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Balta O, Astan S, Altınayak H, Uçar C, Aytekin FY, Kurnaz R. Can C-Reactive Protein-Lymphocyte Ratio Be Used as a Screening Tool to Confirm the Diagnosis of Periprosthetic Joint Infection? Clin Orthop Surg 2023; 15:917-927. [PMID: 38045571 PMCID: PMC10689224 DOI: 10.4055/cios22313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 08/13/2023] [Accepted: 08/13/2023] [Indexed: 12/05/2023] Open
Abstract
Background This study aimed to investigate whether periprosthetic joint infection (PJI) can be predicted by the C-reactive protein-to-lymphocyte ratio (CLR), whether this ratio increases the accuracy of PJI diagnosis, and whether it is more sensitive than other blood values and ratios. Methods The patients were divided into two groups: the septic revision (SR) group and the aseptic revision (AR) group. In cases of septic revision, the diagnosis of PJI was made based on the criteria proposed by the European Bone and Joint Infection Society (EBJIS). The groups were compared in terms of age, sex, body mass index, comorbidity, and preoperative laboratory results. The sensitivity, specificity, and diagnostic performance of the values and ratios were analyzed and compared. Results The receiver operating characteristic (ROC) analysis for the CLR gave a diagnostic value of 15.52, which provided a sensitivity of 91.1% and a specificity of 64.2% for PJI. The CLR gave lower specificity and higher sensitivity compared to the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values. The ROC analysis showed that the CLR had a similar area under the curve (AUC) with the ESR and CRP (0.808). The CLR had a higher specificity than other ratios (platelet volume ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and monocyte-to-lymphocyte ratio) and a higher value of the AUC. In the multivariate analysis, the CLR (hazard ratio, 1.088; 95% confidence interval, 1.063-1.113; p < 0.001) was found to be a significant risk factor. As CLR increased by one unit, the risk of PJI increased by 1.088 times, and it was statistically significant (p < 0.001). Conclusions The findings of this study suggest that CLR can serve as a valuable screening tool for diagnosing PJI. CLR demonstrated higher sensitivity in predicting PJI compared to ESR and CRP, and it exhibited greater specificity than other infection markers.
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Affiliation(s)
- Orhan Balta
- Department of Orthopaedics and Traumatology, Gaziosmanpasa University Hospital, Tokat, Türkiye
| | - Sezer Astan
- Department of Orthopaedics and Traumatology, Tokat State Hospital, Tokat, Türkiye
| | - Harun Altınayak
- Department of Orthopedics and Traumatology, Samsun Training and Research Hospital, Health Sciences University, Samsun, Türkiye
| | - Cihan Uçar
- Department of Orthopedics and Traumatology, Trabzon Kanuni Training and Research Hospital, Trabzon, Türkiye
| | - Feyza Yildiz Aytekin
- Department of Infectious Diseases and Clinical Microbiology, Ministry of Health Prof. Dr. A. Ilhan Özdemir State Hospital, Giresun, Türkiye
| | - Recep Kurnaz
- Department of Orthopaedics and Traumatology, Acıbadem State Hospital, Eskişehir, Türkiye
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Rızvanoglu İH, Sakarya B, Benlier N, Kökçü F. HMGB-1 Levels in Painful Knee Arthroplasty: Is it Possible to Distingue Periprosthetic Joint Infection and Aseptic Loosening? Indian J Orthop 2023; 57:1023-1031. [PMID: 37384002 PMCID: PMC10293519 DOI: 10.1007/s43465-023-00903-9] [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: 01/08/2023] [Accepted: 04/27/2023] [Indexed: 06/30/2023]
Abstract
Introduction We investigated the efficiency of high mobility group box-1 protein (HMGB-1) in differentiation of asymptomatic knee prosthesis, and periprosthetic joint infection and aseptic loosening causing painful knee prosthesis. Materials and Methods The data of patients who consulted our clinic for checking after total knee arthroplasty surgery were recorded prospectively. Blood levels of CRP, ESR, WBC, and HMGB-1 were recorded. Patients whose examination and routine tests were within normal limits comprised group I, asymptomatic total knee arthroplasty (ATKA). Painful patients with abnormal test results underwent three phase bone scintigraphy for further investigation Patients with periprosthetic joint infection (PJI) and aseptic loosening (AL) according to scintigraphy comprised group II and group III, respectively. The mean values of HMGB-1 and cut-off values according to the groups and their correlations with other inflammatory parameters were determined. Results Seventy-three patients were included in the study. Significant differences were observed in three groups, in terms of CRP, ESR, WBC, and HMGB-1. The cut-off value of HMGB-1 was determined as 15.16 ng/ml between ATKA and PJI, 16.92 ng/ml between ATKA and AL, and 27.87 ng/ml between PJI and AL, respectively. Accordingly, the sensitivity, and specificity of HMGB-1 in differentiation of ATKA and PJI were 91%, 88%, and in differentiation of ATKA and AL were 91%, 96%, and in differentiation of PJI and AL were 81%, 73%, respectively. Conclusion HMGB-1 may be utilized as an additional blood test in the differential diagnosis of problematic knee prosthesis patients.
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Affiliation(s)
- İbrahim Halil Rızvanoglu
- Department of Orthopedics and Traumatology, NCR International Hospital, Mücahitler Neighborhood, No: 56. Şehitkamil, 27090 Gaziantep, Turkey
| | - Bülent Sakarya
- Department of Orthopedics and Traumatology, Mersin Toros Government Hospital, Cemalpaşa Neighborhood. 5314 Street, Akdeniz, Mersin, Turkey
| | - Necla Benlier
- Department of Medical Pharmacology, Sanko University School of Medicine, Ali Fuat Cebesoy Boulevard. No: 45, Şehitkamil, Gaziantep, Turkey
| | - Füsun Kökçü
- Department of Nuclear Medicine, Medical Park Gaziantep Hospital, Mücahitler Neighborhood, 52063 St., Şehitkamil, 27584 Gaziantep, Turkey
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Yilmaz MK, Abbaszadeh A, Tarabichi S, Azboy I, Parvizi J. Diagnosis of Periprosthetic Joint Infection: The Utility of Biomarkers in 2023. Antibiotics (Basel) 2023; 12:1054. [PMID: 37370373 DOI: 10.3390/antibiotics12061054] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a rare yet devastating complication following total joint arthroplasty (TJA). Early and accurate diagnosis of PJI is paramount in order to maximize the chances of successful treatment. However, we are yet to identify a single "gold standard" test for the diagnosis of PJI. As a result, the diagnosis of PJI is often challenging. Currently, the 2018 ICM definition of PJI is the only validated diagnostic criteria available. This article will review the importance of serum and synovial biomarkers in the diagnosis of PJI. In addition, it will provide a brief overview of the emerging modalities for the identification of infections in this setting.
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Affiliation(s)
- Mehmet Kursat Yilmaz
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Department of Orthopaedics and Traumatology, School of Medicine, Istanbul Medipol University, Istanbul 34810, Turkey
| | - Ahmad Abbaszadeh
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Saad Tarabichi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Ibrahim Azboy
- Department of Orthopaedics and Traumatology, School of Medicine, Istanbul Medipol University, Istanbul 34810, Turkey
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Sigmund IK, Yeghiazaryan L, Luger M, Windhager R, Sulzbacher I, McNally MA. Three to six tissue specimens for histopathological analysis are most accurate for diagnosing periprosthetic joint infection. Bone Joint J 2023; 105-B:158-165. [PMID: 36722061 DOI: 10.1302/0301-620x.105b2.bjj-2022-0859.r1] [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] [Indexed: 02/02/2023]
Abstract
AIMS The aim of this study was to evaluate the optimal deep tissue specimen sample number for histopathological analysis in the diagnosis of periprosthetic joint infection (PJI). METHODS In this retrospective diagnostic study, patients undergoing revision surgery after total hip or knee arthroplasty (n = 119) between January 2015 and July 2018 were included. Multiple specimens of the periprosthetic membrane and pseudocapsule were obtained for histopathological analysis at revision arthroplasty. Based on the Infectious Diseases Society of America (IDSA) 2013 criteria, the International Consensus Meeting (ICM) 2018 criteria, and the European Bone and Joint Infection Society (EBJIS) 2021 criteria, PJI was defined. Using a mixed effects logistic regression model, the sensitivity and specificity of the histological diagnosis were calculated. The optimal number of periprosthetic tissue specimens for histopathological analysis was determined by applying the Youden index. RESULTS Based on the EBJIS criteria (excluding histology), 46 (39%) patients were classified as infected. Four to six specimens showed the highest Youden index (four specimens: 0.631; five: 0.634; six: 0.632). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of five tissue specimens were 76.5% (95% confidence interval (CI) 67.6 to 81.4), 86.8% (95% CI 81.3 to 93.5), 66.0% (95% CI 53.2 to 78.7), and 84.3% (95% CI 79.4 to 89.3), respectively. The area under the curve (AUC) was calculated with 0.81 (as a function of the number of tissue specimens). Applying the ICM and IDSA criteria (excluding histology), 40 (34%) and 32 (27%) patients were categorized as septic. Three to five specimens had the highest Youden index (ICM 3: 0.648; 4: 0.651; 5: 0.649) (IDSA 3: 0.627; 4: 0.629; 5: 0.625). CONCLUSION Three to six tissue specimens of the periprosthetic membrane and pseudocapsule should be collected at revision arthroplasty and analyzed by a pathologist experienced and skilled in interpreting periprosthetic tissue.Cite this article: Bone Joint J 2023;105-B(2):158-165.
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Affiliation(s)
- Irene K Sigmund
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Lusine Yeghiazaryan
- Medical University of Vienna, Centre for Medical Statistics, Informatics and Intelligent Systems, Institute of Medical Statistics, Vienna, Austria
| | - Markus Luger
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Irene Sulzbacher
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
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Li J, Zhou Q, Deng B. Serum versus synovial fluid interleukin-6 for periprosthetic joint infection diagnosis: a systematic review and meta-analysis of 30 diagnostic test accuracy studies. J Orthop Surg Res 2022; 17:564. [PMID: 36566223 PMCID: PMC9789601 DOI: 10.1186/s13018-022-03458-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/16/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Early and accurate detection of periprosthetic joint infection (PJI) after hip and/or knee arthroplasty remains challenging. This systematic review and meta-analysis of diagnostic test accuracy studies aimed to evaluate the diagnostic accuracy of serum and synovial fluid interleukin (IL)-6 in detecting PJI. METHODS We searched 3 databases for studies through December 31, 2021, using medical sub-headings terms and keywords. Studies reported sensitivity and specificity of serum and synovial fluid IL-6 in detecting PJI were considered. We calculated the pooled sensitivity, specificity, positive and negative likelihood ratio, diagnostic odds ratio (DOR), and the area under the summary receiver operating characteristic curve (AUC) to evaluate the diagnostic accuracy of serum and synovial fluid IL-6. RESULTS Thirty studies were included. The pooled sensitivity, specificity, positive and negative likelihood ratio, DOR, and AUC of serum IL-6 in detecting PJI were 0.76 (0.69-0.81), 0.88 (0.82-0.92), 6.2 (4.3-9.0), 0.28 (0.22-0.35), 22 (14-36), and 0.88 (0.85-0.91), respectively. However, synovial fluid IL-6 achieved a pooled sensitivity of 0.87 (0.75-0.93), specificity of 0.90 (0.85-0.93), positive and negative likelihood ratio of 8.5 (5.3-13.6) and 0.15 (0.08-0.29), DOR of 57 (21-156), and AUC of 0.94 (0.92-0.96), which were higher than serum IL-6. CONCLUSIONS Synovial fluid IL-6 test may be a promising test for PJI after hip and/or knee arthroplasty. However, considering the limited volume of synovial fluid and invasive acquisition of synovial fluid IL-6, serum IL-6 test may be also considered.
