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Tarabichi S, Lizcano JD, Abe EA, Goh GS, Baker CM, Parvizi J. Finding the Optimal Screening Test for Periprosthetic Joint Infection: A Prospective Study. J Arthroplasty 2024; 39:1919-1925.e2. [PMID: 38452860 DOI: 10.1016/j.arth.2024.02.030] [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: 10/22/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Serological markers are often used as screening tools to avoid unnecessary joint aspiration in cases with a low probability of infection. This study aimed to determine the utility of standard-of-care serological tests as a screening tool for PJI in patients undergoing revision arthroplasty. METHODS This prospective study enrolled 502 patients undergoing revision hip or knee arthroplasty between May 2017 and August 2021. A PJI was defined using a modified definition of the 2018 International Consensus Meeting criteria. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. There were 82 patients undergoing reimplantation who were excluded. Additionally, 8 patients who had an inconclusive International Consensus Meeting score were also excluded. Of the 412 included patients, 317 (76.9%) underwent revision for aseptic failure, and 95 (23.1%) had PJI. Receiver operating characteristic curves were used to assess the diagnostic utility of each serological test. A pairwise comparison with Bonferroni correction was performed to determine whether the differences in areas under the curve (AUCs) between the tests were significant. Additional analyses were performed to find the threshold for each test that offered 100% sensitivity, allowing it to be the optimal screening test. RESULTS All 4 serological markers, D-dimer (AUC 0.860, sensitivity 81.3%, specificity 81.7%), CRP (AUC 0.862, sensitivity 90.4%, specificity 70.0%), ESR (AUC 0.833, sensitivity 73.9%, specificity 85.2%), and fibrinogen (AUC 0.798, sensitivity 74.7%, specificity 75.4%), demonstrated comparable accuracy for the diagnosis of PJI (all P > .05). When maximizing sensitivity to 100%, D-dimer demonstrated the highest specificity (AUC 0.860, specificity 40.2%), outperforming ESR (AUC 0.833, specificity 3.3%), fibrinogen (AUC 0.798, specificity 2.3%), and CRP (AUC 0.862, specificity 0%). A plasma D-dimer level of ≥ 244 ng/mL was identified as the optimal cutoff for use as a screening test. CONCLUSIONS Although plasma D-dimer demonstrated similar diagnostic accuracy as CRP, ESR, and fibrinogen, it outperformed all 3 aforementioned serological markers when used as a screening test for PJI. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Saad Tarabichi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Elizabeth A Abe
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts
| | - Colin M Baker
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Cleveland Clinic South Pointe, Cleveland, Ohio
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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2
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Pondugula P, Krumme JW, Seedat R, Patel NK, Golladay GJ. Evaluation of painful total knee arthroplasty: an approach based on common etiologies for total knee arthroplasty revision. Musculoskelet Surg 2024; 108:11-20. [PMID: 37987959 DOI: 10.1007/s12306-023-00800-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/24/2023] [Indexed: 11/22/2023]
Abstract
A differential diagnosis with emphasis on the common indications for revision should be utilized in the workup of painful total knee arthroplasty (TKA). The physician should identify the exact etiology of the patient's pain to maximize outcomes from treatment. Evaluation for infection should be completed using the Musculoskeletal Infection Society (MSIS) criteria. When common causes of revision TKA do not appear to be the cause of the pain, less likely causes should be not be ignored. Further advancements such as pressure sensing devices may be able to improve patient satisfaction and decrease the incidence of pain following TKA.
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Affiliation(s)
- P Pondugula
- Department of Orthopedic Surgery, Virginia Commonwealth University Medical Center, PO Box 980153, Richmond, VA, 23298, USA
| | - J W Krumme
- Department of Orthopedic Surgery, Virginia Commonwealth University Medical Center, PO Box 980153, Richmond, VA, 23298, USA
| | - R Seedat
- Department of Orthopedic Surgery, Virginia Commonwealth University Medical Center, PO Box 980153, Richmond, VA, 23298, USA
| | - N K Patel
- Department of Orthopedic Surgery, Virginia Commonwealth University Medical Center, PO Box 980153, Richmond, VA, 23298, USA
| | - G J Golladay
- Department of Orthopedic Surgery, Virginia Commonwealth University Medical Center, PO Box 980153, Richmond, VA, 23298, USA.
