The Role of Biopsy in Diagnosing Infection After Hip and Knee Arthroplasty: A Meta-Analysis

Abstract Background Early diagnosis of periprosthetic hip and knee infection still represents a major challenge, as no single test can achieve ideal results. Currently, multiple preoperative indicators were performed to diagnose periprosthetic joint infection (PJI) to confirm or exclude infection in the early stage. However, the diagnostic value of biopsy-related tests in diagnosing periprosthetic hip and knee infection remains unclear.Methods Publications in PubMed, Embase, and the Web of Science databases were searched systematically until October 2020. Inclusion and exclusion criteria were used for screening biopsy-related studies of the diagnosis of periprosthetic hip and knee infection. All relevant tests were analyzed using Meta-Disc. For comparison between biopsy-related and conventional diagnostic methods in the diagnosis of PJI, the sensitivity and specificity of selected studies were calculated in the subgroup and compared using the z-test. Quality assessment of the selected literature was performed using the Quality Assessment of Diagnostic Accuracy Studies.Results Three biopsy-related tests were identified in 14 articles and further analyzed in the present meta-analysis. The pooled sensitivity and specificity was 0.90 (95% confidence interval [CI], 0.87–0.93), 0.97 (95% CI, 0.95–0.98) for the combined method (microbial culture plus histology), 0.76 (95% CI: 0.71–0.80) and 0.94 (95% CI: 0.91–0.95) for microbiological tests, and 0.62 (95% CI: 0.45–0.77), 0.97 (95% CI: 0.92–0.99) for histology. The pooled diagnostic odds ratios for diagnosing PJI using the combined method, microbiological test, and histology were 229.61 (95% CI: 94.90–555.56), 40.44 (95% CI: 23.74–68.89), and 54.47 (95% CI: 11.66–254.43), respectively. The combined method had the highest value for the area under the curve (0.9805), followed by histology (0.9425) and microbiological tests (0.9292). In the subgroup, statistical differences were identified in sensitivity and specificity for PJI diagnosis between the synovial fluid culture and biopsy culture group (P＜0.001), as well as in the biopsy-related combined method and serum C-reactive protein (CRP; P＜0.001).ConclusionsBiopsy culture does not appear to be advantageous compared to synovial fluid culture in the preoperative diagnosis of periprosthetic hip and knee infection. In contrast, combined biopsy microbial culture with histology analysis shows great potential in improving the preoperative diagnosis of PJI. The standard procedure of biopsy needs to be further explored. Further research is required to verify our results.

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New Methods in the Diagnosis of Prosthetic Joint Infection

Traumatology and Orthopedics of Russia ◽

10.21823/2311-2905-2019-25-4-56-63 ◽

2019 ◽

Vol 25 (4) ◽

pp. 56-63

Author(s):

S. Karbysheva ◽

N. Renz ◽

K. Yermak ◽

S. Cabric ◽

A. Trampuz

Keyword(s):

