1
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Treu EA, Behrens NF, Blackburn BE, Cushman DM, Archibeck MJ. A "Dry Tap" in Prosthetic Joint Infection Workup of Total Hip Arthroplasty Is Not Reassuring. J Arthroplasty 2024; 39:S220-S224. [PMID: 38401609 DOI: 10.1016/j.arth.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Synovial fluid analysis is important in diagnosing prosthetic joint infection (PJI). The rate of culture-positive PJI in patients who have a dry tap of a total hip arthroplasty (THA) is not well described. METHODS We reviewed all image-guided THA aspirations, performed from 2014 to 2021 at a single academic institution. Aspirations were categorized as successful (≥ 0.5 mL) or unsuccessful (< 0.5 mL, "dry tap"). We analyzed culture data on all repeat aspirations and revision surgeries performed within 90 days of the initial dry tap. RESULTS We reviewed 275 consecutive attempted THA aspirations of which 100 (36.4%) resulted in a dry tap. The dry tap cohort had a significantly higher percentage of fluoroscopic-guided aspirations (64%) and fewer ultrasound-guided aspirations (36%) compared to the successful aspiration cohort (48.9% fluoroscopic, 53.1% ultrasound, P = .0061). Of the 100 patients who have dry taps, 48 underwent revision surgery within 90 days of the initial dry tap, and 15 resulted in 2 or more positive cultures. The rate of PJI defined by MusculoSkeletal Infection Society major criteria in the dry tap cohort was 16.0%. CONCLUSIONS Attempted aspiration of a THA resulted in a dry tap 36.4% of the time. Of those patients who had a dry tap, 16.0% were subsequently found to have PJI based on MusculoSkeletal Infection Society major criteria. Therefore, a "dry tap" does not exclude the diagnosis of infection and should not be considered reassuring for the absence of PJI.
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Affiliation(s)
- Emily A Treu
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Nathan F Behrens
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | | | - Daniel M Cushman
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah; Department of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah
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Al-Jabri T, Ridha M, Wood MJ, Kayani B, Jayadev C, McCulloch RA, Schemitsch E. An overview of the current diagnostic approach to Periprosthetic Joint Infections. Orthop Rev (Pavia) 2024; 16:120308. [PMID: 38957745 PMCID: PMC11218870 DOI: 10.52965/001c.120308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/24/2024] [Indexed: 07/04/2024] Open
Abstract
The diagnosis of periprosthetic joint infections (PJI) presents a formidable challenge to orthopaedic surgeons due to its complex and diverse manifestations. Accurate diagnosis is of utmost importance, as even mild pain following joint replacement surgery may indicate PJI in the absence of a definitive gold standard diagnostic test. Numerous diagnostic modalities have been suggested in the literature, and international societies have continually updated diagnostic criteria for this debilitating complication. This review article aims to comprehensively examine the latest evidence-based approaches for diagnosing PJI. Through a thorough analysis of current literature, we explore promising diagnostic strategies that have demonstrated effectiveness in identifying PJI. These strategies encompass the utilization of laboratory markers, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), alongside imaging techniques such as magnetic resonance imaging (MRI) and leukocyte scintigraphy. Additionally, we highlight the importance of synovial fluid analysis, including the potential role of alpha-defensin as a biomarker, and examine evolving international diagnostic criteria to standardize and improve diagnostic accuracy.
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Affiliation(s)
- Talal Al-Jabri
- Department of Surgery and Cancer Imperial College London
| | | | | | | | - Chethan Jayadev
- Joint Reconstruction Unit Royal National Orthopaedic Hospital NHS Trust
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3
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Altsitzioglou P, Avgerinos K, Karampikas V, Gavriil P, Vlachos A, Soucacou F, Zafiris I, Kontogeorgakos V, Papagelopoulos PJ, Mavrogenis AF. Point of care testing for the diagnosis of periprosthetic joint infections: a review. SICOT J 2024; 10:24. [PMID: 38847648 PMCID: PMC11160401 DOI: 10.1051/sicotj/2024019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 05/04/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) remains a major complication following total joint arthroplasties (TJA), significantly affecting patient outcomes and healthcare costs. Despite advances in diagnostic techniques, challenges persist in accurately diagnosing PJI, underscoring the need for effective point-of-care testing (POCT). METHODS This review examines the current literature and latest developments in POCT for diagnosing PJI, focusing on biomarkers such as alpha-defensin, leukocyte esterase, calprotectin, and C-reactive protein (CRP). Criteria from various societies like the Musculoskeletal Infection Society, Infectious Diseases Society of America, and the International Consensus Meeting were compared to evaluate the effectiveness of these biomarkers in a point-of-care setting. RESULTS POCT provides rapid results essential for the timely management of PJI, with alpha-defensin and leukocyte esterase showing high specificity and sensitivity. Recent advancements have introduced novel biomarkers like calprotectin, which demonstrate high diagnostic accuracy. However, challenges such as the variability in test performance and the need for validation under different clinical scenarios remain. DISCUSSION While POCT for PJI shows promising results, their integration into clinical practice requires standardized protocols and further validation. The evolution of these diagnostic tools offers a potential shift toward more personalized and immediate care, potentially improving outcomes for patients undergoing TJA.
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Affiliation(s)
- Pavlos Altsitzioglou
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Konstantinos Avgerinos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vasileios Karampikas
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis Gavriil
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Apostolos Vlachos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Fotini Soucacou
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Zafiris
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vasileios Kontogeorgakos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis J Papagelopoulos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas F Mavrogenis
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Debbi E, Khilnani T, Gkiatas I, Chiu YF, Miller A, Henry M, Carli A. Changing the definition of treatment success alters treatment outcomes in periprosthetic joint infection: a systematic review and meta-analysis. J Bone Jt Infect 2024; 9:127-136. [PMID: 38895103 PMCID: PMC11184615 DOI: 10.5194/jbji-9-127-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/04/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Variability in the definition of treatment success poses difficulty when assessing the reported efficacy of treatments for hip and knee periprosthetic joint infection (PJI). To address this problem, we determined how definitions of PJI treatment success have changed over time and how this has affected published rates of success after one-stage and two-stage treatments for hip and knee PJI. Methods: A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify one-stage and two-stage revision hip and knee PJI publications in major databases (2006-2021). Definition of treatment success, based on Musculoskeletal Infection Society tier criteria, was identified for each study. Publication year, number of patients, minimum follow-up, and study quality were also recorded. The association of success definitions and treatment success rate was measured using multi-variable meta-regression. Results: Study quality remained unchanged in the 245 publications included. Over time, no antibiotics (tier 1) and no further surgery (tier 3) (40.7 % and 54.5 %, respectively) became the two dominant criteria. After controlling for type of surgery, study quality, study design, follow-up, and year of publication, studies with less strict success definitions (tier 3) reported slightly higher odds ratios of 1.05 [1.01, 1.10] ( p = 0.009 ) in terms of treatment success rates compared to tier 1. Conclusions: PJI researchers have gravitated towards tier-1 and tier-3 definitions of treatment success. While studies with stricter definitions had lower PJI treatment success, the clinical significance of this is unclear. Study quality, reflected in the methodological index for non-randomized studies (MINORS) score, did not improve. We advocate for improving PJI study quality, including clarification of the definition of treatment success.
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Affiliation(s)
- Eytan M. Debbi
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Tyler Khilnani
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Ioannis Gkiatas
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Yu-Fen Chiu
- Biostatistics Core, Research Administration, Hospital for Special Surgery, New York, NY, USA
| | - Andy O. Miller
- Department of Infectious Disease, Hospital for Special Surgery, New York, NY, USA
| | - Michael W. Henry
- Department of Infectious Disease, Hospital for Special Surgery, New York, NY, USA
| | - Alberto V. Carli
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
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Jardon M, Fritz J, Samim M. Imaging approach to prosthetic joint infection. Skeletal Radiol 2023:10.1007/s00256-023-04546-7. [PMID: 38133670 DOI: 10.1007/s00256-023-04546-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/08/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Abstract
The diagnosis of prosthetic joint infection (PJI) remains challenging, despite multiple available laboratory tests for both serum and synovial fluid analysis. The clinical symptoms of PJI are not always characteristic, particularly in the chronic phase, and there is often significant overlap in symptoms with non-infectious forms of arthroplasty failure. Further exacerbating this challenge is lack of a universally accepted definition for PJI, with publications from multiple professional societies citing different diagnostic criteria. While not included in many of the major societies' guidelines for diagnosis of PJI, diagnostic imaging can play an important role in the workup of suspected PJI. In this article, we will review an approach to diagnostic imaging modalities (radiography, ultrasound, CT, MRI) in the workup of suspected PJI, with special attention to the limitations and benefits of each modality. We will also discuss the role that image-guided interventions play in the workup of these patients, through ultrasound and fluoroscopically guided joint aspirations. While there is no standard imaging algorithm that can universally applied to all patients with suspected PJI, we will discuss a general approach to diagnostic imaging and image-guided intervention in this clinical scenario.
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Affiliation(s)
- Meghan Jardon
- Department of Radiology, NYU Langone Medical Center, New York, NY, USA.
| | - Jan Fritz
- Department of Radiology, NYU Langone Medical Center, New York, NY, USA
| | - Mohammad Samim
- Department of Radiology, NYU Langone Medical Center, New York, NY, USA
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Balta O, Astan S, Altınayak H, Uçar C, Aytekin FY, Kurnaz R. Can C-Reactive Protein-Lymphocyte Ratio Be Used as a Screening Tool to Confirm the Diagnosis of Periprosthetic Joint Infection? Clin Orthop Surg 2023; 15:917-927. [PMID: 38045571 PMCID: PMC10689224 DOI: 10.4055/cios22313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 08/13/2023] [Accepted: 08/13/2023] [Indexed: 12/05/2023] Open
Abstract
Background This study aimed to investigate whether periprosthetic joint infection (PJI) can be predicted by the C-reactive protein-to-lymphocyte ratio (CLR), whether this ratio increases the accuracy of PJI diagnosis, and whether it is more sensitive than other blood values and ratios. Methods The patients were divided into two groups: the septic revision (SR) group and the aseptic revision (AR) group. In cases of septic revision, the diagnosis of PJI was made based on the criteria proposed by the European Bone and Joint Infection Society (EBJIS). The groups were compared in terms of age, sex, body mass index, comorbidity, and preoperative laboratory results. The sensitivity, specificity, and diagnostic performance of the values and ratios were analyzed and compared. Results The receiver operating characteristic (ROC) analysis for the CLR gave a diagnostic value of 15.52, which provided a sensitivity of 91.1% and a specificity of 64.2% for PJI. The CLR gave lower specificity and higher sensitivity compared to the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values. The ROC analysis showed that the CLR had a similar area under the curve (AUC) with the ESR and CRP (0.808). The CLR had a higher specificity than other ratios (platelet volume ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and monocyte-to-lymphocyte ratio) and a higher value of the AUC. In the multivariate analysis, the CLR (hazard ratio, 1.088; 95% confidence interval, 1.063-1.113; p < 0.001) was found to be a significant risk factor. As CLR increased by one unit, the risk of PJI increased by 1.088 times, and it was statistically significant (p < 0.001). Conclusions The findings of this study suggest that CLR can serve as a valuable screening tool for diagnosing PJI. CLR demonstrated higher sensitivity in predicting PJI compared to ESR and CRP, and it exhibited greater specificity than other infection markers.
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Affiliation(s)
- Orhan Balta
- Department of Orthopaedics and Traumatology, Gaziosmanpasa University Hospital, Tokat, Türkiye
| | - Sezer Astan
- Department of Orthopaedics and Traumatology, Tokat State Hospital, Tokat, Türkiye
| | - Harun Altınayak
- Department of Orthopedics and Traumatology, Samsun Training and Research Hospital, Health Sciences University, Samsun, Türkiye
| | - Cihan Uçar
- Department of Orthopedics and Traumatology, Trabzon Kanuni Training and Research Hospital, Trabzon, Türkiye
| | - Feyza Yildiz Aytekin
- Department of Infectious Diseases and Clinical Microbiology, Ministry of Health Prof. Dr. A. Ilhan Özdemir State Hospital, Giresun, Türkiye
| | - Recep Kurnaz
- Department of Orthopaedics and Traumatology, Acıbadem State Hospital, Eskişehir, Türkiye
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Krueger JS, Ackmann T, Gosheger G, Moellenbeck B, Puetzler J, Theil C. The Change of Serum Interleukin-6 Fails to Identify Subsequent Periprosthetic Joint Infection in Patients Who Have Two-Stage Revision for Periprosthetic Joint Infection. J Arthroplasty 2023; 38:2698-2703. [PMID: 37315631 DOI: 10.1016/j.arth.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 06/16/2023] Open
Abstract
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.
