Diagnostic Accuracy of Serum, Synovial, and Tissue Testing for Chronic Periprosthetic Joint Infection After Hip and Knee Replacements

Abstract

Background: Chronic periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint replacement. Patients with chronic PJI report a substantially lower quality of life and face a higher risk of short-term mortality. Establishing a diagnosis of chronic PJI is challenging because of conflicting guidelines, numerous tests, and limited evidence. Delays in diagnosing PJI are associated with poorer outcomes and morbid revision surgery. The purpose of this systematic review was to compare the diagnostic accuracy of serum, synovial, and tissue-based tests for chronic PJI. Methods: This review adheres to the Cochrane Collaboration’s diagnostic test accuracy methods for evidence searching and syntheses. A detailed search of MEDLINE, Embase, the Cochrane Library, and the grey literature was performed to identify studies involving the diagnosis of chronic PJI in patients with hip or knee replacement. Eligible studies were assessed for quality and bias using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Meta-analyses were performed on tests with sufficient data points. Summary estimates and hierarchical summary receiver operating characteristic (HSROC) curves were obtained using a bivariate model. Results: A total of 12,616 citations were identified, and 203 studies met the inclusion criteria. Of these 203 studies, 170 had a high risk of bias. Eighty-three unique PJI diagnostic tests were identified, and 17 underwent meta-analyses. Laboratory-based synovial alpha-defensin tests and leukocyte esterase reagent (LER) strips (2+) had the best performance, followed by white blood-cell (WBC) count, measurement of synovial C-reactive protein (CRP) level, measurement of the polymorphonuclear neutrophil percentage (PMN%), and the alpha-defensin lateral flow test kit (Youden index ranging from 0.78 to 0.94). Tissue-based tests and 3 serum tests (measurement of interleukin-6 [IL-6] level, CRP level, and erythrocyte sedimentation rate [ESR]) had a Youden index between 0.61 to 0.75 but exhibited poorer performance compared with the synovial tests mentioned above. Conclusions: The quality of the literature pertaining to chronic PJI diagnostic tests is heterogeneous, and the studies are at a high risk for bias. We believe that greater transparency and more complete reporting in studies of diagnostic test results should be mandated by peer-reviewed journals. The available literature suggests that several synovial fluid-based tests perform well for diagnosing chronic PJI and their use is recommended in the work-up of any suspected case of chronic PJI. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

D-dimer in the diagnosis of periprosthetic joint infection: a systematic review and meta-analysis

“…This is the first systematic review and meta-analysis about the utility of D-dimer for the diagnosis of PJI. We found that D-dimer has limited performance for the diagnosis of PJI, with a pooled sensitivity and specificity of 0.82 and 0.70, respectively, and had a poorer diagnostic value than that of CPR and ESR reported by Carli AV et al [31]. In this systematic review, the pooled sensitivity and specificity of CRP were 0.85 and 0.81, respectively, and the pooled sensitivity and specificity of ESR were 0.82 and 0.79.…”

Diagnosis of knee periprosthetic joint infection

“…• This is a key step in diagnosis; Erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) are routinely available, cheap, and provide rapid results • Based on a recent systematic review, ESR has a sensitivity of 82% and a specificity of 79%, whilst CRP has a sensitivity of 85% and a specificity of 81% [4]. CRP and ESR may not be raised in low virulence PJI [5] • A threshold of ESR > 30 mm/h and CRP > 10 mg/L is recommended for chronic PJI [1] • Plasma viscosity with a threshold of >1.81 mPa•s may also be used with a specificity of 94% and sensitivity of 58% [6] 4.…”

“…• SF culture has been shown to have a pooled sensitivity of 69% and specificity of 96% [4]. Cultures should be maintained for five to seven days, or up to 21 days if there is suspicion of low-virulence organisms.…”

“…• A WBC count >3000 cells/μL and PMN >80% can confirm the presence of infection with a sensitivity of 90% and a specificity of 93% [4]. The SF should be placed within EDTA test tubes to prevent the specimen from clotting • Some conditions such inflammatory arthropathies, the early post-operative phase, periprosthetic fracture and haemarthrosis may result in falsely elevated counts 5.…”

Rapid Skin Temperature Measurement is Valuable in Evaluating Inflammation and Functional Status After Total Knee Arthroplasty：A Case Control Study

“…), joint uid indicators (percentage of neutrophils, c-reactive protein, c-defensin, etc.) and tissue cultures [3,9,16]. The methods used to evaluate functional recovery include an early postoperative range of motion (ROM) measurement, a quadriceps muscle strength measurement, the sit to stand test, the 6-minute walking test [18], and a psychological assessment [7].…”