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Affiliation(s)
- Jian Li
- grid.33199.310000 0004 0368 7223Department of Orthopaedics, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430014 China
| | - Qian Zhou
- grid.33199.310000 0004 0368 7223Department of Pharmacy, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430014 China
| | - Biquan Deng
- grid.33199.310000 0004 0368 7223Department of Orthopaedics, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430014 China
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Dmitrov IA, Zagorodniy NV, Obolenskiy VN, Leval' PS, Zakharyan NG, Apresyan VS, Panin MA, Samkovich DA, Aliev RN, Grigoryan AA. Diagnosis and treatment of periprosthetic infection after hip replacement (a review). BULLETIN OF THE MEDICAL INSTITUTE "REAVIZ" (REHABILITATION, DOCTOR AND HEALTH) 2022. [DOI: 10.20340/vmi-rvz.2022.6.clin.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction. The frequency of hip arthroplasty is steadily increasing throughout the world and, although this operation has become routine, the likelihood of postoperative complications reaches 4.3 % [1]. The most dangerous of them are infectious lesions in the area of the endoprosthesis and adjacent tissues. At the same time, in addition to the threat of generalization of the infectious process, there are functional disorders in the joint area and a general deterioration in the quality of life of the patient. Timely diagnosis and treatment of the infectious process and related disorders can minimize the adverse effects of infection.Target. The purpose of this review is to analyze modern methods for diagnosing and treating periprosthetic infection resulting from hip replacement.Materials and methods. The subject literature was searched using the PubMed and Google Sholar databases.Results. The main methods for diagnosing periprosthetic infection include histological and bacteriological examination of the biopsy specimen, determination of sensitivity to antibiotics, blood, and synovial fluid analysis for the content of leukocytes, IL-6, CRP, PCR diagnostics of infectious agents. Treatment consists of re-intervention and/or antibiotic therapy.Conclusion. The most optimal method for diagnosing periprosthetic infection is a bacteriological study of biopsy specimens taken intraoperatively. The preferred method of treatment is determined by the severity of the infection, the degree of involvement of tissues adjacent to the prosthesis, the comorbid background, the nature of the infectious agent, and includes repeated revision surgery.
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Affiliation(s)
| | - N. V. Zagorodniy
- RUDN University; Pirogov Russian National Research Medical University
| | - V. N. Obolenskiy
- Pirogov Russian National Research Medical University; City Clinical Hospital No. 13
| | - P. Sh. Leval'
- City Clinical Hospital No. 13; European Clinic of Traumatology and Orthopedics (ECSTO)
| | | | | | - M. A. Panin
- RUDN University; City Clinical Hospital No. 17
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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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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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Levack AE, Koch C, Moore HG, Cross MB. The Utility of MRI With Multiacquisition Variable-Resonance Image Combination (MAVRIC) in Diagnosing Deep Total Hip Arthroplasty Infection. HSS J 2022; 18:277-283. [PMID: 35645646 PMCID: PMC9096993 DOI: 10.1177/15563316211009203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/04/2020] [Indexed: 02/07/2023]
Abstract
Background: The 2010 American Academy of Orthopaedic Surgeons Clinical Practice Guidelines report insufficient evidence to address the diagnostic efficacy of magnetic resonance imaging (MRI) for periprosthetic joint infection (PJI). Questions/Purposes: The purpose of this study was to determine the utility of MRI with multiacquisition variable-resonance image combination (MAVRIC) metal artifact suppression techniques in diagnosing PJI in the setting of total hip arthroplasty (THA). Methods: Multiacquisition variable-resonance image combination MRIs obtained of THAs between November 2012 and November 2016 were queried. Radiology reports were classified as positive (suspicious for infection), negative (no features of infection), or inconclusive (infection cannot be excluded or correlation with aspiration suggested if clinically concerned). Chart review identified cases of deep PJI according to the modified Musculoskeletal Infection Society criteria. Results: Of 2156 MRIs of THAs included, MRI was concerning for infection in 1.8% (n = 39), inconclusive in 1.2% (n = 26), and negative in 97.0% (n = 2091). Deep PJI was identified in 53 (2.5%) patients, 30 of whom (56.6%) had conclusively positive finding on MRI (false-negative rate: 43.4%, sensitivity: 56.6%). Of 2103 aseptic THAs, only 9 (0.4%) MRIs were read as suspicious for infection (false-positive rate: 0.4%; specificity: 99.6%). Conclusion: Magnetic resonance imaging with MAVRIC is a highly specific test for PJI with a low false-positive rate. This indicates that when clinicians are provided with an MRI that unexpectedly suggests infection, a formal evaluation for infection is indicated. In patients with otherwise equivocal diagnostic findings, MRI may help confirm, but not refute, a diagnosis of PJI. Prospective study with more experienced image reviewers may further support the use of MRI in PJI.
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Affiliation(s)
- Ashley E. Levack
- Department of Orthopaedic Surgery,
Hospital for Special Surgery, New York, NY, USA
| | - Chelsea Koch
- Department of Orthopaedic Surgery,
Hospital for Special Surgery, New York, NY, USA
| | | | - Michael B. Cross
- Department of Orthopaedic Surgery,
Hospital for Special Surgery, New York, NY, USA
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10
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Rahim MI, Winkel A, Ingendoh-Tsakmakidis A, Lienenklaus S, Falk CS, Eisenburger M, Stiesch M. Bacterial-Specific Induction of Inflammatory Cytokines Significantly Decreases upon Dual Species Infections of Implant Materials with Periodontal Pathogens in a Mouse Model. Biomedicines 2022; 10:biomedicines10020286. [PMID: 35203495 PMCID: PMC8869624 DOI: 10.3390/biomedicines10020286] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/16/2022] Open
Abstract
Cytokine profiles are often perturbed after infections of medical implants. With a non-invasive in vivo imaging system, we report in a mouse model that interferon expression after infection of subcutaneous implants with Streptococcus oralis, Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, and Treponema denticola (alone or as a combination) was species-specific, persisted longer in the presence of implants, and notably decreased upon dual species infections. This type I interferon expression disappeared within two weeks; however, histology of implant–tissue interface indicated high recruitment of immune cells even after three weeks. This was suggestive that biomaterial-associated infections could have prolonged effects, including the systemic stimulation of inflammatory cytokines. The present study investigated the systemic impact of this chronic peri-implant inflammation on the systemic expression of inflammatory cytokines (23) using a multiplex assay. Initially, the cytokine measurement in murine fibroblasts exposed to periodontal pathogens remained limited to the expression of five cytokines, namely, IL-6, G-CSF, CXCL-1/KC, MCP-1 (MCAF), and IL-12 (p40). The systemic determination of cytokines in mice increased to 19 cytokines (IL-1α, IL-2, IL-3, IL-5, IL-6, IL-9, IL-12 (p40), IL-12 (p70), IL-13, IL-17A, CCL-11/Eotaxin, G-CSF, IFN-γ, CXCL1/KC, MCP-1 (MCAF), MIP-1α/CCL3, MIP-1β/CCL4, CCL5/RANTES, and TNF-α). Systemic induction of cytokines was species-specific in the mouse model. The cytokine induction from infected implants differed significantly from sole tissue infections and sterile implants. Notably, systemic cytokine induction decreased after infections with dual species compared to single species infections. These findings describe the systemic effect of chronic peri-implant inflammation on the systemic induction of inflammatory cytokines, and this effect was strongly correlated to the type and composition of initial infection. Systemic modulations in cytokine expression upon dual species infections exhibit an exciting pattern that might explain the complications associated with biomaterial-related infection in patients. Moreover, these findings validate the requirement of multispecies infections for pre-clinical studies involving animal models.
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Affiliation(s)
- Muhammad Imran Rahim
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Department of Prosthetic Dentistry and Biomedical Materials Science, Hannover Medical School, 30625 Hannover, Germany; (A.W.); (A.I.-T.); (M.E.); (M.S.)
- Correspondence: ; Tel.: +49-(0)511-532-7288
| | - Andreas Winkel
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Department of Prosthetic Dentistry and Biomedical Materials Science, Hannover Medical School, 30625 Hannover, Germany; (A.W.); (A.I.-T.); (M.E.); (M.S.)
| | - Alexandra Ingendoh-Tsakmakidis
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Department of Prosthetic Dentistry and Biomedical Materials Science, Hannover Medical School, 30625 Hannover, Germany; (A.W.); (A.I.-T.); (M.E.); (M.S.)
| | - Stefan Lienenklaus
- Institute of Laboratory Animal Science, Hannover Medical School, 30625 Hannover, Germany;
| | - Christine S. Falk
- Institute of Transplant Immunology, Hannover Medical School, 30625 Hannover, Germany;
| | - Michael Eisenburger
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Department of Prosthetic Dentistry and Biomedical Materials Science, Hannover Medical School, 30625 Hannover, Germany; (A.W.); (A.I.-T.); (M.E.); (M.S.)
| | - Meike Stiesch
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Department of Prosthetic Dentistry and Biomedical Materials Science, Hannover Medical School, 30625 Hannover, Germany; (A.W.); (A.I.-T.); (M.E.); (M.S.)
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11
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Prince N, Penatzer JA, Shackleford TL, Stewart EK, Dietz MJ, Boyd JW. Tissue-level cytokines in a rodent model of chronic implant-associated infection. J Orthop Res 2021; 39:2159-2168. [PMID: 33283316 PMCID: PMC8180530 DOI: 10.1002/jor.24940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/28/2020] [Accepted: 12/01/2020] [Indexed: 02/04/2023]
Abstract
Systemic cytokine concentrations have been extensively studied in implant-associated infections, providing sensitive diagnostic markers. However, less is known about the relationships of tissue-level cytokines surrounding the joint. The aim of this study was to define the cytokine profiles of tissues to investigate the use of these cytokines as markers of debridement in chronic joint infection. Using a rodent model, muscle samples were obtained from rats following Kirschner wire implantation and infection with Staphylococcus aureus to determine if: (1) differences exist in cytokine concentrations with proximity to infection, and (2) localized infection-specific markers can be identified on a tissue level to potentially serve as debridement markers in the future. Samples were collected from 4 distinct locations, and the concentrations of interleukin(IL)-1α, IL-1β, IL-4, IL-5, IL-6, IL-10, IL-12p70, IL-13, granulocyte-macrophage colony-stimulating factor, interferon-γ, and tumor necrosis factor-α were quantified in each sample, relative to the amount of tissue. Cytokine concentrations differed with proximity to the joint when implant or infection was present, and tissues at the operative knee joint showed the highest levels of most cytokines. Additionally, IL-1β, IL-4, and IL-6 showed promise, beyond diagnostics, as tissue-level indicators of infection response. Ultimately, this study illustrated that tissue-level evaluation provided insight into infection-specific response, and these markers may be useful for guiding the debridement of implant-associated infections.
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Affiliation(s)
- Nicole Prince
- C. Eugene Bennett Department of Chemistry, West Virginia University, Morgantown, WV, USA,Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Julia A. Penatzer
- C. Eugene Bennett Department of Chemistry, West Virginia University, Morgantown, WV, USA,Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Taylor L. Shackleford
- Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Elizabeth K. Stewart
- Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Matthew J. Dietz
- Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Jonathan W. Boyd
- Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV, USA,Department of Physiology and Pharmacology, West Virginia University, Morgantown, WV, USA,Department of Occupational and Environmental Health Sciences, West Virginia University, WV, USA,Corresponding Author: Jonathan Boyd, West Virginia University School of Medicine, Department of Orthopaedics, 64 Medical Center Drive, 5408 HSS, P.O. Box 9196, Morgantown, WV 26506-9196, Phone: 304-293-1360,
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12
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Sigmund IK, Puchner SE, Windhager R. Serum Inflammatory Biomarkers in the Diagnosis of Periprosthetic Joint Infections. Biomedicines 2021; 9:biomedicines9091128. [PMID: 34572314 PMCID: PMC8467465 DOI: 10.3390/biomedicines9091128] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/16/2021] [Accepted: 08/21/2021] [Indexed: 11/23/2022] Open
Abstract
Accurate preoperative diagnosis of periprosthetic joint infections (PJIs) can be very challenging, especially in patients with chronic PJI caused by low-virulence microorganisms. Serum parameters, such as serum C-reactive protein (CRP) or the erythrocyte sedimentation rate (ESR), are—among other diagnostic test methods—widely used to distinguish septic from aseptic failure after total hip or knee arthroplasty and are recommended by the AAOS in the preoperative setting. However, they are systemic parameters, and therefore, unspecific. Nevertheless, they may be the first and occasionally the only preoperative indication, especially when clinical symptoms are lacking. They are easy to obtain, cheap, and are available worldwide. In the last decade, different novel serum biomarkers (percentage of neutrophils, neutrophils to lymphocytes ratio, platelet count to mean platelet volume ratio, fibrinogen, D-Dimer, Il-6, PCT) were investigated to find a more specific and accurate serum parameter in the diagnosis of PJI. This article reviews the diagnostic value of established (serum CRP, ESR, WBC) and ‘novel’ serum inflammatory biomarkers (fibrinogen, D-dimer, interleukin-6 (IL-6), procalcitonin, percentage of neutrophils (%N), neutrophils to lymphocytes ratio (NLR), platelet count to mean platelet volume ratio (PC/mPV)) for the preoperative diagnosis of periprosthetic joint infections.
