Changes in serum markers failed to predict persistent infection after two-stage exchange arthroplasty

Diagnostic and Predictive Efficacy of Synovial Fluid Versus Serum C-Reactive Protein Levels for Periprosthetic Joint Infection and Reimplantation Success

BACKGROUND

A 2-stage exchange revision for periprosthetic joint infection (PJI) is associated with major risks for reinfection. Although serum markers are frequently used for diagnosis, their effectiveness remains debatable. Synovial fluid markers may offer a more accurate diagnosis of PJI; however, the importance of these biomarkers, notably synovial fluid C-reactive protein (syCRP), remains controversial, particularly in the context of reimplantation. The present study aimed to clarify these diagnostic uncertainties by evaluating the diagnostic efficacy of syCRP versus serum CRP (seCRP) levels in the context of PJI and recurring or persisting infections before reimplantation.

METHODS

A total of 186 patients were enrolled and divided into 2 groups: aseptic revision (n = 112) and PJI revision (n = 74). Of the PJI group, 65 were categorized as success and 9 as failure, based on the presence of recurrent or persistent infection before reimplantation. The syCRP and seCRP levels and their changes were assessed preoperatively and in the first-stage and second-stage revisions. Additionally, receiver operating characteristic (ROC) curves and area under the ROC curves (AUCs) were analyzed.

RESULTS

Both seCRP and syCRP levels were significantly elevated in the PJI group compared with the aseptic group (P < .001). The ROC curve analysis highlighted the enhanced diagnostic accuracy of syCRP for PJI, with an AUC of 0.93 versus 0.80 for seCRP. Furthermore, syCRP proved to be more reliable in predicting reimplantation success, exhibiting an AUC of 0.86 versus 0.63 for seCRP. In evaluating trends in CRP levels to determine reimplantation timing, changes in syCRP levels demonstrated superior diagnostic utility, exhibiting an AUC of 0.79 versus 0.63 for changes in seCRP levels.

CONCLUSIONS

In assessing PJI and infections before reimplantation, syCRP may offer enhanced accuracy compared with seCRP. Nevertheless, variations in both syCRP and seCRP levels did not consistently predict the outcome of reimplantation.

Rotational Thromboelastometry as a Diagnostic Tool for Persistent Infection in Two-Stage Exchange Arthroplasty

Background/Objectives: There is a lack of reliable biomarkers for diagnosis of infection eradication prior to second-stage reimplantation in two-stage exchange arthroplasty for periprosthetic joint infections (PJIs). The aim of this study was to assess the diagnostic accuracy of rotational thromboelastometry (ROTEM) for persistent infection in two-stage exchange arthroplasties. Methods: A pilot, retrospective analysis was performed including 70 patients who underwent a two-stage exchange arthroplasty for PJI. They were categorized as patients without (n = 64) or patients with persistent infection (n = 6) prior to reimplantation. Definition of persistent infection prior to reimplantation was based on the 2018 ICM criteria. Conventional coagulation biomarkers and ROTEM parameters were compared between groups. Results: Higher FIBTEM MCF values were associated with persistent infection (odds ratio [OR], 1.30, 95% confidence interval [CI], 1.04-1.63; p = 0.020), and FIBTEM MCF had the highest diagnostic accuracy for persistent infection prior to second-stage reimplantation (AUC, 0.907; 95% CI, 0.812-1.000). A cut-off value ≥ 18 mm for FIBTEM MCF was found to have 100.0% sensitivity and 73.4% specificity for diagnosing persistent infection prior to second-stage reimplantation. Moreover, the diagnostic accuracy of FIBTEM MCF was higher than that of fibrinogen levels (p = 0.036) and D-dimer (p = 0.006). Conclusions: Our findings indicate that ROTEM parameters have the potential to identify persistent infections before reimplantation in two-stage exchange arthroplasties for PJI. Such coagulation biomarkers could provide guidance regarding the optimal timing for reimplantation. Further studies in larger populations are warranted to validate the diagnostic accuracy of ROTEM parameters for persistent PJI.

