosthetic joint infection. INTERNATIONAL ORTHOPAEDICS 2016; 40:2447-2452. [DOI: 10.1007/s00264-016-3306-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 09/25/2016] [Indexed: 12/31/2022]
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