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13
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Sigmund IK, McNally MA, Luger M, Böhler C, Windhager R, Sulzbacher I. Diagnostic accuracy of neutrophil counts in histopathological tissue analysis in periprosthetic joint infection using the ICM, IDSA, and EBJIS criteria. Bone Joint Res 2021; 10:536-547. [PMID: 34409845 PMCID: PMC8414440 DOI: 10.1302/2046-3758.108.bjr-2021-0058.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Aims Histology is an established tool in diagnosing periprosthetic joint infections (PJIs). Different thresholds, using various infection definitions and histopathological criteria, have been described. This study determined the performance of different thresholds of polymorphonuclear neutrophils (≥ 5 PMN/HPF, ≥ 10 PMN/HPF, ≥ 23 PMN/10 HPF) , when using the European Bone and Joint Infection Society (EBJIS), Infectious Diseases Society of America (IDSA), and the International Consensus Meeting (ICM) 2018 criteria for PJI. Methods A total of 119 patients undergoing revision total hip (rTHA) or knee arthroplasty (rTKA) were included. Permanent histology sections of periprosthetic tissue were evaluated under high power (400× magnification) and neutrophils were counted per HPF. The mean neutrophil count in ten HPFs was calculated (PMN/HPF). Based on receiver operating characteristic (ROC) curve analysis and the z-test, thresholds were compared. Results Using the EBJIS criteria, a cut-off of ≥ five PMN/HPF showed a sensitivity of 93% (95% confidence interval (CI) 81 to 98) and specificity of 84% (95% CI 74 to 91). The optimal threshold when applying the IDSA and ICM criteria was ≥ ten PMN/HPF with sensitivities of 94% (95% CI 79 to 99) and 90% (95% CI 76 to 97), and specificities of 86% (95% CI 77 to 92) and 92% (95% CI 84 to 97), respectively. In rTKA, a better performance of histopathological analysis was observed in comparison with rTHA when using the IDSA criteria (p < 0.001). Conclusion With high accuracy, histopathological analysis can be supported as a confirmatory criterion in diagnosing periprosthetic joint infections. A threshold of ≥ five PMN/HPF can be recommended to distinguish between septic and aseptic loosening, with an increased possibility of detecting more infections caused by low-virulence organisms. However, neutrophil counts between one and five should be considered suggestive of infection and interpreted carefully in conjunction with other diagnostic test methods. Cite this article: Bone Joint Res 2021;10(8):536–547.
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Affiliation(s)
- Irene K Sigmund
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Markus Luger
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Böhler
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Irene Sulzbacher
- Department of Pathology, Medical University of Vienna, Vienna, Austria
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Liu X, Jiang N, Wang T, Yu B. Serum and Synovial Biomarkers for the Diagnosis of Implant-Associated Infection After Orthopedic Surgery. Orthopedics 2021; 44:e158-e166. [PMID: 33416900 DOI: 10.3928/01477447-20210104-07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Implant-associated infection is one of the most devastating complications following orthopedic surgery. Early identification is crucial for treatment. Currently, however, a reliable diagnostic tool is lacking, partly due to disparate bacteria colonies (virulent vs non-virulent), difficulty in distinguishing infection from inflammatory disease, and highly diverse diagnostic thresholds and testing methods. Given the importance of biomarkers in the initial screening for the infection, an extensive effort has been made to develop serum and synovial biomarkers. In this review, the authors summarize the results from the most relevant studies to provide comprehensive information on biomarkers for the diagnosis of implant-associated infection. [Orthopedics. 2021;44(2):e158-e166.].
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Ivy MI, Sharma K, Greenwood-Quaintance KE, Tande AJ, Osmon DR, Berbari EF, Mandrekar J, Beauchamp CP, Hanssen AD, Abdel MP, Lewallen DG, Perry K, Block DR, Snyder MR, Patel R. Synovial fluid α defensin has comparable accuracy to synovial fluid white blood cell count and polymorphonuclear percentage for periprosthetic joint infection diagnosis. Bone Joint J 2021; 103-B:1119-1126. [PMID: 34058872 DOI: 10.1302/0301-620x.103b6.bjj-2020-1741.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to determine the diagnostic accuracy of α defensin (AD) lateral flow assay (LFA) and enzyme-linked immunosorbent assay (ELISA) tests for periprosthetic joint infection (PJI) in comparison to conventional synovial white blood cell (WBC) count and polymorphonuclear neutrophil percentage (PMN%) analysis. METHODS Patients undergoing joint aspiration for evaluation of pain after total knee arthroplasty (TKA) or total hip arthroplasty (THA) were considered for inclusion. Synovial fluids from 99 patients (25 THA and 74 TKA) were analyzed by WBC count and PMN% analysis, AD LFA, and AD ELISA. WBC and PMN% cutoffs of ≥ 1,700 cells/mm3 and ≥ 65% for TKA and ≥ 3,000 cells/mm3 and ≥ 80% for THA were used, respectively. A panel of three physicians, all with expertise in orthopaedic infections and who were blinded to the results of AD tests, independently reviewed patient data to diagnose subjects as with or without PJI. Consensus PJI classification was used as the reference standard to evaluate test performances. Results were compared using McNemar's test and area under the receiver operating characteristic curve (AUC) analysis. RESULTS Expert consensus classified 18 arthroplasies as having failed due to PJI and 81 due to aseptic failure. Using these classifications, the calculated sensitivity and specificity of AD LFA was 83.3% (95% confidence interval (CI) 58.6 to 96.4) and 93.8% (95% CI 86.2 to 98.0), respectively. Sensitivity and specificity of AD ELISA was 83.3% (95% CI 58.6 to 96.4) and 96.3% (95% CI 89.6 to 99.2), respectively. There was no statistically significant difference between sensitivity (p = 1.000) or specificity (p = 0.157) of the two AD assays. AUC for AD LFA was 0.891. In comparison, AUC for synovial WBC count, PMN%, and the combination of the two values was 0.821 (sensitivity p = 1.000, specificity p < 0.001), 0.886 (sensitivity p = 0.317, specificity p = 0.011), and 0.926 (sensitivity p = 0.317, specificity p = 0.317), respectively. CONCLUSION The diagnostic accuracy of synovial AD for PJI diagnosis is comparable and not statistically superior to that of synovial WBC count plus PMN% combined. Cite this article: Bone Joint J 2021;103-B(6):1119-1126.
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Soluble Pecam-1 as a Biomarker in Periprosthetic Joint Infection. J Clin Med 2021; 10:jcm10040612. [PMID: 33562828 PMCID: PMC7914675 DOI: 10.3390/jcm10040612] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/24/2021] [Accepted: 01/29/2021] [Indexed: 02/07/2023] Open
Abstract
A reliable workup with regard to a single diagnostic marker indicating periprosthetic joint infection (PJI) with sufficient sensitivity and specificity is still missing. The immunologically reactive molecule Pecam-1 is shed from the T-cell surface upon activation via proinflammatory signaling, e.g., triggered by specific pathogens. We hypothesized that soluble Pecam-1 (sPecam-1) can hence function as a biomarker of PJI. Fifty-eight patients were prospectively enrolled and assigned to one of the respective treatment groups (native knees prior to surgery, aseptic, and septic total knee arthroplasty (TKA) revision surgeries). Via synovial sample acquisition and ELISA testing, a database on local sPecam-1 levels was established. We observed a significantly larger quantity of sPecam-1 in septic (n = 22) compared to aseptic TKA revision surgeries (n = 20, p ≤ 0.001). Furthermore, a significantly larger amount of sPecam-1 was found in septic and aseptic revisions compared to native joints (n = 16, p ≤ 0.001). Benchmarking it to the gold standard showed a high predictive power for the detection of PJI. Local sPecam-1 levels correlated to the infection status of the implant, and thus bear a strong potential to act as a biomarker of PJI. While a clear role of sPecam-1 in infection could be demonstrated, the underlying mechanism of the molecule’s natural function needs to be further unraveled.
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17
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McNally M, Sousa R, Wouthuyzen-Bakker M, Chen AF, Soriano A, Vogely HC, Clauss M, Higuera CA, Trebše R. The EBJIS definition of periprosthetic joint infection. Bone Joint J 2021; 103-B:18-25. [PMID: 33380199 PMCID: PMC7954183 DOI: 10.1302/0301-620x.103b1.bjj-2020-1381.r1] [Citation(s) in RCA: 291] [Impact Index Per Article: 97.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition. Methods This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance. Results This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI. Conclusion The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice. Cite this article: Bone Joint J 2021;103-B(1):18–25.
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Affiliation(s)
- Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Ricardo Sousa
- Porto Bone Infection Group (GRIP), Orthopaedic Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Antonia F Chen
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - H Charles Vogely
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martin Clauss
- Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic, Florida, USA
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Sigmund IK, Holinka J, Staats K, Sevelda F, Lass R, Kubista B, Giurea A, Windhager R. Inferior performance of established and novel serum inflammatory markers in diagnosing periprosthetic joint infections. INTERNATIONAL ORTHOPAEDICS 2020; 45:837-846. [PMID: 33247312 PMCID: PMC8052219 DOI: 10.1007/s00264-020-04889-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/17/2020] [Indexed: 11/29/2022]
Abstract
Purpose Besides other diagnostic test methods, established serum inflammatory markers such as serum C-reactive protein or leukocyte count are widely used preoperatively to aid in diagnosing periprosthetic joint infections (PJI). Although low accuracies were reported, these parameters are easily accessible and routinely available. Novel biomarkers with promising results in diagnosing PJI (platelet count to mean platelet volume ratio) or other infectious conditions (percentage of neutrophils, neutrophils to lymphocytes ratio) were described. The purpose of this study was to investigate the diagnostic value of established and novel serum inflammatory biomarkers for the diagnosis of PJI so as to compare the results to find the serum inflammatory marker with the best performance. Methods In 177 patients with a previous total hip (n = 91) or knee (n = 86) arthroplasty and indicated revision surgery, the diagnostic value of the routinely available serum inflammatory markers C-reactive protein (CRP), white blood cell count (WBC), percentage of neutrophils (%N), neutrophils to lymphocytes ratio (NLR), fibrinogen and platelet count to mean platelet volume ratio (PC/mPV) were examined retrospectively via receiver operating characteristic curve analysis (AUC). The curves were compared using the z-test. Results Sensitivities of serum CRP, WBC, %N, NLR, fibrinogen and PC/mPV were calculated with 68%, 36%, 66%, 63%, 69% and 43%, respectively. Specificities were 87%, 89%, 67%, 73%, 89% and 81%, respectively. Serum CRP (0.78) and fibrinogen (0.79) showed significantly better AUCs compared with serum WBC (0.63), %N (0.67), NLR (0.68) and PC/mPV (0.62) (p < 0.0001). Patients with PJI caused by a low-virulent microorganism (median CRP: 17.6 mg/L) obtained lower CRP levels compared with infections caused by high-virulent microorganisms (median CRP: 49.2 mg/L; p = 0.044). The combination of CRP and fibrinogen showed a better sensitivity (77%) with similar specificity (83%) than one method alone but not at a significant level (CRP (p = 0.200); fibrinogen (p = 0.437)). Conclusion Serum CRP and fibrinogen showed the best accuracies among these widely available serum inflammatory parameters. However, due to the insufficient performance, these biomarkers can only be recommended as suggestive criteria in diagnosing PJI. The preoperative workup should always be complemented by more specific tests such as synovial fluid analysis.
