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Vale JS, Castelo FS, Barros BS, Ribau AC, Carvalho AD, Sousa RJG. Synovial Fluid Biomarkers for the Diagnosis of Periprosthetic Joint Infection-A Systematic Review and Meta-Analysis of Their Diagnostic Accuracy According to Different Definitions. J Arthroplasty 2023; 38:2731-2738.e3. [PMID: 37321521 DOI: 10.1016/j.arth.2023.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Different synovial fluid biomarkers have emerged to improve periprosthetic joint infection (PJI) diagnosis. The goals of this paper were (i) to assess their diagnostic accuracy and (ii) to evaluate their performance according to different PJI definitions. METHODS A systematic review and meta-analysis was performed using studies that reported diagnostic accuracy of synovial fluid biomarkers using validated PJI definitions published from 2010 to March 2022. A database search was performed through PubMed, Ovid MEDLINE, Central, and Embase. The search identified 43 different biomarkers with four being the more commonly studied, with 75 papers overall: alpha-defensin; leukocyte esterase; synovial fluid C-reactive protein; and calprotectin. RESULTS Overall accuracy was higher for calprotectin, followed by alpha-defensin, leukocyte esterase, and synovial fluid C-reactive protein with sensitivities of 78 to 92% and specificities of 90 to 95%. Their diagnostic performance was different according to which definition was adopted as the reference. Specificity was consistently high across definitions for all four biomarkers. Sensitivity varied the most with lower values for the more sensitive European Bone and Joint Infection Society or Infectious Diseases Society of America definitions with higher values for the Musculoskeletal Infection Society definition. The International Consensus Meeting 2018 definition showed intermediate values. CONCLUSION All evaluated biomarkers had good specificity and sensitivity, making their use acceptable in the diagnosis of PJI. Biomarkers perform differently according to the selected PJI definitions.
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Affiliation(s)
- João S Vale
- Department of Orthopedics, Centro Hospitalar Universitário Santo António, Porto, Portugal
| | - Filipe S Castelo
- Department of Orthopedics, Centro Hospitalar Cova da Beira, Covilhã, Portugal
| | - Bianca S Barros
- Department of Orthopedics, Centro Hospitalar Universitário Santo António, Porto, Portugal
| | - Ana C Ribau
- Department of Orthopedics, Centro Hospitalar Universitário Santo António, Porto, Portugal
| | - André D Carvalho
- Department of Orthopedics, Centro Hospitalar Universitário Santo António, Porto, Portugal
| | - Ricardo J G Sousa
- Department of Orthopedics, Centro Hospitalar Universitário Santo António, Porto, Portugal; Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário Santo António, CUF - Hospitais e Clínicas, Lisbon, Portugal
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Tripathi S, Tarabichi S, Parvizi J, Rajgopal A. Current relevance of biomarkers in diagnosis of periprosthetic joint infection: an update. ARTHROPLASTY 2023; 5:41. [PMID: 37525262 PMCID: PMC10391917 DOI: 10.1186/s42836-023-00192-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/03/2023] [Indexed: 08/02/2023] Open
Abstract
With a significant rise in the number of arthroplasty procedures performed worldwide, the increasing revision burden posed by periprosthetic joint infection (PJI) is a matter of growing concern. In spite of various attempts to diagnose PJI, there are no defined tests that can be called a gold standard. Given the importance of early diagnosis in PJI, newer tests and biomarkers have been introduced to improve cumulative diagnostic accuracy. Novel biomarkers like calprotectin, lipocalcin, monocyte-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and platelet-to-mean platelet volume ratio have demonstrated a potential as diagnostic biomarkers for PJI. This article discusses the relevance of available and newly described diagnostic biomarkers to provide a perspective on the practical applicability in current medical practice, as well as highlights some recent advances in biomarkers for the diagnosis of PJI.
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Affiliation(s)
- Saksham Tripathi
- Institute of Musculoskeletal Disorders and Orthopaedics, Medanta-The Medicity, Gurugram, HR, 122001, India.
| | - Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | - Ashok Rajgopal
- Institute of Musculoskeletal Disorders and Orthopaedics, Medanta-The Medicity, Gurugram, HR, 122001, India
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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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Masters TL, Bhagwate AV, Dehankar MK, Greenwood-Quaintance KE, Abdel MP, Mandrekar JN, Patel R. Human transcriptomic response to periprosthetic joint infection. Gene 2022; 825:146400. [PMID: 35306116 DOI: 10.1016/j.gene.2022.146400] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/17/2021] [Accepted: 03/04/2022] [Indexed: 11/17/2022]
Abstract
Periprosthetic joint infection (PJI), a devastating complication of total joint replacement, is of incompletely understood pathogenesis and may sometimes be challenging to clinically distinguish from other causes of arthroplasty failure. We characterized human gene expression in 93 specimens derived from surfaces of resected arthroplasties, comparing transcriptomes of subjects with infection- versus non-infection-associated arthroplasty failure. Differential gene expression analysis confirmed 28 previously reported potential biomarkers of PJI, including bactericidal/permeability increasing protein (BPI), cathelicidin antimicrobial peptide (CAMP), C-C-motif chemokine ligand 3 (CCL3), 4(CCL4) and C-X-C-motif chemokine ligand 2 (CXCL2), colony stimulating factor 2 receptor beta (CSF2RB), colony stimulating factor 3 (CSF3), alpha-defensin (DEFA4), Fc fragment of IgG receptor 1B (CD64B), intercellular adhesion molecule 1 (ICAM1), interferon gamma (IFNG), interleukin 13 receptor subunit alpha 2 (IL13RA2), interleukin 17D (IL17D), interleukin 1 (IL1A, IL1B, IL1RN), interleukin 2 receptors (IL2RA, IL2RG), interleukin 5 receptor (IL5RA), interleukin 6 (IL6), interleukin 8 (IL8), lipopolysaccharide binding protein (LBP), lipocalin (LCN2), lactate dehydrogenase C (LDHC), lactotransferrin (LTF), matrix metallopeptidase 3 (MMP3), peptidase inhibitor 3 (PI3), and vascular endothelial growth factor A (VEGFA), and identified three novel molecules of potential diagnostic use for detection of PJI, namely C-C-motif chemokine ligand CCL20, coagulation factor VII (F7), and B cell receptor FCRL4. Comparative analysis of infections caused by staphylococci versus bacteria other than staphylococci and Staphylococcus aureus versus Staphylococcus epidermidis showed elevated expression of interleukin 13 (IL13), IL17D, and MMP3 in staphylococcal infections, and of IL1B, IL8, and platelet factor PF4V1 in S. aureus compared to S. epidermidis infections. Pathway analysis of over-represented genes suggested activation of host immune response and cellular maintenance and repair functions in response to invasion of infectious agents. The data presented provides new potential targets for diagnosis of PJI and for differentiation of PJI caused by different infectious agents.
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Affiliation(s)
- Thao L Masters
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Aditya V Bhagwate
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Mrunal K Dehankar
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Kerryl E Greenwood-Quaintance
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jay N Mandrekar
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, United States.
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Synovial Complement Factors in Patients with Periprosthetic Joint Infection after Undergoing Revision Arthroplasty of the Hip or Knee Joint. Diagnostics (Basel) 2021; 11:diagnostics11030434. [PMID: 33806309 PMCID: PMC8002017 DOI: 10.3390/diagnostics11030434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 11/16/2022] Open
Abstract
The role and diagnostic value of the synovial complement system in patients with low-grade periprosthetic joint infection (PJI) are unclear. We sought to evaluate, for the first time, the usefulness of synovial complement factors in these patients by measuring the individual synovial fluid levels of complement factors (C1q, C3b/iC3b, C4b, C5, C5a, C9, factor B, factor D, factor H, factor I, properdin, and mannose-binding lectin [MBL]). The patients (n = 74) were classified into septic (n = 28) and aseptic (n = 46). Receiver-operator characteristic curves and a multiple regression model to determine the feasibility of a combination of the tested cytokines to determine the infection status were calculated. The synovial fluid levels of C1q, C3b/C3i, C4b, C5, C5a, MBL, and properdin were significantly elevated in the PJI group. The best sensitivity and specificity was found for C1q. The multiple regression models revealed that the combination of C1q, C3b/C3i, C4b, C5, C5a, and MBL was associated with the best sensitivity (83.3%) and specificity (79.2%) for a cutoff value of 0.62 (likelihood ratio: 4.0; area under the curve: 0.853). Nevertheless, only a combined model showed acceptable results. The expression patterns of the complement factors suggested that PJI activates all three pathways of the complement system.