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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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Tarabichi S, Goh GS, Baker CM, Chisari E, Shahi A, Parvizi J. Plasma D-Dimer Is Noninferior to Serum C-Reactive Protein in the Diagnosis of Periprosthetic Joint Infection. J Bone Joint Surg Am 2023; 105:501-508. [PMID: 36758110 DOI: 10.2106/jbjs.22.00784] [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: 02/11/2023]
Abstract
BACKGROUND No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Serological markers are often used as screening tools in the workup of patients with suspected PJI. This study aimed to determine the diagnostic utility of plasma D-dimer for PJI in a variety of clinical scenarios. METHODS This prospective study enrolled 502 patients undergoing revision hip or knee arthroplasty. PJI was defined per a modified version of the 2018 International Consensus Meeting (ICM) criteria. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. Receiver operating characteristic curves were used to assess the utility of each biomarker in the diagnosis of PJI. Pairwise comparison with Bonferroni correction was performed to determine whether the differences in areas under the curve (AUCs) between the markers were significant. RESULTS Of the 412 patients included, 317 (76.9%) did not have an infection (aseptic group) and 95 (23.1%) had an infection (PJI group). All 4 serological markers, D-dimer (AUC, 0.860; sensitivity, 81.3%; specificity, 81.7%), CRP (AUC, 0.862; sensitivity, 90.4%; specificity, 70.0%), ESR (AUC, 0.833; sensitivity, 73.9%; specificity, 85.2%), and fibrinogen (AUC, 0.798; sensitivity, 74.7%; specificity, 75.4%), demonstrated comparable accuracy for the diagnosis of PJI (all p > 0.05). When examining the performance of the different inflammatory markers in diagnosing infection caused by indolent organisms, D-dimer demonstrated the highest sensitivity at 93.8%. CONCLUSIONS We found that plasma D-dimer was noninferior to serum CRP and ESR in the diagnosis of PJI and may be a useful adjunct when screening patients undergoing revision total joint arthroplasty. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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A Permanent Articulating Spacer Versus Two-Stage Exchange for Chronic Periprosthetic Joint Infection: A Propensity Score-Matched Study. J Arthroplasty 2023:S0883-5403(23)00057-8. [PMID: 36720418 DOI: 10.1016/j.arth.2023.01.036] [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: 09/09/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although 2-stage revision has been proposed as gold standard for periprosthetic joint infection treatment, limited evidence exists for the role of articulating spacers as definitive management. The purpose of this study was to compare clinical outcomes and costs associated with articulating spacers (1.5-stage) and a matched 2-stage cohort. METHODS A retrospective review was performed for patients who had chronic periprosthetic joint infections after total knee arthroplasty defined by Musculoskeletal Infection Society criteria and were matched via propensity score matching using cumulative Musculoskeletal Infection Society scores and a comorbidity index. Patients who maintained an articulating spacer (cemented cobalt-chrome femoral component and all-poly tibia) were included in the 1.5-stage cohort. Patients who underwent a 2-stage reimplantation procedure were included in the 2-stage cohort. Outcomes included visual analog scale pain scores, 90-day emergency department visits, 90-day readmission, unplanned reoperation, reinfection, as well as cost at 1 and 2-year intervals. A total of 116 patients were included for analyses. RESULTS The 90-day pain scores were lower in the 1.5-stage cohort compared to the 2-stage cohort (2.9 versus 4.6, P = .0001). There were no significant differences between readmission and reoperation rates. Infection clearance was equivalent at 79.3% for both groups. Two-stage exchange demonstrated an increased cost difference of $26,346 compared to 1.5-stage through 2 years (P = .0001). Regression analyses found 2 culture-positive results with the same organism decreased the risk for reinfection [odds ratio: 0.2, 95% confidence interval 0.04-0.8, P = .03]. CONCLUSION For high-risk candidates, articulating spacers can preserve knee function, reduce morbidity from second-stage surgery, and lower the costs with similar rates of infection clearance as 2-stage exchange. LEVEL OF EVIDENCE Level III, therapeutic study.