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Affiliation(s)
- Irene Katharina Sigmund
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Johannes Holinka
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Kevin Staats
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Florian Sevelda
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Richard Lass
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Bernd Kubista
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Alexander Giurea
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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Sahm F, Ziebart J, Jonitz-Heincke A, Hansmann D, Dauben T, Bader R. Alternating Electric Fields Modify the Function of Human Osteoblasts Growing on and in the Surroundings of Titanium Electrodes. Int J Mol Sci 2020; 21:ijms21186944. [PMID: 32971771 PMCID: PMC7555878 DOI: 10.3390/ijms21186944] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 09/18/2020] [Accepted: 09/19/2020] [Indexed: 12/15/2022] Open
Abstract
Endogenous electric fields created in bone tissue as a response to mechanical loading are known to influence the activity and differentiation of bone and precursor cells. Thus, electrical stimulation offers an adjunct therapy option for the promotion of bone regeneration. Understanding the influence of electric fields on bone cell function and the identification of suitable electrical stimulation parameters are crucial for the clinical success of stimulation therapy. Therefore, we investigated the impact of alternating electric fields on human osteoblasts that were seeded on titanium electrodes, which delivered the electrical stimulation. Moreover, osteoblasts were seeded on collagen-coated coverslips near the electrodes, representing the bone stock surrounding the implant. Next, 0.2 V, 1.4 V, or 2.8 V were applied to the in vitro system with 20 Hz frequency. After one, three, and seven days, the osteoblast morphology and expression of osteogenic genes were analysed. The actin organisation, as well as the proliferation, were not affected by the electrical stimulation. Changes in the gene expression and protein accumulation after electrical stimulation were voltage-dependent. After three days, the osteogenic gene expression and alkaline phosphatase activity were up to 2.35-fold higher following the electrical stimulation with 0.2 V and 1.4 V on electrodes and coverslips compared to controls. Furthermore, collagen type I mRNA, as well as the amount of the C-terminal propeptide of collagen type I were increased after the stimulation with 0.2 V and 1.4 V, while the higher electrical stimulation with 2.8 V led to decreased levels, especially on the electrodes.
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Affiliation(s)
- Franziska Sahm
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, Rostock University Medical Centre, 18057 Rostock, Germany; (A.J.-H.); (D.H.); (R.B.)
- Correspondence: (F.S.); (J.Z.); Tel.: +49-0381-4949336 (J.Z.)
| | - Josefin Ziebart
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, Rostock University Medical Centre, 18057 Rostock, Germany; (A.J.-H.); (D.H.); (R.B.)
- Correspondence: (F.S.); (J.Z.); Tel.: +49-0381-4949336 (J.Z.)
| | - Anika Jonitz-Heincke
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, Rostock University Medical Centre, 18057 Rostock, Germany; (A.J.-H.); (D.H.); (R.B.)
| | - Doris Hansmann
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, Rostock University Medical Centre, 18057 Rostock, Germany; (A.J.-H.); (D.H.); (R.B.)
| | - Thomas Dauben
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center, Schillingallee 70, 18057 Rostock, Germany;
| | - Rainer Bader
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, Rostock University Medical Centre, 18057 Rostock, Germany; (A.J.-H.); (D.H.); (R.B.)
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18F FDG-PET/CT has poor diagnostic accuracy in diagnosing shoulder PJI. Eur J Nucl Med Mol Imaging 2019; 46:2013-2022. [PMID: 31292698 DOI: 10.1007/s00259-019-04381-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/28/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE Chronic low-grade periprosthetic joint infection (PJI) of a shoulder replacement can be challenging to diagnose. 18F-FDG PET/CT is suggested as a modality to diagnose lower-limb PJI, but no studies on shoulder replacements exist. The aim of this study was therefore to determine the diagnostic accuracy of 18F-FDG PET/CT in diagnosing chronic PJI of the shoulder. METHODS Patients evaluated for a failed shoulder replacement during a 3-year period were prospectively included in the study. All patients underwent pre-operative 18F-FDG PET/CT, and were evaluated for signs of infection by three independent reviewers using shoulder-specific criteria. Interrater-agreement was calculated between the reviewers. If the patient had revision surgery, biopsy specimens were obtained and cultured with bacterial growth in the cultures serving as gold standard of infection. RESULTS A total of 86 patients were included in the study. Nine patients were 18F-FDG PET/CT positive for infection, with only three true positive. Using the gold standard, infection was diagnosed after revision surgery in 22 cases. All infections were chronic and caused by low-virulent microbes. The sensitivity of 18F-FDG PET/CT was 0.14 95% CI (0.03-0.36), specificity 0.91 95% CI (0.81-0.97), positive predictive value was 0.40 95% CI (0.15-0.71) and negative predictive value 0.71 95% CI (0.67-0.75). The inter-observer agreement was 0.56 (Fleiss' kappa), indicating moderate agreement of the visual FDG-PET evaluation using the shoulder-specific criteria. CONCLUSION 18F-FDG PET/CT has poor diagnostic accuracy in diagnosing low-grade PJI of the shoulder. 18F-FDG PET/CT cannot be recommended as a part of the routine preoperative workup to diagnose low-grade infection of a shoulder replacement.
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Sconfienza LM, Signore A, Cassar-Pullicino V, Cataldo MA, Gheysens O, Borens O, Trampuz A, Wörtler K, Petrosillo N, Winkler H, Vanhoenacker FMHM, Jutte PC, Glaudemans AWJM. Diagnosis of peripheral bone and prosthetic joint infections: overview on the consensus documents by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur Radiol 2019; 29:6425-6438. [PMID: 31250170 DOI: 10.1007/s00330-019-06326-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/27/2019] [Accepted: 06/12/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Peripheral bone infection (PBI) and prosthetic joint infection (PJI) are two different infectious conditions of the musculoskeletal system. They have in common to be quite challenging to be diagnosed and no clear diagnostic flowchart has been established. Thus, a conjoined initiative on these two topics has been initiated by the European Society of Radiology (ESR), the European Association of Nuclear Medicine (EANM), the European Bone and Joint Infection Society (EBJIS), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). The purpose of this work is to provide an overview on the two consensus documents on PBI and PJI that originated by the conjoined work of the ESR, EANM, and EBJIS (with ESCMID endorsement). METHODS AND RESULTS After literature search, a list of 18 statements for PBI and 25 statements for PJI were drafted in consensus on the most debated diagnostic challenges on these two topics, with emphasis on imaging. CONCLUSIONS Overall, white blood cell scintigraphy and magnetic resonance imaging have individually demonstrated the highest diagnostic performance over other imaging modalities for the diagnosis of PBI and PJI. However, the choice of which advanced diagnostic modality to use first depends on several factors, such as the benefit for the patient, local experience of imaging specialists, costs, and availability. Since robust, comparative studies among most tests do not exist, the proposed flowcharts are based not only on existing literature but also on the opinion of multiple experts involved on these topics. KEY POINTS • For peripheral bone infection and prosthetic joint infection, white blood cell and magnetic resonance imaging have individually demonstrated the highest diagnostic performance over other imaging modalities. • Two evidence- and expert-based diagnostic flowcharts involving variable combination of laboratory tests, biopsy methods, and radiological and nuclear medicine imaging modalities are proposed by a multi-society expert panel. • Clinical application of these flowcharts depends on several factors, such as the benefit for the patient, local experience, costs, and availability.
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Affiliation(s)
- Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy. .,Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy.
| | - Alberto Signore
- Nuclear Medicine Unit, Faculty of Medicine and Psychology, Department of Medical-Surgical Sciences and Translational Medicine, "Sapienza" University, Rome, Italy
| | - Victor Cassar-Pullicino
- Department of Diagnostic Imaging, The Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Oswestry, Shropshire, UK
| | - Maria Adriana Cataldo
- Infectious Disease Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS, Rome, Italy
| | - Olivier Gheysens
- Department of Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Olivier Borens
- Division of Orthopaedic Surgery and Traumatology, Septic surgical unit, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Klaus Wörtler
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Munich, Germany
| | - Nicola Petrosillo
- Infectious Disease Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS, Rome, Italy
| | - Heinz Winkler
- Osteitis-Centre, Privatklinik Döbling, Vienna, Austria
| | - Filip M H M Vanhoenacker
- Department of Radiology, Antwerp University Hospital and Antwerp University, Antwerp, Belgium.,AZ Sint-Maarten, Belgium, Mechelen, Belgium.,University of Ghent, Ghent, Belgium
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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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: 54] [Impact Index Per Article: 10.8] [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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23
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Consensus document for the diagnosis of prosthetic joint infections: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur J Nucl Med Mol Imaging 2019; 46:971-988. [PMID: 30683987 PMCID: PMC6450843 DOI: 10.1007/s00259-019-4263-9] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/02/2019] [Indexed: 12/13/2022]
Abstract
Background For the diagnosis of prosthetic joint infection, real evidence-based guidelines to aid clinicians in choosing the most accurate diagnostic strategy are lacking. Aim and Methods To address this need, we performed a multidisciplinary systematic review of relevant nuclear medicine, radiological, orthopaedic, infectious, and microbiological literature to define the diagnostic accuracy of each diagnostic technique and to address and provide evidence-based answers on uniform statements for each topic that was found to be important to develop a commonly agreed upon diagnostic flowchart. Results and Conclusion The approach used to prepare this set of multidisciplinary guidelines was to define statements of interest and follow the procedure indicated by the Oxford Centre for Evidence-based Medicine (OCEBM). Electronic supplementary material The online version of this article (10.1007/s00259-019-4263-9) contains supplementary material, which is available to authorized users.
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Suitability of serum cytokine profiling for early diagnosis of implant-associated infections after orthopaedic surgery: A preliminary prospective study. Cytokine 2019; 116:88-96. [PMID: 30685607 DOI: 10.1016/j.cyto.2018.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 12/06/2018] [Accepted: 12/21/2018] [Indexed: 02/06/2023]
Abstract
The C-reactive protein (CRP) is still the conventional marker used to diagnose implant-associated infections (IAI) after orthopaedic surgery. However, the CRP level can lead to misdiagnosis since it is up-regulated not only during bacterial infection. In this prospective study, we evaluated the serum cytokine profile before (pre-OP) and after orthopaedic surgery (post-OP) as well as after confirmation of a developed infection (COI) to identify candidate biomarkers for diagnosis of IAI. Sera from 10 controls 7 to 1 days pre-OP and 0 to 22 days post-OP as well as from 5 patients who developed IAI 5 to 1 days pre-OP, 0 to 197 days post-OP and after COI were analyzed for 27 different cytokines using a multiplex cytokine assay. In addition to CRP, 14 cytokines IL-1ra, IL-4, IL-5, IL-6, IL-8, IL-12(p70), IL-13, IL-17, eotaxin, G-CSF, IFN-γ, IP-10, MCP-1, and MIP-1β were significantly altered (P ≤ 0.05) during the study although some differences were low-fold elevations compared to the pre-OP levels. IL-6 as well as IL-12(p70) were consistently elevated in infected patients. Surgery influenced cytokine production with some overlap of cytokines in both groups, implying that the use of cytokines is maximized when the cytokines are not or no longer affected by surgical trauma. To lend more robustness to the selection of candidate cytokines, in addition to the statistical differences, we applied a threshold cut-off of approximately 2-fold elevations when comparisons were made. This resulted in the selection of 8 cytokines, namely IL-6, IL-1ra, IL-8, IL-12(p70), eotaxin, IP-10, MCP-1, and MIP-1β, which may be used in a multiplex assay for detection of IAI after surgery. Furthermore, IL-1ra and IL-8 may be used as prognostic cytokines prior to surgery. The present results imply that the use of cytokines may be a suitable alternative to CRP for IAI diagnosis.