Synovial Fluid ◽

Multiplex Pcr ◽

Sensitivity And Specificity ◽

Leukocyte Count ◽

Joint Infection ◽

Accurate Diagnosis ◽

Confirmatory Test ◽

New Methods ◽

Synovial Fluid Culture ◽

Fluid Culture

A timely and accurate diagnosis of periprosthetic joint infection (PJI) is crucial to plan adequate treatment. Purpose of the study. To evaluate the performance of new diagnostic tests for the diagnosis of PJI. Material and Methods. The performance of novel biomarkers in synovial fluid (i.e. D-lactate and alfa-defensin), molecular test (i.e. PCR of synovial fluid and sonication fluid), new methods to dislodge biofilm from implant surface (i.e. MicroDTTect) and sonication of explanted prosthesis were investigated in patients with PJI and aseptic loosening of the prosthesis. Results. D-lactate showed better sensitivity for the diagnosis of PJI compared to leukocyte count (86% and 80%, respectively). The optimal D-lactate cut-off value was calculated at 1.26 mmol/l. The ADLF test showed sensitivity of 84%, 67% and to 54% depending on classification criteria used for the diagnosis of PJI (Musculoskeletal Infection Society (MSIS), The Infectious Diseases Society of America (IDSA) and proposed European Bone and Joint Infection Society (EBJIS) criteria, respectively). Using the proposed EBJIS definition criteria, the sensitivity of the leukocyte count was significantly higher than that of the ADLF test (86% compared with 54%; p<0,001), particularly in chronic PJI (81% compared with 44%, respectively; p<0,001). The sensitivity of synovial fluid PCR was 60% and herewith comparable with synovial fluid culture (52%, p = 0,239). The sensitivity and specificity of sonication fluid culture were 58% and 100%, which was comparable to sonication fluid PCR 51% and 94%, respectively. DTT-based method showed low sensitivity for diagnosis of PJI (40%) compared to sonication (80%, p<0,01). Conclusion. Synovial fluid D-lactate demonstrated good analytical performance and diagnostic value for the diagnosis of PJI. In particular, the high sensitivity for diagnosing infection and rapid availability of the test result make synovial fluid D-lactate suitable as screening test, whereas ADLF had limited sensitivity (54%) but high specificity (>95%) and it should therefore not be used for screening, but rather as a confirmatory test for PJI. Multiplex PCR of synovial fluid and sonication fluid has similar sensitivity and specificity compared to synovial fluid culture, having the advantage of rapid availability of results (within 5 hours) and fully automated process. With further improvement of its performance and inclusion of additional primers, multiplex PCR may complement conventional cultures, especially for rapid and accurate diagnosis of low-grade PJI. Culture of samples obtained by sonication of prostheses showed better sensitivity for the microbiologic diagnosis of prosthetic hip and knee infection compared to chemical based dislodgement such as MicroDTTect.

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Synovial Fluid Aspiration Should Not Be Routinely Performed during the Two-Stage Exchange of the Knee

BioMed Research International ◽

10.1155/2018/6720712 ◽

2018 ◽

Vol 2018 ◽

pp. 1-8 ◽

Cited By ~ 1

Author(s):

Sebastian P. Boelch ◽

Magnus Roth ◽

Joerg Arnholdt ◽

Maximilian Rudert ◽

Martin Luedemann

Keyword(s):

Synovial Fluid ◽

Blood Cell ◽

Sensitivity And Specificity ◽

Pathogen Detection ◽

Joint Infection ◽

Youden Index ◽

Blood Cell Count ◽

Two Stage ◽

Synovial Fluid Culture ◽

Fluid Culture

Purpose. Detection of infection persistence during the two-stage exchange of the knee for periprosthetic joint infection is challenging. Synovial fluid culture (SFC) and synovial white blood cell count (SWBCC) before joint reimplantation are widespread diagnostic means for this indication. The sensitivity and specificity of SFC and of SWBCC for infection persistence before planned reimplantation were evaluated. Methods. 94 two-stage exchanges of the knee with synovial fluid aspiration performed after a drug holiday of at least 14 days and before reimplantation or spacer exchange (planned reimplantation) were retrospectively analyzed. Only cases with at least 3 intraoperative samples at planned reimplantation were included. SFC and SWBCC were compared to pathogen detection (SFC(culture)/SWBCC(culture)) and to histopathological signs of infection persistence (SFC(histo)/SWBCC(histo)) from intraoperative samples at planned reimplantation. For SFC, the sensitivity and specificity were calculated. For SWBCC, the optimal cut-off value with its sensitivity and specificity was calculated with the Youden-Index. Results. Sensitivity and specificity of SFC(culture) were 0.0% and 98.9%. Sensitivity and specificity of SFC(histo) were 3.4% and 100%. The optimal cut-off value for SWBCC(culture) was 4450 cells/μl with a sensitivity of 50.0% and a specificity of 86.5%. The optimal cut-off value for SWBCC(histo) was 3250 cells/μl with a sensitivity of 35.7% and a specificity of 92.9%. Conclusion. The detection of infection persistence remains challenging and a consented approach is lacking. The results do not warrant the routine performance of SFC during the two-stage exchange at the knee. SWBCC can be used to confirm infection persistence at high cut-offs, but they only occur in few patients and are therefore inappropriate for the routine use.

