Acute or chronic periprosthetic joint infection? Using the ESR ∕ CRP ratio to aid in determining the acuity of periprosthetic joint infections

Abstract. Introduction: The gold standard for determining the duration of periprosthetic joint infection (PJI) is a thorough history. Currently, there are no well-defined objective criteria to determine the duration of PJI, and little evidence exists regarding the ratio between ESR (mm/h) and CRP (mg/L) in joint arthroplasty. This study suggests the ESR / CRP ratio will help differentiate acute from chronic PJI. Methods: Retrospective review of patients with PJI was performed. Inclusion criteria: patients >18 years old who underwent surgical revision for PJI and had documented ESR and CRP values. Subjects were divided into two groups: PJI for greater (chronic) or less than (acute) 4 weeks and the ESR / CRP ratio was compared between them. Receiver-operating characteristic (ROC) curves were evaluated to determine the utility of the ESR / CRP ratio in characterizing the duration of PJI. Results: 147 patients were included in the study (81 acute and 66 chronic). The mean ESR / CRP ratio in acute patients was 0.48 compared to 2.87 in chronic patients (p<0.001). The ESR / CRP ROC curve demonstrated an excellent area under the curve (AUC) of 0.899. The ideal cutoff value was 0.96 for ESR / CRP to predict a chronic (>0.96) vs. acute (<0.96) PJI. The sensitivity at this value was 0.74 (95 % CI 0.62–0.83) and the specificity was 0.90 (95 % CI 0.81–0.94). Conclusions: The ESR / CRP ratio may help determine the duration of PJI in uncertain cases. This metric may give arthroplasty surgeons more confidence in defining the duration of the PJI and therefore aid in treatment selection.

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ESR and CRP Diagnostic Thresholds for Prosthetic Joint Infection in Hip Hemiarthroplasty

The Journal of Hip Surgery ◽

10.1055/s-0040-1719115 ◽

2020 ◽

Vol 4 (04) ◽

pp. 187-192

Author(s):

Jared A. Warren ◽

Oliver Scotting ◽

Hiba K. Anis ◽

James Bircher ◽

Alison K. Klika ◽

...

Keyword(s):

Prosthetic Joint Infection ◽

Joint Infection ◽

Area Under The Curve ◽

Roc Curves ◽

Musculoskeletal Infection ◽

Hip Hemiarthroplasty ◽

Diagnostic Thresholds ◽

Diagnostic Threshold ◽

Prosthetic Joint ◽

The Mean

AbstractDiagnostic thresholds used to standardize the definition for prosthetic joint infection (PJI) have largely focused on total joint arthroplasty (TJA). Established PJI thresholds exist for serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in TJA; however, they do not exist for revision hip hemiarthroplasty (rHHA). The purpose of this study was to establish thresholds for (1) ESR and (2) CRP to diagnose PJI in rHHA. Data were collected on a prospective cohort of 69 rHHA patients undergoing orthopaedic surgery between 1/2017 and 2/2019 in a single health care system. Procedures were categorized as septic or aseptic revisions using Musculoskeletal Infection Society (MSIS) criteria (2013). There were 44 ESRs (n = 28 aseptic, n = 16 septic) and 46 CRPs (n = 29 aseptic, n = 17 septic) available for analysis. Two tailed t-tests were performed to compare the mean ESR and CRP in aseptic and septic cases. Receiver operator characteristic (ROC) curves were generated to obtain diagnostic cutoff thresholds using the Youden's Index (J) for ESR and CRP. The mean ESR was 50.3 ± 30.6 mm/h versus 15.4 ± 17.7 mm/h (p < 0.001), while the mean CRP was 29.9 ± 24.8 mg/L versus 4.1 ± 8.2 mg/L (p < 0.001) for septic and aseptic revisions, respectively. The diagnostic threshold for PJI determined by the ROC curve was 44 mm/h for ESR (sensitivity = 56.3%; specificity = 100.0%; J = 0.563; area under the curve (AUC) = 0.845), while it was 12.5 mg/L for CRP (sensitivity = 70.6%; specificity = 96.6%; J = 0.672; AUC = 0.896). For patients with HHA, an ESR of 44 mm/h was and a CRP of 12.5 mg/L was highly specific for PJI. The thresholds are similar to the MSIS thresholds currently published. Larger prospective trials are needed to establish more robust and conclusive diagnostic criteria for PJI in HHA, including investigations not only of ESR and CRP but synovial white blood cell count and synovial polymorphonuclear leukocytes % as well.