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Affiliation(s)
- Johanna S Krueger
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Thomas Ackmann
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Georg Gosheger
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Burkhard Moellenbeck
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Jan Puetzler
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Christoph Theil
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
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Mozella ADP, Cobra HADAB, Minamoto STN, Salim R, Leal AC. Accuracy of Serological Markers, Synovial Fluid, Microbiological Culture, and Histopathological Examination for Diagnosing Periprosthetic Knee Infection. Rev Bras Ortop 2023; 58:e917-e923. [PMID: 38077763 PMCID: PMC10708974 DOI: 10.1055/s-0043-1776907] [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: 08/29/2022] [Accepted: 01/18/2023] [Indexed: 08/03/2024] Open
Abstract
Objective This study assessed the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of serological tests, synovial fluid markers, microbiological tissue culture, and histopathological examination of the periprosthetic membrane in diagnosing periprosthetic knee infection. Methods This study is prospective, and it includes patients undergoing total knee arthroplasty revision surgery from November 2019 to December 2021. The analysis consisted of serological tests (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], and D-dimer), synovial fluid markers (leukocyte and polymorphonuclear cell counts), periprosthetic tissue culture, and histopathological examination of the periprosthetic membrane of all patients. Results Sixty-two patients had periprosthetic joint infection (PJI) according to the 2018 International Consensus Meeting criteria (infection group), while 22 subjects had no infection. ESR sensitivity and specificity were 83.6% and 45.4%, respectively. CRP sensitivity and specificity were 64.5% and 100%, whereas D-dimer sensitivity and specificity were 78.9% and 25%, respectively. Leukocyte count sensitivity and specificity were 75.6% and 100%, polymorphonuclear cell count sensitivity and specificity were 33% and 100%, respectively. Periprosthetic tissue culture sensitivity and specificity culture were, respectively, 77.4% and 100%. Histopathological examination sensitivity and specificity were 43.7% and 100%, respectively. Conclusions In our study, the total blood cell count in synovial fluid and microbiological cultures of periprosthetic tissues were the most accurate tests for PJI diagnosis. In contrast, polymorphonuclear cell percentage was the least accurate test for PJI diagnosis.
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Affiliation(s)
- Alan de Paula Mozella
- Médico ortopedista e traumatologista do Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
| | - Hugo Alexandre de Araújo Barros Cobra
- Médico ortopedista e traumatologista do Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
| | - Sandra Tie Nishibe Minamoto
- Médico ortopedista e traumatologista do Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
| | - Rodrigo Salim
- Médico ortopedista e traumatologista do Departamento de Ortopedia e Anestesiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP-RP), Ribeirão Preto, São Paulo, Brasil
| | - Ana Carolina Leal
- Pesquisadora da Divisão de Ensino e Pesquisa, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
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Weissman BN, Palestro CJ, Fox MG, Bell AM, Blankenbaker DG, Frick MA, Jawetz ST, Kuo PH, Said N, Stensby JD, Subhas N, Tynus KM, Walker EA, Kransdorf MJ. ACR Appropriateness Criteria® Imaging After Total Hip Arthroplasty. J Am Coll Radiol 2023; 20:S413-S432. [PMID: 38040462 DOI: 10.1016/j.jacr.2023.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
This article reviews evidence for performing various imaging studies in patients with total hip prostheses. Routine follow-up is generally performed with radiography. Radiographs are also usually the initial imaging modality for patients with symptoms related to the prosthesis. Following acute injury with pain, noncontrast CT may add information to radiographic examination regarding the presence and location of a fracture, component stability, and bone stock. Image-guided joint aspiration, noncontrast MRI, and white blood cell scan and sulfur colloid scan of the hip, are usually appropriate studies for patients suspected of having periprosthetic infection. For evaluation of component loosening, wear, and/or osteolysis, noncontrast CT or MRI are usually appropriate studies. Noncontrast MRI is usually appropriate for identifying adverse reaction to metal debris related to metal-on-metal articulations. For assessing patients after hip arthroplasty, who have trochanteric pain and nondiagnostic radiographs, ultrasound, or MRI are usually appropriate studies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | | | | | - Angela M Bell
- Rush University Medical Center, Chicago, Illinois; American College of Physicians
| | - Donna G Blankenbaker
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | | | - Phillip H Kuo
- University of Arizona, Tucson, Arizona; Commission on Nuclear Medicine and Molecular Imaging
| | - Nicholas Said
- Duke University Medical Center, Durham, North Carolina
| | | | | | - Katherine M Tynus
- Northwestern Memorial Hospital, Chicago, Illinois; American College of Physicians
| | - Eric A Walker
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Uniformed Services University of the Health Sciences, Bethesda, Maryland
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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.
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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;
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11
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Sousa R, Carvalho A, Soares D, Abreu MA. Interval between two-stage exchanges: what is optimal and how do you know? ARTHROPLASTY 2023; 5:33. [PMID: 37403130 DOI: 10.1186/s42836-023-00185-4] [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: 12/27/2022] [Accepted: 04/04/2023] [Indexed: 07/06/2023] Open
Abstract
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.
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Affiliation(s)
- Ricardo Sousa
- Department of Orthopedics, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal.
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal.
| | - André Carvalho
- Department of Orthopedics, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal
| | - Daniel Soares
- Department of Orthopedics, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal
| | - Miguel Araújo Abreu
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal
- Department of Infectious Diseases, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
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12
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Treu EA, Cushman DM, Wheelwright J, Blackburn B, Teramoto M, Archibeck M. Is ultrasound-guided hip aspiration more successful than fluoroscopic-guided aspiration in diagnosing prosthetic joint infection? J Bone Jt Infect 2023; 8:151-163. [PMID: 38774034 PMCID: PMC11106766 DOI: 10.5194/jbji-8-151-2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/26/2023] [Indexed: 05/24/2024] Open
Abstract
Introduction: aspiration of total hip arthroplasty (THA) is commonly performed to assist in the diagnosis of prosthetic joint infection (PJI). This study aimed to determine whether fluoroscopic- or ultrasound- guided hip aspiration differs in the ability to acquire synovial fluid and in the accuracy of diagnosing infection. Methods: all THA aspirations performed between 2014 and 2021 at our institution were retrospectively identified. Aspirations were classified as successful or dry. If successful, the volume of fluid obtained was recorded. The sensitivity and specificity of hip aspiration in identifying PJI were calculated with four methods: (1) culture results excluding saline lavage, (2) culture results including saline lavage, (3) 2018 Musculoskeletal Infection Society (MSIS) International Consensus Meeting (ICM) criteria, and (4) 2021 European Bone and Joint Infection Society (EBJIS) criteria. Analyses were performed using Student's t test or Wilcoxon rank sum for continuous variables and chi-squared or Fisher's exact test for categorical variables. Results: 290 aspirations were included (155 fluoroscopic-guided and 135 ultrasound-guided). Success of aspiration (> 0.5 mL) was more common in the ultrasound cohort (69 %) than fluoroscopy (53 %) (p < 0.0055 ). When successful, more volume was obtained in the ultrasound cohort (mean 13.1 mL vs. 10.0 mL; p = 0.0002 ). Ultrasound-guided aspiration was more sensitive than fluoroscopy in diagnosing PJI using culture results excluding saline lavage (85 % vs. 73 %; p = 0.03 ), culture results including saline lavage (85 % vs. 69 %; p = 0.001 ), 2018 MSIS-ICM criteria (77 % vs. 52 %; p = 0.02 ), and 2021 EBJIS criteria (87 % vs. 65 %; p = 0.02 ). Ultrasound-guided aspiration was more specific than fluoroscopy in diagnosing PJI using 2021 EBJIS criteria (100 % vs. 96 %; p = 0.001 ). Conclusions: ultrasound-guided aspiration is more frequently successful and yields more fluid than fluoroscopic-guided aspiration of THA. Ultrasound-guided aspiration is more sensitive in diagnosing PJI than fluoroscopy using culture data, 2018 MSIS-ICM criteria, and 2021 EBJIS criteria.
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Affiliation(s)
- Emily A. Treu
- Department of Orthopedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Daniel M. Cushman
- Department of Orthopedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
- Department of Physical Medicine & Rehabilitation, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - John C. Wheelwright
- Department of Orthopedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Brenna E. Blackburn
- Department of Orthopedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Masaru Teramoto
- Department of Physical Medicine & Rehabilitation, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Michael J. Archibeck
- Department of Orthopedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
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13
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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: 6] [Impact Index Per Article: 6.0] [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.
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14
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Dong S, Mei F, Li JJ, Xing D. Global Cluster Analysis and Network Visualization in Prosthetic Joint Infection: A Scientometric Mapping. Orthop Surg 2023; 15:1165-1178. [PMID: 36855945 PMCID: PMC10102317 DOI: 10.1111/os.13681] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/22/2022] [Accepted: 12/15/2022] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVE Prosthetic joint infection (PJI) is the main reason of failure of total joint arthroplasty (TJA). This study aimed to investigate the global trends and network visualization in research of PJI. METHODS Publications in PJI search during 1980-2022 were extracted from the Science Citation Index-Expanded of Web of Science Core Collection database (WoSCC). The source data was investigated and analyzed by bibliometric methodology. For network visualization, VOS viewer and R software was used to perform bibliographic coupling, co-citation, co-authorship and co-occurrence analysis and to predict the publication trends in PJI research. RESULTS There were 7288 articles included. The number of publications and relative research interests increased gradually per year globally. The USA made the highest contributions in the world and with the highest H-index and the most citations. Journal of Arthroplasty published the highest number of articles in this area. The Mayo Clinic, Thomas Jefferson University (Rothman Institute), Hospital Special Surgery and the Rush University were the most contributive institutions by network visualization. Included studies were divided into four clusters: bacterial pathogenic mechanism and antibacterial drugs study, TJA complications, risk factors and epidemiology of PJI, diagnosis of PJI, and revision surgical management. More articles in PJI could be published over the next few years. CONCLUSION The number of publications about PJI will be increasing dramatically based on the global trends and network visualization. The USA made the highest contributions in PJI. Diagnosis and revision management may be the next hot spots in this field.
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Affiliation(s)
- Shengjie Dong
- Orthopedic Department, Yantaishan Hospital, Yantai, China
| | - Fengyao Mei
- Arthritis Clinic & Research Center, Peking University People's Hospital, Peking University, Beijing, China.,Arthritis Institute, Peking University, Beijing, China
| | - Jiao Jiao Li
- School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, Ultimo, Australia
| | - Dan Xing
- Arthritis Clinic & Research Center, Peking University People's Hospital, Peking University, Beijing, China.,Arthritis Institute, Peking University, Beijing, China
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15
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Complete blood platelet and lymphocyte ratios increase diagnostic accuracy of periprosthetic joint infection following total hip arthroplasty. Arch Orthop Trauma Surg 2023; 143:1441-1449. [PMID: 35098356 DOI: 10.1007/s00402-021-04309-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/04/2021] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Systemically, changes in serum platelet to lymphocyte ratio (PLR), platelet count to mean platelet volume ratio (PVR), neutrophil to lymphocyte ratio (NLR) and monocyte to lymphocyte (MLR) represent primary responses to early inflammation and infection. This study aimed to determine whether PLR, PVR, NLR, and MLR can be useful in diagnosing periprosthetic joint infection (PJI) in total hip arthroplasty (THA) patients. METHODS A total of 464 patients that underwent revision THA with calculable PLR, PVR, NLR, and MLR in 2 groups was evaluated: 1) 191 patients with a pre-operative diagnosis of PJI, and 2) 273 matched patients treated for revision THA for aseptic complications. RESULTS The sensitivity and specificity of PLR combined with erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), synovial white blood cell count (WBC) and synovial polymorphonuclear leukocytes (PMN) (97.9%; 98.5%) is significantly higher than only ESR combined with CRP, synovial WBC and synovial PMN (94.2%; 94.5%; p < 0.01). The sensitivity and specificity of PVR combined with ESR, CRP and synovial WBC, and synovial PMN (98.4%; 98.2%) is higher than only ESR combined with CRP, synovial WBC and synovial PMN (94.2%; 94.5%; p < 0.01). CONCLUSION The study results demonstrate that both PLR and PVR calculated from complete blood counts when combined with serum and synovial fluid markers have increased diagnostic sensitivity and specificity in diagnosing periprosthetic joint infection in THA patients. LEVEL OF EVIDENCE III, case-control retrospective analysis.
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16
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Klemt C, Padmanabha A, Esposito JG, Laurencin S, Smith EJ, Kwon YM. Elevated ESR and CRP Prior to Second-Stage Reimplantation Knee Revision Surgery for Periprosthetic Joint Infection Are Associated with Increased Reinfection Rates. J Knee Surg 2023; 36:354-361. [PMID: 34375998 DOI: 10.1055/s-0041-1733902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although two-stage revision surgery is considered as the most effective treatment for managing chronic periprosthetic joint infection (PJI), there is no current consensus on the predictors of optimal timing to second-stage reimplantation. This study aimed to compare clinical outcomes between patients with elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) prior to second-stage reimplantation and those with normalized ESR and CRP prior to second-stage reimplantation. We retrospectively reviewed 198 patients treated with two-stage revision total knee arthroplasty for chronic PJI. Cohorts included patients with: (1) normal level of serum ESR and CRP (n = 96) and (2) elevated level of serum ESR and CRP prior to second-stage reimplantation (n = 102). Outcomes including reinfection rates and readmission rates were compared between both cohorts. At a mean follow-up of 4.4 years (2.8-6.5 years), the elevated ESR and CRP cohort demonstrated significantly higher reinfection rates compared with patients with normalized ESR and CRP prior to second-stage reimplantation (33.3% vs. 14.5%, p < 0.01). Patients with both elevated ESR and CRP demonstrated significantly higher reinfection rates, when compared with patients with elevated ESR and normalized CRP (33.3% vs. 27.6%, p = 0.02) as well as normalized ESR and elevated CRP (33.3% vs. 26.3%, p < 0.01). This study demonstrates that elevated serum ESR and/or CRP levels prior to reimplantation in two-stage knee revision surgery for chronic PJI are associated with increased reinfection rate after surgery. Elevation of both ESR and CRP were associated with a higher risk of reinfection compared with elevation of either ESR or CRP, suggesting the potential benefits of normalizing ESR and CRP prior to reimplantation in treatment of chronic PJI.