The Change of Serum Interleukin-6 Fails to Identify Subsequent Periprosthetic Joint Infection in Patients Who Have Two-Stage Revision for Periprosthetic Joint Infection

BACKGROUND

The diagnosis of persistent infection prior to second-stage reimplantation in 2-stage exchanges for periprosthetic joint infection (PJI) can be challenging as there is no optimal diagnostic tool. This study investigates the usefulness of pre-reimplantation serum C-reactive protein (CRP) and interleukin-6 (IL-6) and its change between both stages to identify patients who have subsequent PJI.

METHODS

There were 125 patients who underwent planned 2-stage exchange for chronic knee or hip PJI from a single center retrospectively identified. Patients were included if preoperative CRP and IL-6 were available for both stages. Subsequent PJI was defined as 2 positive microbiological cultures at reimplantation or subsequent surgery or death due to PJI during follow-up.

RESULTS

Prior to reimplantation, the median serum CRP (total knee arthroplasties [TKAs]: 1.0 versus 0.5 mg/dL, P = .028; total hip arthroplasties [THAs]: 1.3 versus 0.5 mg/dL, P = .015) and median IL-6 (TKA: 8.0 versus 6.0 pg/mL, P = .052; THA: 7.0 versus 6.0 pg/mL, P = .239) were higher in patients who had subsequent PJI. The IL-6 and CRP values showed moderate sensitivity (TKA/CRP: 66.7%; THA/CRP: 58.8%; TKA/IL-6: 46.7%; THA/IL-6: 35.3%) and good specificity (TKA/CRP: 66.7%; THA/CRP: 81.0%; TKA/IL-6: 86.3%; THA/IL-6: 83.3%). The change in CRP and IL-6 between the stages did not differ between the groups, respectively.

CONCLUSIONS

Serum CRP and IL-6 show low to moderate sensitivity and good specificity in the diagnosis of subsequent PJI prior to reimplantation, which questions their usefulness as a rule-out test. Furthermore, the change in between stages does not appear to identify subsequent PJI.

Interval between two-stage exchanges: what is optimal and how do you know?

BACKGROUND

Two-stage exchange arthroplasty remains the most popular option for the treatment of chronic periprosthetic joint infection (PJI). Determining infection eradication and optimal timing of reimplantation can be challenging. Information to allow for a truly informed evidence-based decision is scarce.

METHODS

We conducted a critical review of available evidence on the presently available tests to help determine timing of reimplantation.

RESULTS

Serology is traditionally used to follow up patients after the first stage. Despite tradition mandates waiting for normal inflammatory markers, there is actually no evidence that they correlate with persistent infection. The role of synovial fluid investigation between stages is also explored. Cultures lack sensitivity and neither differential leukocyte counts nor alternative biomarkers have proven to be accurate in identifying persistent infection with a spacer in situ. We also examined the evidence regarding the optimal time interval between resection and reimplantation and whether there is evidence to support the implementation of a two week "antibiotic holiday" prior to proceeding with reimplantation. Finally, wound healing and other important factors in this setting will be discussed.

CONCLUSION

Currently there are no accurate metrics to aid in the decision on the optimal timing for reimplantation. Decision must therefore rely on the resolution of clinical signs and down trending serological and synovial markers.

Utility of Diagnostic Tests Before Reimplantation in Patients Undergoing 2-Stage Revision Total Joint Arthroplasty: A Systematic Review and Meta-analysis

INTRODUCTION

Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty (TJA), with treatment failure occurring in 12% to 28% after 2-stage revision. It is vital to identify diagnostic tools indicative of persistent infection or treatment failure after 2-stage revision for PJI.

METHODS

The Cochrane Library, PubMed (MEDLINE), and EMBASE were searched for randomized controlled trials and comparative observational studies published before October 3, 2021, which evaluated the utility of serum/plasma biomarkers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], interleukin-6 [IL-6], fibrinogen, D-dimer), synovial biomarkers (white blood cell [WBC] count, neutrophil percentage [PMN %], alpha-defensin [AD], leukocyte esterase [LE]), tissue frozen section, tissue culture, synovial fluid culture, or sonicated spacer fluid culture indicative of persistent infection before the second stage of 2-stage revision for PJI or treatment failure after 2-stage revision for PJI.