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25
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Bratengeier C, Bakker AD, Fahlgren A. Mechanical loading releases osteoclastogenesis-modulating factors through stimulation of the P2X7 receptor in hematopoietic progenitor cells. J Cell Physiol 2018; 234:13057-13067. [PMID: 30536959 DOI: 10.1002/jcp.27976] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/20/2018] [Indexed: 01/20/2023]
Abstract
Mechanical instability of bone implants stimulate osteoclast differentiation and peri-implant bone loss, leading to prosthetic loosening. It is unclear which cells at the periprosthetic interface transduce mechanical signals into a biochemical response, and subsequently facilitate bone loss. We hypothesized that mechanical overloading of hematopoietic bone marrow progenitor cells, which are located near to the inserted bone implants, stimulates the release of osteoclast-inducing soluble factors. Using a novel in vitro model to apply mechanical overloading, we found that hematopoietic progenitor cells released adenosine triphosphate (ATP) after only 2 min of mechanical loading. The released ATP interacts with its specific receptor P2X7 to stimulate the release of unknown soluble factors that inhibit (physiological loading) or promote (supraphysiological loading) the differentiation of multinucleated osteoclasts derived from bone marrow cultures. Inhibition of ATP-receptor P2X7 by Brilliant Blue G completely abolished the overloading-induced stimulation of osteoclast formation. Likewise, stimulation of P2X7 receptor on hematopoietic cells by BzATP enhanced the release of osteoclastogenesis-stimulating signaling molecules to a similar extent as supraphysiological loading. Supraphysiological loading affected neither gene expression of inflammatory markers involved in aseptic implant loosening (e.g., interleukin-1β (IL-1β), IL-6, tumor necrosis factor-α, and PTGES2) nor expression of the osteoclast modulators receptor activator of nuclear factor κ-Β ligand and osteoprotegerin. Our findings suggest that murine hematopoietic progenitor cells are a potential key player in local mechanical loading-induced bone implant loosening via the ATP/P2X7-axis. Our approach identifies potential therapeutic targets to prevent prosthetic loosening.
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Affiliation(s)
- Cornelia Bratengeier
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
| | - Astrid D Bakker
- Department of Oral Cell Biology, ACTA, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Anna Fahlgren
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
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26
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Sultan AA, Cantrell WA, Khlopas A, Berger RJ, Sodhi N, Molloy RM, Krebs VE, Mont MA. Evidence-Based Management of Trunnionosis in Metal-on-Polyethylene Total Hip Arthroplasty: A Systematic Review. J Arthroplasty 2018; 33:3343-3353. [PMID: 29929829 DOI: 10.1016/j.arth.2018.05.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 05/21/2018] [Accepted: 05/23/2018] [Indexed: 02/01/2023] Open
Abstract
Multiple recent reports have indicated a rising awareness of trunnionosis-related implant failures, accounting for up to 3% of all total hip arthroplasty revisions. Moreover, aseptic loosening and osteolysis from local release of metal debris can be the presenting manifestations, and thus the true incidence of trunnionosis is thought to be underreported. Furthermore, the relatively unclear and multifactorial pathogenesis and the widely variable clinical presentations pose a diagnostic challenge. A consensus regarding the ideal intervention and its timing is also lacking. Because of the relative paucity of reports regarding the diagnosis and management of trunnionosis, we conducted this evidence-based review to evaluate the (1) incidence, (2) pathogenesis, (3) diagnosis, and (4) treatment of trunnionosis in metal-on-polyethylene total hip arthroplasty. We then propose an algorithm for the diagnostic work-up and management of this condition.
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Affiliation(s)
- Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Ryan J Berger
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York City, NY
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Viktor E Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH; Department of Orthopaedic Surgery, Lenox Hill Hospital, New York City, NY
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Sebastian S, Malhotra R, Dhawan B. Prosthetic Joint Infection: A Major Threat to Successful Total Joint Arthroplasty. Indian J Med Microbiol 2018; 36:475-487. [DOI: 10.4103/ijmm.ijmm_19_11] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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28
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A meta-analysis of synovial biomarkers in periprosthetic joint infection: Synovasure™ is less effective than the ELISA-based alpha-defensin test. Knee Surg Sports Traumatol Arthrosc 2018; 26:3039-3047. [PMID: 29557491 DOI: 10.1007/s00167-018-4904-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 03/16/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE (1) To determine the overall accuracy of synovial alpha-defensin, synovial C-reactive protein (sCRP), interleukin-6 (sIL-6), and leukocyte esterase (sLE) as diagnostic markers for periprosthetic joint infection (PJI) and (2) to independantly evaluate the accuracy of both the laboratory-based ELISA alpha-defensin test and the Synovasure™ alpha-defensin test kit. METHODS An EMBASE and MEDLINE (PubMed) database search was performed using a set of professionally set search terms. Two independent reviewers rated eligible articles. Sensitivity and specificity were meta-analysed using a bivariate random-effects model. RESULTS Accuracy values were extracted from 42 articles. Pooled sensitivity and specificity of the represented biomarkers were: alpha-defensin ELISA 0.97 (95% CI 0.91-0.99) and 0.97 (95% CI 0.94-0.98), respectively; Synovasure™ test kit assay 0.80 (95% CI 0.65-0.89) and 0.89 (95% CI 0.76-0.96), respectively; sLE 0.79 (95% CI 0.67-0.87) and 0.92 (95% CI 0.87-0.92), respectively; sIL-6 0.76 (95% CI 0.65-0.84) and 0.91 (95% CI 0.88-0.94), respectively; sCRP 0.86 (95% CI 0.81-0.91) and 0.90 (95% CI 0.86-0.93), respectively. CONCLUSION The labararory-based alpha-defensin ELISA test showed the highest ever reported accuracy for PJI diagnosis. However, this did not apply for the Synovasure™ alpha-defensin test, which was comparable in its overall diagnostic accuracy to sCRP, sIL-6 and sLE. The later biomarkers also did not yield an overall diagnostic accuracy higher than that previously reported for synovial white cell count (sWBC) or culture bacteriology. Based on current evidence, no synovial biomarker should be applied as a standalone diagnostic tool. Furthermore, the use of the laboratory-based alpha-defensin ELISA test should be encouraged, still, the Synovasure™ alpha-defensin test kit should be critically appreciated. LEVER OF EVIDENCE III.
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Slullitel PA, Oñativia JI, Buttaro MA, Sánchez ML, Comba F, Zanotti G, Piccaluga F. State-of-the-art diagnosis and surgical treatment of acute peri-prosthetic joint infection following primary total hip arthroplasty. EFORT Open Rev 2018; 3:434-441. [PMID: 30233819 PMCID: PMC6129958 DOI: 10.1302/2058-5241.3.170032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Acute peri-prosthetic joint infection (PJI) following total hip arthroplasty (THA) is a potentially devastating and undesired complication, with a prevalence of 0.3% to 2.9%. Its suspicion begins with a meticulous physical examination and anamnesis. Diagnosis should be made on the basis of the Musculoskeletal Infection Society criteria. Serum and synovial biomarkers are very useful tools when major criteria are absent.Although sometimes not possible due to medical conditions, surgery is usually the first line of treatment. Although its outcome is highly correlated with the isolated microorganism, irrigation and debridement with implant retention (DAIR) is the gold standard for treatment. Ideally, the prior approach should be proximally and distally extended to augment the field of view and remove all of the prosthetic modular components, that is, femoral head and acetabular insert.Given DAIR's unclear control of infection, with successful outcomes in the range of 30% to 95%, one- or two-stage revision protocols may play a role in certain cases of acute infections; nonetheless, further prospective, randomized studies are necessary to compare long-term outcomes between DAIR and revision surgeries.Following surgical treatment, length of antibiotherapy is in the range of six weeks to six months, without any difference in outcomes between short and long protocols. Treatment should be adjusted to the isolated bacteria and controlled further with post-operative serum biomarker levels. Cite this article: EFORT Open Rev 2018;3:434-441. DOI: 10.1302/2058-5241.3.170032.
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Affiliation(s)
| | | | | | | | - Fernando Comba
- Hip Surgery Unit, Italian Hospital of Buenos Aires, Argentina
| | - Gerardo Zanotti
- Hip Surgery Unit, Italian Hospital of Buenos Aires, Argentina
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Gallo J, Svoboda M, Zapletalova J, Proskova J, Juranova J. Serum IL-6 in combination with synovial IL-6/CRP shows excellent diagnostic power to detect hip and knee prosthetic joint infection. PLoS One 2018; 13:e0199226. [PMID: 29927991 PMCID: PMC6013214 DOI: 10.1371/journal.pone.0199226] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 06/04/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The diagnosis of prosthetic joint infection (PJI) is still a challenge in some patients after total joint replacement. Interleukin-6 (IL-6) strongly participates in the arrangement of the host-bacteria response. Therefore, increased levels of IL-6 should accompany every PJI. PURPOSE The aim of the study was to show diagnostic characteristics of serum IL-6 for the diagnosis of prosthetic joint infection (PJI). We also compared the diagnostic values of serum IL-6 with synovial IL-6 (sIL-6) and synovial C-reactive protein (sCRP). STUDY DESIGN We performed a prospective study of 240 patients in whom serum IL-6 was determined before total hip (n = 124) or knee (n = 116) reoperations. The PJI diagnosis was based on the MSIS (Musculoskeletal Infection Society) criteria (2011). Receiver operating characteristic plots were constructed for IL-6, sIL-6, and sCRP. RESULTS PJI was diagnosed in 93 patients, and aseptic revision was diagnosed in 147 patients. The AUC (area under curve) for IL-6 was 0.938 (95% CI; 0.904-0.971). The optimal IL-6 cut-off value for PJI was 12.55 ng/L. Positive and negative likelihood ratios for IL-6 were 8.24 (95% CI; 4.79-14.17) and 0.15 (95% CI; 0.09-0.26), respectively. The optimal sIL-6 and sCRP cut-off values were 20,988 ng/L and 8.80 mg/L, respectively. Positive and negative likelihood ratios for sIL-6 were 40.000 (95% CI; 5.7-280.5) and 0.170 (95% CI; 0.07-0.417), respectively. Negative likelihood ratio for sCRP was 0.083 (95% CI; 0.022-0.314). CONCLUSIONS The present study identified the cut-off values for serum/synovial IL-6 and synovial CRP for diagnostics of PJI at the site of THA and TKA and separately for each site. The diagnostic odds ratio for serum/synovial IL-6 and synovial CRP is very good. Simultaneous positivity of serum IL-6 either with synovial IL-6 or synovial CRP almost excludes false negative detection of PJI at the site of interest.
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Affiliation(s)
- Jiri Gallo
- Department of Orthopaedics, Teaching Hospital Olomouc, Faculty of Medicine, Palacky University Olomouc, Olomouc, Czech Republic
- * E-mail:
| | - Michal Svoboda
- Department of Orthopaedics, Teaching Hospital Olomouc, Faculty of Medicine, Palacky University Olomouc, Olomouc, Czech Republic
| | - Jana Zapletalova
- Department of Medical Biophysics, Faculty of Medicine, Palacky University Olomouc, Olomouc, Czech Republic
| | - Jitka Proskova
- Department of Clinical Biochemistry, Teaching Hospital Olomouc, Olomouc, Czech Republic
| | - Jarmila Juranova
- Department of Hemato-Oncology, Teaching Hospital Olomouc, Faculty of Medicine, Palacky University Olomouc, Olomouc, Czech Republic
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Histopathology in Periprosthetic Joint Infection: When Will the Morphomolecular Diagnosis Be a Reality? BIOMED RESEARCH INTERNATIONAL 2018; 2018:1412701. [PMID: 29862251 PMCID: PMC5971260 DOI: 10.1155/2018/1412701] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/07/2018] [Indexed: 02/07/2023]
Abstract
The presence of a polymorphonuclear neutrophil infiltrate in periprosthetic tissues has been shown to correlate closely with the diagnosis of septic implant failure. The histological criterion considered by the Musculoskeletal Infection Society to be diagnostic of periprosthetic joint infection is “greater than five neutrophils per high-power field in five high-power fields observed from histologic analysis of periprosthetic tissue at ×400 magnification.” Surgeons and pathologists should be aware of the qualifications introduced by different authors during the last years in the histological techniques, samples for histological study, cutoffs used for the diagnosis of infection, and types of patients studied. Recently, immunohistochemistry and histochemistry studies have appeared which suggest that the cutoff point of five polymorphonuclear neutrophils in five high-power fields is too high for the diagnosis of many periprosthetic joint infections. Therefore, morphomolecular techniques could help in the future to achieve a more reliable histological diagnosis of periprosthetic joint infection.