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Synovial C-Reactive Protein is a Useful Adjunct for Diagnosis of Periprosthetic Joint Infection. J Arthroplasty 2022; 37:2437-2443.e1. [PMID: 35750152 DOI: 10.1016/j.arth.2022.06.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The diagnostic utility of synovial C-reactive protein (CRP) has been debated for a while. Existing studies are limited by small sample sizes and using outdated criteria for periprosthetic joint infection (PJI). Furthermore, the relationship between synovial and serum CRP has rarely been investigated in the setting of PJI. This study aimed to evaluate the diagnostic utility of synovial CRP and to assess its relationship with serum CRP and other common biomarkers. METHODS We reviewed 621 patients who underwent evaluation for PJI prior to revision arthroplasty from 2014 to 2021. Biomarkers, including serum CRP and erythrocyte sedimentation rate, synovial CRP, polymorphonuclear leukocyte percentage, white blood cell count, and alpha-defensin, were evaluated using the 2018 International Consensus Meeting criteria. RESULTS In total, 194 patients had a PJI; 394 were considered aseptic failures and 33 were inconclusive. Synovial CRP showed an area under the curve (AUC) of 0.951 (95% CI, 0.932-0.970) with 74.2% sensitivity and 98.0% specificity, whereas, serum CRP had an AUC of 0.926 (95% CI, 0.903-0.949) with 83.5% sensitivity and 88.3% specificity. There was a good correlation between synovial and serum CRP (R = 0.703; 95% CI, 0.604-0.785). The combination of serum and synovial CRP yielded a significantly higher AUC than that obtained when using serum CRP alone (AUC 0.964 versus 0.926, P = .016). CONCLUSION Synovial CRP demonstrated excellent accuracy when used to determine the presence of PJI. There was a good correlation between serum and synovial CRP levels in revision arthroplasty patients and the combined use of serum and synovial CRP proved to be more accurate than the serum test alone. These findings support the use of synovial CRP as an adjunct in the workup of PJI.
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8
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Goh GS, Tarabichi S, Clarkson SJ, Zanna L, Citak M, Parvizi J. Positive Cultures Can Be Safely Ignored in Revision Arthroplasty Patients That Do Not Meet the 2018 International Consensus Meeting Criteria. J Arthroplasty 2022; 37:2257-2261. [PMID: 35569707 DOI: 10.1016/j.arth.2022.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/04/2022] [Accepted: 05/07/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND During aseptic revision total joint arthroplasty (TJA), one or more cultures may occasionally isolate an organism. The hypothesis of this study was that in a portion of patients undergoing revision arthroplasty for aseptic failure, culture may isolate an organism(s) that can be left untreated. METHODS All patients undergoing revision TJA from 2000 to 2017 at two institutions were retrospectively reviewed. Patients were categorized as aseptic if they were appropriately investigated preoperatively and did not meet the 2018 International Consensus Meeting criteria. In the aseptic revision cohort, patients with a single positive culture or multiple cultures positive for different organisms ("organism-positive") and patients who had negative intraoperative cultures ("organism-negative") were compared based on demographics, comorbidities, operative details, subsequent reoperations, and periprosthetic joint infection (PJI). RESULTS In total, 3,234 International Consensus Meeting-negative aseptic revision TJAs were included, of which 215 patients (6.6%) were organism-positive, 196 (91.2%) had a single positive culture, and 19 (8.8%) were positive for 2 or more distinct organisms (ie, polymicrobial). The most prevalent organisms were coagulase-negative Staphylococci (37.5%), Staphylococcus epidermidis (9.6%), and Cutibacterium acnes (8.0%). Demographics and operative details were comparable between the groups. Using multiple regressions there was no association between culture positivity and the rate of reoperation or PJI. CONCLUSION Isolation of organisms by culture in patients undergoing revision for aseptic failure was not uncommon. As long as these patients were appropriately investigated preoperatively and PJI was excluded, these findings suggest that culture results may be ignored without subjecting patients to additional antimicrobial treatment.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Samuel J Clarkson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Luigi Zanna
- Traumatology and General Orthopedics Department, Careggi University Hospital, Florence, Italy
| | | | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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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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10
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Cheok T, Smith T, Siddiquee S, Jennings MP, Jayasekera N, Jaarsma RL. Synovial fluid calprotectin performs better than synovial fluid polymerase chain reaction and interleukin-6 in the diagnosis of periprosthetic joint infection : a systematic review and meta-analysis. Bone Joint J 2022; 104-B:311-320. [PMID: 35227091 DOI: 10.1302/0301-620x.104b3.bjj-2021-1320.r1] [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] [Indexed: 01/08/2023]