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Diagnostic accuracy of neutrophil counts in histopathological tissue analysis in periprosthetic joint infection using the ICM, IDSA, and EBJIS criteria

Bone and Joint Research ◽

10.1302/2046-3758.108.bjr-2021-0058.r1 ◽

2021 ◽

Vol 10 (8) ◽

pp. 536-547

Author(s):

Irene K. Sigmund ◽

Martin A. McNally ◽

Markus Luger ◽

Christoph Böhler ◽

Reinhard Windhager ◽

...

Keyword(s):

Operating Characteristic ◽

Joint Infection ◽

Test Methods ◽

Polymorphonuclear Neutrophils ◽

Histopathological Analysis ◽

Roc Curve Analysis ◽

International Consensus ◽

Joint Infections ◽

Test Thresholds ◽

The Mean

Aims Histology is an established tool in diagnosing periprosthetic joint infections (PJIs). Different thresholds, using various infection definitions and histopathological criteria, have been described. This study determined the performance of different thresholds of polymorphonuclear neutrophils (≥ 5 PMN/HPF, ≥ 10 PMN/HPF, ≥ 23 PMN/10 HPF) , when using the European Bone and Joint Infection Society (EBJIS), Infectious Diseases Society of America (IDSA), and the International Consensus Meeting (ICM) 2018 criteria for PJI. Methods A total of 119 patients undergoing revision total hip (rTHA) or knee arthroplasty (rTKA) were included. Permanent histology sections of periprosthetic tissue were evaluated under high power (400× magnification) and neutrophils were counted per HPF. The mean neutrophil count in ten HPFs was calculated (PMN/HPF). Based on receiver operating characteristic (ROC) curve analysis and the z-test, thresholds were compared. Results Using the EBJIS criteria, a cut-off of ≥ five PMN/HPF showed a sensitivity of 93% (95% confidence interval (CI) 81 to 98) and specificity of 84% (95% CI 74 to 91). The optimal threshold when applying the IDSA and ICM criteria was ≥ ten PMN/HPF with sensitivities of 94% (95% CI 79 to 99) and 90% (95% CI 76 to 97), and specificities of 86% (95% CI 77 to 92) and 92% (95% CI 84 to 97), respectively. In rTKA, a better performance of histopathological analysis was observed in comparison with rTHA when using the IDSA criteria (p < 0.001). Conclusion With high accuracy, histopathological analysis can be supported as a confirmatory criterion in diagnosing periprosthetic joint infections. A threshold of ≥ five PMN/HPF can be recommended to distinguish between septic and aseptic loosening, with an increased possibility of detecting more infections caused by low-virulence organisms. However, neutrophil counts between one and five should be considered suggestive of infection and interpreted carefully in conjunction with other diagnostic test methods. Cite this article: Bone Joint Res 2021;10(8):536–547.

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Novel Physique Index for the Screening of Skeletal Dysplasia at Birth

Children ◽

10.3390/children8050331 ◽

2021 ◽

Vol 8 (5) ◽

pp. 331

Author(s):

Ryoji Aoki ◽

Nobuhiko Nagano ◽

Aya Okahashi ◽

Shoko Ohashi ◽

Yoshinori Fujinaka ◽

...