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32
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Balato G, Franceschini V, Ascione T, Lamberti A, Balboni F, Baldini A. Diagnostic accuracy of synovial fluid, blood markers, and microbiological testing in chronic knee prosthetic infections. Arch Orthop Trauma Surg 2018; 138:165-171. [PMID: 29103074 DOI: 10.1007/s00402-017-2832-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This retrospective study was undertaken to define cut-off values for synovial fluid (SF) leukocyte count and neutrophil percentage for differentiating aseptic failure and periprosthetic joint infection (PJI) and to evaluate the diagnostic accuracy of blood inflammatory markers, and microbiological testing according to the criteria proposed by the International Consensus Meeting (ICM) of Philadelphia. METHODS All patients who underwent revision total knee arthroplasty from January 2010 to July 2015 were included: we identified and classified 31 PJIs and 136 aseptic joints. The diagnostic performance of single test was assessed by receiver operating characteristic curve analyses. The sensitivity and specificity were calculated for each of the cut-off values and the area under the curve (AUC) was calculated. RESULTS The median SF leukocyte count as well as the neutrophil percentage and inflammatory markers were significantly higher in patients with PJI than in those with aseptic failure (p < 0.001). A leukocyte count of > 2.8 × 103/μL had a sensitivity of 83.8% and a specificity of 89.7% whereas a neutrophil percentage of > 72% yielded a marginally higher sensitivity of 84% and a specificity of 91%. Applying the ICM criteria we found a significant correlation between all these diagnostic measures and PJI (p < 0.001) except for a single positive culture. The most accurate criterion of the ICM was the synovial neutrophil differential (AUC = 0.89; 95% CI 0.81-0.97), followed by SF leukocyte count (AUC = 0.86; 95% CI 0.78-0.94), increased inflammatory markers (AUC = 0.85; 95% CI 0.76-0.93), and two positive periprosthetic cultures (AUC = 0.84; 95% CI 0.73-0.94). The presence of sinus tract communicating with the joint and a single positive culture showed unfavourable diagnostic accuracy (AUC = 0.60, 95% CI 0.47-0.72; AUC = 0.49, 95% CI 0.38-0.61, respectively) CONCLUSIONS: The present study highlights the adequate ability of fluid cell count and neutrophil differential to distinguish between PJI and aseptic loosening. The clinical utility of fluid analysis in diagnosing infection can be improved by evaluation of other diagnostic criteria. LEVEL OF EVIDENCE Level I Diagnostic Study.
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Affiliation(s)
- Giovanni Balato
- Department of Public Health, School of Medicine, Federico II University, Via S. Pansini, Naples, Italy.
| | | | - Tiziana Ascione
- Department of Infectious Diseases, D. Cotugno Hospital, AORN Dei Colli, Naples, Italy
| | | | - Fiamma Balboni
- Department of Laboratory Medicine, IFCA Clinic, Florence, Italy
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Yoon JR, Yang SH, Shin YS. Diagnostic accuracy of interleukin-6 and procalcitonin in patients with periprosthetic joint infection: a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2018; 42:1213-1226. [DOI: 10.1007/s00264-017-3744-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 12/18/2017] [Indexed: 11/24/2022]
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34
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Screening for Infection Before Revision Hip Arthroplasty: A Meta-analysis of Likelihood Ratios of Erythrocyte Sedimentation Rate and Serum C-reactive Protein Levels. J Am Acad Orthop Surg 2017; 25:809-817. [PMID: 29176504 DOI: 10.5435/jaaos-d-16-00642] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Diagnosing periprosthetic joint infection (PJI) before revision hip arthroplasty is critical to ensure effective treatment of patients undergoing surgery for reasons other than infection. The main objective of our study is to determine whether the erythrocyte sedimentation rate (ESR) and the serum C-reactive protein (CRP) level are sufficient to use for testing to rule out infection in patients undergoing revision hip surgery. METHODS We performed a systematic review of the literature in the MEDLINE, Ovid, and Embase databases. We included studies in which the investigators used the ESR (>30 mm/h) and serum CRP level (>10 mg/L) for the diagnosis of PJI of the hip. We obtained meta-estimates of sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-). RESULTS From 511 articles, we analyzed 12 studies in which the investigators reported data on 2,736 patients. Sensitivity and specificity for the ESR were 0.860 (95% confidence interval [CI], 0.825 to 0.890) and 0.723 (95% CI, 0.704 to 0.742), respectively, and for the CRP level were 0.869 (95% CI, 0.835 to 0.899) and 0.786 (95% CI, 0.769 to 0.803), respectively. For the ESR, LR+ was 3.42 (95% CI, 2.55 to 4.59) and LR- was 0.22 (95% CI, 0.12 to 0.41). For the CRP level, LR+ was 4.18 (95% CI, 3.42 to 5.11) and LR- was 0.20 (95% CI, 0.12 to 0.32). DISCUSSION With a low pretest probability of PJI, a negative test result for either the ESR or CRP level is enough to rule out infection before revision hip arthroplasty. LEVEL OF EVIDENCE III.
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The Diagnostic Utility of Synovial Fluid Markers in Periprosthetic Joint Infection: A Systematic Review and Meta-analysis. J Am Acad Orthop Surg 2017; 25:763-772. [PMID: 29059113 DOI: 10.5435/jaaos-d-16-00548] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION This study is a systematic review of all reported synovial fluid markers for the diagnosis of periprosthetic joint infection and a meta-analysis of the most frequently reported markers to identify those of greatest diagnostic utility. METHODS A search of six databases was conducted to identify all studies evaluating the utility of synovial fluid markers in the diagnosis of periprosthetic joint infection. Two observers assessed methodologic quality and extracted data independently. A meta-analysis of the most frequently reported markers was performed. RESULTS Twenty-three studies were included in the meta-analysis. The most common markers (and their respective area under the curve) were interleukin-17 (0.974), leukocyte esterase (0.968), α-defensin (0.958), interleukin-6 (0.956), interleukin-1β (0.948), and C-reactive protein (0.927). Among these markers, α-defensin had the highest diagnostic odds ratio but did not achieve statistically significant superiority. CONCLUSION The most frequently studied synovial fluid markers for the diagnosis of periprosthetic joint infection are C-reactive protein, leukocyte esterase, interleukin-6, interleukin-1β, α-defensin, and interleukin-17, all of which have high diagnostic utility. LEVEL OF EVIDENCE Level II.
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Alrashidi Y, Galhoum AE, Wiewiorski M, Herrera-Pérez M, Hsu RY, Barg A, Valderrabano V. How To Diagnose and Treat Infection in Total Ankle Arthroplasty. Foot Ankle Clin 2017; 22:405-423. [PMID: 28502355 DOI: 10.1016/j.fcl.2017.01.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Periprosthetic infection after total ankle arthroplasty (TAA) is a serious complication, often requiring revision surgery, including revision arthroplasty, conversion to ankle arthrodesis, or even amputation. Risk factors for periprosthetic ankle infection include prior surgery at the site of infection, low functional preoperative score, diabetes, and wound healing problems. The clinical presentation of patients with periprosthetic ankle joint infection can be variable and dependent on infection manifestation: acute versus chronic. The initial evaluation in patients with suspected periprosthetic joint infections should include blood tests: C-reactive protein and erythrocyte sedimentation rate. Joint aspiration and synovial fluid analysis can help confirm suspected periprosthetic ankle infection.
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Affiliation(s)
- Yousef Alrashidi
- Orthopaedic Department, College of Medicine, Taibah University, P.O. Box 30001, Almadinah Almunawwarah 41411, Kingdom of Saudi Arabia
| | - Ahmed E Galhoum
- Nasser Institute for Research and Treatment, Cairo, Egypt; Department of Orthopaedics and Traumatology, Swiss Ortho Center, Schmerzklinik Basel, Hirschgässlein 15, Basel 4010, Switzerland
| | - Martin Wiewiorski
- Orthopaedic and Trauma Department, Kantonsspital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Mario Herrera-Pérez
- Orthopaedic Department, University Hospital of Canary Islands, La Laguna, Calle El Pilar 50 4 piso, 38002 Tenerife, Spain
| | - Raymond Y Hsu
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Victor Valderrabano
- Orthopaedic Department, Swiss Ortho Center, Schmerzklinik Basel, Swiss Medical Network, Hirschgässlein 15, Basel 4010, Switzerland.
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Serum and Synovial Fluid Interleukin-6 for the Diagnosis of Periprosthetic Joint Infection. Sci Rep 2017; 7:1496. [PMID: 28473693 PMCID: PMC5431429 DOI: 10.1038/s41598-017-01713-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 03/31/2017] [Indexed: 01/29/2023] Open
Abstract
A gold standard for diagnosis of periprosthetic joint infection (PJI) has not yet been established. The objective of this study was to evaluate the diagnostic value of serum and synovial fluid interleukin (IL)-6 levels for PJI. The MEDLINE and EMBASE databases were searched for studies describing PJI diagnosis using serum and synovial fluid IL-6 and published between January 1990 and October 2016. Seventeen studies were included in the analysis. The pooled sensitivities of serum and synovial fluid IL-6 were 0.72 (95% confidence interval [CI]: 0.63–0.80) and 0.91 (95% CI: 0.82–0.96), respectively. The pooled specificities of serum and synovial fluid IL-6 were 0.89 (95% CI: 0.77–0.95) and 0.90 (95% CI: 0.84–0.95), respectively. The pooled diagnostic odds ratios (DORs) of serum and synovial fluid IL-6 were 20 (95% CI: 7–58) and 101 (95% CI: 28–358), respectively, and the pooled areas under the curve (AUCs) were 0.83 (95% CI: 0.79–0.86) and 0.96 (95% CI: 0.94–0.98), respectively. Synovial fluid IL-6 had high diagnostic value for PJI. Although serum IL-6 test was less sensitive than synovial fluid IL-6 test, it may be regularly prescribed for patients with prosthetic failure owing to its high specificity.
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How Reliable Is the Alpha-defensin Immunoassay Test for Diagnosing Periprosthetic Joint Infection? A Prospective Study. Clin Orthop Relat Res 2017; 475:408-415. [PMID: 27343056 PMCID: PMC5213924 DOI: 10.1007/s11999-016-4906-0] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND A key issue in the treatment of periprosthetic joint infection (PJI) is the correct diagnosis. The main problem is lack of diagnostic tools able to diagnose a PJI with high accuracy. Alpha-defensin has been proposed as a possible solution, but in the current literature, there is a lack of independent validation. QUESTIONS/PURPOSES We performed a prospective study to determine (1) what is the sensitivity, specificity, and positive and the negative predictive values of the alpha-defensin immunoassay test in diagnosing PJI; and (2) which clinical features may be responsible for false-positive and false-negative results? METHODS Preoperative aspiration was performed in all patients presenting with a painful hip/knee arthroplasty, including both primary and revision implants. Metallosis, other inflammatory comorbidities, and previous/concomitant antibiotic therapy were not considered as exclusion criteria. An inadequate amount of synovial fluid for culture was an exclusion criterion. A total of 156 patients (65 knees, 91 hips) were included in this prospective study. At the time of revision, synovial fluid samples were taken to perform the alpha-defensin assay. During surgical débridement of tissue, samples for cultures and histologic evaluation were taken, and samples were cultured until positive or until negative at 14 days. A diagnosis of PJI was confirmed in 29 patients according to the International Consensus Group on PJI. RESULTS The sensitivity of the alpha-defensin immunoassay was 97% (95% confidence interval [CI], 92%-99%), the specificity was 97% (95% CI, 92%-99%), the positive predictive value was 88% (95% CI, 81%-92%), and the negative predictive value was 99% (95% CI, 96%-99%). Among four false-positive patients, two had metallosis and one had polyethylene wear. The false-negative case presented with a draining sinus, and intraoperative cultures were also negative. CONCLUSIONS Alpha-defensin assay appears to be a reliable test, but followup evaluation is needed to estimate longer term performance of the test. The authors believe that alpha-defensin has demonstrated itself to be sufficiently robust that PJI diagnostic criteria now should include this test. Future studies are needed to compare the differences among the diagnostic capability of the available tests, in particular when metallosis is present, because metallosis may predispose the test to a false-positive result. LEVEL OF EVIDENCE Level I, diagnostic study.
