1
|
Sax FH, Hoyka M, Blersch BP, Fink B. Diagnostics in Late Periprosthetic Infections-Challenges and Solutions. Antibiotics (Basel) 2024; 13:351. [PMID: 38667027 PMCID: PMC11047502 DOI: 10.3390/antibiotics13040351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/29/2024] Open
Abstract
The rising number of arthroplasties is combined with a rising number of periprosthetic joint infections, which leads to life-concerning consequences for the patients, including extended antibiotic treatment, further surgery and increased mortality. The heterogeneity of the symptoms and inflammatory response of the patients due to, e.g., age and comorbidities and the absence of a single diagnostic test with 100% accuracy make it very challenging to choose the right parameters to confirm or deny a periprosthetic joint infection and to establish a standardized definition. In recent years, additional diagnostic possibilities have emerged primarily through the increasing availability of new diagnostic methods, such as genetic techniques. The aim of the review is to provide an overview of the current state of knowledge about the various tests, including the latest developments. The combination of different tests increases the accuracy of the diagnosis. Each physician or clinical department must select the tests from the available methods that can be best implemented for them in organizational and technical terms. Serological parameters and the cultivation of the samples from aspiration or biopsy should be combined with additional synovial tests to create an accurate figure for the failure of the prosthesis, while imaging procedures are used to obtain additional information for the planned therapeutic procedure.
Collapse
Affiliation(s)
- Florian Hubert Sax
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
| | - Marius Hoyka
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
| | - Benedikt Paul Blersch
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
| | - Bernd Fink
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
- Orthopaedic Department, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| |
Collapse
|
2
|
Choe H, Kamono E, Abe K, Hieda Y, Ike H, Kumagai K, Kobayashi N, Inaba Y. Accuracy of Albumin, Globulin, and Albumin-Globulin Ratio for Diagnosing Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:7512. [PMID: 38137581 PMCID: PMC10743640 DOI: 10.3390/jcm12247512] [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: 10/16/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Periprosthetic joint infection (PJI) is one of the most intractable orthopedic diseases, partly because of the difficulty in differentiating septic from aseptic conditions. We aimed to evaluate and consolidate the diagnostic accuracy of the quantitative assessment of serum albumin (Alb), globulin (Glb), and albumin-globulin ratio (AGR), alone or in combination with the inflammatory marker, C-reactive protein (CRP), for PJI. We searched the PubMed, CINAHL, and Cochrane Library databases for studies that quantitatively measured Alb, Glb, or AGR for the diagnosis of PJI up until the 30 April 2023. A total of 2339 patients were included from 10 studies, including 845 patients with a definitive diagnosis of PJI and 1494 with non-PJI. The pooled sensitivity, specificity, and area under the curve (AUC) in the summary receiver-operating characteristic curve were as follows: 0.625, 0.732, and 0.715 for Alb; 0.815, 0.857, and 0.887 for Glb; 0.753, 0.757, and 0.875 for AGR; 0.788, 0.837, and 0.876 for CRP; 0.879, 0.890, and 0.917 for the CRP-Alb ratio; and 0.845, 0.855, and 0.908 for the CRP-AGR ratio. Serum Alb, Glb, and AGR levels are feasible and accurate diagnostic markers for PJI, and the combination of these markers with CRP levels may potentially improve preoperative serum diagnostic accuracy. Future prospective studies are required to verify these findings because of the small numbers of included studies.
Collapse
Affiliation(s)
- Hyonmin Choe
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City 236-0004, Japan; (K.A.); (Y.H.); (H.I.); (K.K.); (Y.I.)
| | - Emi Kamono
- Department of Orthopedic Surgery, Yokohama City University Medical Center, 4-57 Urahune-cho, Minami-ku, Yokohama City 232-0024, Japan; (E.K.); (N.K.)
| | - Koki Abe
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City 236-0004, Japan; (K.A.); (Y.H.); (H.I.); (K.K.); (Y.I.)
| | - Yuta Hieda
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City 236-0004, Japan; (K.A.); (Y.H.); (H.I.); (K.K.); (Y.I.)
| | - Hiroyuki Ike
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City 236-0004, Japan; (K.A.); (Y.H.); (H.I.); (K.K.); (Y.I.)
| | - Ken Kumagai
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City 236-0004, Japan; (K.A.); (Y.H.); (H.I.); (K.K.); (Y.I.)