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Deirmengian C, Madigan J, Kallur Mallikarjuna S, Conway J, Higuera C, Patel R. Validation of the Alpha Defensin Lateral Flow Test for Periprosthetic Joint Infection. J Bone Joint Surg Am 2021; 103:115-122. [PMID: 33165130 DOI: 10.2106/jbjs.20.00749] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The synovial fluid test for alpha defensin has been reported to have an excellent performance in diagnosing periprosthetic joint infection (PJI). The purpose of this study was to evaluate the performance of the lateral flow test for synovial fluid alpha defensin by using the methods of a formal diagnostic accuracy study and to compare its performance with that of the laboratory-based alpha defensin test for PJI. METHODS We conducted a diagnostic accuracy study of the index lateral flow immunoassay for synovial fluid alpha defensin relative to the reference 2013 Musculoskeletal Infection Society (MSIS) multicriteria definition of PJI. The study included a prospective multicenter cohort of outpatients with a failed hip or knee arthroplasty and a supplemental control cohort of fresh synovial fluid specimens submitted by physicians for diagnostic PJI testing. RESULTS Among 57 patients with PJI and 248 patients without PJI in the overall prospective patient cohort, the sensitivity and specificity of the alpha defensin lateral flow test were 89.5% (95% confidence interval [CI]: 78.5% to 96.0%) and 94.8% (95% CI: 91.2% to 97.2%), respectively. The sensitivity increased to 94.3% (95% CI: 84.3% to 98.8%) after exclusion of 17 patients with grossly bloody aspirates (>1 million red blood cells/µL). Among the supplemental control cohort of fresh synovial fluid samples, including 65 samples from patients with PJI and 397 from patients without PJI, the sensitivity and specificity of the alpha defensin lateral flow test were 98.5% (95% CI: 91.7% to 100.0%) and 98.2% (95% CI: 96.4% to 99.3%), respectively. A comparison of the sensitivity and specificity of the alpha defensin lateral flow test with those of the alpha defensin enzyme-linked immunosorbent assay (ELISA) in the combined cohort did not demonstrate a significant difference in sensitivity (94.3% [95% CI: 88.5% to 97.7%] compared with 93.0% [95% CI: 87.1% to 96.7%]) or specificity (96.9% [95% CI: 95.3% to 98.1%] compared with 97.8% [95% CI: 96.4% to 98.8%]) (both p > 0.05). CONCLUSIONS The results of this study demonstrate the solid diagnostic performance of the alpha defensin test and have resulted in the U.S. Food and Drug Administration (FDA) authorization of the lateral-flow test with an intended use as an aid in the clinical diagnosis of PJI. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Carl Deirmengian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania.,CD Diagnostics, Zimmer Biomet, Claymont, Delaware
| | - John Madigan
- CD Diagnostics, Zimmer Biomet, Claymont, Delaware
| | | | - Janet Conway
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Carlos Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, and Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Mihalič R, Zdovc J, Brumat P, Trebše R. Synovial fluid interleukin-6 is not superior to cell count and differential in the detection of periprosthetic joint infection. Bone Jt Open 2020; 1:737-742. [PMID: 33367280 PMCID: PMC7750741 DOI: 10.1302/2633-1462.112.bjo-2020-0166.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Aims Synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells (%PMN) are elevated at periprosthetic joint infection (PJI). Leucocytes produce different interleukins (IL), including IL-6, so we hypothesized that synovial fluid IL-6 could be a more accurate predictor of PJI than synovial fluid WBC count and %PMN. The main aim of our study was to compare the predictive performance of all three diagnostic tests in the detection of PJI. Methods Patients undergoing total hip or knee revision surgery were included. In the perioperative assessment phase, synovial fluid WBC count, %PMN, and IL-6 concentration were measured. Patients were labeled as positive or negative according to the predefined cut-off values for IL-6 and WBC count with %PMN. Intraoperative samples for microbiological and histopathological analysis were obtained. PJI was defined as the presence of sinus tract, inflammation in histopathological samples, and growth of the same microorganism in a minimum of two or more samples out of at least four taken. Results In total, 49 joints in 48 patients (mean age 68 years (SD 10; 26 females (54%), 25 knees (51%)) were included. Of these 11 joints (22%) were infected. The synovial fluid WBC count and %PMN predicted PJI with sensitivity, specificity, accuracy, PPV, and NPV of 82%, 97%, 94%, 90%, and 95%, respectively. Synovial fluid IL-6 predicted PJI with sensitivity, specificity, accuracy, PPV, and NPV of 73%, 95%, 90%, 80%, and 92%, respectively. A comparison of predictive performance indicated a strong agreement between tests. Conclusions Synovial fluid IL-6 is not superior to synovial fluid WBC count and %PMN in detecting PJI. Level of Evidence: Therapeutic Level II Cite this article: Bone Jt Open 2020;1-12:737–742.
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Affiliation(s)
- René Mihalič
- Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
| | - Jurij Zdovc
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Brumat
- Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
| | - Rihard Trebše
- Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Analysis of synovial biomarkers with a multiplex protein microarray in patients with PJI undergoing revision arthroplasty of the hip or knee joint. Arch Orthop Trauma Surg 2020; 140:1883-1890. [PMID: 32133538 DOI: 10.1007/s00402-020-03388-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Diagnosing a (low-grade) periprosthetic joint infection (PJI) after hip or knee arthroplasty remains a diagnostic challenge. The aim of this study was to evaluate the utility of using a novel multiplex protein microarray system for synovial biomarkers in determining PJI in patients undergoing revision knee or hip arthroplasty. MATERIALS AND METHODS The individual synovial fluid levels of 12 cytokines (IL-1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, IL-17, GM-CSF, TNF-α, and INF-γ) were analysed with a novel multiplex protein microarray system in 32 patients undergoing revision hip (n = 22) or knee (n = 10) arthroplasty. Cases were classified into septic and aseptic groups on basis of pre- and interoperative findings: [PJI (n = 14) vs. non-PJI (n = 18)]. Receiver operator characteristic (ROC) curves were calculated to assess the discriminatory strength of the individual parameters. A multiple regression model was used to determine the utility of using a combination of the tested cytokines to determine the infection status. RESULTS The levels of all of the evaluated cytokines were significantly elevated in the PJI-group. Best sensitivity and specificity were found for IL-6, followed by IL-1b, IL-10, and IL-17. The multiple regression models revealed a combination of IL-2, IL-4, IL-5, IL6, lL-12, and GM-CSF to be associated with the best sensitivity (100%) and specificity (88.9%) for a cut-off value of 0.41, with a likelihood ratio of 9.0. CONCLUSION Analysis of individual synovial fluid cytokine levels showed both high sensitivity and high specificity in diagnosing PJI. A combined model using several cytokines showed even higher sensitivity and specificity in diagnosing PJI and could thus be a useful predictive tool to determine the probability of PJI in patients with a painful prosthesis. LEVEL OF EVIDENCE Diagnostic IV.
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Swarup I, LaValva S, Shah R, Sankar WN. Septic Arthritis of the Hip in Children: A Critical Analysis Review. JBJS Rev 2020; 8:e0103. [PMID: 32224630 DOI: 10.2106/jbjs.rvw.19.00103] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Septic arthritis of the hip is a common and potentially devastating condition in children. Septic arthritis is most commonly caused by Staphylococcus aureus, but other pathogens should be considered on the basis of patient age and presence of risk factors. Diagnosis of septic arthritis is based on history and physical examination, laboratory tests, radiographs, ultrasound, and arthrocentesis. Treatment comprises empiric antibiotics and joint debridement, and antibiotics are subsequently tailored on the basis of culture data, local resistance patterns, and clinical response. Late sequelae of septic arthritis include osteonecrosis, chondrolysis, growth disturbance, subluxation or dislocation, and progressive ankylosis. Surgical treatments to address these issues have been described.
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Affiliation(s)
- Ishaan Swarup
- UCSF Benioff Children's Hospital, Oakland, California
| | - Scott LaValva
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ronit Shah
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Ding BT, Tan KG, Kau CY, Chan HYH, Mohd Fadil MFB. Accuracy of the α-defensin lateral flow assay for diagnosing periprosthetic joint infection in Asians. J Orthop Surg (Hong Kong) 2020; 27:2309499019828459. [PMID: 30744473 DOI: 10.1177/2309499019828459] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE This study aimed to test the accuracy of the Synovasure®, α-defensin lateral flow test kit, in diagnosing periprosthetic joint infections (PJIs) in a predominantly Asian population and to evaluate whether other patient or disease factors may affect its results. METHODS 61 Asian patients comprising 70 hip or knee prosthetic joints, performed between November 2015 and November 2018, were retrospectively evaluated. Cases were categorized as infected or not infected using Musculoskeletal Infection Society (MSIS) Criteria. Synovial fluid was tested for α-defensin using a commercially available kit. . RESULTS The Synovasure test had a sensitivity of 73.7% (95% confidence interval (CI): 48.8-90.9%) and specificity of 92.2% (95% CI: 81.1-97.8%) in an Asian population, which was slightly lower compared to previously reported studies in a predominantly Caucasian population. The positive predictive value was 77.8% (95% CI: 56.8-90.3%) and the negative predictive value was 90.4% (95% CI: 81.5-95.2%). The test had an area under curve (AUC) of the receiver operating characteristic (ROC) graph of 0.938, which represents an accuracy that is similar to synovial white blood cells (WBCs) and almost equivalent to that of synovial polymorphonuclear cells (PMNs). The presence of diabetes ( p = 0.26), systemic inflammatory joint disease ( p = 0.33), other metallic implants ( p = 0.53), immunosuppression ( p = 0.13), prior antibiotic usage ( p = 0.99), and chronicity of symptoms ( p = 0.34) was not significantly associated with a positive test in patients with PJI. CONCLUSION The α-defensin lateral flow test kit is highly accurate in the diagnosis of PJI but with slightly lower sensitivity and specificity in an Asian population when compared with previous studies. The test should be used in conjunction with other MSIS criteria to provide clinically relevant and meaningful results for the diagnosis of PJI.