Keyword(s):

Birth Weight ◽

Skeletal Dysplasia ◽

Operating Characteristic ◽

Area Under The Curve ◽

Roc Curves ◽

Regression Equations ◽

Fetal Ultrasound ◽

The Mean ◽

Gestational Age At Birth ◽

Age At Birth

This study aimed to devise a novel physique index and investigate its accuracy in identifying newborns with skeletal dysplasia in comparison with head circumference (HC)/height (HT) ratio. The birth weight (W), HT, and HC at birth of 1500 newborns were retrospectively collected. The linear regression equations and coefficients of determination (R2) were determined. The formulated equation was corrected by the mean weight for gestational age at birth (Wcorr) as a novel physique index for screening skeletal dysplasia. The index accuracy was assessed using receiver operating characteristic (ROC) curves in 11 newborns by fetal ultrasound and compared with that of the HC/HT ratio. The R2 values between W and HT, (HT)2, and (HT) 3 were 0.978, 0.990, and 0.993, respectively. Those between W and HC, (HC)2, and (HC)3 were 0.974, 0.984, and 0.988, respectively. W/Wcorr × (HC/HT)3 was used as a novel physique index. Seven newborns had skeletal dysplasia. Our novel physique index had a higher area under the curve (AUC), sensitivity, and specificity than the HC/HT ratio (AUC: 1.00 vs. 0.86, sensitivity: 1.00 vs. 0.86, and specificity: 1.00 vs. 0.75, respectively). Our novel physique index was more accurate than HC/HT ratio and has the potential to accurately identify newborns with skeletal dysplasia.

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Serum D-Lactate, a Novel Serological Biomarker, Is Promising for the Diagnosis of Periprosthetic Joint Infection

10.21203/rs.3.rs-1216974/v1 ◽

2022 ◽

Author(s):

Yanyang Chen ◽

Huhu Wang ◽

Xiyao Chen ◽

Hairong Ma ◽

Jingjie Zheng ◽

...

Keyword(s):

Periprosthetic Joint Infection ◽

Operating Characteristic ◽

Point Of Care ◽

Joint Infection ◽

Revision Arthroplasty ◽

Roc Curves ◽

Serological Screening ◽

Musculoskeletal Infection ◽

Highly Sensitive ◽

Diagnostic Values

Abstract Background: Although many markers are used for diagnosis of periprosthetic joint infection (PJI), serological screening and diagnosis for PJI are still challenging. We evaluated the performance of serum D-lactate and compared it with ESR, coagulation-related biomarkers and synovial D-lactate for the diagnosis of PJI.Methods: Consecutive patients with preoperative blood and intraoperative joint aspiration of a prosthetic hip or knee joint before revision arthroplasty were prospectively included. The diagnosis of PJI was based on the criteria of the Musculoskeletal Infection Society, and the diagnostic values of markers were estimated based on receiver operating characteristic (ROC) curves by maximizing sensitivity and specificity using optimal cutoff values.Results: Of 52 patients, 26 (50%) were diagnosed with PJI, and 26 (50%) were diagnosed with aseptic failure. ROC curves showed that serum D-lactate, fibrinogen (FIB) and ESR had equal areas under the curve (AUCs) of 0.80, followed by D-dimer and fibrin degradation product, which had AUCs of 0.67 and 0.69, respectively. Serum D-lactate had the highest sensitivity of 88.46% at the optimal threshold of 1.14 mmol/L, followed by FIB and ESR, with sensitivities of 80.77% and 73.08%, respectively, while there were no significant differences in specificity (73.08%, 73.08% and 76.92%, respectively). Conclusion: Serum D-lactate showed similar performance to FIB and ESR for diagnosis of PJI. The advantages of serum D-lactate are pathogen-specific, highly sensitive, minimally invasive and rapidly available making serum D-lactate useful as a point-of-care screening test for PJI.