RESULTS

A total of 47 studies including 6,605 diagnostic tests among 3,781 2-stage revisions for PJI were analyzed. Among those cases, 723 (19.1%) experienced persistent infection or treatment failure. Synovial LE (sensitivity 0.25 [0.10-0.47], specificity 0.99 [0.93-1.00], positive likelihood ratio 14.0 [1.45-135.58]) and serum IL-6 (sensitivity 0.52 [0.33-0.70], specificity 0.92 [0.85-0.96], positive likelihood ratio 7.90 [0.86-72.61]) had the highest diagnostic accuracy. However, no biomarker was associated with a clinically useful negative likelihood ratio. In subgroup analysis, synovial PMN %, synovial fluid culture, serum ESR, and serum CRP had limited utility for detecting persistent infection before reimplantation (positive likelihood ratios ranging 2.33-3.74; negative likelihood ratios ranging 0.31-0.9) and no utility for predicting failure after the second stage of 2-stage revision.

CONCLUSIONS

Synovial WBC count, synovial PMN %, synovial fluid culture, serum ESR, and serum CRP have modest sensitivity and specificity for predicting persistent infection during the second stage of 2-stage revision, suggesting some combination of these diagnostic tests might be useful before reimplantation. No biomarker or culture accurately predicted treatment failure after reimplantation.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

Diagnostic Utility and Thresholds for Commonly Obtained Serum and Synovial Markers Prior to Reimplantation in Periprosthetic Joint Infection

BACKGROUND

Accurate diagnosis of persistent periprosthetic joint infection (PJI) during 2-stage exchange remains a challenge. This study evaluated the diagnostic performance and thresholds of several commonly obtained serum and synovial markers to better guide reimplantation timing.

METHODS

This was a retrospective review of 249 patients who underwent 2-stage exchange with antibiotic spacers for PJI. Serum and synovial markers analyzed included white blood cell (WBC) count, polymorphonuclear percentage (PMN%), neutrophil-to-lymphocyte ratio (NLR), and absolute neutrophil count (ANC). Serum markers analyzed were erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), as well as percentage change in ESR and CRP from initial diagnosis to reimplantation. Area under the curve (AUC) analyses were performed to determine diagnostic accuracy of detecting PJI.

RESULTS

In TKAs, synovial ANC and WBC had the highest AUCs (0.76), with thresholds of 2,952 and 3,800 cells/μL, respectively. The next best marker was serum CRP (0.73) with a threshold of 5.2 mg/dL. In THAs, serum CRP had the highest AUC (0.84) with a threshold of 4.3 mg/dL, followed by synovial PMN% (0.80) with a threshold of 77%. Percentage change in serum ESR or CRP provided low diagnostic value overall.

CONCLUSION

Regarding serum markers, CRP consistently performed well in detecting persistent PJI in patients with antibiotic spacers. Absolute values of serum CRP and ESR had better diagnostic value than trends for guiding reimplantation timing. Diagnostic performance differed with joint type; however, synovial markers outperformed serum counterparts. No marker alone can be utilized to diagnose residual PJI in these patients, and further work is needed in this domain.

Diagnostic Value of C-Reactive Protein and Serum White Blood Cell Count during Septic Two-Stage Revision of Total Knee Arthroplasties

AIMS AND METHODS

In septic two-stage revision arthroplasty, the timing of reimplantation is crucial for therapeutic success. Recent studies have shown that singular values of C-reactive protein (CRP) and white blood cell count (WBC count) display weak diagnostic value in indicating whether periprosthetic joint infection (PJI) is controlled or not during two-stage revision surgery of knee arthroplasty. Therefore, in addition to the values of CRP and WBC, the course of CRP and WBC counts were compared between groups with and without later reinfection in 95 patients with two-stage revision (TSR) of infected total knee arthroplasties (TKA). Of these patients, 16 had a reinfection (16.84%).