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Affiliation(s)
- Benjamin Tk Ding
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Chung Yuan Kau
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
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Han X, Xie K, Jiang X, Wang L, Wu H, Qu X, Yan M. Synovial fluid α-defensin in the diagnosis of periprosthetic joint infection: the lateral flow test is an effective intraoperative detection method. J Orthop Surg Res 2019; 14:274. [PMID: 31455372 PMCID: PMC6712677 DOI: 10.1186/s13018-019-1320-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 08/16/2019] [Indexed: 12/29/2022] Open
Abstract
Background Synovial fluid α-defensin is a valuable biomarker for periprosthetic joint infection (PJI). Its diagnostic value for PJI has been widely evaluated recently, but results are inconsistent, especially for different test methods. The objective of this study was to evaluate the diagnostic value of laboratory-based immunoassay and lateral flow testing for the detection of α-defensin against hip and knee PJI. Methods We systematically searched MEDLINE and EMBASE for articles on the diagnostic accuracy of α-defensin for PJI published up to September 2018. The pooled sensitivity, specificity, area under the curve (AUC), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were calculated for the evaluation of the diagnostic value of α-defensin for PJI. Results Nineteen studies were included. Eleven evaluated laboratory-based immunoassay, and 10 evaluated the lateral flow test results. The pooled sensitivity, specificity, AUC, PLR, NLR, and DOR of laboratory-based immunoassays were 0.96 (95% confidence interval [CI] 0.90–0.98), 0.97 (95% CI 0.95–0.99), 0.99 (95% CI 0.98–1.00), 35.0 (95% CI 18.5–66.2), 0.04 (95% CI 0.02–0.11), and 811 (95% CI 220–2990), respectively. The pooled sensitivity, specificity, AUC, PLR, NLR, and DOR of the lateral flow test were 0.86 (95% CI 0.81–0.91), 0.96 (95% CI 0.93–0.98), 0.95 (95% CI 0.93–0.97), 21.2 (95% CI 11.7–38.5), 0.14 (95% CI 0.10–0.21), and 148 (95% CI 64–343), respectively. Conclusions Laboratory-based immunoassay of α-defensin is highly accurate for the diagnosis of hip and knee PJI. The lateral flow test is less sensitive but still a useful intraoperative detection tool for PJI.
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Affiliation(s)
- Xuequan Han
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Kai Xie
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Xu Jiang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Liao Wang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Haishan Wu
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, 145 Middle Shandong Road, Shanghai, China
| | - Mengning Yan
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, China.
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Majors I, Jagadale VS. Serum interleukin 6 could be a valuable initial diagnostic tool in prosthetic knee joint infections. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:1781-1788. [PMID: 31350652 DOI: 10.1007/s00590-019-02519-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/22/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Accurate preoperative diagnosis of prosthetic joint infection (PJI) in the absence of obvious clinical signs or laboratory findings is challenging. Interleukin 6 (IL-6) has been proposed as an infection marker but supportive data are limited. We studied the diagnostic utility of serum IL-6 in infected total knee arthroplasty (TKA). METHODS A prospective cohort study was done in 52 patients (59 knees) with a painful TKA. The abnormal limits for serum IL-6, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), synovial fluid white cell counts (WBC) and synovial fluid neutrophils (PMN) were determined from receiver operating characteristic curves. An infection was defined as the presence of sinus tract or positive culture > two separate tissue or fluid samples. We utilized Mann-Whitney test, Spearman's correlation and Fischer's exact test to determine the sensitivity, specificity, positive predictive value, negative predictive value (NPV) and accuracy of serum IL-6. RESULTS The optimal threshold concentration of serum IL-6 was 9.14 pg/ml. Independently, this yielded a sensitivity, specificity and NPV of 81%, 63% and 85%, respectively, and when combined with synovial fluid WBC, values were 100%, 90%, 100%, respectively. The sensitivity and specificity of ESR (70%, 63.6%), CRP (66.7%, 66.7%), synovial WBC (66.7%, 81%) and synovial PMN (82.4%, 73.7%) were also calculated. Serum IL-6 levels strongly correlate with all markers in PJI. CONCLUSIONS Serum IL-6 improves the diagnosis of PJI over existing methods, especially when combined with synovial fluid WBC. Its optimal usage is as an excellent screening test to rule out infected total knee arthroplasty. LEVEL OF EVIDENCE Diagnostic Level II.
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Affiliation(s)
- Isaac Majors
- Department of Orthopedic Surgery, Central Arkansas Veterans Healthcare System, University of Arkansas College of Medicine, 4300 West 7th St, Little Rock, AR, 72205, USA
| | - Vivek S Jagadale
- Department of Orthopedic Surgery, Central Arkansas Veterans Healthcare System, University of Arkansas College of Medicine, 4300 West 7th St, Little Rock, AR, 72205, USA.
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13
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Does inflammatory joint diseases affect the accuracy of infection biomarkers in patients with periprosthetic joint infections? A prospective comparative reliability study. J Orthop Sci 2019; 24:286-289. [PMID: 30268355 DOI: 10.1016/j.jos.2018.08.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 07/23/2018] [Accepted: 08/27/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND The diagnosis of periprosthetic joint infections (PJI) in patients with inflammatory joint diseases (IJD) could be challenging. Several tests used for diagnosing PJI may be inaccurate due to baseline inflammatory characteristics of such diseases. We aimed to evaluate the accuracy of several infection biomarkers, in a specific subgroup of patients with PJI and IJD. METHODS From January 2014 to August 2017, patients with resisting pain at the relevant site, following total knee arthroplasty were evaluated prospectively. A total of 38 patients were undergone revision arthroplasty. Patients were categorized in terms of MSIS criteria: Patients with PJI (Group 1, n = 17) and patients without PJI (Group 2, n = 21). Serum ESR, CRP, Procalcitonin, synovial cell count, percentage of neutrophils in synovial fluid, synovial CRP, Lactoferrin, ELA-2, Thiol - Disulphide levels, BPI and the Alpha defensin test results were obtained. The results of two groups were compared and the diagnostic accuracy of each variable was evaluated. RESULTS There were 22 women, 16 men with a mean age of 67.8 ± 6.9 years. The differences were significant in all evaluated biomarkers in terms of PJI (p values of all biomarker were <0.001). Alpha defensin, Lactoferrin, ELA-2, BPI, Procalcitonin and synovial CRP were the most accurate tests with area under curve >0.90. CONCLUSIONS Our results demonstrated that IJD may not affect the accuracy of infection biomarkers in patients with PJI. Alpha defensin test, Lactoferrin, ELA-2, BPI, Procalcitonin and synovial CRP can be used in the diagnosis of PJI in patients with IJD.
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Pecora JR, Lima ALM, Helito CP, Gobbi RG, Demange MK, Camanho GL. PROTOCOL FOR TREATING ACUTE INFECTIONS IN CASES OF TOTAL KNEE ARTHROPLASTY. ACTA ORTOPEDICA BRASILEIRA 2019; 27:27-30. [PMID: 30774525 PMCID: PMC6362700 DOI: 10.1590/1413-785220192701134183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: To retrospectively evaluate the results after applying a protocol for treating acute infections in cases of total knee arthroplasty and to establish factors predictive of success or failure. Methods: Thirty-two patients who were diagnosed with acute infection of the knee following total arthroplasty between 2004 and 2009 were retrospectively evaluated. Infections following arthroplasty were treated in accordance with the protocol for acute infections following arthroscopy recommended at our institution. Results: With application of a treatment protocol for acute infections following total knee arthroplasty, 26 patients (81.2%) had good results and 6 (18.8%) had unsatisfactory results. Statistical analysis showed that the variables correlated with a worse prognosis were age (p = 0.038) and number of surgical debridement procedures performed (p = 0.038). Conclusion: Our treatment routine was effective for infection. Prosthesis revision was performed in 2 cases when the initial surgical debridement failed to control the infection. Nível de Evidência IV, Série de casos.