Abstract
AIMS The preoperative diagnosis of periprosthetic joint infection (PJI) remains a challenge due to a lack of biomarkers that are both sensitive and specific. We investigated the performance characteristics of polymerase chain reaction (PCR), interleukin-6 (IL6), and calprotectin of synovial fluid in the diagnosis of PJI. METHODS We performed systematic search of PubMed, Embase, The Cochrane Library, Web of Science, and Science Direct from the date of inception of each database through to 31 May 2021. Studies which described the diagnostic accuracy of synovial fluid PCR, IL6, and calprotectin using the Musculoskeletal Infection Society criteria as the reference standard were identified. RESULTS Overall, 31 studies were identified: 20 described PCR, six described IL6, and five calprotectin. The sensitivity and specificity were 0.78 (95% confidence interval (CI) 0.67 to 0.86) and 0.97 (95% CI 0.94 to 0.99), respectively, for synovial PCR;, 0.86 (95% CI 0.74 to 0.92), and 0.94 (95% CI 0.90 to 0.96), respectively, for synovial IL6; and 0.94 (95% CI 0.82 to 0.98) and 0.93 (95% CI 0.85 to 0.97), respectively, for synovial calprotectin. Likelihood ratio scattergram analyses recommended clinical utility of synovial fluid PCR and IL6 as a confirmatory test only. Synovial calprotectin had utility in the exclusion and confirmation of PJI. CONCLUSION Synovial fluid PCR and IL6 had low sensitivity and high specificity in the diagnosis of PJI, and is recommended to be used as confirmatory test. In contrast, synovial fluid calprotectin had both high sensitivity and specificity with utility in both the exclusion and confirmation of PJI. We recommend use of synovial fluid calprotectin studies in the preoperative workup of PJI. Cite this article: Bone Joint J 2022;104-B(3):311-320.
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Affiliation(s)
- Tim Cheok
- Department of Trauma and Orthopaedics, Alice Springs Hospital, Alice Springs, Australia
| | - Thomas Smith
- Department of Trauma and Orthopaedics, Alice Springs Hospital, Alice Springs, Australia.,College of Medicine and Public Health, Flinders University College of Medicine and Public Health, Bedford Park, Australia
| | - Shihab Siddiquee
- Department of Anatomical Pathology, Royal Adelaide Hospital, Adelaide, Australia.,Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Matthew P Jennings
- Department of Trauma and Orthopaedics, Alice Springs Hospital, Alice Springs, Australia
| | - Narlaka Jayasekera
- Department of Trauma and Orthopaedics, Alice Springs Hospital, Alice Springs, Australia
| | - Ruurd L Jaarsma
- Department of Trauma and Orthopaedics, Alice Springs Hospital, Alice Springs, Australia.,College of Medicine and Public Health, Flinders University College of Medicine and Public Health, Bedford Park, Australia.,Department of Orthopaedic Sugery, Flinders Medical Centre, Bedford Park, Australia
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11
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Lex JR, Koucheki R, Stavropoulos NA, Michele JD, Toor JS, Tsoi K, Ferguson PC, Turcotte RE, Papagelopoulos PJ. Megaprosthesis anti-bacterial coatings: A comprehensive translational review. Acta Biomater 2022; 140:136-148. [PMID: 34879295 DOI: 10.1016/j.actbio.2021.11.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 12/15/2022]
Abstract
Periprosthetic joint infections (PJI) are catastrophic complications for patients with implanted megaprostheses and pose significant challenges in the management of orthopaedic oncology patients. Despite various preventative strategies, with the increasing rate of implanted orthopaedic prostheses, the number of PJIs may be increasing. PJIs are associated with a high rate of amputation. Therefore, novel strategies to combat bacterial colonization and biofilm formation are required. A promising strategy is the utilization of anti-bacterial coatings on megaprosthetic implants. In this translational review, a brief overview of the mechanism of bacterial colonization of implants and biofilm formation will be provided, followed by a discussion and classification of major anti-bacterial coatings currently in use and development. In addition, current in vitro outcomes, clinical significance, economic importance, evolutionary perspectives, and future directions of anti-bacterial coatings will also be discussed. Megaprosthetic anti-bacterial coating strategies will help reduce infection rates following the implantation of megaprostheses and would positively impact sarcoma care. STATEMENT OF SIGNIFICANCE: This review highlights the clinical challenges and a multitude of potential solutions to combating peri-prosthetic join infections in megaprotheses using anti-bacterial coatings. Reducing infection rates following the implantation of megaprostheses would have a major impact on sarcoma care and major trauma surgeries that require reconstruction of large skeletal defects.