RESULTS

CRP values decreased significantly after the first stage of TSR in both the reinfection and no-reinfection groups. WBC count values decreased significantly in the no-reinfection group. Decrease in WBC count was not significant in the reinfection group. No significant difference could be found in either the CRP values or the WBC counts at the first stage of TSR, the second stage of TSR, or their difference between stages when comparing groups with and without reinfection. Area under the curve (AUC) values ranging between 0.631 and 0.435 showed poor diagnostic value for the calculated parameters. The courses of CRP over 14 days after the first stage of both groups were similar with near identical AUC.

CONCLUSIONS

CRP and WBC count as well as their course over 14 days postoperatively are not suitable for defining whether a PJI of the knee is under control or not.

Diagnostic Value of CRP and Serum WBC Count during Septic Two-Stage Revision of Total Hip Arthroplasties

The diagnostic value of C-reactive protein (CRP) and the serum white blood cell (WBC) count is still barely defined for decision making during septic two-stage revision surgery of hip arthroplasty. We, therefore, compared these values between stages as well as between the groups without and with reinfection in 117 patients. A total of 106 patients were reinfection-free (91%). The median follow-up was 51 months. With a ΔCRP of −10 mg/L and a ΔWBC count of −1000/µL, a significant decrease between stages (p = 0.001) could be observed. When comparing the CRP and WBC count values between groups, however, no significant difference was found at stage one, stage two and even the difference between these two time points (reinfection-free ΔCRP of −11 mg/L and ΔWBC count of −1000/µL vs. reinfection ΔCRP of −5 mg/L (p = 0.131) and ΔWBC count of −1100/µL) (p = 0.424). The diagnostic value was poor for the calculated parameters (area under the curve (AUC) 0.5–0.6). The courses of the mean CRP values of both groups were similar. We conclude that the CRP and WBC count are not helpful to guide the decision making in individual cases.

The potential performance of serum albumin to globulin ratio, albumin and globulin in the diagnosis of periprosthetic joint infection and prediction of reinfection following reimplantation

Background

This study was conducted to evaluate the performance of serum albumin (ALB), globulin (GLO), and albumin to globulin ratio (AGR) in the diagnosis of PJI and prediction of reinfection following reimplantation in PJI patients who underwent two-stage revision.

Methods

We perform a retrospective data collection on identified patients who underwent revision arthroplasties in our institution from January 2010 to January 2020. A total of 241 patients were stratified into: group A (PJI), group B (aseptic loosening). Fifty-five patients who underwent two-stage revision in group A were assigned to group C. Group C was stratified into subgroup 1 (reinfection) and subgroup 2 (non-reinfection). Receiver operating characteristic curves were used to evaluate the utility of serum markers for diagnosing PJI and predicting reinfection following reimplantation.

Results

In the diagnosis of PJI, there were significant differences in the levels of ALB, GLO, and AGR between groups A and group B (P < 0.05). The AUC value of serum AGR (0.851) was similar to ESR (0.841) and CRP (0.866) (all p > 0.05). The AUC values of serum ALB and GLO were 0.757 and 0.753, respectively. As for predicting reinfection following reimplantation, the serum ALB in the non-reinfection group was higher than that in the reinfection group (p = 0.041). The AUC value of serum ALB was 0.7.

Conclusion

AGR was promising adjunct marker for the diagnosis of PJI, similar to CRP and ESR. ALB and GLO have an acceptable value for the diagnosis of PJI. ALB may be expected to be a kind of effective marker for predicting reinfection following reimplantation.

Globulin and albumin to globulin ratio precisely diagnose periprosthetic joint infection and determine the timing of second-stage reimplantation

Background

Periprosthetic joint infection (PJI) is one of the most challenging complications of total joint arthroplasty (TJI). An early and accurate diagnosis of PJI is associated with better treatment outcomes. However, whether the platelet-related markers and globulin-related markers can be used to assist the diagnosis of PJI remains elusive.