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15
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Stone WZ, Gray CF, Parvataneni HK, Al-Rashid M, Vlasak RG, Horodyski M, Prieto HA. Clinical Evaluation of Synovial Alpha Defensin and Synovial C-Reactive Protein in the Diagnosis of Periprosthetic Joint Infection. J Bone Joint Surg Am 2018; 100:1184-1190. [PMID: 30020121 DOI: 10.2106/jbjs.17.00556] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Diagnosing periprosthetic joint infection after total joint arthroplasty is often challenging. The alpha defensin test has been recently reported as a promising diagnostic test for periprosthetic joint infection. The goal of this study was to determine the diagnostic accuracy of alpha defensin testing. METHODS One hundred and eighty-three synovial alpha defensin and synovial fluid C-reactive protein (CRP) tests performed in 183 patients undergoing evaluation for periprosthetic joint infection were reviewed. Results were compared with the Musculoskeletal Infection Society (MSIS) criteria for periprosthetic joint infection. RESULTS Alpha defensin tests were performed prior to surgical treatment for infection, and 37 of these patients who had these tests were diagnosed by MSIS criteria as having infections. Among this group, the alpha defensin test had a sensitivity of 81.1% (95% confidence interval [CI], 64.8% to 92.0%) and a specificity of 95.9% (95% CI, 91.3% to 98.5%). There were 6 false-positive results, 4 of which were associated with metallosis. There were 7 false negatives, all of which were associated with either draining sinuses (n = 3) or low-virulence organisms (n = 4). A combined analysis of alpha defensin and synovial fluid CRP tests was performed in which a positive result was represented by a positive alpha defensin test and a positive synovial fluid CRP test (n = 28). Among this group, the sensitivity was calculated to be 73.0% (95% CI, 55.9% to 86.2%) and the specificity was calculated to be 99.3% (95% CI, 96.2% to 99.9%). An additional combined analysis was performed where a positive result was represented by a positive alpha defensin test or positive synovial fluid CRP test (n = 64). Among this group, the sensitivity was calculated to be 91.9% (95% CI, 78.1% to 98.3%) and the specificity was calculated to be 79.5% (95% CI, 72.0% to 85.7%). CONCLUSIONS Alpha defensin in combination with synovial fluid CRP demonstrates very high sensitivity for diagnosing periprosthetic joint infection, but may yield false-positive results in the presence of metallosis or false-negative results in the presence of low-virulence organisms. When both alpha defensin and synovial fluid CRP tests are positive, there is a very high specificity for diagnosing periprosthetic joint infection. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- William Z Stone
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida
| | - Chancellor F Gray
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida
| | - Hari K Parvataneni
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida
| | - Mamun Al-Rashid
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida
| | - Richard G Vlasak
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida
| | - MaryBeth Horodyski
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida
| | - Hernan A Prieto
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida
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16
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Balato G, Franceschini V, Ascione T, Lamberti A, D'Amato M, Ensini A, Baldini A. High performance of α-defensin lateral flow assay (Synovasure) in the diagnosis of chronic knee prosthetic infections. Knee Surg Sports Traumatol Arthrosc 2018; 26:1717-1722. [PMID: 28988303 DOI: 10.1007/s00167-017-4745-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 10/03/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE This prospective study was undertaken to evaluate the diagnostic accuracy of the Synovasure™ α-defensin lateral flow assay to detect or exclude infection and to compare it to the sensitivity and specificity of other diagnostic criteria according to the International Consensus Group on Periprosthetic Joint Infection (PJI). METHODS All patients who have undergone revision total knee arthroplasty (TKA) from September 2015 to July 2016 were included: 16 chronic (more than 3 months after performing arthroplasty) infections and 35 aseptic joints were identified. The diagnostic performance of single test was assessed by receiver operating characteristic (ROC) curve analyses. The sensitivity and specificity were calculated for each of the cut-off values and the area under the curve (AUC) was also calculated. RESULTS The median synovial fluid (SF) leukocyte count, as well as the neutrophil percentage, was significantly higher in patients with PJI than in those with aseptic failure (p < 0.001). The sensitivity of α-defensin was 87.5% (95%; CI 74.6-94.7), the specificity was 97.1% (95% CI 86.9-99.7), the positive predictive value 93.3% (95% CI 81.8-98.1), and negative predictive value was 94.4% (95% CI 83.2-98.6). The results in terms of sensitivity and negative predictive value were greater than those of the other tests (cultures, synovial cell count, erythrocyte sedimentation rate, and C-reactive protein). The diagnostic accuracy of α-defensin, with an area under the curve of 0.92, was found to be higher than all the minor criteria for PJI. CONCLUSIONS In this study, the α-defensin lateral flow test was found to have the highest performance of all tests studied to identify PJI. Synovasure™ holds the potential to be included in the daily clinical practice. 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.
| | - Vincenzo Franceschini
- Department of Orthopaedics and Traumatology, "Sapienza" University of Rome, ICOT, Latina, Italy
| | - Tiziana Ascione
- Department of Infectious Diseases, D. Cotugno Hospital, AORN Dei Colli, Naples, Italy
| | | | - Michele D'Amato
- Orthopaedic and Traumatology Clinic I, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Andrea Ensini
- Orthopaedic and Traumatology Clinic I, Rizzoli Orthopaedic Institute, Bologna, Italy
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Erdemli B, Özbek EA, Başarir K, Karahan ZC, Öcal D, Biriken D. Proinflammatory biomarkers' level and functional genetic polymorphisms in periprosthetic joint infection. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:143-147. [PMID: 29305046 PMCID: PMC6136306 DOI: 10.1016/j.aott.2017.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 10/11/2017] [Accepted: 11/06/2017] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The aims of this study were 1) to identify the level of inflammatory biomarkers interleukin (IL)-1α, IL-1β, IL-6, IL-8, IL-17, C-reactive protein (CRP), granulocyte colony-stimulating factor (GCSF), ferritin, and tumor necrosis factor (TNF)-α in serum and synovial fluid samples of patients who underwent revision arthroplasty surgery; 2) to establish the relationship between serum and synovial fluid levels; 3) to determine if any of the 11 genetic polymorphisms of TNFα, IL-1, IL-6, IL-8, IL-17, and GCSF on the encoding genes was associated with periprosthetic joint infection (PJI). METHODS Synovial fluid and serum was collected from 88 patients who underwent revision arthroplasty surgery. The Musculoskeletal Infection Society definition was used to classify these patients into 2 groups: 36 PJIs and 52 aseptic failures. Synovial fluid and serum samples were tested for 9 biomarkers using a micro enzyme-linked immunosorbent assay. Genetic polymorphisms were evaluated with polymerase chain reaction and restriction endonuclease analysis. RESULTS Synovial fluid-derived IL-1α, IL-1β, IL-8, IL-17, CRP, GCSF, TNFα, and serum-derived IL-6, IL-17, ferritin, CRP were found suitable to classify PJI and aseptic failure. In addition, IL-17 and CRP levels demonstrated a positive correlation between synovial fluid and serum. TNFα-238, IL6-174, GCSF3R, and IL1 RN-VNTR genetic polymorphisms occurred more frequently in individuals with septic failure. CONCLUSION Significant differences between the two groups were observed in the functional polymorphisms of the genes encoding the cytokines investigated. These differences could be interpreted as indicating that there is an association between PJI and genetic polymorphisms. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Bülent Erdemli
- Ankara University Medicine Faculty, İbn'i Sina Hospital, Orthopedics and Traumatology Department, Ankara, Turkey.
| | - Emre Anıl Özbek
- Ankara University Medicine Faculty, İbn'i Sina Hospital, Orthopedics and Traumatology Department, Ankara, Turkey.
| | - Kerem Başarir
- Ankara University Medicine Faculty, İbn'i Sina Hospital, Orthopedics and Traumatology Department, Ankara, Turkey.
| | - Zeynep Ceren Karahan
- Medical Microbiology Department, Ankara University Medicine Faculty, Ankara, Turkey.
| | - Duygu Öcal
- Ataturk Training and Research Hospital, Department of Medical Microbiology, Ankara, Turkey.
| | - Derya Biriken
- Medical Microbiology Department, Ankara University Medicine Faculty, Ankara, Turkey.