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Grammatopoulos G, Munemoto M, Inagaki Y, Tanaka Y, Athanasou NA. The Diagnosis of Infection in Metal-on-Metal Hip Arthroplasties. J Arthroplasty 2016; 31:2569-2573. [PMID: 27235328 DOI: 10.1016/j.arth.2016.03.064] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/15/2016] [Accepted: 03/29/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Distinction of aseptic from septic hip arthroplasty failure can be challenging. Some studies report an increased incidence of septic failure with metal-on-metal (MoM) hip arthroplasties. The Musculoskeletal Infection Society (MSIS) have formulated criteria to facilitate the diagnosis of periprosthetic joint infection (PJI). In this study, we determined the prevalence and histologic features of septic MoM hip failure. METHODS Overall, 104 cases of failed MoM hip arthroplasty, classified as septic or aseptic by MSIS microbiological criteria, were analyzed. The overall prevalence of septic failure was determined and the nature of the causative organisms noted. The extent of the neutrophil polymorph (NP) infiltrate in periprosthetic tissue in all cases was analyzed by hematoxylin-eosin and chloroacetate esterase staining. RESULTS The prevalence of septic MoM hip arthroplasty failure was 6.7%. Infective organisms were coagulase-negative Staphylococcus in 4 cases; Staphylococcus aureus, Streptococcus, and Propionibacterium species were isolated in the remaining cases. Chloroacetate esterase staining facilitated identification of NPs. All cases of PJI contained more than 5 NPs per high-power field (HPF) on average. Four cases of aseptic MoM implant failure contained scanty or scattered NPs (less than 5 per HPF on average). CONCLUSION The prevalence of PJI as a cause of MoM hip arthroplasty failure was relatively high compared to other hip bearing combinations; however, the organisms responsible were similar. Histologically, a minority of aseptic MoM implant failures contained some NPs, but the MSIS criteria for the histologic diagnosis of PJI (>5 NPs/HPF) correctly identified all microbiologically confirmed cases of septic failure.
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Affiliation(s)
- George Grammatopoulos
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal and Clinical Laboratory Services (NDORMS), University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Mitsuru Munemoto
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal and Clinical Laboratory Services (NDORMS), University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Yusuke Inagaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal and Clinical Laboratory Services (NDORMS), University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Nicholas A Athanasou
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal and Clinical Laboratory Services (NDORMS), University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
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Frangiamore SJ, Siqueira MBP, Saleh A, Daly T, Higuera CA, Barsoum WK. Synovial Cytokines and the MSIS Criteria Are Not Useful for Determining Infection Resolution After Periprosthetic Joint Infection Explantation. Clin Orthop Relat Res 2016; 474:1630-9. [PMID: 26821163 PMCID: PMC4887354 DOI: 10.1007/s11999-016-4710-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Diagnosing periprosthetic joint infection (PJI) requires a combination of clinical and laboratory parameters, which may be expensive and difficult to interpret. Synovial fluid cytokines have been shown to accurately differentiate septic from aseptic failed total knee (TKA) and hip (THA) arthroplasties. However, after first-stage explantation, there is still no reliable test to rule out PJI before a second-stage reimplantation procedure. QUESTIONS/PURPOSES (1) Which synovial fluid cytokines have the highest diagnostic accuracy for PJI? (2) Which cytokine shows the greatest decrease associated with the resolution of infection in the same patient between explantation and subsequent reimplantation of an infected arthroplasty? (3) What is the accuracy of synovial fluid cytokines and the Musculoskeletal Infection Society (MSIS) criteria to rule out PJI after first-stage explantation? (4) What are the most studied synovial fluid cytokines for diagnosing PJI as reported in the literature and what are their cumulative diagnostic accuracy? METHODS Between May 2013 and March 2014, 104 patients with painful THA and TKA evaluated for possible PJI were included in our study. Of these, 90 (87%) had cytokine levels measured from synovial fluid samples collected as part of this prospective study (n = 33 hips, n = 57 knees). A second group of 35 patients (n = 36 samples) who presented during the same time period with an antibiotic spacer also had synovial cytokines measured before second-stage reimplantation. For the first group of 90 patients, the MSIS definition classified each joint at the time of surgery as infected (n = 31) or not infected (n = 59) and was used as the standard to test the accuracy in diagnosing PJI. Of the 35 patients with synovial marker data before second-stage surgery, 15 patients had cytokine measurements both at explantation and reimplantation and were used to quantify the change between stages. The reimplantation group had a minimum 1-year followup (with four [11%] patients lost to followup) and was classified into successful or failed treatment based on Delphi-based consensus data and was used to test the accuracy in detecting infection resolution at reimplantation. RESULTS Interleukin (IL)-1β and interferon-γ demonstrated the highest diagnostic utility (area under the curve 0.92, 0.91, respectively); IL-1β and IL-6 had the highest sensitivities (0.90 [95% confidence interval {CI}, 0.74-0.98] and 0.81 [0.63-0.93]). As a measure of infection resolution, IL-1β had the greatest decrease (12.4-fold; level at explantation: 232.4 [range, 23.1-1545.7]; level at reimplantation: 18.8 (range 1.2-298.9); mean difference: 325.5 [95% CI, 65.0-596.0]; p = 0.0001), and IL-6 had a nearly similar decrease (11.2-fold; level at explantation: 228.1 [range, 10,158.4-182,725.0]; level at reimplantation: 2518.2 [range, 10.4-41,319.3]; mean difference: 33,176.0 [95% CI, 7543.6-58,808.3]; p < 0.0001). Cytokines and MSIS criteria had low sensitivity to rule out infection in a joint treated for PJI. CONCLUSIONS IL-6 and IL-1β demonstrated high sensitivities to diagnose PJI and showed the greatest decrease between first and second stages, which may potentially be used to monitor treatment response to PJI. However, cytokines and MSIS criteria had low sensitivity to rule out infection before reimplantation. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Salvatore J Frangiamore
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue/A41, Cleveland, OH, 44195, USA
| | - Marcelo B P Siqueira
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue/A41, Cleveland, OH, 44195, USA
| | - Anas Saleh
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue/A41, Cleveland, OH, 44195, USA
| | - Thomas Daly
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue/A41, Cleveland, OH, 44195, USA
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue/A41, Cleveland, OH, 44195, USA.
| | - Wael K Barsoum
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue/A41, Cleveland, OH, 44195, USA
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Lenski M, Scherer MA. Diagnostic potential of inflammatory markers in septic arthritis and periprosthetic joint infections: a clinical study with 719 patients. Infect Dis (Lond) 2015; 47:399-409. [DOI: 10.3109/00365548.2015.1006674] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Yi PH, Cross MB, Moric M, Levine BR, Sporer SM, Paprosky WG, Jacobs JJ, Della Valle CJ. Do serologic and synovial tests help diagnose infection in revision hip arthroplasty with metal-on-metal bearings or corrosion? Clin Orthop Relat Res 2015; 473:498-505. [PMID: 25171935 PMCID: PMC4294906 DOI: 10.1007/s11999-014-3902-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The diagnosis of periprosthetic joint infection (PJI) in patients with failed metal-on-metal (MoM) bearings and corrosion reactions in hip arthroplasties can be particularly difficult, because the clinical presentation of adverse local tissue reactions may mimic that of PJI, because it can also occur concurrently with PJI, and because common laboratory tests used to diagnose PJI may be elevated in patients with MoM THAs. QUESTIONS/PURPOSES We sought to determine the test properties of the serum erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), synovial fluid white blood cell (WBC) count, and synovial fluid differential (percent polymorphonuclear cells [PMNs]) in diagnosing PJI in either MoM hips undergoing revision for a variety of indications or in non-MoM hips undergoing revision for either corrosion reaction or full-thickness wear. Additionally, we sought to describe how MoM bearings, metal debris, and corrosion reactions can confound the analysis of the synovial fluid WBC count and affect its diagnostic use for PJI. METHODS We reviewed 150 revision hips meeting specified inclusion criteria (92 MoM total hips, 19 MoM hip resurfacings, 30 non-MoM bearings with corrosion, and nine full-thickness bearing surface wear with metallosis). In our review, we diagnosed 19 patients as infected using Musculoskeletal Infection Society (MSIS) criteria. Mean laboratory values were compared between infected and not infected patients and receiver operator characteristic curves were generated with an area under the curve (AUC) to determine test performance and optimal cutoffs. RESULTS After excluding the inaccurate synovial fluid samples, the synovial fluid WBC count (performed accurately in 102 patients) was the best test for the diagnosis of PJI (AUC=98%, optimal cutoff 4350 WBC/μL) followed by the differential (performed accurately in 102 patients; AUC=90%, optimal cutoff 85% PMN). The ESR (performed in 131 patients) and CRP (performed in 129 patients) both had good sensitivity (83% and 94%, respectively). Patients meeting MSIS criteria for PJI had higher mean serum ESR, CRP, synovial fluid WBC count, and differential than those not meeting MSIS criteria (p<0.05 for all). An observer blinded to the MSIS diagnosis of the patient assessed the synovial fluid samples for inaccuracy secondary to metal or cellular debris. Synovial fluid sample "inaccuracy" was defined as the laboratory technician noting the presence of metal or amorpous material, fragmented cells, or clots, or the sample having some defect preventing an automated cell count from being performed. Of the 141 patients who had a synovial fluid sample initially available for review, 47 (33%) had a synovial fluid sample deemed to be inaccurate. A synovial fluid WBC count was still reported; however, 35 of these 47 hips (75%) and 11 of these 35 (31%) were falsely positive for infection. CONCLUSIONS The diagnosis of PJI is extremely difficult in patients with MoM bearings or corrosion and the synovial fluid WBC count can frequently be falsely positive and should be relied on only if a manual count is done and if a differential can be performed. A more aggressive approach to preoperative evaluation for PJI is recommended in these patients to allow for careful evaluation of the synovial fluid specimen, the integration of synovial fluid culture results, and repeat aspiration if necessary. LEVEL OF EVIDENCE Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Paul H. Yi
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612 USA
| | | | - Mario Moric
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612 USA
| | - Brett R. Levine
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612 USA
| | - Scott M. Sporer
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612 USA
| | - Wayne G. Paprosky
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612 USA
| | - Joshua J. Jacobs
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612 USA
| | - Craig J. Della Valle
- Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612 USA
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Yuan K, Chen HL, Cui ZM. Diagnostic Accuracy of C-Reactive Protein for Periprosthetic Joint Infection: A Meta-Analysis. Surg Infect (Larchmt) 2014; 15:548-59. [PMID: 24833084 DOI: 10.1089/sur.2013.066] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Kun Yuan
- 1 Department of Orthopedics, Nantong First People's Hospital , Nantong, China
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Chen AF, Parvizi J. Emerging Technologies for the Diagnosis of Periprosthetic Infection. JBJS Rev 2014; 2:01874474-201408000-00001. [DOI: 10.2106/jbjs.rvw.m.00121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Lenski M, Scherer MA. Synovial IL-6 as inflammatory marker in periprosthetic joint infections. J Arthroplasty 2014; 29:1105-9. [PMID: 24559521 DOI: 10.1016/j.arth.2014.01.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 10/09/2013] [Accepted: 01/14/2014] [Indexed: 02/01/2023] Open
Abstract
We analyzed serum and synovial biomarkers of 69 patients. 31 of them suffered from a periprosthetic joint infection (PJI) and 38 from aseptic arthralgia after total joint arthroplasty. We used Receiver-Operating-Characteristic-curves to calculate the Area-under-the-curve (AUC), cutoff-values, positive (+LR), negative (-LR) and interval-Likelihood-Ratios (iLR) for predicting a PJI. The most significant parameter was synovial interleukin-6 (IL-6) (cutoff-value ≥ 30,750 pg/ml, AUC = 0.959, SE = 90.0%, SP = 94.7%, +LR = 17.27), followed by synovial lactate (cutoff-value ≥ 8.3 mmol/l, AUC = 0.844, SE = 71.4%, SP=88.0%, +LR = 5.95), and synovial glucose (cutoff-value ≤ 44 mg/dl, AUC = 0.829, SE = 79.2%, SP = 78.6%, +LR = 3.69). IL-6 ≥ 30,750 pg/ml and lactate ≥ 10 mmol/l make a PJI very likely, IL-6 <10,000pg/ml or lactate <4.3 mmol/l makes a PJI very unlikely. If none of these thresholds are met, physicians should use the iLR of IL-6, glucose and lactate to estimate the likelihood of PJI.