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Affiliation(s)
- Christian Klemt
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anand Padmanabha
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John G Esposito
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Laurencin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Evan J Smith
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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17
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Fisher CR, Patel R. Profiling the Immune Response to Periprosthetic Joint Infection and Non-Infectious Arthroplasty Failure. Antibiotics (Basel) 2023; 12:antibiotics12020296. [PMID: 36830206 PMCID: PMC9951934 DOI: 10.3390/antibiotics12020296] [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: 12/30/2022] [Revised: 01/20/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023] Open
Abstract
Arthroplasty failure is a major complication of joint replacement surgery. It can be caused by periprosthetic joint infection (PJI) or non-infectious etiologies, and often requires surgical intervention and (in select scenarios) resection and reimplantation of implanted devices. Fast and accurate diagnosis of PJI and non-infectious arthroplasty failure (NIAF) is critical to direct medical and surgical treatment; differentiation of PJI from NIAF may, however, be unclear in some cases. Traditional culture, nucleic acid amplification tests, metagenomic, and metatranscriptomic techniques for microbial detection have had success in differentiating the two entities, although microbiologically negative apparent PJI remains a challenge. Single host biomarkers or, alternatively, more advanced immune response profiling-based approaches may be applied to differentiate PJI from NIAF, overcoming limitations of microbial-based detection methods and possibly, especially with newer approaches, augmenting them. In this review, current approaches to arthroplasty failure diagnosis are briefly overviewed, followed by a review of host-based approaches for differentiation of PJI from NIAF, including exciting futuristic combinational multi-omics methodologies that may both detect pathogens and assess biological responses, illuminating causes of arthroplasty failure.
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Affiliation(s)
- Cody R. Fisher
- Mayo Clinic Graduate School of Biomedical Sciences, Department of Immunology, Mayo Clinic, Rochester, MN 55905, USA
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Correspondence:
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18
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Dilley JE, Seetharam A, Meneghini RM, Kheir MM. Synovial Fluid Absolute Neutrophil Count and Neutrophil-To-Lymphocyte Ratio are not Superior to Polymorphonuclear Percentage in Detecting Periprosthetic Joint Infection. J Arthroplasty 2023; 38:146-151. [PMID: 35843381 DOI: 10.1016/j.arth.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/08/2022] [Accepted: 07/08/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Serum and synovial biomarkers are currently used to diagnose periprosthetic joint infection (PJI). Serum neutrophil-to-lymphocyte ratio (NLR) has shown promise as an inexpensive test in diagnosing infection, but there are no reports of synovial NLR or absolute neutrophil count (ANC) for diagnosing chronic PJI. The purpose of this study was to investigate the diagnostic potential of both markers. METHODS A retrospective review of 730 patients who underwent total joint arthroplasty and subsequent aspiration was conducted. Synovial white blood cell (WBC) count, synovial polymorphonuclear percentage (PMN%), synovial NLR, synovial ANC, serum erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), serum WBC, serum PMN%, serum NLR, and serum ANC had their utility in diagnosing PJI examined by area-under-the-curve analyses (AUC). Pairwise comparisons of AUCs were performed. RESULTS The AUCs for synovial WBC, PMN%, NLR, and ANC were 0.84, 0.84, 0.83, and 0.85, respectively. Synovial fluid ANC was a superior marker to synovial NLR (P = .027) and synovial WBC (P = .003) but not PMN% (P = .365). Synovial NLR was inferior to PMN% (P = .006) but not different from synovial WBC (P > .05). The AUCs for serum ESR, CRP, WBC, PMN%, NLR, and ANC were 0.70, 0.79, 0.63, 0.72, 0.74, and 0.67, respectively. Serum CRP outperformed all other serum markers (P < .05) except for PMN% and NLR (P > .05). Serum PMN% and NLR were similar to serum ESR (P > .05). CONCLUSION Synovial ANC had similar performance to PMN% in diagnosing chronic PJI, whereas synovial NLR was a worse diagnostic marker. The lack of superiority to synovial PMN% limits the utility of these tests compared to established criteria.
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Affiliation(s)
- Julian E Dilley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Abhijit Seetharam
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael M Kheir
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
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19
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Cobra HADAB, Mozella AP, da Palma IM, Salim R, Leal AC. Cell-free Deoxyribonucleic Acid: A Potential Biomarker of Chronic Periprosthetic Knee Joint Infection. J Arthroplasty 2022; 37:2455-2459. [PMID: 35840076 DOI: 10.1016/j.arth.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The correct diagnosis of a chronic periprosthetic joint infection (PJI) is a major challenge in clinical practice, with the "gold standard" for diagnosis yet to be established. Synovial fluid analysis has been proven to be a useful tool for that purpose. Cell-free DNA (cf-DNA) levels have been shown to be increased in several conditions such as cancer, trauma, and sepsis. Therefore, this study was designed to evaluate the potential of synovial fluid cf-DNA quantification for the diagnosis of chronic periprosthetic infections following total knee arthroplasty. METHODS A prospective study with patients undergoing total knee arthroplasty revision surgery for any indication was performed. PJI diagnosis was defined according to the Second International Consensus Meeting on Musculoskeletal Infection (2018) criteria. The study cohort consisted of 26 patients classified as infected and 40 as noninfected. Synovial fluid cf-DNA direct quantification by fluorescent staining was made. Sensitivity, specificity, and receiver operating characteristic curve were calculated. RESULTS The cf-DNA levels were significantly higher in patients who had PJIs (122.5 ± 57.2 versus 4.6 ± 2.8 ng/μL, P < .0001). With a cutoff of 15 ng/μL, the area under the receiver operating characteristic, sensitivity, and specificity of cf-DNA were 0.978, 96.2%, and 100%, respectively. CONCLUSION The present study has shown that cf-DNA is increased in synovial fluid of patients who have chronic PJIs. It is a promising biomarker for knee PJI diagnosis and further studies are needed to confirm its utility.
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Affiliation(s)
- Hugo A de A B Cobra
- Center for Surgery of Knee, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Alan P Mozella
- Center for Surgery of Knee, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Idemar M da Palma
- Rios D'or Hospital, Rio de Janeiro, Brazil; Montese Medical Center, Rio de Janeiro, Brazil
| | - Rodrigo Salim
- Department of Orthopaedics and Anaesthesiology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ana C Leal
- Teaching and Research Division, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
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20
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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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21
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Yan S, Zhang X, Lyu Z, Liu J. Decreased serum superoxide dismutase concentration has a high value for the diagnosis of periprosthetic joint infection-a single-center, retrospective study. BMC Musculoskelet Disord 2022; 23:1000. [PMID: 36411448 PMCID: PMC9677697 DOI: 10.1186/s12891-022-05965-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/08/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSE As the most serious complication of total knee arthroplasty (TKA), periprosthetic joint infection (PJI) often leads to disastrous consequences. An accurate preoperative diagnosis plays a significant role in saving prostheses and optimizing treatment outcomes. Through this retrospective case-control study, we aimed to investigate the potential of superoxide dismutase (SOD) as a novel serum biomarker in the diagnosis of PJI. METHODS We conducted a retrospective review of all patients who underwent TKA and received adequate follow-ups in our hospital from June 2015 to December 2021. A total of 50 patients were enrolled in the PJI group based on the 2018 International Consensus Meeting (ICM) criteria. Besides that, we enrolled 100 patients who underwent TKA in the same period and had a good postoperative course in the control group. Patient characteristics, comorbidities, laboratory results (serum, synovial, and microbial), and intraoperative findings (purulence and histopathology) were documented and compared by univariate analysis. Receiver operating characteristic (ROC) analysis was used to determine the sensitivity, specificity, and diagnostic performance. RESULTS The median serum SOD level in the PJI and control group was 135.95 ± 24.47 U/ml (IQR, 111.85-158.30 U/ml) and 173.83 ± 13.9 U/ml (IQR,162.83-183.5 U/ml) (p < 0.05), respectively. With the calculated cutoff of SOD at 149.5U/L, the area under the ROC curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were 0.919, 0.72, 0.97, 0.923, and 0.874, respectively. In subgroup analysis, the specificity of SOD in diagnosing culture-negative PJI remained extremely high (0.98). Combined diagnosis of serum SOD and C-reactive protein (CRP) made AUC increase to 0.972. CONCLUSION Serum SOD showed great potential in the diagnosis of PJI.
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Affiliation(s)
- Shuo Yan
- grid.417028.80000 0004 1799 2608Department of Joints, Tianjin Hospital, No. 406 Jiefang South Rd, Tianjin, 300211 Hexi District China ,grid.265021.20000 0000 9792 1228Graduate School of Tianjin Medical University, 22 Qixiang Tai Road, Tianjin, 300203 Heping District China
| | - Xiaofei Zhang
- grid.417028.80000 0004 1799 2608Department of Joints, Tianjin Hospital, No. 406 Jiefang South Rd, Tianjin, 300211 Hexi District China ,grid.412645.00000 0004 1757 9434Department of Orthopaedics, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, 300052 Heping District China
| | - Zhen Lyu
- grid.417028.80000 0004 1799 2608Department of Joints, Tianjin Hospital, No. 406 Jiefang South Rd, Tianjin, 300211 Hexi District China
| | - Jun Liu
- grid.417028.80000 0004 1799 2608Department of Joints, Tianjin Hospital, No. 406 Jiefang South Rd, Tianjin, 300211 Hexi District China
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22
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Su X, Chen Y, Zhan Q, Zhu B, Chen L, Zhao C, Yang J, Wei L, Xu Z, Wei K, Huang W, Qin L, Hu N. The Ratio of IL-6 to IL-4 in Synovial Fluid of Knee or Hip Performances a Noteworthy Diagnostic Value in Prosthetic Joint Infection. J Clin Med 2022; 11:jcm11216520. [PMID: 36362748 PMCID: PMC9654466 DOI: 10.3390/jcm11216520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
The diagnosis of prosthetic joint infection (PJI) is still a challenge, the ratio of interleukin-6 (IL-6) to IL-4 in the joint fluid of knee or hip was used to analyze whether the diagnostic accuracy of PJI can be improved. Between January 2017 and May 2022, 180 patients who developed pain after revision total hip or knee arthroplasty were enrolled retrospectively. 92 patients of PJI and 88 of aseptic failure were included. PJI was as defined by the Musculoskeletal Infection Society (MSIS). The content of IL-6 and IL-4 in synovial fluid of knee or hip were measured, and the areas under the receiver operating characteristic curve (ROC) and IL-6/IL-4 curve were analyzed to obtain a better diagnostic effect. The area under the curve of IL-6/IL-4 in synovial fluid of knee or hip was 0.9623, which was more accurate than ESR 0.5994 and C-reactive protein 0.6720. The optimal threshold of IL-6/IL-4 ratio was 382.10. Its sensitivity and specificity were 81.32% and 98.86%, respectively. The positive predictive value for the diagnosis of PJI was 98.91%. This study showed that the level of IL-6/IL-4 in synovial fluid of knee or hip could further improve the diagnostic accuracy for PJI.
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Affiliation(s)
- Xudong Su
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing 400016, China
| | - Yuelong Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Qian Zhan
- The Center for Clinical Molecular Medical detection, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Bo Zhu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing 400016, China
| | - Li Chen
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing 400016, China
| | - Chen Zhao
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing 400016, China
| | - Jianye Yang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing 400016, China
| | - Li Wei
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing 400016, China
| | - Zhenghao Xu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing 400016, China
| | - Keyu Wei
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing 400016, China
| | - Wei Huang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing 400016, China
| | - Leilei Qin
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing 400016, China
- Correspondence: (L.Q.); (N.H.)
| | - Ning Hu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Laboratory of Orthopedics, Chongqing Medical University, Chongqing 400016, China
- Correspondence: (L.Q.); (N.H.)
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Blom AW, Beswick AD, Burston A, Carroll FE, Garfield K, Gooberman-Hill R, Harris S, Kunutsor SK, Lane A, Lenguerrand E, MacGowan A, Mallon C, Moore AJ, Noble S, Palmer CK, Rolfson O, Strange S, Whitehouse MR. Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/hdwl9760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background
People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery.