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18
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Cruz AI, Anari JB, Ramirez JM, Sankar WN, Baldwin KD. Distinguishing Pediatric Lyme Arthritis of the Hip from Transient Synovitis and Acute Bacterial Septic Arthritis: A Systematic Review and Meta-analysis. Cureus 2018; 10:e2112. [PMID: 29581924 PMCID: PMC5866113 DOI: 10.7759/cureus.2112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective Lyme arthritis is an increasingly recognized clinical entity that often prompts orthopaedic evaluation in pediatric patients. While Lyme arthritis is most common in the knee, the clinical presentation of Lyme arthritis of the hip can be similar to both acute bacterial septic arthritis and transient synovitis. Accurately distinguishing these clinical entities is important since the definitive treatment of each is distinct. Because there is limited literature on monoarticular Lyme arthritis of the hip, the purpose of this study was to perform a systematic review and meta-analysis of clinical and laboratory parameters associated with Lyme arthritis (LA) of the hip and compare them to septic arthritis (SA) and transient synovitis (TS). Study design A systematic review of the literature was performed using the following search terms, including the variants and plural counterparts “hip” and “Lyme arthritis.” A final database of individual patients was assembled from the published literature and direct author correspondence, when available. A previously published cohort of patients with hip transient synovitis or septic arthritis was used for comparative analysis. A comparative statistical analysis was performed to the assembled database to assess differences in laboratory and clinical variables between the three diagnoses. Results Data on 88 patients diagnosed with Lyme arthritis of the hip was collected and consolidated from the 12 articles meeting inclusion criteria. The average age of patients presenting with Lyme arthritis was 7.5 years (± 3.5 years), the mean erythrocyte sedimentation rate (ESR), and the C-reactive protein (CRP) was 41 mm/hr and 3.9 mg/L, respectively. Peripheral white blood cell (WBC) count averaged 10.6 x 109cells/L with the synovial WBC count averaging 55,888 cells/mm3. Compared to a previous cohort of patients with confirmed transient synovitis or septic arthritis, the 95% confidence interval for ESR was 21 - 33 mm/hr in those diagnosed with toxic synovitis (TS), 37 - 46 mm/hr for Lyme arthritis (LA), and 44 - 64 mm/hr for septic arthritis (SA). Synovial WBC counts (cells/mm3) 95% confidence intervals (CI) were 5,644 - 15,388 cells/mm3 for TS, 47,533 - 64,242 cells/mm3 for LA, and 105,432 - 260,214 cells/mm3 for SA. There was a statistically significant difference in the incidence of fever > 38.5oC (P < 0.001) and refusal to bear weight (P < 0.01) between SA, LA, and TS. Conclusions Monoarticular Lyme arthritis can be a cause of hip pain in certain geographic areas and has clinical and diagnostic overlap with transient synovitis and acute bacterial septic arthritis. This study consolidates the available literature and represents the largest series of patients diagnosed with Lyme arthritis of the hip to date. We propose a diagnostic algorithm that serially incorporates ESR, followed by a synovial neutrophil count, when evaluating pediatric patients with an irritable hip in Lyme endemic areas.
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Affiliation(s)
| | - Jason B Anari
- Orthopaedic Surgery, Children's Hospital of Philadelphia
| | - Jose M Ramirez
- Orthopaedic Surgery, Warren Alpert Medical School of Brown University
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19
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Abstract
BACKGROUND Lyme arthritis (LA) of the hip can present similarly to septic arthritis (SA) and transient synovitis (TS). The primary purpose of this study was to determine clinical and laboratory parameters differentiating LA of the hip from SA or TS among children who had undergone hip aspiration during the evaluation of hip pain. METHODS This was a retrospective review of all patients who underwent hip aspiration for the evaluation of hip pain at a tertiary care children's hospital in a Lyme endemic area. Clinical and laboratory data were reviewed and comparative analyses were performed between those diagnosed with LA, SA, and TS. Independent samples t test, ANOVA, and χ test were used to compare clinical and laboratory variables as appropriate. Multivariable logistic regression was used to elucidate independent predictors of LA. Statistical significance was set at P<0.05. RESULTS Ninety-three hip aspirations (93 patients) were included in the final analysis. Seventeen patients were diagnosed with LA, 40 with SA, and 36 with TS. Multivariable logistic regression revealed febrile history (OR=16.3; 95% CI, 2.35-113.0) and increased peripheral white blood cell (WBC) count (OR=1.26; 95% CI, 1.01-1.58) to be significantly associated with increased odds of being diagnosed with SA versus LA. Increased erythrocyte sedimentation rate (ESR) was significantly associated with increased odds of being diagnosed with LA versus TS (OR=1.06; 95% CI, 1.02-1.10), whereas febrile history (OR=0.06; 95% CI, 0.01-0.49) and increased peripheral WBC count (OR=0.8; 95% CI, 0.65-0.98) were associated with decreased odds of LA. CONCLUSIONS Children presenting in a Lyme endemic area with an isolated hip effusion are more likely to have LA versus SA if they have no history of fever and a decreased peripheral WBC count. Compared with TS, patients with LA are more likely to have an elevated ESR. This study adds to existing knowledge because there are few investigations examining isolated LA of the hip. LEVEL OF EVIDENCE Level III-retrospective case-control study.
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20
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Alvand A, Rezapoor M, Parvizi J. The Role of Biomarkers for the Diagnosis of Implant-Related Infections in Orthopaedics and Trauma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 971:69-79. [PMID: 28243953 DOI: 10.1007/5584_2017_11] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Diagnosis of implant-related (periprosthetic joint) infections poses a major challenge to infection disease physicians and orthopaedic surgeons. Conventional diagnostic tests continue to suffer from issues of accuracy and feasibility. Biomarkers are used throughout medicine for diagnostic and prognostic purposes, as they are able to objectively determine the presence of a disease or a biological state. There is increasing evidence to support the measurement of specific biomarkers in serum and/or synovial fluid of patients with suspected periprosthetic joint infections. Promising serum biomarkers include interleukin (IL)-4, IL-6, tumour necrosis factor (TNF)-α, procalcitonin, soluble intercellular adhesion molecule 1 (sICAM-1), and D-dimer. In addition to c-reactive protein and leucocyte esterase, promising biomarkers that can be measured in synovial fluid include antimicrobial proteins such as human β-defensin (HBD)-2 and human β-defensin (HBD)-3, and cathelicidin LL-37, as well as several interleukins such as IL-1β, IL-6, IL-8, IL-17, TNF- α, interferon-δ, and vascular endothelial growth factor.
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Affiliation(s)
- Abtin Alvand
- The Rothman Institute, 925 Chestnut Street, Philadelphia, PA, 19107, USA.
| | - Maryam Rezapoor
- The Rothman Institute, 925 Chestnut Street, Philadelphia, PA, 19107, USA
| | - Javad Parvizi
- The Rothman Institute, 925 Chestnut Street, Philadelphia, PA, 19107, USA
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21
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Abstract
The increasing number of implantations will lead to more periprosthetic infections. Periprosthetic infections in patients with rheumatism, who are often undergoing immunosuppressive treatment, represent a challenge for the treating physicians. The optimal care and treatment therefore necessitate an interdisciplinary agreement between orthopedic surgeons, specialists for infections and rheumatologists.
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Abstract
The role of serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as the first line for evaluating a patient with periprosthetic joint infection (PJI) has been debunked.We are living in the era of biomarkers for the diagnosis of PJI, and to that effect, several biomarkers have been introduced such as synovial fluid alpha defensin and leukocyte esterase.The synovial fluid leukocyte esterase test has a low cost, is accessible, and has provided promising results for diagnosing PJI.There is an urgent need for an accurate and reliable serum biomarker for diagnosing patients with PJI. Cite this article: Shahi A, Parvizi J. The role of biomarkers in the diagnosis of periprosthetic joint infection. EFORT Open Rev 2016;1:275-278. DOI: 10.1302/2058-5241.1.160019.
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Affiliation(s)
- AliSina Shahi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, USA
| | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, USA
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Frangiamore SJ, Saleh A, Grosso MJ, Farias Kovac M, Zhang X, Daly TM, Bauer TW, Derwin KA, Iannotti JP, Ricchetti ET. Neer Award 2015: Analysis of cytokine profiles in the diagnosis of periprosthetic joint infections of the shoulder. J Shoulder Elbow Surg 2017; 26:186-196. [PMID: 27720413 DOI: 10.1016/j.jse.2016.07.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) after shoulder arthroplasty can present a diagnostic and therapeutic challenge. This study evaluated the diagnostic utility of broader synovial fluid cytokine analysis for identifying PJI in patients undergoing revision shoulder arthroplasty. METHODS Synovial fluid levels of 9 cytokines (interleukin [IL] 6, granulocyte-macrophage colony-stimulating factor, IL-1β, IL-12, IL-2, IL-8, interferon-γ, IL-10, and tumor necrosis factor-α) were measured in 75 cases of revision shoulder arthroplasty with a multiplex immunoassay. Cases were classified into infection categories and groups based on objective perioperative findings. Differences in cytokine levels among infection groups were evaluated. Receiver operating characteristic curves were used to assess the diagnostic utility of the individual synovial fluid cytokines and combinations of cytokines in determining infection status. RESULTS Synovial IL-6, granulocyte-macrophage colony-stimulating factor, interferon-γ, IL-1β, IL-2, IL-8, and IL-10 were significantly elevated in cases of revision shoulder arthroplasty classified as infected. Individually, IL-6, IL-1β, IL-8, and IL-10 showed the best combination of sensitivity and specificity for predicting infection, and a combined cytokine model consisting of IL-6, tumor necrosis factor-α, and IL-2 showed better diagnostic test characteristics than any cytokine alone, with sensitivity of 0.80, specificity of 0.93,, positive and negative predictive values of 0.87 and 0.89, and positive and negative likelihood ratios of 12.0 and 0.21. CONCLUSIONS Individual and combined synovial fluid cytokine analysis were both more effective than routine perioperative testing, such as serum erythrocyte sedimentation rate and C-reactive protein, in the diagnosis of PJI of the shoulder. Once validated, combined synovial fluid cytokine analysis could be used as a predictive tool to determine the probability of PJI in patients undergoing revision shoulder arthroplasty and better guide treatment.