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Monitoring Method for Deep Infection after TKA: Significance of Intraoperative Synovial Fluid Culture and Postoperative Suction Drainage Tip Culture

The Journal of the Korean Orthopaedic Association ◽

10.4055/jkoa.2006.41.2.239 ◽

2006 ◽

Vol 41 (2) ◽

pp. 239

Author(s):

Key Yong Kim ◽

Seung Suk Seo ◽

Chae Oh Na ◽

Dong Joon Ha ◽

Jin Seok Kim

Keyword(s):

Synovial Fluid ◽

Deep Infection ◽

Suction Drainage ◽

Monitoring Method ◽

Synovial Fluid Culture ◽

Fluid Culture

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Performance of automated multiplex polymerase chain reaction (mPCR) using synovial fluid in the diagnosis of native joint septic arthritis in adults

The Bone & Joint Journal ◽

10.1302/0301-620x.101b3.bjj-2018-0868.r1 ◽

2019 ◽

Vol 101-B (3) ◽

pp. 288-296 ◽

Cited By ~ 4

Author(s):

I. K. Sigmund ◽

J. Holinka ◽

F. Sevelda ◽

K. Staats ◽

S. Heisinger ◽

...

Keyword(s):

Polymerase Chain Reaction ◽

Synovial Fluid ◽

Septic Arthritis ◽

Multiplex Polymerase Chain Reaction ◽

Microbiological Analysis ◽

Chain Reaction ◽

Cutibacterium Acnes ◽

Polymerase Chain ◽

Synovial Fluid Culture ◽

Fluid Culture

Aims This study aimed to assess the performance of an automated multiplex polymerase chain reaction (mPCR) technique for rapid diagnosis of native joint septic arthritis Patients and Methods Consecutive patients with suspected septic arthritis undergoing aseptic diagnostic joint aspiration were included. The aspirate was used for analysis by mPCR and conventional microbiological analysis. A joint was classed as septic according to modified Newman criteria. Based on receiver operating characteristic (ROC) analysis, the area under the ROC curve (AUC) values of the mPCR and the synovial fluid culture were compared using the z-test. A total of 72 out of 76 consecutive patients (33 women, 39 men; mean age 64 years (22 to 92)) with suspected septic arthritis were included in this study. Results Of 72 patients, 42 (58%) were deemed to have septic joints. The sensitivity of mPCR and synovial fluid culture was 38% and 29%, respectively. No significant differences were found between the AUCs of both techniques (p = 0.138). A strong concordance of 89% (Cohen’s kappa: 0.65) was shown. The mPCR failed to detect Staphylococcus aureus (n = 1) and Streptococcus pneumoniae (n = 1; no primer included in the mPCR), whereas the synovial fluid culture missed six microorganisms (positive mPCR: S. aureus (n = 2), Cutibacterium acnes (n = 3), coagulase-negative staphylococci (n = 2)). Conclusion The automated mPCR showed at least a similar performance to the synovial fluid culture (the current benchmark) in diagnosing septic arthritis, having the great advantage of a shorter turnaround time (within five hours). Cite this article: Bone Joint J 2019;101-B:288–296.