Methods

A total of 206 patients who underwent revision hip or knee arthroplasty in our institution were divided into two groups: 79 patients in PJI group and 127 patients in aseptic failure group. The levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), platelet-related markers including platelet count (PLT), mean platelet volume (MPV), plateletcrit (PCT) and PLT to MPV ratio (PMR) and globulin-related markers such as globulin (GLB), albumin to globulin ratio (AGR) and PLT to AGR ratio were compared. The diagnostic value was measured using area under the curve (AUC) after constructing receiver operating characteristic (ROC) curves. The potential of each marker for determining the timing of second-staged reimplantation was also evaluated.

Results

Significantly increased levels of ESR, CRP, PLT, PCT, PMR, GLB and PLT to AGR ratio were identified in PJI group, while decreased levels of MPV and AGR were also found. The diagnostic values of all platelet-related markers and GLB were considered as fair, and good diagnostic values of AGR and PLT to AGR ratio were found, which were comparable to those of ESR and CRP. The levels of GLB and AGR can also be used to predict negative culture result and the timing of second-stage reimplantation.

Conclusions

Globulin and albumin to globulin ratio were found to have good diagnostic values for PJI, and they can precisely predict the culture results and persistent infection.

Plasma fibrinogen is a reliable marker for diagnosing periprosthetic joint infection and determining the timing of second-stage revision

OBJECTIVES

We investigated the diagnostic value of fibrinolytic markers for periprosthetic joint infection (PJI), determined their relationship with culture results, and evaluated whether these markers could assess infection control and determine the timing of second-stage reimplantation.

DESIGN/METHODS

This single-center-retrospective study included 206 patients who underwent revision hip or knee arthroplasty (PJI group, n = 79; aseptic loosening [AL] group, n = 127). The plasma levels of fibrinogen, d-dimer, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were compared, and receiver operating characteristic curves were constructed. Subgroup analysis within the PJI group was also performed.

RESULTS

The plasma levels of fibrinogen, d-dimer, ESR, and CRP were significantly lower in the AL group, with an area under the curve of 0.848, 0.669, 0.865, and 0.841, respectively. The plasma level of d-dimer was significantly lower in patients with culture-negative PJI. In patients with residual infection, the levels of all the markers had not significantly changed, while noticeably decreased plasma levels of fibrinogen, ESR, and CRP were detected in patients with successful second-stage reimplantation.

CONCLUSIONS

Plasma fibrinogen is a promising marker for diagnosing PJI and evaluating persistent infection. Decreased plasma levels of d-dimer in patients with PJI might be linked with negative culture results.

The change in plasma D-dimer does not help to guide the timing of reimplantation in two stage exchange for periprosthetic joint infection

D-dimer has been included in the criteria by the Musculoskeletal Infection Society in 2018 as a novel parameter to diagnose prosthetic joint infection (PJI). However, it is unclear how D-dimer levels change in between stages of a two-stage exchange. We prospectively investigated 30 patients who underwent a two-stage exchange using a spacer for PJI. D-Dimer, CRP and IL-6 were collected before first and second stage surgery and the difference (Δ) in between stages was calculated. The levels of plasma D-Dimer did not change from first to second stage surgery (2770 ng/ml (IQR, 1600–3770 ng/ml) versus 2340 ng/ml (IQR, 1270–4100 ng/ml); p = 0.8) while CRP (4.0 mg/dl (IQR, 1.7–5.5 mg/dl) versus 0.6 mg/dl (IQR, 0.5–0.8 mg/dl); p < 0.001) and IL-6 (21 pg/ml (IQR, 10–29 pg/ml) versus 6 pg/ml (4–9 pg/ml); p < 0.001) decreased. The ΔD-dimer between both stages was 300 ng/ml (range: − 2820 to 4280 ng/ml), the median ΔCRP was − 3.4 mg/dl (IQR, − 1.2 to − 4.8 mg/dl) and ΔIL-6 was − 13 pg/ml (IQR, − 4 to − 20 pg/ml). In 15 of 30 cases (50%) the D-dimer level increased between both stages, whereas the level of CRP (93%; 28/30) and IL-6 (96%; 28/29) decreased in most patients. As the level of serum D-dimers varies greatly, lacks a uniform decrease and does not identify persisting infection, surgeons should be cautious when using it at the timing of reimplantation.