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Affiliation(s)
- Salvatore J Frangiamore
- Department of Orthopaedic Surgery, Cleveland Clinic, Orthopaedic & Rheumatologic Institute, Cleveland, OH, USA
| | - Anas Saleh
- Department of Orthopaedic Surgery, Cleveland Clinic, Orthopaedic & Rheumatologic Institute, Cleveland, OH, USA
| | - Matthew J Grosso
- Department of Orthopaedic Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Mario Farias Kovac
- Department of Orthopaedic Surgery, Cleveland Clinic, Orthopaedic & Rheumatologic Institute, Cleveland, OH, USA
| | - Xiaochun Zhang
- Department of Laboratory Medicine, Cleveland Clinic, Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland, OH, USA
| | - Thomas M Daly
- Department of Laboratory Medicine, Cleveland Clinic, Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland, OH, USA
| | - Thomas W Bauer
- Department of Pathology, Cleveland Clinic, Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland, OH, USA
| | - Kathleen A Derwin
- Department of Orthopaedic Surgery, Cleveland Clinic, Orthopaedic & Rheumatologic Institute, Cleveland, OH, USA
| | - Joseph P Iannotti
- Department of Orthopaedic Surgery, Cleveland Clinic, Orthopaedic & Rheumatologic Institute, Cleveland, OH, USA
| | - Eric T Ricchetti
- Department of Orthopaedic Surgery, Cleveland Clinic, Orthopaedic & Rheumatologic Institute, Cleveland, OH, USA.
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Patel R, Alijanipour P, Parvizi J. Advancements in Diagnosing Periprosthetic Joint Infections after Total Hip and Knee Arthroplasty. Open Orthop J 2016; 10:654-661. [PMID: 28144375 PMCID: PMC5220175 DOI: 10.2174/1874325001610010654] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 06/16/2016] [Accepted: 07/15/2016] [Indexed: 02/08/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a complication of total joint arthroplasty that is challenging to diagnose. Currently, there is no "gold standard" for definite diagnosis of PJI. A multi-criteria definition has been described for PJI based on microbiology cultures, serum markers, such as erythrocyte sedimentation rate and C-reactive protein (CRP), synovial fluid biomarkers, such as leukocyte esterase and histopathology assessment of the periprosthetic tissue. The conventional serum markers are generally nonspecific and can be elevated in inflammatory conditions. Therefore, they cannot be relied on for definite diagnosis of PJI. Hence, with the use of proteomics, synovial fluid biomarkers such as α-defensin, IL-6, and CRP have been proposed as more accurate biomarkers for PJI. Current methods to culture micro-organisms have several limitations, and can be false-negative and false-positive in a considerable number of cases. In an attempt to improve culture sensitivity, diagnostic methods to target biofilms have recently been studied. The understanding of the concept of biofilms has also allowed for the development of novel techniques for PJI diagnosis, such as visualizing biofilms with fluorescent in-situ hybridization and detection of bacteria via DNA microarray. Lastly, the use of amplification-based molecular techniques has provided methods to identify specific species of bacteria that cause culture-negative PJI. While diagnosing PJI is difficult, these advances could be valuable tools for clinicians.
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Affiliation(s)
- Ripal Patel
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pouya Alijanipour
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Choi HR, Agrawal K, Bedair H. The diagnostic thresholds for synovial fluid analysis in late periprosthetic infection of the hip depend on the duration of symptoms. Bone Joint J 2016; 98-B:1355-1359. [DOI: 10.1302/0301-620x.98b10.37615] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 06/01/2016] [Indexed: 11/05/2022]
Abstract
Aims We hypothesised that the synovial white blood cell (WBC) count in patients with a late periprosthetic joint infection (PJI) of the hip would depend on the duration of a patient’s symptoms, and that the optimal diagnostic threshold would also depend on this period of time. Patients and Methods The synovial WBC count and percentage of polymorphonuclear cells (%PMN), and the serum CRP and ESR levels obtained > six weeks after primary THA were compared between 50 infected and 88 non-infected THAs, and in patients with symptoms for more than or less than two weeks. Diagnostic thresholds for the synovial WBC count were calculated using area under the curve calculation. Results The synovial WBC count was significantly higher in patients with symptoms for ≤ two weeks compared with those with symptoms for > two weeks (p = 0.03). The optimal threshold for diagnosing PJI for the synovial WBC count was 5750 cells/µL (sensitivity 94; specificity 100; PPV 100%; NPV 89%; AUC 99%) and 1556 cells/µL (sensitivity 91; specificity 94; PPV 87% and NPV 97%; AUC 95%), respectively. The thresholds for the cut-offs based on duration of symptoms improved the diagnostic performance of this test. Conclusion This study shows that the diagnostic thresholds for synovial fluid analysis in late periprosthetic infection following THA may depend on duration of symptoms. Cite this article: Bone Joint J 2016;98-B:1355–9.
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Affiliation(s)
- H-R. Choi
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - K. Agrawal
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - H. Bedair
- Massachusetts General Hospital, Boston, Massachusetts, USA
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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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α-Defensin Accuracy to Diagnose Periprosthetic Joint Infection-Best Available Test? J Arthroplasty 2016; 31:456-60. [PMID: 26545577 DOI: 10.1016/j.arth.2015.09.035] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 09/14/2015] [Accepted: 09/21/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to test the accuracy of a single synovial fluid biomarker, α-defensin, in diagnosing periprosthetic joint infection in revision total hip and revision total knee arthroplasty. METHODS A total of 102 patients comprising 116 revision total hip arthroplasty and revision total knee arthroplasty procedures performed between May 2013 and March 2014 were prospectively evaluated. Cases were categorized as infected or notinfected using Musculoskeletal Infection Society criteria. Synovial fluid was obtained and tested for α-defensin using a commercially available kit (Synovasure [CD Diagnostics, Baltimore, Maryland]). RESULTS For first-stage and single-stage revisions, the α-defensin test had a sensitivity of 100% (95% confidence interval [CI], 86%-100%) and a specificity of 98% (95% CI, 90%-100%) with a positive predictive value of 96% (95% CI, 80%-99%) and negative predictive value of 100% (95% CI, 93%-100%). CONCLUSION A positive α-defensin test result was significantly more sensitive and specific for predicting infection than current diagnostic testing and should be considered when managing periprosthetic joint infection. LEVEL OF EVIDENCE Level III, Study of Diagnostic Test.
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Abstract
The diagnosis of periprosthetic joint infection (PJI) has been performed by obtaining a history and physical examination, blood tests, and analysis of the synovial fluid and tissue samples. The measurement of serum biomarkers are routinely used to diagnose PJI. These markers may be elevated in other inflammatory conditions, necessitating the need for more specific biomarkers to diagnose PJI. Serum biomarkers may be more specific to PJI. Synovial CRP, α-defensin, human β-defensin-2 and -3, leukocyte esterase, and cathelicidin LL-37 biomarkers hold promise for the diagnosis of PJI.
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Affiliation(s)
- Laura Matsen Ko
- Rothman Institute, Thomas Jefferson University, 4703 33rd Avenue Northeast, Seattle, WA 98105, USA.
| | - Javad Parvizi
- Sidney Kimmel School of Medicine, Rothman Institute, Thomas Jefferson University, Sheridan Building, Suite 1000, 125 South 9th Street, Philadelphia, PA 19107, USA
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Boot W, Moojen DJF, Visser E, Lehr AM, De Windt TS, Van Hellemondt G, Geurts J, Tulp NJA, Schreurs BW, Burger BJ, Dhert WJA, Gawlitta D, Vogely HC. Missed low-grade infection in suspected aseptic loosening has no consequences for the survival of total hip arthroplasty. Acta Orthop 2015; 86:678-83. [PMID: 26364842 PMCID: PMC4750766 DOI: 10.3109/17453674.2015.1086942] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Aseptic loosening and infection are 2 of the most common causes of revision of hip implants. Antibiotic prophylaxis reduces not only the rate of revision due to infection but also the rate of revision due to aseptic loosening. This suggests under-diagnosis of infections in patients with presumed aseptic loosening and indicates that current diagnostic tools are suboptimal. In a previous multicenter study on 176 patients undergoing revision of a total hip arthroplasty due to presumed aseptic loosening, optimized diagnostics revealed that 4-13% of the patients had a low-grade infection. These infections were not treated as such, and in the current follow-up study the effect on mid- to long-term implant survival was investigated. PATIENTS AND METHODS Patients were sent a 2-part questionnaire. Part A requested information about possible re-revisions of their total hip arthroplasty. Part B consisted of 3 patient-related outcome measure questionnaires (EQ5D, Oxford hip score, and visual analog scale for pain). Additional information was retrieved from the medical records. The group of patients found to have a low-grade infection was compared to those with aseptic loosening. RESULTS 173 of 176 patients from the original study were included. In the follow-up time between the revision surgery and the current study (mean 7.5 years), 31 patients had died. No statistically significant difference in the number of re-revisions was found between the infection group (2 out of 21) and the aseptic loosening group (13 out of 152); nor was there any significant difference in the time to re-revision. Quality of life, function, and pain were similar between the groups, but only 99 (57%) of the patients returned part B. INTERPRETATION Under-diagnosis of low-grade infection in conjunction with presumed aseptic revision of total hip arthroplasty may not affect implant survival.