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Routine synovial fluid culture: is it necessary? Lessons from an audit

Rheumatology ◽

10.1093/rheumatology/36.10.1116 ◽

1997 ◽

Vol 36 (10) ◽

pp. 1116-1117 ◽

Cited By ~ 6

Author(s):

B. Pal ◽

E. J. Nash ◽

B. Oppenheim ◽

S. Maxwell ◽

L. McFarlane

Keyword(s):

Synovial Fluid ◽

Synovial Fluid Culture ◽

Fluid Culture

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The fate of acutely inflamed joints with a negative synovial fluid culture

International Orthopaedics ◽

10.1007/s00264-012-1503-z ◽

2012 ◽

Vol 36 (7) ◽

pp. 1487-1492 ◽

Cited By ~ 2

Author(s):

Ihab Hujazi ◽

David Oni ◽

Arvind Arora ◽

Garciela Muniz ◽

Vikas Khanduja

Keyword(s):

Synovial Fluid ◽

Synovial Fluid Culture ◽

Fluid Culture

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Differential Diagnosis of Large Joints Chronical Synovitis

N.N. Priorov Journal of Traumatology and Orthopedics ◽

10.17816/vto201623167-70 ◽

2016 ◽

Vol 23 (1) ◽

pp. 67-70

Author(s):

V. V Zar ◽

S. N Shatokhina

Keyword(s):

Differential Diagnosis ◽

Synovial Fluid ◽

Study Results ◽

Large Joint ◽

Group 15 ◽

Biological Liquid ◽

Synovial Fluid Culture ◽

Fluid Culture

To determine the genesis of large joint chronical synovitis the morphologic picture (facia) of synovial exudate was studied in 23 patients using the method of cuneate dehydration of biological liquid. Cytologic investigation showed leukocytosis with prevalence of neutrophils in all patients. All patients were divided into two groups. First group included 8 patients in whom septic pattern of inflammation was confirmed by the results of synovial fluid culture inoculation, second group - 15 patients with negative bacteriologic study results. The obtained data enabled to describe two types of synovial fluid facia that allowed differentiating septic pattern of inflammation from the reactive one.

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Diagnostic Performance of [18F]-Labeled PET/CT Tracers for Lymph Node/Bone Metastasis and Biochemical Recurrence Detection in Advanced Prostate Cancer: A Meta-Analysis

Urologia Internationalis ◽

10.1159/000518478 ◽

2021 ◽

pp. 1-19

Author(s):

YiRui Guo ◽

Yu Tian ◽

Yuxin Deng ◽

ChunMei Lu ◽

YanJuan Wang ◽

...

Keyword(s):

Prostate Cancer ◽

Lymph Node ◽

Bone Metastasis ◽

Quality Assessment ◽

Sensitivity And Specificity ◽

Biochemical Recurrence ◽

Advanced Prostate Cancer ◽

Meta Analysis ◽

Diagnostic Value ◽

Diagnostic Efficacy

Purpose: The aim of this study was to explore the diagnostic value of different fluorine-18 (18F)-labeled tracers for lymph node/bone metastasis and biochemical recurrence detection in advanced prostate cancer (PCa). Methods: PubMed, Embase, Web of Science, Cochrane databases, and the WHO International Clinical Trial Center were searched. The inclusion criteria were determined based on the Preferred Report Items of the Systematic Review and Meta-Analysis Guidelines. The Quality Assessment of Diagnostic Accuracy Studies-2 was used to assess the quality assessment of the included studies. The quantitative analysis of the included literature was performed on the patient and lesion basis, and the equivocal findings were considered negative or positive results, respectively. Results: Thirty-seven articles were included. On the patient basis, the pooled sensitivity and specificity of [18F]-labeled tracers were 0.80 (95% confidence interval [CI]: 0.78–0.83) and 0.89 (95% CI: 0.87–0.90) when equivocal results were considered to be positive and 0.80 (95% CI: 0.77–0.82) and 0.87 (95% CI: 0.85–0.89) when equivocal results were considered to be negative. On the lesion basis, the pooled sensitivity and specificity of [18F]-labeled tracers were 0.82 (95% CI: 0.80–0.83) and 0.91 (95% CI: 0.90–0.92) when equivocal lesions were regarded as positive and 0.81 (95% CI: 0.80–0.82) and 0.91 (95% CI: 0.90–0.92) when equivocal lesions were considered to be negative. Conclusion: [18F]-labeled tracers have high diagnostic efficacy for lymph node/bone metastasis and biochemical recurrence in advanced PCa.

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