Objectives
To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments.
Design
Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire.
Setting
Our studies are relevant to the NHS, to the Swedish health system and internationally.
Participants
People with prosthetic joint infection after hip or knee replacement and surgeons.
Interventions
Revision of hip prosthetic joint infection with a single- or two-stage procedure.
Main outcome measures
Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal.
Data sources
National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial.
Review methods
Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis.
Results
In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity.
Limitations
Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small.
Conclusions
We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months.
Future work
For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria.
Study registration
The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664).
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley W Blom
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Fran E Carroll
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kirsty Garfield
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shaun Harris
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athene Lane
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Charlotte Mallon
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cecily K Palmer
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Ola Rolfson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon Strange
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Ciriello V, Ghannadian S, Saracco M, Logroscino G. Is Fibrinogen a Reliable Biomarker in the Diagnosis of Peri-Prosthetic Joint Infection? A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2022; 23:787-795. [PMID: 36269621 DOI: 10.1089/sur.2022.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: In recent years, several studies have identified closed correlations between the coagulation cascade and inflammatory mechanisms in infective diseases. Fibrinogen (PF) is emerging as promising biomarker for the diagnosis of peri-prosthetic joint infection (PJI). This study aims to investigate the diagnostic value of PF in diagnosing PJI and to explore potential causes influencing the diagnostic value of PF. Materials and Methods: PubMed, Embase, and Cochrane Library were searched regarding the role of fibrinogen as a biomarker in the diagnosis of PJI. Studies in English were included in the meta-analysis if they determined the diagnostic value of fibrinogen for PJI detection after hip or knee arthroplasty, applying the recognized diagnostic criteria for PJI. A quality evaluation of the studies included was performed. The pooled sensitivity, specificity, likelihood ratios and diagnostic odds ratio (DOR) and the area under the receiver operating characteristic curve (AUROC) were obtained using the statistical software STATA, version 17 (StataCorp, College Station, TX). Results: Ten studies (9 retrospective) were included in the study. Low publication bias was detected, but with high heterogeneity among them. Plasma fibrinogen showed a good diagnostic accuracy and clinical utility in PJI (sensitivity, 0.81 [95% confidence interval {CI}, 0.75-0.86]; specificity, 0.82 [95% CI, 0.76-0.86]; AUROC, 0.88 [95% CI, 0.85-0.91]; DOR, 19 [95% CI, 14-26]). Conclusions: The attempt to find an "ideal" biomarker is crucial to improve the sensitivity and specificity of the current diagnostic algorithms for PJI. The analysis performed in the current study indicates that plasma fibrinogen test is a valid biomarker for PJI diagnosis.
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Affiliation(s)
- Vincenzo Ciriello
- Department of Orthopaedics and Trauma, ASO "S. Croce e Carle", Cuneo, Italy
| | | | - Michela Saracco
- Department of Orthopaedics, "A. Gemelli" IRCCS University Hospital Foundation - Catholic University of the Sacred Heart, Rome, Italy.,Department of Orthopaedics and Trauma, "San Giovanni di Dio" Hospital, ASL Napoli2 Nord, Naples, Italy
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Tang H, Xu J, Yuan W, Wang Y, Yue B, Qu X. Reliable Diagnostic Tests and Thresholds for Preoperative Diagnosis of Non-Inflammatory Arthritis Periprosthetic Joint Infection: A Meta-analysis and Systematic Review. Orthop Surg 2022; 14:2822-2836. [PMID: 36181336 PMCID: PMC9627080 DOI: 10.1111/os.13500] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 02/06/2023] Open
Abstract
Objective The current diagnostic criteria for periprosthetic joint infection (PJI) are diverse and controversial, leading to delayed diagnosis. This study aimed to evaluate and unify their diagnostic accuracy and the threshold selection of serum and synovial routine tests for PJI at an early stage. Methods We searched the MEDLINE and Embase databases for retrospective or prospective studies which reported preoperative‐available assays (serum, synovial, or culture tests) for the diagnosis of chronic PJI among inflammatory arthritis (IA) or non‐IA populations from January 1, 2000 to June 30, 2022. Threshold effective analysis was performed on synovial polymorphonuclear neutrophils (PMN%), synovial white blood cell (WBC), serum C‐reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to find the relevant cut‐offs. Results Two hundred and sixteen studies and information from 45,316 individuals were included in the final analysis. Synovial laboratory‐based α‐defensin and calprotectin had the best comprehensive sensitivity (0.91 [0.86–0.94], 0.95 [0.88–0.98]) and specificity (0.96 [0.94‐0.97], 0.95 [0.89–0.98]) values. According to the threshold effect analysis, the recommended cut‐offs are 70% (sensitivity 0.89 [0.85–0.92], specificity 0.90 [0.87–0.93]), 4100/μL (sensitivity 0.90 [0.87–0.93], specificity 0.97 [0.93–0.98]), 13.5 mg/L (sensitivity 0.84 [0.78–0.89], specificity 0.83 [0.73–0.89]), and 30 mm/h (sensitivity 0.79 [0.74–0.83], specificity 0.78 [0.72–0.83]) for synovial PMN%, synovial WBC, serum CRP, and ESR, respectively, and tests seem to be more reliable among non‐IA patients. Conclusions The laboratory‐based synovial α‐defensin and synovial calprotectin are the two best independent preoperative diagnostic tests for PJI. A cut off of 70% for synovial PMN% and tighter cut‐offs for synovial WBC and serum CRP could have a better diagnostic accuracy for non‐IA patients with chronic PJI.
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Affiliation(s)
- Haozheng Tang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jialian Xu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei'en Yuan
- Ministry of Education Engineering Research Center of Cell & Therapeutic Antibody, School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - You Wang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Yue
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Abdelaziz H, Aljawabra A, Rossmann M, Tien CS, Citak M, Klatte TO, Gehrke T. What Is the Impact of Automated Synovial Cell Counting on Different Aseptic Causes and Periprosthetic Conditions Associated With Revision THA? Clin Orthop Relat Res 2022; 480:905-914. [PMID: 34851871 PMCID: PMC9007196 DOI: 10.1097/corr.0000000000002063] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/03/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Studies have suggested that automated synovial cell counting may overestimate the white blood cell (WBC) count, resulting in false positive tests when evaluating patients for the possibility of periprosthetic joint infection (PJI) after THA. However, associations between WBC counts high enough to mimic PJI in patients whose arthroplasties are not infected but rather are experiencing a variety of aseptic problems-including but not limited to metallosis, polyethylene wear, and recurrent dislocation-have not, to our knowledge, been adequately addressed. In addition, there is a lack of analyses about the polymorphonuclear percentage (PMN%) when assessed by automated analyzers in this context. QUESTIONS/PURPOSES In the context of different indications for aseptic revision and different periprosthetic hip pathologic findings, we asked: (1) What were the synovial WBC count levels, and what proportion of values were above the 2018 International Consensus Meeting (ICM) cutoff (3000 cells/μL)? (2) What were the synovial PMN% levels, and what proportion of values were above the 2018 ICM (70%)? METHODS We retrospectively studied the preoperative cell count analyses of synovial fluid in patients who underwent revision THA for aseptic reasons at our tertiary referral arthroplasty center between January 2015 and December 2017. We considered all revisions performed on patients during that time potentially eligible, and after prespecified exclusions were applied (exclusions mainly included 15% [197 of 1306] sporadic missing data and 12% [155 of 1306] insufficient synovial fluid obtained in the aspirate), a total of 702 patients undergoing revision THA for aseptic reasons remained for the final analysis. As far as we know, no patients underwent re-revision for PJI at a mean follow-up of 46 ± 11 months, which tends to confirm our impression that indeed these hips did not have PJI. Cell count analyses were conducted using an automated analyzer. Clinical findings, preoperative radiographs, and surgical reports--confirmed by available histologic results--were used to establish diagnoses. We evaluated these hips considering the recommendations of the 2018 ICM (WBC count of 3000 cells/μL and PMN% of 70%) to see what proportion of them would have been characterized as likely having PJI on basis of those cutoff values. The mean WBC count for the entire cohort was 2120 ± 2395 cells/μL. The mean PMN% for the entire cohort was 36% ± 22%. RESULTS Compared with aseptic loosening and recurrent dislocation, polyethylene wear had the highest mean WBC count (3817 ± 3711 cells/μL; p < 0.001). Of the investigated periprosthetic conditions, wear-induced synovitis had the highest value (4464 ± 3620 cells/μL; p < 0.001). Considering the ICM threshold, polyethylene wear showed the highest proportion of WBC counts above 3000 cells/μL among the indications for aseptic revision (60% [25 of 42]; p < 0.001). Of the periprosthetic conditions, wear-induced synovitis showed the highest proportion beyond the ICM cutoff (60% [50 of 83]; p < 0.001). The mean PMN% for aseptic causes ranged between 28% and 44% without differences among them (p = 0.12). Patients with metallosis had the highest mean PMN% of the periprosthetic conditions investigated (45% ± 25%; p = 0.007). Regarding the ICM threshold, metallosis resulted in the largest proportion of patients with a PMN% above 70% (21% [10 of 47]; p = 0.003), and that for wear-induced synovitis was 6% (5 of 83; p = 0.42) and for osteolysis was 3% (1 of 33; p = 0.51). There were no differences among aseptic loosening, recurrent dislocation, and polyethylene wear in terms of the proportion above 70% among the aseptic revision causes. CONCLUSION Using automated cell counting, we found that WBC counts differ widely across indications for aseptic revision THA, and a high proportion of patients who underwent revision THA for aseptic reasons had WBC counts above the commonly used threshold of 3000 cells/μL. However, the PMN% was much less affected in several common indications for aseptic revision THA, making this measure more reliable for interpreting aspiration results using an automated analyzer. Based on the data distributions we observed, manual counting techniques might be considered in particular among patients with polyethylene wear, metal-on-metal bearing surfaces, or suspected metallosis. However, an elevated WBC count alone, observed using an automated analyzer in the context of polyethylene wear, should not be considered to be strongly suggestive of PJI, since that finding occurred so commonly among patients without infection. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Hussein Abdelaziz
- Department of Orthopaedic Surgery, Helios ENDO-Klinik, Hamburg, Germany
| | - Alaa Aljawabra
- Department of Orthopaedic Surgery, Helios ENDO-Klinik, Hamburg, Germany
| | - Markus Rossmann
- Department of Orthopaedic Surgery, Helios ENDO-Klinik, Hamburg, Germany
| | - Calvin Shum Tien
- Department of Orthopaedic Surgery, Helios ENDO-Klinik, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik, Hamburg, Germany
| | - Till Orla Klatte
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik, Hamburg, Germany
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Gazendam A, Wood TJ, Tushinski D, Bali K. Diagnosing Periprosthetic Joint Infection: a Scoping Review. Curr Rev Musculoskelet Med 2022; 15:219-229. [PMID: 35368214 DOI: 10.1007/s12178-022-09751-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to provide an up to date understanding of the utility and limitations of the current tests utilized in the diagnosis of periprosthetic joint infection (PJI) in total knee and hip arthroplasty. RECENT FINDINGS Despite the growth in literature surrounding PJI diagnosis, there remains challenges in establishing a diagnosis of PJI. A combination of clinical, serum, and synovial tests and microbiologic and histologic examinations can yield a diagnosis in the majority of cases. Novel molecular and imaging studies may be beneficial for indeterminant cases. A number of emerging diagnostic tests have been proposed and may be incorporated into diagnostic algorithms in the future. Recently proposed stepwise diagnostic algorithms have shown high sensitivity and specificity. The diagnosis of PJI remains challenging due to a lack of tests that can definitively rule out infection. Diagnosis and investigations should occur in a stepwise fashion. There has been a plethora of new diagnostic tests introduced in attempts to improve the accuracy of diagnostic algorithms. The definition and algorithms for the diagnoses of PJI will continue to evolve as new techniques and tests are introduced.
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Affiliation(s)
- Aaron Gazendam
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Thomas J Wood
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Tushinski
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kamal Bali
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada. .,Juravinski Hospital, 711 Concession St, Hamilton, Ontario, L8V 1C3, Canada.