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Affiliation(s)
- Johnathan R Lex
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Robert Koucheki
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
| | | | - Joseph Di Michele
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jay S Toor
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Kim Tsoi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Canada; University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada
| | - Peter C Ferguson
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada; University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada
| | - Robert E Turcotte
- Division of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Panayiotis J Papagelopoulos
- 1st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, Greece
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Leggett A, Li DW, Sindeldecker D, Staats A, Rigel N, Bruschweiler-Li L, Brüschweiler R, Stoodley P. Cadaverine Is a Switch in the Lysine Degradation Pathway in Pseudomonas aeruginosa Biofilm Identified by Untargeted Metabolomics. Front Cell Infect Microbiol 2022; 12:833269. [PMID: 35237533 PMCID: PMC8884266 DOI: 10.3389/fcimb.2022.833269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 01/18/2022] [Indexed: 12/16/2022] Open
Abstract
There is a critical need to accurately diagnose, prevent, and treat biofilms in humans. The biofilm forming P. aeruginosa bacteria can cause acute and chronic infections, which are difficult to treat due to their ability to evade host defenses along with an inherent antibiotic-tolerance. Using an untargeted NMR-based metabolomics approach, we identified statistically significant differences in 52 metabolites between P. aeruginosa grown in the planktonic and lawn biofilm states. Among them, the metabolites of the cadaverine branch of the lysine degradation pathway were systematically decreased in biofilm. Exogenous supplementation of cadaverine caused significantly increased planktonic growth, decreased biofilm accumulation by 49% and led to altered biofilm morphology, converting to a pellicle biofilm at the air-liquid interface. Our findings show how metabolic pathway differences directly affect the growth mode in P. aeruginosa and could support interventional strategies to control biofilm formation.
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Affiliation(s)
- Abigail Leggett
- Ohio State Biochemistry Program, The Ohio State University, Columbus, OH, United States
- Department of Chemistry and Biochemistry, The Ohio State University, Columbus, OH, United States
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, United States
| | - Da-Wei Li
- Campus Chemical Instrument Center, The Ohio State University, Columbus, OH, United States
| | - Devin Sindeldecker
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, United States
- Biomedical Sciences Graduate Program, The Ohio State University, Columbus, OH, United States
| | - Amelia Staats
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, United States
- Department of Microbiology, The Ohio State University, Columbus, OH, United States
| | - Nicholas Rigel
- Department of Chemistry and Biochemistry, The Ohio State University, Columbus, OH, United States
| | - Lei Bruschweiler-Li
- Campus Chemical Instrument Center, The Ohio State University, Columbus, OH, United States
| | - Rafael Brüschweiler
- Ohio State Biochemistry Program, The Ohio State University, Columbus, OH, United States
- Department of Chemistry and Biochemistry, The Ohio State University, Columbus, OH, United States
- Campus Chemical Instrument Center, The Ohio State University, Columbus, OH, United States
- Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, OH, United States
- *Correspondence: Rafael Brüschweiler, ; Paul Stoodley,
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, United States
- Department of Microbiology, The Ohio State University, Columbus, OH, United States
- Department of Orthopaedics, The Ohio State University, Columbus, OH, United States
- National Biofilm Innovation Centre (NBIC) and National Centre for Advanced Tribology at Southampton (nCATS), Mechanical Engineering, University of Southampton, Southampton, United Kingdom
- *Correspondence: Rafael Brüschweiler, ; Paul Stoodley,
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13
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Synovial calprotectin for the diagnosis of periprosthetic joint infection: a diagnostic meta-analysis. J Orthop Surg Res 2022; 17:2. [PMID: 34983582 PMCID: PMC8725344 DOI: 10.1186/s13018-021-02746-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/21/2021] [Indexed: 12/04/2022] Open
Abstract