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Affiliation(s)
- Willemijn Boot
- Departments of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dirk Jan F Moojen
- Departments of Orthopaedics, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Els Visser
- Departments of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A Mechteld Lehr
- Departments of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Tommy S De Windt
- Departments of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Jan Geurts
- Departments of Orthopaedics, Maastricht University Medical Center, Research Institute CAPHRI, Maastricht, the Netherlands
| | - Niek J A Tulp
- Departments of Orthopaedics, Isala Clinics, Zwolle, the Netherlands
| | - B Wim Schreurs
- Departments of Orthopaedics, University Medical Center St. Radboud, Nijmegen, the Netherlands
| | - Bart J Burger
- Departments of Orthopaedics, Medical Center Alkmaar, Alkmaar, the Netherlands
| | - Wouter J A Dhert
- Departments of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - H Charles Vogely
- Departments of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands,Correspondence:
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Potter BK. From Bench to Bedside: Alpha-defensing--The Biggest Thing in Joint Replacement Infections Since Prophylactic Antibiotics? Clin Orthop Relat Res 2015; 473:3105-7. [PMID: 25869063 PMCID: PMC4562918 DOI: 10.1007/s11999-015-4297-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/03/2015] [Indexed: 01/31/2023]
Affiliation(s)
- Benjamin K. Potter
- />Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, America Building (19), 2nd Floor – Ortho, Bethesda, MD 20889 USA , />Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD USA
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Frangiamore SJ, Saleh A, Grosso MJ, Kovac MF, Higuera CA, Iannotti JP, Ricchetti ET. α-Defensin as a predictor of periprosthetic shoulder infection. J Shoulder Elbow Surg 2015; 24:1021-7. [PMID: 25672257 DOI: 10.1016/j.jse.2014.12.021] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 11/26/2014] [Accepted: 12/06/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Diagnosis of periprosthetic joint infection (PJI) in revision shoulder arthroplasty can be challenging because of the indolent nature of the common offending organisms. The purpose of this study was to evaluate the diagnostic utility of synovial fluid α-defensin levels in identifying PJI of the shoulder. METHODS Thirty patients evaluated for painful shoulder arthroplasty were prospectively enrolled and underwent revision surgery (n = 33 cases). Cases were categorized into infection (n = 11) and no-infection (n = 22) groups on the basis of preoperative and intraoperative findings. Synovial fluid was obtained from preoperative aspirations or intraoperative aspiration before arthrotomy. α-Defensin was tested by the Synovasure (CD Diagnostics, Wynnewood, PA, USA) test for joint infection. Synovial fluid was also obtained intraoperatively from a control group undergoing arthroscopic rotator cuff repair (n = 16) for baseline data on normal α-defensin levels in the shoulder. A receiver operating characteristic curve was used to determine the diagnostic utility of synovial fluid α-defensin. RESULTS Synovial α-defensin had an area under the curve, sensitivity, specificity, and positive and negative likelihood ratios of 0.78, 63%, 95%, 12.1, and 0.38, respectively. There was a significant difference in α-defensin levels between the infection (median, 3.2 S/CO [signal to cutoff ratio]) and no-infection groups (median, 0.21 S/CO; P = .006). Synovial α-defensin was elevated in the presence of a culture positive for Propionibacterium acnes (median, 1.33 S/CO; P = .03) and showed moderate correlation with the number of positive cultures. CONCLUSION Synovial fluid α-defensin was more effective than current diagnostic testing in predicting positive cultures and may be an effective adjunct in the workup of shoulder PJI.
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Affiliation(s)
| | - Anas Saleh
- Department of Orthopedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Matthew J Grosso
- Department of Orthopedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mario Farias Kovac
- Department of Orthopedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Carlos A Higuera
- Department of Orthopedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Joseph P Iannotti
- Department of Orthopedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Eric T Ricchetti
- Department of Orthopedic Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA.
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Springer BD. The Diagnosis of Periprosthetic Joint Infection. J Arthroplasty 2015; 30:908-11. [PMID: 25913561 DOI: 10.1016/j.arth.2015.03.042] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 02/24/2015] [Accepted: 03/13/2015] [Indexed: 02/01/2023] Open
Abstract
Periprosthetic joint infection remains one of the most common failure modes following total hip and total knee arthroplasty. As such, a systematic and cost effective approach to the evaluation and work-up of a patient with a suspected periprosthetic joint infection should be undertaken in every patient with a painful total joint. Although we have many diagnostic tools, a history and physical remain the most important. Many of the current laboratory tests are indirect measure of infection, lack specificity for diagnosis of infection, but serve as sensitive and cost effective screening tools. In addition, a new definition of periprosthetic infection helps to standardize the diagnosis. Biomarkers hold the promise of improved specificity and are becoming increasingly popular as a diagnostic tool.
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Leitner G, Blum SE, Rivas AL. Visualizing the indefinable: three-dimensional complexity of 'infectious diseases'. PLoS One 2015; 10:e0123674. [PMID: 25875169 PMCID: PMC4397090 DOI: 10.1371/journal.pone.0123674] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 02/20/2015] [Indexed: 12/13/2022] Open
Abstract
Background The words ‘infection’ and ‘inflammation’ lack specific definitions. Here, such words are not defined. Instead, the ability to visualize host-microbial interactions was explored. Methods Leukocyte differential counts and four bacterial species (Staphylococcus aureus, Streptococcus dysgalactiae, Staphylococcus chromogenes, and Escherichia coli) were determined or isolated in a cross-sectional and randomized study conducted with 611 bovine milk samples. Two paradigms were evaluated: (i) the classic one, which measures non-structured (count or percent) data; and (ii) a method that, using complex data structures, detects and differentiates three-dimensional (3D) interactions among lymphocytes (L), macrophages (M), and neutrophils (N). Results Classic analyses failed to differentiate bacterial-positive (B+) from –negative (B−) observations: B− and B+ data overlapped, even when statistical significance was achieved. In contrast, the alternative approach showed distinct patterns, such as perpendicular data inflections, which discriminated microbial-negative/mononuclear cell-predominating (MCP) from microbial-positive/phagocyte-predominating (PP) subsets. Two PP subcategories were distinguished, as well as PP/culture-negative (false-negative) and MCP/culture-positive (false-positive) observations. In 3D space, MCP and PP subsets were perpendicular to one another, displaying ≥91% specificity or sensitivity. Findings supported five inferences: (i) disease is not always ruled out by negative bacterial tests; (ii) low total cell counts can coexist with high phagocyte percents; (iii) neither positive bacterial isolation nor high cell counts always coincide with PP profiles; (iv) statistical significance is not synonymous with discrimination; and (v) hidden relationships cannot be detected when simple (non-structured) data formats are used and statistical analyses are performed before data subsets are identified, but can be uncovered when complexity is investigated. Conclusions Pattern recognition-based assessments can detect host-microbial interactions usually unobserved. Such cutoff-free, confidence interval-free, gold standard-free approaches provide interpretable information on complex entities, such as ‘infection’ and ‘inflammation’, even without definitions. To investigate disease dynamics, combinations of observational and experimental longitudinal studies, on human and non-human infections, are recommended.