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Goud A, Nützinger D, van der Bij A, Jenniskens K, Groenewold J, de Gast A, Bekkers JEJ. Synovial-Based Tests Outperform Serum Markers to Rule Out Infection in Total Knee Arthroplasty and Total Hip Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2022; 37:802-808.e5. [PMID: 34952165 DOI: 10.1016/j.arth.2021.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/22/2021] [Accepted: 12/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) provides successful results in most patients. Periprosthetic joint infection (PJI) accounts for up to 25% of failed TKAs needing revision. In clinical practice, consensus in diagnostic strategy for excluding or diagnosing PJI is still lacking. In this systematic review and meta-analysis, we aim to provide a simplified data-driven diagnostic strategy for aseptic knee and hip revision surgeons to rule out PJI in the outpatient clinic phase. METHODS A literature search in EMBASE, MEDLINE, PubMed, and Cochrane was conducted. Studies involving the diagnosis of PJI in patients with failed TKAs and total hip arthroplasties needing revision were identified. Only studies using the Musculoskeletal Infection Society criteria were included. Quality was assessed using MINORS criteria. Meta-analysis was performed for each diagnostic test identified in the included studies. Pooled estimates of diagnostic accuracy measures were calculated using a bivariate model and plotted in summary receiver-operator characteristic curves. Positive and negative predictive values were calculated in a hypothetical sample of patients with a given disease prevalence. RESULTS Twenty-four studies met the inclusion criteria, describing a total of 2974 patients. Quality scores ranged from 13 to 19. Meta-analysis could be performed on 7 unique diagnostic tests. Highest pooled sensitivity and specificity were demonstrated for α-defensin with values of 86% and 96.6%, respectively. α-defensin and white blood cell count in synovial fluid demonstrate highest negative predictive value values. CONCLUSIONS We recommend, in a clinical setting with low-intermediate prevalence of PJI, performing arthrocentesis and joint fluid analysis using α-defensin and/or white blood cell count before revision TKA and revision total hip arthroplasty surgery to rule out PJI.
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Affiliation(s)
- Annemarie Goud
- Department of Orthopedic Surgery, Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands
| | - Don Nützinger
- Department of Orthopedic Surgery, Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands; Clinical Orthopedic Research Center Midden Nederland, Diakonessenhuis Utrecht/Zeist, Zeist, the Netherlands
| | - Akke van der Bij
- Department of Microbiology and Immunology, Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands
| | - Kevin Jenniskens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), University Utrecht, Utrecht, the Netherlands
| | - Joel Groenewold
- University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
| | - Arthur de Gast
- Clinical Orthopedic Research Center Midden Nederland, Diakonessenhuis Utrecht/Zeist, Zeist, the Netherlands
| | - Joris E J Bekkers
- Department of Orthopedic Surgery, Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands; Clinical Orthopedic Research Center Midden Nederland, Diakonessenhuis Utrecht/Zeist, Zeist, the Netherlands
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Karbysheva S, Cabric S, Koliszak A, Bervar M, Kirschbaum S, Hardt S, Perka C, Trampuz A. Clinical evaluation of dithiothreitol in comparison with sonication for biofilm dislodgement in the microbiological diagnosis of periprosthetic joint infection. Diagn Microbiol Infect Dis 2022; 103:115679. [DOI: 10.1016/j.diagmicrobio.2022.115679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 02/26/2022] [Accepted: 03/04/2022] [Indexed: 11/03/2022]
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Felstead A, Kundasamy P, Penfold G, Whiting K, Buck J, Sturridge S, Meda M. The combined measurement of synovial markers in the diagnosis of periprosthetic joint infection. Ann R Coll Surg Engl 2021; 104:334-339. [PMID: 34939833 DOI: 10.1308/rcsann.2021.0186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Currently there is no single test for periprosthetic joint infection (PJI) that demonstrates an acceptable level of sensitivity. The aim of this pilot study was to identify a combination of biomarkers that could exclude periprosthetic infection prior to revision surgery in hip and knee arthroplasty. This would help in equivocal cases of PJI, such as those with low-virulence organisms, chronic low-grade infection or 'aseptic' loosening. Current research has focused on measuring the levels of biomarkers in the patient's synovial fluid, and these can be combined to improve accuracy. METHODS We selected synovial white cell count (SF-WCC) and C-reactive protein (SF-CRP), as they demonstrated an acceptable level of sensitivity and specificity which could be measured using existing equipment. One hundred and sixty-one synovial fluid samples from 134 patients were collected and analysed prospectively using calculated cut-off values of 10mg/l for SF-CRP and 3,000×106/l for SF-WCC. Samples were deemed positive for infection when either of the SF-CRP or SF-WCC values were above the cut-off. RESULTS The combined test demonstrated a sensitivity greater than 98.5% and specificity above 80% in all samples analysed or looked at separately for total hip replacement and total knee replacement infections. All ten aspirates taken from chronically infected joints tested positive. CONCLUSIONS The combination of SF-CRP and SF-WCC measurement has been shown to have high sensitivity of over 99% in detecting both acute and chronic PJI in both hip and knee arthroplasty. This ability of the test to exclude infection with a high degree of certainty will help in preoperative planning of PJIs.
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Affiliation(s)
| | | | - G Penfold
- Frimley Health NHS Foundation Trust, UK
| | - K Whiting
- Frimley Health NHS Foundation Trust, UK
| | - J Buck
- Frimley Health NHS Foundation Trust, UK
| | | | - M Meda
- Frimley Health NHS Foundation Trust, UK
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Walinga AB, Stornebrink T, Langerhuizen DWG, Struijs PAA, Kerkhoffs GMMJ, Janssen SJ. What are the best diagnostic tests for diagnosing bacterial arthritis of a native joint? : a systematic review of 27 studies. Bone Joint J 2021; 103-B:1745-1753. [PMID: 34847715 DOI: 10.1302/0301-620x.103b12.bjj-2021-0114.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS This study aimed to answer two questions: what are the best diagnostic methods for diagnosing bacterial arthritis of a native joint?; and what are the most commonly used definitions for bacterial arthritis of a native joint? METHODS We performed a search of PubMed, Embase, and Cochrane libraries for relevant studies published between January 1980 and April 2020. Of 3,209 identified studies, we included 27 after full screening. Sensitivity, specificity, area under the curve, and Youden index of diagnostic tests were extracted from included studies. We grouped test characteristics per diagnostic modality. We extracted the definitions used to establish a definitive diagnosis of bacterial arthritis of a native joint per study. RESULTS Overall, 28 unique diagnostic tests for diagnosing bacterial arthritis of a native joint were identified. The following five tests were deemed most useful: serum ESR (sensitivity: 34% to 100%, specificity: 23% to 93%), serum CRP (sensitivity: 58% to 100%, specificity: 0% to 96%), serum procalcitonin (sensitivity: 0% to 100%, specificity: 68% to 100%), the proportion of synovial polymorphonuclear cells (sensitivity: 42% to 100%, specificity: 54% to 94%), and the gram stain of synovial fluid (sensitivity: 27% to 81%, specificity: 99% to 100%). CONCLUSION Diagnostic methods with relatively high sensitivities, such as serum CRP, ESR, and synovial polymorphonuclear cells, are useful for screening. Diagnostic methods with a relatively high specificity, such as serum procalcitonin and synovial fluid gram stain, are useful for establishing a diagnosis of bacterial arthritis. This review helps to interpret the value of various diagnostic tests for diagnosing bacterial arthritis of a native joint in clinical practice. Cite this article: Bone Joint J 2021;103-B(12):1745-1753.
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Affiliation(s)
- Alex B Walinga
- Department of Orthopedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Academic Center for Evidence-based Sports medicine, Amsterdam, the Netherlands.,Amsterdam Collaboration for Health and Safety in Sports, International Olympic Committee Research Center Amsterdam UMC, Amsterdam, the Netherlands
| | - Tobias Stornebrink
- Department of Orthopedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Academic Center for Evidence-based Sports medicine, Amsterdam, the Netherlands.,Amsterdam Collaboration for Health and Safety in Sports, International Olympic Committee Research Center Amsterdam UMC, Amsterdam, the Netherlands
| | - David W G Langerhuizen
- Department of Orthopedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Academic Center for Evidence-based Sports medicine, Amsterdam, the Netherlands.,Amsterdam Collaboration for Health and Safety in Sports, International Olympic Committee Research Center Amsterdam UMC, Amsterdam, the Netherlands
| | - Peter A A Struijs
- Department of Orthopedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Academic Center for Evidence-based Sports medicine, Amsterdam, the Netherlands.,Amsterdam Collaboration for Health and Safety in Sports, International Olympic Committee Research Center Amsterdam UMC, Amsterdam, the Netherlands
| | - Gino M M J Kerkhoffs
- Department of Orthopedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Academic Center for Evidence-based Sports medicine, Amsterdam, the Netherlands.,Amsterdam Collaboration for Health and Safety in Sports, International Olympic Committee Research Center Amsterdam UMC, Amsterdam, the Netherlands
| | - Stein J Janssen
- Department of Orthopedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Academic Center for Evidence-based Sports medicine, Amsterdam, the Netherlands.,Amsterdam Collaboration for Health and Safety in Sports, International Olympic Committee Research Center Amsterdam UMC, Amsterdam, the Netherlands
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Öztürk Ö, Özdemir M, Turgut MC, Altay M. The Fate of Failed Debridement, Antibiotics, and Implant Retention in Infected Knee Arthroplasties: Nothing to Lose. Cureus 2021; 13:e18946. [PMID: 34722006 PMCID: PMC8544802 DOI: 10.7759/cureus.18946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 12/19/2022] Open
Abstract
Purpose The frequency of periprosthetic knee infections increases yearly because of the popularity of the total knee prostheses. Revision knee arthroplasty is an annoying problem for both the surgeons and the patients. Debridément, antibiotics, and implant retention (DAIR) is a popular alternative for the treatment of periprosthetic knee infections. Little is known about the fate of the failed DAIR patients. This study aims to investigate the effect of the failed DAIR on the clinical result after two-staged revision arthroplasty. Method Ninety-nine two-staged revision arthroplasties and 85 DAIR patients from two reference clinics were retrospectively analyzed. The minimum follow-up was 36 months. Patients were grouped according to the treatment as, two-staged revision without DAIR, two-staged revision after failed DAIR, and successful DAIR. Their Knee Society Scores (KSS), functional KSS (KSS-f) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were analyzed and compared. Results DAIR has a 52.9% success rate for the treatment of infection. Elevated erythrocyte sedimentation rates and C-reactive peptide levels are not risk factors for failure, but the time passed since the index surgery is a risk factor for worse outcome scores. Failed DAIR is not a risk factor for reinfection after two-staged revision. Last KSS after failed DAIR, successful DAIR, and two-staged revision were 83.98±7.033, 91.89±4.386, and 91.38±4.735, respectively. Last KSS-f after failed DAIR, successful DAIR, and two-staged revision were 86.25±9.524, 94.56±8.106, and 94.85±5.996, respectively. Last WOMAC after failed DAIR, successful DAIR, and two-staged revision were 86.16±7.745, 94.750±4.964, and 93.319±5.961, respectively. Conclusion Failed DAIR is associated with lesser, but still good, or excellent clinical scores. DAIR is suggested as a promising treatment option for periprosthetic knee infections in well-selected patients.
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Affiliation(s)
- Özkan Öztürk
- Department of Orthopedics and Traumatology, Erzurum Regional Training and Research Hospital, Erzurum, TUR
| | - Mahmut Özdemir
- Department of Orthopedics and Traumatology, VM Medical Park Hospital, Ankara, TUR
| | - Mehmet Cenk Turgut
- Department of Orthopedics and Traumatology, Erzurum Regional Training and Research Hospital, Erzurum, TUR
| | - Murat Altay
- Department of Orthopaedics and Traumatology, Keçiören Healthy Practice and Research Center, Ankara, TUR
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Which International Consensus Meeting Preoperative Minor Criteria is the Most Accurate Marker for the Diagnosis of Periprosthetic Joint Infection in Hip and Knee Arthroplasty? J Arthroplasty 2021; 36:3728-3733. [PMID: 34281702 DOI: 10.1016/j.arth.2021.06.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The accurate preoperative diagnosis of periprosthetic joint infection (PJI) is critical. The aim of this study was to evaluate the diagnostic accuracy and performance of the 2018 International Consensus Meeting (ICM) preoperative minor criteria for the diagnosis of chronic PJI in total hip and knee arthroplasty. METHODS We retrospectively reviewed 260 patients that underwent a revision knee or hip arthroplasty at our institution between 2015 and 2017. All major and minor 2018 ICM criteria (except erythrocyte sedimentation rate, D-dimer) were available for all patients included. Cases with at least 1 major criterion were considered as infected. Receiver operative characteristic curve analysis was performed for preoperative minor criteria. RESULTS The diagnostic performance of the preoperative minor criteria ranked as per the area under the curve was PMN% (0.926), alpha defensin (0.922), white blood cell count (0.916), leukocyte esterase (0.861), and serum C-reactive protein (0.860). Increasing the PMN % cutoff from 70% to 77.8% improves the diagnostic accuracy (86.5% vs 90.8%). The highest diagnostic performance was achieved by combining all 5 preoperative parameters, and at current ICM thresholds, the diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive were 93.5%, 95.4%, 92.1%, 89.7%, and 96.5%, respectively. CONCLUSION The diagnostic performance of preoperative minor criteria was outstanding (PMN%, alpha defensin, white blood cell count) or excellent (leukocyte esterase, serum C-reactive protein). PMN% showed the best diagnostic utility (area under the curve) and should have an increased weight-adjusted score in the ICM scoring system.