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Uterine Artery Pulsatility Index as a Pre-eclampsia Predictor in the 3 Trimesters in Women with Singleton Pregnancies

Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics ◽

10.1055/s-0041-1740273 ◽

2021 ◽

Vol 43 (12) ◽

pp. 904-910

Author(s):

Yuly Natalia Guzmán ◽

Montserrat Uriel ◽

Alexandra Porras Ramírez ◽

Ximena Carolina Romero

Keyword(s):

Pulsatility Index ◽

Uterine Artery ◽

Operating Characteristic ◽

Area Under The Curve ◽

Roc Curves ◽

Uterine Arteries ◽

Kaplan Meier ◽

High Prevalence ◽

The Mean ◽

Singleton Pregnancies

Abstract Objective To evaluate the mean uterine artery pulsatility index (UtAPI) in each trimester of pregnancy as a predictor of early or late pre-eclampsia (PE) in Colombian pregnant women. Methods The UtAPI was measured in singleton pregnancies in each trimester. Uterine artery pulsatility index as predictor of PE was evaluated by odds ratio (OR), receiver operating characteristic (ROC) curves, and Kaplan-Meier diagram. Results Analysis in the 1st and 3rd trimester showed that abnormal UtAPI was associated with early PE (OR: 5.99: 95% confidence interval [CI]: 1.64–21.13; and OR: 10.32; 95%CI: 2.75–42.49, respectively). Sensitivity and specificity were 71.4 and 79.6%, respectively, for developing PE (area under the curve [AUC]: 0.922). The Kaplan-Meier curve showed that a UtAPI of 0.76 (95%CI: 0.58–1.0) in the 1st trimester was associated with early PE, and a UtAPI of 0.73 (95%CI: 0.55–0.97) in the 3rd trimester was associated with late PE. Conclusion Uterine arteries proved to be a useful predictor tool in the 1st and 3rd trimesters for early PE and in the 3rd trimester for late PE in a pregnant population with high prevalence of PE.

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The role of fibrinogen in predicting reinfection after DAIR for periprosthetic joint infections

BMC Musculoskeletal Disorders ◽

10.1186/s12891-021-04357-8 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Dacheng Zhao ◽

Jinwen He ◽

Xingwen Wang ◽

Xiaobing Zhao ◽

Yayi Xia ◽

...

Keyword(s):

Sensitivity And Specificity ◽

Characteristic Curve ◽

Joint Infection ◽

Area Under The Curve ◽

Roc Curves ◽

Reactive Protein ◽

Joint Infections ◽

Implant Retention ◽

Sensitivity Specificity

Abstract Background Fibrinogen (FIB) has been found to be a promising marker in diagnosing periprosthetic joint infection (PJI), however, the value of FIB in predicting reinfection of PJI is unknown. The purpose of this study was to evaluate the value of FIB in predicting reinfection after debridement, antibiotics, and implant retention (DAIR) for PJI. Methods We retrospectively analyzed the clinical data of patients who were diagnosed with PJI and underwent DAIR from 2013 to 2019. The levels of the FIB, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were measured before DAIR. After DAIR, patients were followed and reinfections were identified. For both acute and chronic PJI, the predictive value of FIB was evaluated by calculating the sensitivity, specificity, and area under the curve (AUC) of the receiver operating characteristic curve (ROC), and was compared with traditional inflammatory markers including ESR and CRP. Results The expression of FIB differed between patients reinfected and those not reinfected in both acute and chronic PJI (p < 0.05). In patients who underwent DAIR for acute PJI, the sensitivity and specificity of FIB were 81.82 and 83.33%, respectively, which were significantly higher than that of CRP (sensitivity, 72.73%; specificity, 50%; p < 0.05), while the specificity was higher than that of ESR (specificity, 41.67%; p < 0.05). In patients who underwent DAIR for chronic PJI, the sensitivity and specificity of FIB were 80.00 and 66.66%, respectively, which were significantly higher than that of CRP (sensitivity, 53.33%; specificity, 66.66%; p < 0.05) and ESR (sensitivity was 66.00%; specificity, 16.66%; p < 0.05). The ROC curves showed that FIB demonstrated the highest AUC among the biomarkers in both acute and chronic PJI. Conclusion FIB is a promising indicator in predicting reinfection after DAIR for both acute and chronic PJI, and it seems to perform better than ESR and CRP.

