The Diagnostic Utility of Fast Tests for Detecting C-Reactive Protein in Synovial Fluid in Periprosthetic Joint Infections

Grzelecki, Dariusz; Grajek, Aleksandra; Otworowski, Maciej; Paskal, Wiktor; Fulin, Petr; Kowalczewski, Jacek

doi:10.2106/jbjs.23.00252

Cited by 3 publications

(1 citation statement)

References 30 publications

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“…In testing prior to revision TJA, a fast POC synovial C-reactive protein (CRP) cassette test with a minimum cutoff value of ‡8 mg/L had very good accuracy for the diagnosis of chronic PJI 20 . This POC test had comparable sensitivity and slightly lower specificity when compared with a laboratory method (threshold, 2.7 mg/L).…”

Section: Diagnosismentioning

confidence: 99%

What’s New in Musculoskeletal Infection

Otero,

Dombrowski,

Brown

et al. 2024

Journal of Bone and Joint Surgery

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Periprosthetic joint infection (PJI) continues to be a devastating complication after total joint arthroplasty (TJA) and remains one of the most common causes for revision TJA. Projections are clear that primary TJA will continue to increase annually and, with it, PJI. In 2022, there was an emphasis on the global economics of PJI management, whereas, in 2023, the literature attempted to provide a more granular look at the financial burden of PJI. Wixted et al. analyzed the direct costs of PJI at a tertiary referral center, including the costs of relevant ancillary services, and demonstrated that the failure of successful reimplantation and the need for additional surgical procedures more than doubled the direct costs of PJI management ($38,865 compared with $79,223) 1 . Additionally, Charalambous et al. assessed cost drivers of 2-stage exchange for PJI treatment and found that age, illicit drug use, the Elixhauser comorbidity index, and number of surgical procedures before reimplantation were all associated with an increased cost of PJI treatment and that failure to clear infection was associated with a >50% increase in total costs at 2 years after treatment 2 . In 2023, the psychosocial impact of PJI was also highlighted. Shichman et al. demonstrated that the sequelae of PJI decreased patientreported quality of life, social satisfaction, and mental health, with approximately 1 of 4 patients regretting their initial decision to undergo primary TJA 3 . Das et al. demonstrated that patients who underwent spacer placement for PJI after TJA had a disproportionately higher incidence of mental health disorders following a surgical procedure compared with aseptic revisions and primary TJA, urging surgeons to consider collaborative management with mental health professionals in the treatment of PJI 4 .Not only are mental health disorders a consequence of PJI, but they are also likely a risk factor. Harmer et al. demonstrated that depression and anxiety were associated with an increased risk of any infection, and specifically with an increased risk of PJI after revision total knee arthroplasty (TKA) 5 .Two-stage exchange continues to be considered the mainstay treatment of PJI, although 1-stage treatment is gaining popularity. In an Australian cost-utility analysis using a Markov model, Okafor et al. found that opting for an index 2-stage revision instead of a 1-stage revision when there is no compelling indication for 2-stage exchange is not likely to be cost-effective 6 . In the United States, most surgeons are utilizing 2-stage exchange, with 75% of American Association of Hip and Knee Surgeons (AAHKS) survey respondents reporting the use of 2-stage exchange rather than 1-stage exchange and with the majority of surgeons handling <20 PJI cases per year 7 . Despite this, the use of single-stage exchange is increasing across the globe, with a single high-volume European center reporting a >30% increase in 1-stage exchange from 2008 to 2021 8 . Fehring et al. reported a 99% reimplantation rate after 2-stage exchange at the...

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Section: Diagnosismentioning

confidence: 99%

What’s New in Musculoskeletal Infection

Otero,

Dombrowski,

Brown

et al. 2024

Journal of Bone and Joint Surgery

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Point of care testing for the diagnosis of periprosthetic joint infections: a review

Altsitzioglou,

Avgerinos,

Karampikas

et al. 2024

SICOT-J

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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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Synovial Fluid C-reactive Protein Clinical Decision Limit and Diagnostic Accuracy for Periprosthetic Joint Infection

Miamidian,

Toler,

McLaren

et al. 2024

Cureus

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Introduction C-reactive protein (CRP) has long served as a prototypical biomarker for periprosthetic joint infection (PJI). Recently, synovial fluid (SF)-CRP has garnered interest as a diagnostic tool, with several studies demonstrating its diagnostic superiority over serum CRP for the diagnosis of PJI. Although previous studies have identified diagnostic thresholds for SF-CRP, they have been limited in scope and employed various CRP assays without formal validation for PJI diagnosis. This study aimed to conduct a formal single clinical laboratory validation to determine the optimal clinical decision limit of SF-CRP for the diagnosis of PJI. Methods A retrospective analysis of prospectively collected data was performed using receiver operating characteristic (ROC) and area under the curve (AUC) analyses. Synovial fluid samples from hip and knee arthroplasties, received from over 2,600 institutions, underwent clinical testing for PJI at a single clinical laboratory (CD Laboratories, Zimmer Biomet, Towson, MD) between 2017 and 2022. Samples were assayed for SF-CRP, alpha-defensin, white blood cell count, neutrophil percentage, and microbiological culture. After applying selection criteria, the samples were classified with the 2018 ICM PJI scoring system as "infected," "not infected," or "inconclusive." Data were divided into training and validation sets. The Youden Index was employed to optimize the clinical decision limit. Results A total of 96,061 samples formed the training (n = 67,242) and validation (n = 28,819) datasets. Analysis of the biomarker median values, culture positivity, anatomic distribution, and days from aspiration to testing revealed nearly identical specimen characteristics in both the training set and validation set. SF-CRP demonstrated an AUC of 0.929 (95% confidence interval (CI): 0.926-0.932) in the training set, with an optimal SF-CRP clinical decision limit for PJI diagnosis of 4.45 mg/L. Applying this cutoff to the validation dataset yielded a sensitivity of 86.1% (95% CI: 85.0-87.1%) and specificity of 87.1% (95% CI: 86.7-87.5%). No statistically significant difference in diagnostic performance was observed between the validation and training sets. Conclusion This study represents the largest single clinical laboratory evaluation of an SF-CRP assay for PJI diagnosis. The optimal CRP cutoff (4.45 mg/L) for PJI, which yielded a sensitivity of 86.1% and a specificity of 87.1%, is specific to the assay methodology and laboratory performing the assay. We propose that an SF-CRP test with a laboratory-validated optimal clinical decision limit for PJI may be preferable, in a clinical diagnostic setting, to serum CRP tests that do not have laboratory-validated clinical decision limits for PJI.

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The Diagnostic Utility of Fast Tests for Detecting C-Reactive Protein in Synovial Fluid in Periprosthetic Joint Infections

Cited by 3 publications

References 30 publications

What’s New in Musculoskeletal Infection

What’s New in Musculoskeletal Infection

Point of care testing for the diagnosis of periprosthetic joint infections: a review

Synovial Fluid C-reactive Protein Clinical Decision Limit and Diagnostic Accuracy for Periprosthetic Joint Infection

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