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Kanthawang T, Bodden J, Joseph GB, Vail T, Ward D, Patel R, Link TM. Diagnostic value of fluoroscopy-guided hip aspiration for periprosthetic joint infection. Skeletal Radiol 2021; 50:2245-2254. [PMID: 33956170 DOI: 10.1007/s00256-021-03795-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/17/2021] [Accepted: 04/22/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the value of preoperative joint aspiration in detecting periprosthetic joint infection (PJI) in patients undergoing revision hip arthroplasty and to compare these with the clinical findings, serum markers, and intraoperative findings. MATERIALS AND METHODS Fluoroscopically guided hip aspirations in patients with pain after hip arthroplasty were retrospectively reviewed from January 2014 to December 2018. All hips underwent subsequent revision hip arthroplasty. Antibiotics were discontinued at least 2 weeks before the aspiration. The 2018 Musculoskeletal Infection Society (MSIS) criteria served as a standard of reference for PJI. Clinical, serum, synovial, and intraoperative parameters were recorded in all patients. Correlations between all parameters with PJI diagnosis were analyzed using linear and logistic regression models with ROC analysis. RESULTS In 202 hips that included 91 septic hips, hip aspiration (AUC = 0.78) and intraoperative (0.80) parameters performed better than serum-based tests (0.64) and clinical parameters (0.68) in detecting PJI. Using MSIS criteria as a standard of reference, hip aspiration had a sensitivity of 64.0% and an accuracy of 78.5% for cultures and a sensitivity of 74.2% and an accuracy of 82.1% for synovial polymorphonuclear neutrophils% (PMN%). Results substantially improved sensitivity after excluding patients that were treated with antibiotics, particularly culture results. CONCLUSIONS Preoperative hip aspiration showed good diagnostic performance in diagnosing PJI compared with MSIS criteria as a standard of reference. But a negative result from aspirate could not rule out PJI. Based on our findings, hip aspiration is an essential test for treatment planning in patients with pain after hip arthroplasty.
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Affiliation(s)
- Thanat Kanthawang
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94158, USA. .,Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Jannis Bodden
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94158, USA.,Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gabby B Joseph
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94158, USA
| | - Thomas Vail
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Derek Ward
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Rina Patel
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94158, USA
| | - Thomas M Link
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 185 Berry St, Suite 350, San Francisco, CA, 94158, USA
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Preoperative Serum C-Reactive Protein/Albumin Ratio Is a Predictor of Complications After Single-stage Revision for the Treatment of Periprosthetic Joint Infection. J Am Acad Orthop Surg 2021; 29:e1013-e1024. [PMID: 34570745 DOI: 10.5435/jaaos-d-20-00613] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/29/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The C-reactive protein/albumin ratio (CAR) is a marker of inflammation that has been associated with negative outcomes in the general surgery. This study investigates the potential association of preoperative CAR with postoperative complications and readmission rates in the treatment of patients with single-stage revision total joint arthroplasty for periprosthetic joint infection. METHODS A total of 213 consecutive patients who had undergone single-stage revision for total joint arthroplasty with the preoperative diagnosis of periprosthetic joint infection and preoperative C-reactive protein and albumin values were included. The area under receiver operating characteristic curves was calculated to evaluate the CAR as a predictive value for the complications. RESULTS Significant differences between the mean CAR were found for patients with 30- and 60-day readmissions and reinfection (P < 0.01). CAR combined with serum and synovial fluid markers demonstrated significantly higher sensitivities and specificities for the prediction of 30-day (total knee arthroplasty [TKA]: 94%; 95%; total hip arthroplasty [THA]: 91%; 96%) and 60-day readmissions (THA: 94%; 95%; TKA: 92%; 96%) and reinfections (TKA: 94%; 95%; THA: 87%; 96%), when compared with only serum and synovial fluid markers combined (83%; 84%; 85%; 87%; 85%; 88%; P <0.01). DISCUSSION High preoperative CAR, when combined with serum and synovial fluid markers, was associated with increased risk of reinfection and 30- and 60-day readmissions, suggesting that preoperative CAR is a clinically useful predictor for postoperative complications in patients with periprosthetic hip and knee joint infections.
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36
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Echeverria AP, Cohn IS, Danko DC, Shanaj S, Blair L, Hollemon D, Carli AV, Sculco PK, Ho C, Meshulam-Simon G, Mironenko C, Ivashkiv LB, Goodman SM, Grizas A, Westrich GH, Padgett DE, Figgie MP, Bostrom MP, Sculco TP, Hong DK, Hepinstall MS, Bauer TW, Blauwkamp TA, Brause BD, Miller AO, Henry MW, Ahmed AA, Cross MB, Mason CE, Donlin LT. Sequencing of Circulating Microbial Cell-Free DNA Can Identify Pathogens in Periprosthetic Joint Infections. J Bone Joint Surg Am 2021; 103:1705-1712. [PMID: 34293751 DOI: 10.2106/jbjs.20.02229] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Over 1 million Americans undergo joint replacement each year, and approximately 1 in 75 will incur a periprosthetic joint infection. Effective treatment necessitates pathogen identification, yet standard-of-care cultures fail to detect organisms in 10% to 20% of cases and require invasive sampling. We hypothesized that cell-free DNA (cfDNA) fragments from microorganisms in a periprosthetic joint infection can be found in the bloodstream and utilized to accurately identify pathogens via next-generation sequencing. METHODS In this prospective observational study performed at a musculoskeletal specialty hospital in the U.S., we enrolled 53 adults with validated hip or knee periprosthetic joint infections. Participants had peripheral blood drawn immediately prior to surgical treatment. Microbial cfDNA from plasma was sequenced and aligned to a genome database with >1,000 microbial species. Intraoperative tissue and synovial fluid cultures were performed per the standard of care. The primary outcome was accuracy in organism identification with use of blood cfDNA sequencing, as measured by agreement with tissue-culture results. RESULTS Intraoperative and preoperative joint cultures identified an organism in 46 (87%) of 53 patients. Microbial cfDNA sequencing identified the joint pathogen in 35 cases, including 4 of 7 culture-negative cases (57%). Thus, as an adjunct to cultures, cfDNA sequencing increased pathogen detection from 87% to 94%. The median time to species identification for cases with genus-only culture results was 3 days less than standard-of-care methods. Circulating cfDNA sequencing in 14 cases detected additional microorganisms not grown in cultures. At postoperative encounters, cfDNA sequencing demonstrated no detection or reduced levels of the infectious pathogen. CONCLUSIONS Microbial cfDNA from pathogens causing local periprosthetic joint infections can be detected in peripheral blood. These circulating biomarkers can be sequenced from noninvasive venipuncture, providing a novel source for joint pathogen identification. Further development as an adjunct to tissue cultures holds promise to increase the number of cases with accurate pathogen identification and improve time-to-speciation. This test may also offer a novel method to monitor infection clearance during the treatment period. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Ian S Cohn
- Hospital for Special Surgery Research Institute, New York, NY
| | - David C Danko
- Tri-Institutional Computational Biology and Medicine Program, Weill Cornell Medicine of Cornell University, New York, NY
| | - Sara Shanaj
- Hospital for Special Surgery Research Institute, New York, NY
| | | | | | - Alberto V Carli
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Peter K Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Carine Ho
- Karius, Inc., Redwood City, California
| | | | - Christine Mironenko
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Lionel B Ivashkiv
- Hospital for Special Surgery Research Institute, New York, NY.,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Susan M Goodman
- Department of Medicine, Weill Cornell Medical College, New York, NY.,Department of Rheumatology, Hospital for Special Surgery, New York, NY
| | - Alexandra Grizas
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, NY
| | - Geoffrey H Westrich
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Douglas E Padgett
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Mark P Figgie
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Mathias P Bostrom
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Thomas P Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.,Department of Medicine, Weill Cornell Medical College, New York, NY
| | | | - Matthew S Hepinstall
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.,Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Thomas W Bauer
- Department of Medicine, Weill Cornell Medical College, New York, NY.,Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, NY
| | | | - Barry D Brause
- Department of Medicine, Weill Cornell Medical College, New York, NY.,Infectious Diseases, Department of Medicine, Hospital for Special Surgery, New York, NY
| | - Andy O Miller
- Department of Medicine, Weill Cornell Medical College, New York, NY.,Infectious Diseases, Department of Medicine, Hospital for Special Surgery, New York, NY
| | - Michael W Henry
- Department of Medicine, Weill Cornell Medical College, New York, NY.,Infectious Diseases, Department of Medicine, Hospital for Special Surgery, New York, NY
| | | | - Michael B Cross
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Christopher E Mason
- Tri-Institutional Computational Biology and Medicine Program, Weill Cornell Medicine of Cornell University, New York, NY.,Department of Physiology and Biophysics and the Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY.,The HRH Prince Alwaleed Bin Talal Bin Abdulaziz Alsaud Institute for Computational Biomedicine, Weill Cornell Medicine, New York, NY.,The WorldQuant Initiative for Quantitative Prediction, Weill Cornell Medicine, New York, NY.,The Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY
| | - Laura T Donlin
- Hospital for Special Surgery Research Institute, New York, NY.,Department of Medicine, Weill Cornell Medical College, New York, NY.,Department of Physiology and Biophysics and the Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY
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Wang H, Qin L, Wang J, Hu N, Huang W. Combined serum and synovial C-reactive protein tests: a valuable adjunct to the diagnosis of chronic prosthetic joint infection. BMC Musculoskelet Disord 2021; 22:670. [PMID: 34372816 PMCID: PMC8353858 DOI: 10.1186/s12891-021-04545-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/28/2021] [Indexed: 01/08/2023] Open
Abstract
Background Diagnosis of periprosthetic joint infection (PJI), especially chronic PJI, is very confusing and challenging. The value of C-reactive protein (CRP) in infectious diseases has been recognized, but the diagnostic value of CRP in chronic PJI is unknown. Our aim was to investigate the diagnostic value of synovial CRP in chronic PJI and to explore the role of combined serum and synovial CRP in distinguishing chronic PJI from aseptic failure after knee and hip arthroplasties. Methods We prospectively enrolled patients scheduled to have a revision surgery for chronic PJI or aseptic loosening from January 2019 to December 2020, in which synovial CRP was additionally measured along with routine preoperative diagnostic serum ((ESR, CRP) and synovial (PMN%) biomarkers. The receiver operating characteristic (ROC) curves and area under the curve (AUC) were analyzed for each biomarker to determine diagnostic efficacy. Results There were no statistically significant differences between the infection (n = 39) and aseptic (n = 58) groups, including 61 hips and 36 knees. The synovial CRP levels were significantly higher in the infection group than in the aseptic group (median: 9.93 mg/l vs 3.58 mg/l; p < .001). The optimal cut-off value for detecting chronic PJI of Synovial fluid (SF) CRP was of 7.26 mg/l with a sensitivity of 84.62%, a specificity of 93.10%. The combined model I (Serum CRP > 10.2 mg/l OR SF CRP > 7.26 mg/l) had a negative predictive value (NPV) of 96.67%, and a sensitivity of 97.44%. The combined model II (Serum CRP > 10.2 mg/l AND Synovial CRP > 7.26 mg/l) led to a specificity of 1, and a positive predictive value (PPV) of 1. Conclusions The present study demonstrated that the combination of serum and synovial CRP can be used as an adjunct to the diagnosis of chronic PJI. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04545-6.
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Affiliation(s)
- Hai Wang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.,Department of Orthopaedics, Fuling Central Hospital of Chongqing City, Chongqing, 408099, China
| | - Leilei Qin
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Jiawei Wang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Ning Hu
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Wei Huang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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38
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Gramlich Y, Kremer M, Brüning C, Breuer J, Hofmann L, Klug A, Hoffmann R. Implementation of a standardized clinical test kit for diagnostics of periprosthetic infections in the clinical routine. Unfallchirurg 2021; 124:247-254. [PMID: 34338839 DOI: 10.1007/s00113-021-01016-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The number of primary arthroplasties is increasing and the proportion of revision arthroplasties is becoming increasingly more important. The need for standardized and guideline-based diagnostics for the safe detection of a periprosthetic joint infection (PJI) is becoming apparent. In the past 10 years various organizations have published definitions and diagnostic guidelines. The implementation of an inhouse standard test kit could help to simplify the process and could improve the diagnostic quality. METHOD In 2016 a test kit was compiled in a monocentric prospective study, taking the International Consensus Meeting (ICM) criteria 2014 and the Infectious Diseases Society of America (IDSA) criteria into account, which also fulfils the definitions of the ICM criteria 2018 and criteria of the European Bone and Joint Infection Society 2021. The test kit was implemented in the clinical setting of a special department for aseptic and septic revision arthroplasty. The usability and accuracy of the test kit were examined. RESULTS The test kit was implemented using blood samples (leukocyte count; C‑reactive protein, CRP), samples for examining the synovial fluid (white blood cell count, PMN cell differentiation, microbiological culture for incubation over 14 days, alpha-defensin enzyme-linked immunosorbent assay, ELISA, leukocyte esterase test strips) together with information and request forms. Between April 2016 and February 2020 a total of 405 patients were investigated. Within 3 calendar years, the use of the test kit increased from 59% initially to 86%, and finally to 96% of cases in the third calendar year. The leukocyte esterase test strip was reliable in only 72%, due to undifferentiated readability or blood contamination. The costs increased by the only commercially available alpha-defensin ELISA test by approx. 52€ per puncture. The best individual test showed a sensitivity/specificity of 92.8%/95.2% with alpha-defensin. It was calculated which combinations showed a similar test quality and different combinations, such as CRP+ cell count+ microbiology showed a sensitivity/specificity both of around 90%. Metallosis is a challenge for preoperative PJI diagnostics. DISCUSSION In a prospective study it was shown, that the implementation of the standardized test kit lead to a guideline based PJI diagnostic in all cases and thus to a significantly increase of the diagnostic quality. There is currently no single test that reliably excludes or proves an infection. The alpha-defensin laboratory ELISA test showed the best test accuracy, whereby the consideration of test combinations is obligatory and at the same time safe.