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Synovial fluid IL-1β appears useful for the diagnosis of chronic periprosthetic joint infection

10.21203/rs.3.rs-157718/v1 ◽

2021 ◽

Author(s):

Hai Wang ◽

LeiLei Qin ◽

Jiawei Wang ◽

Wei Huang

Keyword(s):

Synovial Fluid ◽

Periprosthetic Joint Infection ◽

Demographic Data ◽

Joint Infection ◽

Area Under The Curve ◽

Roc Curves ◽

Threshold Value ◽

Optimal Threshold ◽

Diagnostic Efficacy ◽

Aseptic Failure

Abstract Purpose The purpose of this study was to investigate the role of synovial fluid interleukin (IL)-1β in diagnosing chronic periprosthetic joint infection (PJI) and to identify the optimal threshold of synovial fluid IL-1β for differentiating chronic PJI from aseptic failure after knee and hip arthroplasties.Methods Between January 2019 and December 2019, we prospectively included patients scheduled to have a revision surgery for chronic PJI or aseptic failure after total joint arthroplasty. Then synovial IL-1β was additionally measured along with routine preoperative diagnostic serum and synovial biomarkers. The receiver operating characteristic (ROC) curves and area under the curve (AUC) were analyzed for each biomarker to determine diagnostic efficacy.Results Of the 93 patients included, their demographic data were not found to be statistically significant. The median synovial IL-1β levels were significantly higher in the chronic PJI group than in the aseptic group (894.73 pg/mL vs. 34.49 pg/mL, P<0.01). The AUC for synovial fluid IL-1β was 0.991, which was higher than serum ESR (0.627) and CRP (0.712). The optimal threshold value for detecting chronic PJI of synovial IL-1β was 312.7 pg/mL, with a sensitivity of 97.3% and a specificity of 94.64%. And the combined measurement of synovial fluid IL-1β and synovial fluid PMN% can led to a specificity of 1, and a negative predictive value (NPV) of 1.Conclusions The present study demonstrated that synovial fluid IL-1β is a valuable biomarker for detection of chronic PJI. The combination of synovial fluid IL-1β and PMN% led to an improvement in specificity compared with evaluation of each single index.

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Globulin and Albumin To Globulin Ratio Precisely Diagnose Periprosthetic Joint Infection and Determine The Timing of Second-Stage Reimplantation

10.21203/rs.3.rs-961626/v1 ◽

2021 ◽

Author(s):

Guangqian Shang ◽

Zhixuan Fei ◽

Hao Xu ◽

Yingzhen Wang ◽

Shuai Xiang

Keyword(s):