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Affiliation(s)
- Markus Lenski
- Department of Orthopedics and Trauma Surgery, Klinikum Dachau, Academic Teaching Hospital of the Ludwig-Maximilians-University of Munich, 7 Krankenhausstraße 15, 85221 Dachau, Germany; Faculty of Medicine, Technical University of Munich, Munich, Germany
| | - Michael A Scherer
- Department of Orthopedics and Trauma Surgery, Klinikum Dachau, Academic Teaching Hospital of the Ludwig-Maximilians-University of Munich, 7 Krankenhausstraße 15, 85221 Dachau, Germany
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Abstract
Prosthetic joint infection (PJI) is a tremendous burden for individual patients as well as the global health care industry. While a small minority of joint arthroplasties will become infected, appropriate recognition and management are critical to preserve or restore adequate function and prevent excess morbidity. In this review, we describe the reported risk factors for and clinical manifestations of PJI. We discuss the pathogenesis of PJI and the numerous microorganisms that can cause this devastating infection. The recently proposed consensus definitions of PJI and approaches to accurate diagnosis are reviewed in detail. An overview of the treatment and prevention of this challenging condition is provided.
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Affiliation(s)
- Aaron J. Tande
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robin Patel
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Randau TM, Friedrich MJ, Wimmer MD, Reichert B, Kuberra D, Stoffel-Wagner B, Limmer A, Wirtz DC, Gravius S. Interleukin-6 in serum and in synovial fluid enhances the differentiation between periprosthetic joint infection and aseptic loosening. PLoS One 2014; 9:e89045. [PMID: 24586496 PMCID: PMC3931684 DOI: 10.1371/journal.pone.0089045] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/13/2014] [Indexed: 12/20/2022] Open
Abstract
The preoperative differentiation between septic and aseptic loosening after total hip or knee arthroplasty is essential for successful therapy and relies in part on biomarkers. The objective of this study was to assess synovial and serum levels of inflammatory proteins as diagnostic tool for periprosthetic joint infection and compare their accuracy with standard tests. 120 patients presenting with a painful knee or hip endoprosthesis for surgical revision were included in this prospective trial. Blood samples and samples of intraoperatively acquired joint fluid aspirate were collected. White blood cell count, C-reactive protein, procalcitonin and interleukin-6 were determined. The joint aspirate was analyzed for total leukocyte count and IL-6. The definite diagnosis of PJI was determined on the basis of purulent synovial fluid, histopathology and microbiology. IL-6 in serum showed significantly higher values in the PJI group as compared to aseptic loosening and control, with specificity at 58.3% and a sensitivity of 79.5% at a cut-off value of 2.6 pg/ml. With a cut-off >6.6 pg/ml, the specificity increased to 88.3%. IL-6 in joint aspirate had, at a cut-off of >2100 pg/ml, a specificity of 85.7% and sensitivity of 59.4%. At levels >9000 pg/ml, specificity was almost at 100% with sensitivity just below 50%, so PJI could be considered proven with IL-6 levels above this threshold. Our data supports the published results on IL-6 as a biomarker in PJI. In our large prospective cohort of revision arthroplasty patients, the use of IL-6 in synovial fluid appears to be a more accurate marker than either the white blood cell count or the C-reactive protein level in serum for the detection of periprosthetic joint infection. On the basis of the results we recommend the use of the synovial fluid biomarker IL-6 for the diagnosis of periprosthetic joint infection following total hip and knee arthroplasty.
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Affiliation(s)
- Thomas M. Randau
- University Clinic of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Max J. Friedrich
- University Clinic of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Matthias D. Wimmer
- University Clinic of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Ben Reichert
- University Clinic of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Dominik Kuberra
- University Clinic of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Birgit Stoffel-Wagner
- University Clinic of Bonn, Institute for Clinical Chemistry and Clinical Pharmacology, Bonn, Germany
| | - Andreas Limmer
- University Clinic of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Dieter C. Wirtz
- University Clinic of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
| | - Sascha Gravius
- University Clinic of Bonn, Department of Orthopedics and Trauma Surgery, Bonn, Germany
- * E-mail:
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Qu X, Zhai Z, Liu X, Li H, Wu C, Li Y, Li H, Zhu Z, Qin A, Dai K. Evaluation of white cell count and differential in synovial fluid for diagnosing infections after total hip or knee arthroplasty. PLoS One 2014; 9:e84751. [PMID: 24416276 PMCID: PMC3885622 DOI: 10.1371/journal.pone.0084751] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 11/19/2013] [Indexed: 02/05/2023] Open
Abstract
Background The accuracy of synovial fluid (SF) white cell count (WCC) and polymorphonuclear (PMN) cell evaluation for predicting prosthetic joint infection (PJI) at the total hip arthroplasty (THA) or total knee arthroplasty (TKA) site is unknown. Therefore, we performed a meta-analysis to summarize the diagnostic validity of SF-WCC and SF-PMN for diagnosing PJI. Methods The MEDLINE, EMBASE, and OVID databases were searched for studies that had evaluated the diagnostic validity of SF-WCC and SF-PMN between January 1990 and May 2013. Meta-analysis methods were used to pool sensitivity, specificity, diagnostic odd ratios (DORs), the area under the receiver-operating characteristic curve (AUC), positive likelihood ratios (PLR), negative likelihood ratios (NLR), and post-test probability. We also conducted heterogeneity, publication bias, subgroup, and meta-regression analyses. Results Fifteen articles (15 SF-WCC and 14 SF-PMN) that included a total of 2787 patients fulfilled the inclusion criteria and were considered for analysis. The pooled sensitivity and specificity for PJI detection was 0.88 (95% confidence intervals [CI], 0.81–0.93) and 0.93 (95% CI, 0.88–0.96) for SF-WCC and 0.90 (95% CI, 0.84–0.93) and 0.88 (95% CI, 0.83–0.92) for SF-PMN, respectively. The AUC was 0.96 for SF-WCC and 0.95 for SF-PMN. PLR and NLR were 13.3 and 0.13 for SF-WCC, and 7.6 and 0.12 for SF-PMN, respectively. There was no evidence of publication bias. Low-clinical-scenario (pre-test probability, 20%) post-test probabilities were 3% for both negative SF-WCC and SF-PMN results. The subgroup analyses indicated that the sensitivity/specificity of THA were 0.73/0.96 for SF-WCC and 0.85/0.83 for SF-PMN, whereas those of TKA were 0.90/0.91 for SF-WCC and 0.90/0.88 for SF-PMN. We also found that collection of SF-WCC preoperatively had a higher sensitivity than that obtained intraoperatively (0.91 vs. 0.77). Conclusions SF-WCC and SF-PMN have an adequate and clinically acceptable diagnostic value for detecting PJI, particularly after TKA.
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Affiliation(s)
- Xinhua Qu
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedic Implant, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zanjing Zhai
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedic Implant, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xuqiang Liu
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedic Implant, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haowei Li
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedic Implant, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chuanlong Wu
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedic Implant, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yang Li
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedic Implant, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Huiwu Li
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedic Implant, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhenan Zhu
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedic Implant, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - An Qin
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedic Implant, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Kerong Dai
- Department of Orthopedics, Shanghai Key Laboratory of Orthopedic Implant, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Gollwitzer H, Dombrowski Y, Prodinger PM, Peric M, Summer B, Hapfelmeier A, Saldamli B, Pankow F, von Eisenhart-Rothe R, Imhoff AB, Schauber J, Thomas P, Burgkart R, Banke IJ. Antimicrobial peptides and proinflammatory cytokines in periprosthetic joint infection. J Bone Joint Surg Am 2013; 95:644-51. [PMID: 23553300 DOI: 10.2106/jbjs.l.00205] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Differentiation between septic and aseptic loosening of joint replacements is essential for successful revision surgery, but reliable markers for the diagnosis of low-grade infection are lacking. The present study was performed to assess intra-articular and systemic levels of antimicrobial peptides and proinflammatory cytokines as diagnostic markers for periprosthetic joint infection. METHODS Fifteen consecutive patients with staphylococcal periprosthetic joint infections and twenty control patients with aseptic loosening of total hip and knee replacements were included in this prospective, single-center, controlled clinical trial. Expression of the antimicrobial peptides human β-defensin-2 (HBD-2), human β-defensin-3 (HBD-3), and cathelicidin LL-37 (LL-37) was determined by ELISA (enzyme-linked immunosorbent assay) in serum and joint aspirates. Proinflammatory cytokines were assessed in serum and joint aspirates with use of cytometric bead arrays. C-reactive protein in serum, microbiology, and histopathology of periprosthetic tissue served as the "gold standard" for the diagnosis of infection. RESULTS The antimicrobial peptides HBD-3 and LL-37 were significantly elevated in joint aspirates from patients with periprosthetic joint infection compared with patients with aseptic loosening, and the area under the curve (AUC) in a receiver operating characteristic curve analysis was equal to 0.745 and 0.875, respectively. Additionally, significant local increases in the proinflammatory cytokines interleukin (IL)-1β, IL-4, IL-6, IL-17A, interferon (IFN)-γ, and tumor necrosis factor (TNF)-α were observed to be associated with infection. Logistic regression analysis indicated that the combination of an antimicrobial peptide with another synovial fluid biomarker improved diagnostic accuracy; the AUC value was 0.916 for LL-37 and IL-4, 0.895 for LL-37 and IL-6, 0.972 for HBD-3 and IL-4, and 0.849 for HBD-3 and IL-6. In contrast, the only antimicrobial peptides and cytokines in serum that showed a significant systemic increase in association with infection were HBD-2, IL-4, and IL-6 (all of which had an AUC value of <0.75). CONCLUSIONS The present study showed promising results for the use of antimicrobial peptides and other biomarkers in synovial fluid for the diagnosis of periprosthetic joint infection, and analysis of the levels in synovial fluid was more accurate than analysis of serum.
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Affiliation(s)
- Hans Gollwitzer
- Clinic of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straβe 22, 81675 München, Germany.
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Abstract
STUDY DESIGN A prospective microbiological analysis of intervertebral disk material in surgically treated patients presenting lumbar disk degeneration. OBJECTIVE To determine the prevalence and species of bacteria in degenerated lumbar disks, their eventual role in the pathophysiology, and the possible influence of risk factors. SUMMARY OF BACKGROUND DATA Intervertebral disk degeneration results from biochemical, mechanical, genetic, and toxic factors. The hypothesis of low-grade infection has been raised but not elucidated to date. METHODS Eighty-three patients (34 males, 49 females, 41 y) were treated by lumbar disk replacement at L3-L4, L4-L5, or L5-S1. An intraoperative biopsy and microbiological culture were performed for each disk to determine if intradiskal bacteria were present. Magnetic resonance stages were Pfirrmann IV or V, with Modic I in 32, and Modic II in 25 cases. A preoperative discography was performed in 49 patients, 24 had previous nucleotomy. RESULTS Bacteria were found in 40 disks, 43 cultures were sterile. The following bacteria were evidenced: Propionibacterium acnes 18, coagulase-negative staphylococci 16, gram-negative bacilli 3, Micrococcus 3, Corynebacterium 3, others 5. Ten biopsies presented 2 different species. Multinucleated cells were evidenced histologically in 33% of positive biopsies. Bacteria were predominantly found in males (P=0.012). The mostly positive level was L4-L5 (P=0.075). There was no significant relationship between bacterial evidence and Modic sign. A preoperative discography or previous nucleotomy did not represent significant contamination sources. None of the patients presented infectious symptoms. CONCLUSIONS Although the hypothesis of biopsy contamination cannot be excluded, intradiskal bacteria might play a role in the pathophysiology of disk degeneration. However, the histologic presence of multinucleated cells may indicate an inflammatory process that could sustain the hypothesis of low-grade spondylodiscitis at 1 stage of the cascade of lumbar disk degeneration. These microbiological and histologic findings would need to be compared with nondegenerated disks. LEVEL OF EVIDENCE : Diagnostic level III.
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