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Affiliation(s)
- Y Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany.
| | - M Kremer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - C Brüning
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - J Breuer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - L Hofmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - A Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - R Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
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Alpha defensin-1 attenuates surgically induced osteoarthritis in association with promoting M1 to M2 macrophage polarization. Osteoarthritis Cartilage 2021; 29:1048-1059. [PMID: 33892137 DOI: 10.1016/j.joca.2021.04.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 03/22/2021] [Accepted: 04/12/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Macrophages play an important part in the pathogenesis of osteoarthritis (OA). Our objective was to determine the effects of α-defensin-1 on macrophage polarization and consequently OA. METHODS OA synovial tissue and synovial fluid were assessed for the presence of M1 (CD68+CD16+CD206-) and M2 (CD68+CD206+CD16-) macrophages by flow cytometry. M0, M1, and M2 macrophages were co-cultured with OA chondrocytes to determine their influence on chondrogenic phenotype. Polarization of THP-1 activated monocytes from M1 to M2 in response to α-defensin-1 was evaluated by flow cytometry, RT-PCR and RNA sequencing. Effects of intra-articular α-defensin-1 in vivo were evaluated in a rat meniscal/ligamentous injury (MLI) model. RESULTS The quantity of M1 exceeded M2 polarized macrophages in human OA synovial tissue (mean difference 26.1% [13.6-38.6%], P < 0.001) and fluid (mean difference 10.5% [5.0-16.1%], P = 0.003). M1 to M2 polarization in vitro was most effectively promoted with 10 ng/mL α-defensin-1. Compared with untreated macrophages, the α-defensin-1 polarized macrophages modified co-cultured OA chondrocytes from a pro-catabolic state to a pro-anabolic (regenerative-like) state based on expression of COL2A1, ACN, MMP3, MMP13 and ADAMTS5. Intra-articular α-defensin-1 decreased severity of cartilage damage and synovitis in the MLI rat model. RNAseq analyses suggested insulin and Toll-like receptor signaling pathways in the chondroprotective α-defensin-1 mechanism of action. CONCLUSION α-defensin-1 promotes M1 to M2 macrophage polarization in vitro, has beneficial effects on chondrocytes indirectly via M2 macrophage polarization, and attenuates the severity of OA in vivo, suggesting it might be a candidate treatment for OA.
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Gramlich Y, Kremer M, Brüning C, Breuer J, Hofmann L, Klug A, Hoffmann R. [Implementation of a standardized clinical test kit for diagnostics of periprosthetic infections in the clinical routine. German version]. Unfallchirurg 2021; 125:381-388. [PMID: 34189589 DOI: 10.1007/s00113-021-01017-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The number of primary arthroplasties is increasing and the proportion of revision arthroplasties is becoming increasingly more important. The need for standardized and guideline-based diagnostics for the safe detection of a periprosthetic joint infection (PJI) is becoming apparent. In the past 10 years various organizations have published definitions and diagnostic guidelines. The implementation of an inhouse standard test kit could help to simplify the process and could improve the diagnostic quality. METHOD In 2016 a test kit was compiled in a monocentric prospective study, taking the International Consensus Meeting (ICM) criteria 2014 and the Infectious Diseases Society of America (IDSA) criteria into account, which also fulfils the definitions of the ICM criteria 2018 and criteria of the European Bone and Joint Infection Society 2021. The test kit was implemented in the clinical setting of a special department for aseptic and septic revision arthroplasty. The usability and accuracy of the test kit were examined. RESULTS The test kit was implemented using blood samples (leukocyte count; C‑reactive protein, CRP), samples for examining the synovial fluid (white blood cell count, PMN cell differentiation, microbiological culture for incubation over 14 days, alpha-defensin enzyme-linked immunosorbent assay, ELISA, leukocyte esterase test strips) together with information and request forms. Between April 2016 and February 2020 a total of 405 patients were investigated. Within 3 calendar years, the use of the test kit increased from 59% initially to 86%, and finally to 96% of cases in the third calendar year. The leukocyte esterase test strip was reliable in only 72%, due to undifferentiated readability or blood contamination. The costs increased by the only commercially available alpha-defensin ELISA test by approx. 52€ per puncture. The best individual test showed a sensitivity/specificity of 92.8%/95.2% with alpha-defensin. It was calculated which combinations showed a similar test quality and different combinations, such as CRP+ cell count+ microbiology showed a sensitivity/specificity both of around 90%. Metallosis is a challenge for preoperative PJI diagnostics. DISCUSSION In a prospective study it was shown, that the implementation of the standardized test kit lead to a guideline based PJI diagnostic in all cases and thus to a significantly increase of the diagnostic quality. There is currently no single test that reliably excludes or proves an infection. The alpha-defensin laboratory ELISA test showed the best test accuracy, whereby the consideration of test combinations is obligatory and at the same time safe.
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Affiliation(s)
- Y Gramlich
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland.
| | - M Kremer
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - Chr Brüning
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - J Breuer
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - L Hofmann
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - A Klug
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - R Hoffmann
- Abteilung für Orthopädie und Unfallchirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
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Salar O, Phillips J, Porter R. Diagnosis of knee prosthetic joint infection; aspiration and biopsy. Knee 2021; 30:249-253. [PMID: 33964686 DOI: 10.1016/j.knee.2020.12.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/04/2020] [Accepted: 12/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Prosthetic joint infection (PJI) is a significant cause of morbidity and mortality following knee replacement surgery. The diagnosis can be challenging and is based on a combination of clinical suspicion, radiographic findings and also biochemical/ microbiological investigations. Our Aim was to review the role of aspiration and biopsy in the diagnosis of PJI in Total Knee Arthroplasty (TKA). METHOD/RESULTS Aspirated synovial fluid should be analysed by direct culture, via blood culture bottles, EDTA bottles for cell count and 'point of care' testing such as leucocyte esterase or alpha defensin. Synovial WCC and PMN cell percentage are important steps in diagnosis of both acute and chronic PJI. A minimum of 5 deep samples using a 5 clean instrument technique should be obtained and sent for tissue culture done either blind or arthroscopic. Formal fluoroscopic guided interface biopsy has also been described with excellent results. In a recent series of 86 TKRs preoperative arthroscopic biopsy group had a sensitivity of 100%, specificity of 94.7%, positive predictive value of 87.4% and a negative predictive value of 100%. CONCLUSION In the presence of clinical suspicion with raised biomarkers, it is recommended that aspiration +/- biopsy with synovial fluid testing is performed. Direct culture and cell count are recommended. 'Point of care tests' such as Leucocyte Esterase testing should be considered. Duration of culture, including pathogen and host factors, should be discussed with a local microbiology/ID department in the context of a formal multi-disciplinary team.
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Affiliation(s)
- Omer Salar
- Department of Trauma and Orthopaedics, Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospitals, Barrack Road, EX2 5DW, United Kingdom.
| | - Jonathan Phillips
- Department of Trauma and Orthopaedics, Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospitals, Barrack Road, EX2 5DW, United Kingdom
| | - Robert Porter
- Department of Microbiology, Royal Devon and Exeter Hospitals, Barrack Road, United Kingdom
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Balato G, De Franco C, Balboni F, De Matteo V, Ascione T, Baldini A, Lippi G. The role of D-dimer in periprosthetic joint infection: a systematic review and meta-analysis. ACTA ACUST UNITED AC 2021; 9:3-10. [PMID: 34013679 DOI: 10.1515/dx-2021-0032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/19/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The current literature on diagnosis of periprosthetic joint infection (PJI) provides controversial evidence on the diagnostic accuracy of D-dimer. Therefore, this critical literature search and meta-analysis was aimed to summarize the diagnostic accuracy of D-dimer for diagnosing PJI. CONTENT We searched MEDLINE, Scopus, and Web of Science, for studies on D-dimer for diagnosing PJI, according to the PRISMA flowchart. QUADAS was used for assessing study quality. Sensitivity, specificity, positive (PLR) and negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were analyzed using bivariate diagnostic random-effects model. The area under the receiver-operating curve (AUC-ROC) was calculated. Subgroup analysis and univariate meta-regression were carried out for detecting potential sources of heterogeneity. SUMMARY We included 12 articles, totaling 1,818 patients (539 with PJI). The pooled sensitivity and specificity of D-dimer for diagnosing PJI were 0.739 (95% CI: 0.616-0.833) and 0.785 (95% CI: 0.679-0.863). The pooled PLR, NLR, DOR were 3.359 (95% CI, 2.340-4.821), 0.295 (95% CI, 0.180-0.484), and 11.787 (95% CI, 5.785-24.018). The cumulative ROC plot displayed an AUC of 0.688 (95% CI, 0.663-0.713; p<0.001). No threshold effects could be observed. The type of blood sample was identified as possible source of heterogeneity for DOR (p=0.01). OUTLOOK Evidence emerged from this meta-analysis suggests that D-dimer displays sufficient diagnostic accuracy to rule out PJI. The type of blood sample (plasma vs. serum) and the study design could influence the results in terms of DOR and sensitivity. However, further perspective studies would be needed to validate its potential diagnostic usefulness.
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Affiliation(s)
- Giovanni Balato
- Department of Public Health, Orthopedic Unit, Federico II University Naples, Naples, Italy
| | - Cristiano De Franco
- Department of Public Health, Orthopedic Unit, Federico II University Naples, Naples, Italy
| | - Fiamma Balboni
- Laboratory Service, Istituto Fiorentino Cura e Assistenza IFCA Florence, Florence, Italy
| | - Vincenzo De Matteo
- Department of Public Health, Orthopedic Unit, Federico II University Naples, Naples, Italy
| | - Tiziana Ascione
- Department of Medicine, Service of Infectious Disease, Cardarelli Hospital Naples, Naples, Italy
| | - Andrea Baldini
- Orthopedic Unit, Istituto Fiorentino Cura e Assistenza IFCA Florence, Florence, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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van den Kieboom J, Tirumala V, Xiong L, Klemt C, Kwon YM. Concomitant Hip and Knee Periprosthetic Joint Infection in Periprosthetic Fracture: Diagnostic Utility of Serum and Synovial Fluid Markers. J Arthroplasty 2021; 36:722-727. [PMID: 32893059 DOI: 10.1016/j.arth.2020.08.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Diagnosing periprosthetic joint infection (PJI) in patients with a periprosthetic fracture can be challenging due to concerns regarding the reliability of commonly used serum and synovial fluid markers. This study aimed at determining the diagnostic performance of serum and synovial fluid markers for diagnosing PJI in patients with a periprosthetic fracture of a total joint arthroplasty. METHODS A total of 144 consecutive patients were included: (1) 41 patients with concomitant PJI and periprosthetic fracture and (2) 103 patients with periprosthetic fracture alone. Serum markers erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and synovial markers white blood cell (WBC) count and polymorphonuclear percentage were assessed. RESULTS ESR demonstrated 87% sensitivity and 48% specificity at the Musculoskeletal Infection Society threshold, area under the curve (AUC) of 0.74, and optimal threshold of 45.5 mm/h (76% sensitivity, 68% specificity). CRP showed 94% sensitivity and 40% specificity, AUC of 0.68 with optimal threshold of 16.7 mg/L (84% sensitivity, 51% specificity). Synovial WBC count demonstrated 87% sensitivity and 78% specificity, AUC of 0.90 with optimal threshold of 4552 cells/μL (86% sensitivity, 85% specificity). Polymorphonuclear percentage showed 79% sensitivity and 63% specificity, AUC of 0.70 with optimal threshold of 79.5% (74% sensitivity, 63% specificity). The AUC of all combined markers was 0.90 with 84% sensitivity and 79% specificity. CONCLUSION The diagnostic utility of the serum and synovial markers for diagnosing PJI was lower in the setting of concomitant periprosthetic fracture compared to PJI alone. Using the Musculoskeletal Infection Society thresholds, ESR, CRP, and WBC count showed high sensitivity, yet low specificity, thus higher thresholds and utilizing all serum and synovial markers in combination should be considered.
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Affiliation(s)
- Janna van den Kieboom
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Venkatsaiakhil Tirumala
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Liang Xiong
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christian Klemt
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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McNally M, Sousa R, Wouthuyzen-Bakker M, Chen AF, Soriano A, Vogely HC, Clauss M, Higuera CA, Trebše R. The EBJIS definition of periprosthetic joint infection. Bone Joint J 2021; 103-B:18-25. [PMID: 33380199 PMCID: PMC7954183 DOI: 10.1302/0301-620x.103b1.bjj-2020-1381.r1] [Citation(s) in RCA: 269] [Impact Index Per Article: 89.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition. Methods This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance. Results This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI. Conclusion The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice. Cite this article: Bone Joint J 2021;103-B(1):18–25.