Background Periprosthetic joint infections (PJI) are a rare but severe complication of total joint arthroplasty (TJA). However, the diagnosis of PJI remains difficult. It is one of the research that focuses about diagnosis for PJI for majority researchers to discover a novel biomarker. This meta-analysis tried to evaluate diagnostic value of synovial calprotectin for PJI. Methods This meta-analysis search of the literature was conducted in PubMed, EMBASE, Web of Science, and the Cochrane Library. Literature quality was appraised using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) based on RevMan (version 5.3). The diagnostic value of calprotectin for PJI was evaluated by calculating sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), diagnostic score and area under SROC (AUC) based on the Stata version 14.0 software. We conduct subgroup analysis according to the study design, cutoff values, the country of study, and gold standard. Results Seven studies were included in this meta-analysis. The pooled sensitivity of synovial calprotectin for the diagnosis of PJI was 0.94 (95% CI, 0.87–0.98), and the specificity was 0.93 (95% CI, 0.87–0.96). The pooled AUC, PLR, and NLR for synovial calprotectin were 0.98 (95% CI, 0.96–0.99), 13.65 (95% CI, 6.89–27.07), and 0.06 (95% CI, 0.02–0.15), respectively. The pooled diagnostic score and DOR were 5.4 (95% CI, 3.96–6.85) and 222.32 (95% CI, 52.52–941.12), respectively. Conclusion In summary, this meta-analysis indicates that synovial calprotectin is a promising biomarker of assistant diagnosis for PJI, as well as recommended test for excluding diagnostic tool. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02746-2.
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Mohanty SS, Poduval M. Changing Paradigms in Arthroplasty Practice. Indian J Orthop 2021; 55:1065-1067. [PMID: 34824705 PMCID: PMC8586393 DOI: 10.1007/s43465-021-00519-x] [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: 02/04/2023]
Affiliation(s)
- Shubhranshu S. Mohanty
- Present Address: Orthopaedics, King Edward Memorial Hospital, Parel, Mumbai 400012 India , Indian Arthroplasty Association, Mumbai, India
| | - Murali Poduval
- Present Address: Engineering and Industrial Services (Medical Devices and Diagnostics), Tata Consultancy Services, Mumbai, India
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A retrospective comparison of thromboelastography and conventional coagulation parameters for periprosthetic joint infection diagnosis and reimplantation timing. Clin Chim Acta 2021; 519:118-125. [PMID: 33895127 DOI: 10.1016/j.cca.2021.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/24/2021] [Accepted: 04/16/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE The diagnostic significance of coagulation parameters in periprosthetic joint infection (PJI) is currently attracting increasing attention. We assessed the diagnostic accuracy of thromboelastography (TEG) for PJI and compared the values of various coagulation indicators for PJI diagnosis and reimplantation timing. METHODS We enrolled 250 patients undergoing revision for aseptic failure (Group A), revision for PJI (Group B), or reimplantation (Group C) during 2013-2020. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), representative coagulation-related indicators (reaction time [R], clotting time [K], angle and maximum amplitude [MA]) of TEG and routine coagulation indicators, including fibrinogen, D-dimer, fibrin degradation product (FDP), platelets count (PC), mean platelet volume (MPV), distribution width (PDW) and plateletcrit (PCT) as well as PC/MPV ratio(PVR)were measured preoperatively. Receiver operating characteristic (ROC) curves were used to evaluate the utility of all tested indicators for assessing infection. RESULTS All the indicators showed significant differences between groups A and B (P < 0.05) and, except for D-dimer, FDP, MPV and R, between groups B and C (P < 0.05). Similar differences were also observed in biomarkers before first-stage revision and second-stage reimplantation. ROC curves showed that fibrinogen, K, angle and MA outperformed the other coagulation indicators, with areas under the curve of 0.864 to 0.893 and threshold values of 3.55 g/L, 1.2 min, 72.4 deg and 69.1 mm, respectively. The multiple tests of TEG indices (K, angle and MA) and traditional inflammatory markers (CRP and ESR) or conventional coagulation indicators (fibrinogen, PC and PVR) had good sensitivity and specificity for PJI diagnosis, and the diagnostic values of TEG and platelet-associated indicators (PC and PVR) varied in the different subgroups. CONCLUSION TEG was closely related to PJI and could serve as a valuable technique for identifying residual infection before reimplantation. Fibrinogen showed high diagnostic accuracy for PJI and effectively guided the timing of reimplantation.