| | - Naomi Kobayashi
- Department of Orthopedic Surgery, Yokohama City University Medical Center, 4-57 Urahune-cho, Minami-ku, Yokohama City 232-0024, Japan; (E.K.); (N.K.)
| | - Yutaka Inaba
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City 236-0004, Japan; (K.A.); (Y.H.); (H.I.); (K.K.); (Y.I.)
| |
Collapse
|
3
|
Grünwald L, Schmidutz F, Döttger P, Erne F, Schreiner AJ, Hemmann P. Leukocyte esterase and alpha-defensin in periprosthetic joint infection: predictive quality and correlation in a prospective study. INTERNATIONAL ORTHOPAEDICS 2023; 47:2663-2668. [PMID: 37582980 PMCID: PMC10602937 DOI: 10.1007/s00264-023-05914-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/17/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE Periprosthetic joint infection (PJI) is a rare but serious complication of total joint arthroplasty (TJA). An accurate diagnosis of PJI preoperatively does not exist. Alpha-defensin (AD) is a proven and common indicator. The diagnostic marker of leukocyte esterase (LE) promises some advantages: feasibility, availability, and fast result reporting. The aim of this study was the evaluation of the predictive quality and correlation between both diagnostic tools in the diagnosis of PJI. METHODS A prospective study was conducted between April 2018 and August 2022. All patients with suspicion of PJI on hip and knee joint were included and underwent a routine and standardized joint punction. For laboratory diagnostics of AD, the synovial liquid was analyzed by ELISA. The sample was additionally applied to a LE test strip (Combur 10 Test, Roche Diagnostics, Mannheim, Germany). RESULTS A total of 249 patients were examined (mean age 67.12 ± 11.89; gender distribution man/woman 139 (55.8%)/110(44.2%), hip/knee 71(28.5%)/178 (71.5%). According to EBJIS criteria, PJI was diagnosed in 54 (21.7%) patients. AD showed excellent results with an AUC of 0.930 (sensitivity/specificity 0.870/0.990). LE yielded very good results with an AUC of 0.820 (sensitivity/specificity 0.722/0.918). Both parameters showed a strong positive correlation. CONCLUSION LE is a rapidly available alternative in PJI diagnostics. The simultaneous determination of both markers may enhance diagnostic reliability. A routine usage may shorten the time from diagnosis to treatment of PJI.
Collapse
Affiliation(s)
- Leonard Grünwald
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Schnarrenbergstrasse 95, 72076, Tuebingen, Germany
| | - Florian Schmidutz
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University of Munich (LMU), Munich, Germany
- Orthozentrum Rosenheim, Äußere Münchener Str. 94, 83026, Rosenheim, Germany
| | - Philipp Döttger
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Schnarrenbergstrasse 95, 72076, Tuebingen, Germany
| | - Felix Erne
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Schnarrenbergstrasse 95, 72076, Tuebingen, Germany.
- Siegfried Weller Institute for Trauma Research, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, 72076, Germany.
| | - Anna Janine Schreiner
- Siegfried Weller Institute for Trauma Research, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, 72076, Germany
| | - Philipp Hemmann
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Schnarrenbergstrasse 95, 72076, Tuebingen, Germany
| |
Collapse
|
4
|
Nelson SB, Pinkney JA, Chen AF, Tande AJ. Periprosthetic Joint Infection: Current Clinical Challenges. Clin Infect Dis 2023; 77:e34-e45. [PMID: 37434369 PMCID: PMC11004930 DOI: 10.1093/cid/ciad360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Indexed: 07/13/2023] Open
Abstract
Over the last several decades, periprosthetic joint infection has been increasing in incidence and is occurring in more complex patients. While there have been advances in both surgical and medical treatment strategies, there remain important gaps in our understanding. Here, we share our current approaches to the diagnosis and management of periprosthetic joint infection, focusing on frequent clinical challenges and collaborative interdisciplinary care.