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Affiliation(s)
- Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Ricardo Sousa
- Porto Bone Infection Group (GRIP), Orthopaedic Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Antonia F Chen
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - H Charles Vogely
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martin Clauss
- Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic, Florida, USA
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Abdelbary H, Cheng W, Ahmadzai N, Carli AV, Shea BJ, Hutton B, Fergusson DA, Beaulé PE. Combination Tests in the Diagnosis of Chronic Periprosthetic Joint Infection: Systematic Review and Development of a Stepwise Clinical Decision-Making Tool. J Bone Joint Surg Am 2020; 102:114-124. [PMID: 32870618 DOI: 10.2106/jbjs.20.00097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Our objective was to identify combination tests used to diagnose chronic periprosthetic joint infection (PJI) and develop a stepwise decision-making tool to facilitate diagnosis. METHODS We conducted a systematic review of existing combinations of serum, synovial, and tissue-based tests for diagnosing chronic PJI after hip or knee replacement. This work is an extension of our systematic review of single tests, from which we chose eligible studies that also described the diagnostic performance of combination tests. RESULTS Thirty-seven eligible articles described the performance of 56 combination tests, of which 8 combinations had at least 2 studies informing both sensitivity and specificity. We also identified 5 types of combination tests: (1) a type-I Boolean combination, which uses Boolean logic (AND, OR) and usually increases specificity at the cost of sensitivity; (2) a type-II Boolean combination, which usually increases sensitivity at the cost of specificity; (3) a triage-conditional rule, in which the value of 1 test serves to triage the use of another test; (4) an arithmetic operation on the values of 2 tests; and (5) a model-based prediction rule based on a fitted model applied to biomarker values. CONCLUSIONS Clinicians can initiate their diagnostic process with a type-II Boolean combination of serum C-reactive protein (CRP) and interleukin-6 (IL-6). False negatives of the combination can be minimized when the threshold is chosen to reach 90% to 95% sensitivity for each test. Once a joint infection is suspected on the basis of serum testing, joint aspiration should be performed. If joint aspiration yields a wet tap, a leukocyte esterase (LER) strip is highly recommended for point-of-care testing, with a reading of ++ or greater indicating PJI; a reading below ++ should be followed by one of the laboratory-based synovial tests. If joint aspiration yields a dry tap, clinicians should rely on preoperative tissue culture and histological analysis for diagnosis. Combinations based on triage-conditional, arithmetic, and model-based prediction rules require further research. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hesham Abdelbary
- Division of Orthopaedic Surgery (H.A. and P.E.B.) and School of Epidemiology and Public Health (B.J.S. and B.H.), University of Ottawa, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nadera Ahmadzai
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Beverley J Shea
- Division of Orthopaedic Surgery (H.A. and P.E.B.) and School of Epidemiology and Public Health (B.J.S. and B.H.), University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Brian Hutton
- Division of Orthopaedic Surgery (H.A. and P.E.B.) and School of Epidemiology and Public Health (B.J.S. and B.H.), University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery (H.A. and P.E.B.) and School of Epidemiology and Public Health (B.J.S. and B.H.), University of Ottawa, Ottawa, Ontario, Canada
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Elevated ESR/CRP Ratio Is Associated With Reinfection After Debridement, Antibiotics, and Implant Retention in Chronic Periprosthetic Joint Infections. J Arthroplasty 2020; 35:3254-3260. [PMID: 32631730 DOI: 10.1016/j.arth.2020.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/22/2020] [Accepted: 06/03/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Ratios of established inflammatory markers, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), have been used for diagnostic purposes in the surgical field; however, the ESR:CRP ratio (ECR) has not been evaluated as a marker for predicting infection resolution in patients with periprosthetic joint infections (PJIs). This study aimed to evaluate the diagnostic accuracy of ECR in predicting postoperative reinfection in patients who underwent debridement, antibiotics, and implant retention (DAIR). METHODS This is a retrospective review of 179 consecutive patients who underwent DAIR revision total joint arthroplasty for PJI. Patients were stratified by acuity of their infection: acute PJI, acute hematogenous PJI, and chronic PJI. The area under the receiver operating characteristic curve was calculated to evaluate ECR as diagnostic marker for predicting postoperative reinfection in patients who underwent DAIR. RESULTS Statistically significant differences in ECR were found in patients who underwent DAIR revision total joint arthroplasty for chronic infection (1.23 vs 2.33; P = .04). There was no significant difference in ECR in patients who underwent DAIR for acute infection (P = .70) and acute hematogenous infection (P = .56). In patients who underwent DAIR for chronic PJI, ECR demonstrated a sensitivity and specificity of 75% and 84%, respectively, for the prediction of postoperative reinfection, which was significantly higher than that of ESR (sensitivity, 67%; specificity, 47%; P < .001) and CRP (sensitivity, 50%; specificity, 26%; P < .001). CONCLUSION Elevated ECR was associated with an increased reinfection risk in patients who underwent DAIR for chronic PJI, suggesting that preoperative ECR may be a useful predictor to identify patients at increased risk of reinfection after DAIR for chronic PJIs.
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Alvand A, Morgan-Jones R. Diagnosis of knee periprosthetic joint infection. Knee 2020; 27:1671-1675. [PMID: 32847691 DOI: 10.1016/j.knee.2020.07.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Qu PF, Li R, Xu C, Chai W, Li H, Fu J, Chen JY. A Clinical Pilot Study to Evaluate CD64 Expression on Blood Monocytes as an Indicator of Periprosthetic Joint Infection. J Bone Joint Surg Am 2020; 102:e99. [PMID: 32358410 DOI: 10.2106/jbjs.20.00057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The preoperative diagnosis of periprosthetic joint infection (PJI) depends on a series of blood biomarkers. Previous studies have shown that CD64 expression on blood neutrophils and monocytes has a good diagnostic efficacy for diagnosing systemic and local infections. The purpose of the present study was to investigate the role of blood CD64 in the diagnosis of PJI. METHODS On the basis of estimations made before the study was performed, 62 patients were recruited for joint revision surgery following the failure of primary hip or knee replacement. Venous blood was obtained within 24 hours after patient admission, and flow cytometry was performed to evaluate the CD64 expression of 3 groups of white blood cells (WBCs). CD64 expression was measured as CD64 mean fluorescence intensity (CD64MFI). The neutrophil CD64 index (nCD64 index; neutrophil CD64MFI [nCD64MFI]/lymphocyte CD64MFI [lCD64MFI]) and monocyte CD64 index (mCD64 index; monocyte CD64MFI [mCD64MFI]/lCD64MFI) were then calculated. The C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) at admission, synovial fluid indicators, leukocyte esterase test results, intraoperative histological results, and tissue or synovial fluid culture results were recorded. According to the modified Musculoskeletal Infection Society (MSIS) criteria, patients were divided into the PJI group and the non-PJI group. These blood indicators were then analyzed for the diagnosis of PJI. RESULTS The PJI group included 18 patients, and the non-PJI group included 44 patients. The diagnostic value of the area under the receiver operating characteristic curve (AUC) was low for lCD64MFI, the nCD64 index, and the mCD64 index. The diagnostic value for nCD64MFI was moderate, with an AUC of 0.735 (95% confidence interval [CI], 0.595 to 0.874; p = 0.004). The diagnostic value for mCD64MFI was high, with an AUC of 0.898 (95% CI, 0.821 to 0.975; p < 0.001). The cutoff value for mCD64MFI was 28,968, with a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 1, 0.75, 0.62, and 1, respectively. This result was confirmed by internal validation with a different antibody. CONCLUSIONS Flow cytometry can be used for patient screening before revision surgery, and blood mCD64MFI is a promising indicator for 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)
- Peng-Fei Qu
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, People's Republic of China
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Klim SM, Amerstorfer F, Glehr G, Hauer G, Smolle MA, Leitner L, Leithner A, Glehr M. Combined serum biomarker analysis shows no benefit in the diagnosis of periprosthetic joint infection. INTERNATIONAL ORTHOPAEDICS 2020; 44:2515-2520. [PMID: 32712786 PMCID: PMC7679358 DOI: 10.1007/s00264-020-04731-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/14/2020] [Indexed: 12/16/2022]
Abstract
Purpose In many cases, the diagnosis of a periprosthetic joint infection (PJI) consisting of the clinical appearance, laboratory tests, and other diagnostic tools remains a difficult task. Single serum biomarkers are easy to collect, are suitable for periodical assessment, and are a crucial tool in PJI diagnosis, but limited sensitivity or specificity is reported in literature. The aim of this study was to combine the best-performing single serum biomarkers into a multi-biomarker model aiming to improve the diagnostic properties. Methods Within a 27-month period, 124 surgical procedures (aseptic or septic revision total knee arthroplasty (TKA) or total hip arthroplasty (THA)) were prospectively included. The serum leukocyte count, C-reactive protein (CRP), interleukin-6, procalcitonin, interferon alpha, and fibrinogen were assessed 1 day prior to surgery. Logistic regression with lasso-regularization was used for the biomarkers and all their ratios. After randomly splitting the data into a training (75%) and a test set (25%), the multi-biomarker model was calculated and validated in a cross-validation approach. Results CRP (AUC 0.91, specificity 0.67, sensitivity 0.90, p value 0.03) and fibrinogen (AUC 0.93, specificity 0.73, sensitivity 0.94, p value 0.02) had the best single-biomarker performances. The multi-biomarker model including fibrinogen, CRP, the ratio of fibrinogen to CRP, and the ratio of serum thrombocytes to CRP showed a similar performance (AUC 0.95, specificity 0.91, sensitivity 0.72, p value 0.01). Conclusion In this study, multiple biomarkers were tested for their diagnostic performance, with CRP and fibrinogen showing the best results regarding the AUC, accuracy, sensitivity, and specificity. It was not possible to further increase the diagnostic accuracy by combining multiple biomarkers using sophisticated statistical methods.
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Affiliation(s)
- S M Klim
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - F Amerstorfer
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - G Glehr
- Statistical Bioinformatics Department, University of Regensburg, Am BioPark 9, 93053, Regensburg, Germany
| | - G Hauer
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - M A Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - L Leitner
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
| | - A Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - M Glehr
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
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Lu G, Li T, Ye H, Liu S, Zhang P, Wang W. D-dimer in the diagnosis of periprosthetic joint infection: a systematic review and meta-analysis. J Orthop Surg Res 2020; 15:265. [PMID: 32677991 PMCID: PMC7364596 DOI: 10.1186/s13018-020-01761-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/23/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND D-dimer, a coagulation-related indicator, has recently been used as a tool for the diagnosis of periprosthetic joint infection (PJI), but its reliability is uncertain. The purpose of this systematic review and meta-analysis was to explore the accuracy of D-dimer in the diagnosis of PJI after joint arthroplasty. METHODS We systematically searched the MEDLINE, EMBASE, and Cochrane databases for relevant literature about D-dimer in the diagnosis of PJI. QUADAS-2 was used to assess the risk of bias and clinical applicability of each included study. We used the bivariate meta-analysis framework to pool the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the SROC curve (AUC). Univariate meta-regression and subgroup analyses were performed to explore the sources of heterogeneity. RESULTS We included 8 eligible studies. The pooled diagnostic sensitivity and specificity were 0.82 (95% CI, 0.70-0.89) and 0.70 (95% CI, 0.55-0.82), respectively. The pooled PLR, NLR, and DOR were 2.7 (95% CI, 1.7-4.4), 0.26 (95% CI, 0.15-0.46), and 10 (95% CI, 4-25), respectively. The AUC was 0.83 (95% CI, 0.8-0.86). Serum D-dimer might have higher diagnostic accuracy than plasma D-dimer for PJI (pooled sensitivity: 0.88 vs 0.67; pooled specificity: 0.76 vs 0.61). CONCLUSIONS D-dimer has limited performance for the diagnosis of PJI.
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Affiliation(s)
- Guangxu Lu
- Department of Logistics University of PAP, Tianjin, 300309, China.,Department of Orthopedics, Characteristic Medical Center of PAP, Tianjin, 300162, China.,Department of Orthopedics, Er Quan Hospital of PAP, Wuxi, 214000, China
| | - Tong Li
- Department of Orthopedics, Characteristic Medical Center of PAP, Tianjin, 300162, China
| | - Haoqi Ye
- Department of Logistics University of PAP, Tianjin, 300309, China
| | - Shujin Liu
- Department of Logistics University of PAP, Tianjin, 300309, China.,Department of Orthopedics, Characteristic Medical Center of PAP, Tianjin, 300162, China
| | - Peng Zhang
- Department of Orthopedics, Characteristic Medical Center of PAP, Tianjin, 300162, China
| | - Wenliang Wang
- Department of Orthopedics, Characteristic Medical Center of PAP, Tianjin, 300162, China.
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