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The Graphical Representation of Cell Count Representation: A New Procedure for the Diagnosis of Periprosthetic Joint Infections. Antibiotics (Basel) 2021; 10:antibiotics10040346. [PMID: 33804988 PMCID: PMC8063952 DOI: 10.3390/antibiotics10040346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 11/19/2022] Open
Abstract
Aim: This study was designed to answer the question whether a graphical representation increase the diagnostic value of automated leucocyte counting of the synovial fluid in the diagnosis of periprosthetic joint infections (PJI). Material and methods: Synovial aspirates from 322 patients (162 women, 160 men) with revisions of 192 total knee and 130 hip arthroplasties were analysed with microbiological cultivation, determination of cell counts and assay of the biomarker alpha-defensin (170 cases). In addition, microbiological and histological analysis of the periprosthetic tissue obtained during the revision surgery was carried out using the ICM classification and the histological classification of Morawietz and Krenn. The synovial aspirates were additionally analysed to produce dot plot representations (LMNE matrices) of the cells and particles in the aspirates using the hematology analyser ABX Pentra XL 80. Results: 112 patients (34.8%) had an infection according to the ICM criteria. When analysing the graphical LMNE matrices from synovia cell counting, four types could be differentiated: the type “wear particles” (I) in 28.3%, the type “infection” (II) in 24.8%, the “combined” type (III) in 15.5% and “indeterminate” type (IV) in 31.4%. There was a significant correlation between the graphical LMNE-types and the histological types of Morawietz and Krenn (p < 0.001 and Cramer test V value of 0.529). The addition of the LMNE-Matrix assessment increased the diagnostic value of the cell count and the cut-off value of the WBC count could be set lower by adding the LMNE-Matrix to the diagnostic procedure. Conclusion: The graphical representation of the cell count analysis of synovial aspirates is a new and helpful method for differentiating between real periprosthetic infections with an increased leukocyte count and false positive data resulting from wear particles. This new approach helps to increase the diagnostic value of cell count analysis in the diagnosis of PJI.
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Lavender C, Adil S, Patel T, Bullock M, Oliashirazi A. Incisionless Synovium and Bone Biopsy of a Painful Total Knee Arthroplasty. Arthrosc Tech 2021; 10:e475-e479. [PMID: 33680781 PMCID: PMC7917144 DOI: 10.1016/j.eats.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/18/2020] [Indexed: 02/03/2023] Open
Abstract
Knee arthroscopy has evolved greatly from its inception in the 20th century. Arthroscopic synovectomy is performed in the case of infection or significant synovitis. We continue to develop more minimally invasive procedures, and the NanoScope (Arthrex, Naples, FL) has provided a new generation of possibilities. The system does not require the use of a standard incision or portal, and using the GraftNet (Arthrex), we can harvest tissue with a standard shaver for further evaluation. This technique provides an option to perform a synovial and bone biopsy in a painful total knee arthroplasty without the use of standard arthroscopy portals through an incisionless approach. This technique provides distinct advantages over a more open approach in the setting of a prosthetic joint. Specifically, this technique is useful for a difficult-to-diagnose painful total knee arthroplasty.
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Affiliation(s)
- Chad Lavender
- Address correspondence to Chad Lavender, M.D., Marshall University, 300 Corporate Center Dr, Scott Depot, WV 25560, U.S.A.
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