Collapse
Affiliation(s)
- Sandra B Nelson
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jodian A Pinkney
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antonia F Chen
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron J Tande
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
5
|
Tsikopoulos K, Meroni G. Periprosthetic Joint Infection Diagnosis: A Narrative Review. Antibiotics (Basel) 2023; 12:1485. [PMID: 37887186 PMCID: PMC10604393 DOI: 10.3390/antibiotics12101485] [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: 08/27/2023] [Revised: 09/20/2023] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
Replacement of native joints aims to restore patients' quality of life by relieving pain and improving joint function. While periprosthetic joint infection (PJI) affects a small percentage of patients, with an estimated incidence of 1-9% following primary total joint replacement, this postoperative complication necessitates a lengthy hospitalisation, extended antibiotic treatment and further surgery. It is highlighted that establishing the correct diagnosis of periprosthetic infections is critical in order for clinicians to avoid unnecessary treatments in patients with aseptic failure. Of note, the PJI diagnosis could not purely rely upon clinical manifestations given the fact that heterogeneity in host factors (e.g., age and comorbidities), variability in infection period, difference in anatomical location of the involved joint and discrepancies in pathogenicity/virulence of the causative organisms may confound the clinical picture. Furthermore, intra-operative contamination is considered to be the main culprit that can result in early or delayed infection, with the hematogenous spread being the most prevalent mode. To elaborate, early and hematogenous infections often start suddenly, whereas chronic late infections are induced by less virulent bacteria and tend to manifest in a more quiescent manner. Last but not least, viruses and fungal microorganisms exert a role in PJI pathogenesis.
Collapse
Affiliation(s)
- Konstantinos Tsikopoulos
- 1st Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Gabriele Meroni
- One Health Unit, Department of Biomedical, Surgical and Dental Sciences, School of Medicine, University of Milan, 20133 Milan, Italy;
| |
Collapse
|
6
|
Yilmaz MK, Abbaszadeh A, Tarabichi S, Azboy I, Parvizi J. Diagnosis of Periprosthetic Joint Infection: The Utility of Biomarkers in 2023. Antibiotics (Basel) 2023; 12:1054. [PMID: 37370373 DOI: 10.3390/antibiotics12061054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a rare yet devastating complication following total joint arthroplasty (TJA). Early and accurate diagnosis of PJI is paramount in order to maximize the chances of successful treatment. However, we are yet to identify a single "gold standard" test for the diagnosis of PJI. As a result, the diagnosis of PJI is often challenging. Currently, the 2018 ICM definition of PJI is the only validated diagnostic criteria available. This article will review the importance of serum and synovial biomarkers in the diagnosis of PJI. In addition, it will provide a brief overview of the emerging modalities for the identification of infections in this setting.
Collapse
Affiliation(s)
- Mehmet Kursat Yilmaz
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Department of Orthopaedics and Traumatology, School of Medicine, Istanbul Medipol University, Istanbul 34810, Turkey
| | - Ahmad Abbaszadeh
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Saad Tarabichi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Ibrahim Azboy
- Department of Orthopaedics and Traumatology, School of Medicine, Istanbul Medipol University, Istanbul 34810, Turkey
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA
| |
Collapse
|
7
|
Li Z, Maimaiti Z, Fu J, Li ZY, Hao LB, Xu C, Chen JY. The superiority of immune-inflammation summary index for diagnosing periprosthetic joint infection. Int Immunopharmacol 2023; 118:110073. [PMID: 36989888 DOI: 10.1016/j.intimp.2023.110073] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/07/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Accurate and rapid diagnosis of periprosthetic joint infections (PJI) is particularly challenging. This study aimed to evaluate the diagnostic value of a newly developed immune-inflammation summary index (IISI) for PJI. METHODS Our study enrolled 171 aseptic loosening (AL) and 172 PJI cases. Based on a biological-driven approach, the IISI was formulated as C-reaction protein (CRP) × globulin × neutrophil / [lymphocyte × albumin]. Receiver operating characteristic (ROC) curves were constructed to compare the diagnostic performance of IISI with other known serum markers. Subgroup analysis was also performed to explore the robustness of IISI. Restricted cubic splines were used to evaluate the dose-response association. Additionally, changes in IISI levels prior to reimplantation were investigated. RESULTS The levels of all tested biomarkers were significantly different between the PJI and AL groups (all P < 0.05). ROC analysis revealed that IISI outperformed any other marker in diagnosing PJI with an area under the curve (AUC) value of 0.890. The diagnostic performance of IISI was also optimal in the hip (0.898), knee (0.903), low-grade infection (0.841), and culture-negative (0.919) subgroups. The optimal cut-off value is stabilized at around 1.6. The nonlinear association between IISI scores and PJI was also confirmed (P < 0.001). The levels of IISI before reimplantation demonstrated a significant decrease (P < 0.001) and were comparable to those of the AL group (P = 0.143). CONCLUSION IISI can improve the utilization of serum indicators and is superior to other well-known biomarkers in diagnosing PJI. Further studies should evaluate its specific role in different infectious and inflammatory diseases.
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|