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Affiliation(s)
- Gabriel Leitner
- National Mastitis Reference Center, Kimron Veterinary Institute, Bet Dagan, Israel
- * E-mail:
| | - Shlomo E. Blum
- National Mastitis Reference Center, Kimron Veterinary Institute, Bet Dagan, Israel
| | - Ariel L. Rivas
- Center for Global Health, Internal Medicine, Health Sciences Center, University of New Mexico, Albuquerque, New Mexico, United States of America
- Population Health and Pathobiology, North Carolina Sate University, Raleigh, North Carolina, United States of America
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Deirmengian C, Kardos K, Kilmartin P, Cameron A, Schiller K, Parvizi J. Diagnosing periprosthetic joint infection: has the era of the biomarker arrived? Clin Orthop Relat Res 2014; 472:3254-62. [PMID: 24590839 PMCID: PMC4182392 DOI: 10.1007/s11999-014-3543-8] [Citation(s) in RCA: 264] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The diagnosis of periprosthetic joint infection (PJI) remains a serious clinical challenge. There is a pressing need for improved diagnostic testing methods; biomarkers offer one potentially promising approach. QUESTIONS/PURPOSES We evaluated the diagnostic characteristics of 16 promising synovial fluid biomarkers for the diagnosis of PJI. METHODS Synovial fluid was collected from 95 patients meeting the inclusion criteria of this prospective diagnostic study. All patients were being evaluated for a revision hip or knee arthroplasty, including patients with systemic inflammatory disease and those already receiving antibiotic treatment. The Musculoskeletal Infection Society (MSIS) definition was used to classify 29 PJIs and 66 aseptic joints. Synovial fluid samples were tested by immunoassay for 16 biomarkers optimized for use in synovial fluid. Sensitivity, specificity, and receiver operating characteristic curve analysis were performed to assess for diagnostic performance. RESULTS Five biomarkers, including human α-defensin 1-3, neutrophil elastase 2, bactericidal/permeability-increasing protein, neutrophil gelatinase-associated lipocalin, and lactoferrin, correctly predicted the MSIS classification of all patients in this study, with 100% sensitivity and specificity for the diagnosis of PJI. An additional eight biomarkers demonstrated excellent diagnostic strength, with an area under the curve of greater than 0.9. CONCLUSIONS Synovial fluid biomarkers exhibit a high accuracy in diagnosing PJI, even when including patients with systemic inflammatory disease and those receiving antibiotic treatment. Considering that these biomarkers match the results of the more complex MSIS definition of PJI, we believe that synovial fluid biomarkers can be a valuable addition to the methods utilized for the diagnosis of infection. LEVEL OF EVIDENCE Level II, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Carl Deirmengian
- CD Diagnostics Inc, Lankenau Institute for Medical Research, 100 Lancaster Avenue, MOB 456, Wynnewood, PA 19096 USA ,The Rothman Institute, Thomas Jefferson University, Philadelphia, PA USA
| | - Keith Kardos
- CD Diagnostics Inc, Lankenau Institute for Medical Research, 100 Lancaster Avenue, MOB 456, Wynnewood, PA 19096 USA
| | - Patrick Kilmartin
- CD Diagnostics Inc, Lankenau Institute for Medical Research, 100 Lancaster Avenue, MOB 456, Wynnewood, PA 19096 USA
| | - Alexander Cameron
- CD Diagnostics Inc, Lankenau Institute for Medical Research, 100 Lancaster Avenue, MOB 456, Wynnewood, PA 19096 USA
| | - Kevin Schiller
- CD Diagnostics Inc, Lankenau Institute for Medical Research, 100 Lancaster Avenue, MOB 456, Wynnewood, PA 19096 USA
| | - Javad Parvizi
- The Rothman Institute, Thomas Jefferson University, Philadelphia, PA USA
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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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Abstract
➤ The unique bacterial flora of the shoulder present diagnostic and treatment challenges that are distinct from those seen with failed hip and knee arthroplasties.➤ The presentation, diagnosis, and management of suppurative periprosthetic joint infections of the shoulder are similar to those of the hip and the knee.➤ Failed arthroplasties with positive cultures (FAPCs) are poorly performing shoulder reconstructions associated with low-virulence microorganisms that do not evoke a suppurative inflammatory response. Propionibacterium acnes is the predominant bacterium isolated from these cases.➤ With improved surgeon awareness and the addition of longer tissue-culture incubation times, detection of FAPCs has become more common. However, management is hampered by the lack of reliable, timely tests that can determine the presence of less virulent organisms in the preoperative or intraoperative settings.➤ The implications of positive culture results in FAPCs are unclear. Key test characteristics such as the false-positive rate and the prevalence of positive cultures in well-performing shoulders are unknown as there is no useful confirmatory test to validate the culture data and no reliable way to detect the presence of less virulent microorganisms without reoperation.➤ Soft-tissue and osseous deficits are frequently encountered when revising previously infected shoulders. The rate of complications in these scenarios is high, and the outcomes are the least favorable compared with revisions for any other indication.➤ The development of a consensus definition of a periprosthetic shoulder infection is critical to future investigations of these devastating complications.
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Affiliation(s)
- William R Mook
- Department of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC 27710. E-mail address for W.R. Mook:
| | - Grant E Garrigues
- Department of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC 27710. E-mail address for W.R. Mook:
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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
BACKGROUND We have previously described a unique gene expression signature exhibited by synovial fluid leukocytes in response to bacterial infection, identifying a number of potential biomarkers for infection. However, the diagnostic performance of these potential biomarkers in an immunoassay format is unknown. QUESTIONS/PURPOSES We therefore evaluated the sensitivity, specificity, and accuracy of several potential synovial fluid biomarkers for infection, and compared them to current standards of testing for periprosthetic infection. METHODS We prospectively collected synovial fluid from 14 patients classified as having a periprosthetic infection and 37 patients classified as having an aseptic failure. The synovial fluid samples were tested for 23 potential biomarkers for periprosthetic infection. We then determined differences in biomarker levels between infected and aseptic groups, then computed the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for select biomarkers, and finally compared those to current standard tests for infection. RESULTS Twelve synovial fluid biomarkers had substantially higher average levels in the synovial fluid of infected versus aseptic patients. Synovial fluid levels of IL-1 were a mean of 258 times higher in patients with a periprosthetic infection compared to patients having revision for aseptic diagnoses. Synovial fluid IL-1 and IL-6 levels correctly classified all patients in this study with a sensitivity, specificity, positive predictive value, negative predictive value and accuracy equal to 1. Several markers tested in this study outperformed the ESR and CRP tests. CONCLUSIONS Patients with a periprosthetic infection have elevated levels of numerous synovial fluid biomarkers, when compared to patients with aseptic diagnoses. Several of these biomarkers exhibited nearly ideal sensitivity, specificity, and accuracy in this study, suggesting that synovial fluid biomarkers could be a valuable tool for diagnosing periprosthetic infection. LEVEL OF EVIDENCE Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Infections of prosthetic joints and related problems. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Gollwitzer H, Diehl P, Gerdesmeyer L, Mittelmeier W. [Diagnostic strategies in cases of suspected periprosthetic infection of the knee. A review of the literature and current recommendations]. DER ORTHOPADE 2007; 35:904, 906-8, 910-6. [PMID: 16794850 DOI: 10.1007/s00132-006-0977-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Reliable confirmation of periprosthetic infection after total knee arthroplasty is a diagnostic challenge. The present work reviews published data evaluating the available diagnostic tools. Erythrocyte sedimentation rate and C-reactive protein serum levels are relatively sensitive methods with rather low specificity towards periprosthetic infection and are mainly applied to exclude infection. Studies evaluating scintigraphic methods--especially white cell scans--provide inconsistent data with varying accuracy. Consequently, white cell scans cannot be recommended as standard methods. Immunoscintigraphy with antigranulocyte antibodies and FDG-PET scans demonstrated promising results with particularly high sensitivities, but have to be validated in larger studies. Microbiological evaluation of joint aspirates proved high specificity for periprosthetic infection. However, an average of 20% of infected cases remained undetected. Nevertheless, aspiration is widely recommended for preoperative isolation of the infecting organism. Intraoperative frozen sections demonstrated excellent specificity with good sensitivity. The real accuracy of intraoperative culture and permanent histology cannot be determined due to the missing golden standard; however, a combination of both methods is recommended to define the final diagnosis. Large studies validating both methods and criteria for the final diagnosis of periprosthetic infection are necessary to optimize the diagnostic algorithm.
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Affiliation(s)
- H Gollwitzer
- Abteilung für Unfall- und Wiederherstellungschirurgie, Berufsgenossenschaftliche Unfallklinik, Prof.-Küntscher-Strasse 8, 82418, Murnau/Staffelsee.
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Liu M, Popper SJ, Rubins KH, Relman DA. Early days: genomics and human responses to infection. Curr Opin Microbiol 2006; 9:312-9. [PMID: 16679048 PMCID: PMC7108404 DOI: 10.1016/j.mib.2006.04.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Accepted: 04/24/2006] [Indexed: 10/26/2022]
Abstract
DNA microarray-based gene transcript-profiling of the responses of primates to infection has begun to yield new insights into host-pathogen interactions; this approach, however, remains plagued by challenges and complexities that have yet to be adequately addressed. The rapidly changing nature over time of acute infectious diseases in a host, and the genetic diversity of microbial pathogens present unique problems for the design and interpretation of functional-genomic studies in this field. In addition, there are the more common problems related to heterogeneity within clinical samples, the complex, non-standardized confounding variables associated with human subjects and the complexities posed by the analysis and validation of highly parallel data. Whereas various approaches have been developed to address each of these issues, there are significant limitations that remain to be overcome. The resolution of these problems should lead to a better understanding of the dialogue between the host and pathogen.
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Affiliation(s)
- Minghsun Liu
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Grant S-169, Stanford, CA 94305, USA
| | - Stephen J Popper
- Department of Microbiology and Immunology, Stanford University School of Medicine, 279 Campus Drive, Beckman B403, Stanford, CA 94305, USA
| | - Kathleen H Rubins
- Department of Microbiology and Immunology, Stanford University School of Medicine, 279 Campus Drive, Beckman B403, Stanford, CA 94305, USA
| | - David A Relman
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Grant S-169, Stanford, CA 94305, USA
- Department of Microbiology and Immunology, Stanford University School of Medicine, 279 Campus Drive, Beckman B403, Stanford, CA 94305, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
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