Periprosthetic Joint Infection ◽

Joint Infection ◽

Area Under The Curve ◽

Roc Curves ◽

Diagnostic Value ◽

Failure Group ◽

Reactive Protein ◽

Second Stage ◽

Diagnostic Values ◽

Albumin To Globulin Ratio

Abstract Background Periprosthetic joint infection (PJI) is one of the most challenging complication of total joint arthroplasty (TJI). An early and accurate diagnosis of PJI is associated with better treatment outcomes. However, whether the platelet-related markers and globulin-related markers can be used to assist the diagnosis of PJI remains elusive. Methods 206 patients underwent revision hip or knee arthroplasty in our institution were divided into two groups: 79 patients in PJI group and 127 patients in aseptic failure group. The levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), platelet-related markers including platelet count (PLT), mean platelet volume (MPV), plateletcrit (PCT) and PLT to MPV raito (PMR) and globulin-related markers, such as globulin, albumin to globulin ratio (AGR), and PLT to AGR ratio were compared. The diagnostic value was measured using area under the curve (AUC) after constructing receiver operating characteristic (ROC) curves. The potential of each marker for determining the timing of second-staged reimplantation was also evaluated. Results Significantly increased levels of ESR, CRP, PLT, PCT, PMR, GLB, and PLT to AGR ratio were identified in PJI group, while decreased levels of MPV and AGR were also found. The diagnostic values of all platelet-related markers and GLB were considered as fair, and good diagnostic values of AGR and PLT to AGR ratio were found, which were comparable to those of ESR and CRP. The levels of GLB and AGR can also be used to predict negative culture result and the timing of second-stage reimplantation. Conclusions Globulin and albumin to globulin ratio were found to have good diagnostic values for PJI, and they can precisely predict the culture results and persistent infection.

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Globulin and albumin to globulin ratio precisely diagnose periprosthetic joint infection and determine the timing of second-stage reimplantation

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-021-02899-0 ◽

2022 ◽

Vol 17 (1) ◽

Author(s):

Guangqian Shang ◽

ZhiXuan Fei ◽

Hao Xu ◽

Yingzhen Wang ◽

Shuai Xiang

Keyword(s):

Periprosthetic Joint Infection ◽

Joint Infection ◽

Area Under The Curve ◽

Roc Curves ◽

Diagnostic Value ◽

Failure Group ◽

Reactive Protein ◽

Second Stage ◽

Diagnostic Values ◽

Albumin To Globulin Ratio

Abstract Background Periprosthetic joint infection (PJI) is one of the most challenging complications of total joint arthroplasty (TJI). An early and accurate diagnosis of PJI is associated with better treatment outcomes. However, whether the platelet-related markers and globulin-related markers can be used to assist the diagnosis of PJI remains elusive. Methods A total of 206 patients who underwent revision hip or knee arthroplasty in our institution were divided into two groups: 79 patients in PJI group and 127 patients in aseptic failure group. The levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), platelet-related markers including platelet count (PLT), mean platelet volume (MPV), plateletcrit (PCT) and PLT to MPV ratio (PMR) and globulin-related markers such as globulin (GLB), albumin to globulin ratio (AGR) and PLT to AGR ratio were compared. The diagnostic value was measured using area under the curve (AUC) after constructing receiver operating characteristic (ROC) curves. The potential of each marker for determining the timing of second-staged reimplantation was also evaluated. Results Significantly increased levels of ESR, CRP, PLT, PCT, PMR, GLB and PLT to AGR ratio were identified in PJI group, while decreased levels of MPV and AGR were also found. The diagnostic values of all platelet-related markers and GLB were considered as fair, and good diagnostic values of AGR and PLT to AGR ratio were found, which were comparable to those of ESR and CRP. The levels of GLB and AGR can also be used to predict negative culture result and the timing of second-stage reimplantation. Conclusions Globulin and albumin to globulin ratio were found to have good diagnostic values for PJI, and they can precisely predict the culture results and persistent infection.

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Plasma fibrinogen in the diagnosis of periprosthetic joint infection

Scientific Reports ◽

10.1038/s41598-020-80547-z ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Fei Yang ◽

Chenyu Zhao ◽

Rong Huang ◽

Hui Ma ◽

Xiaohe Wang ◽

...

Keyword(s):

Periprosthetic Joint Infection ◽

Predictive Value ◽

Joint Infection ◽

Area Under The Curve ◽

Revision Arthroplasty ◽

Cost Effective ◽

Plasma Fibrinogen ◽

Evidence Based ◽

Joint Infections ◽

Auc Value

AbstractPeriprosthetic joint infections (PJIs) have become the most catastrophic complication for patients after arthroplasty. Although previous studies have found that many biomarkers have good performance for diagnosing PJI, early diagnosis remains challenging and a gold standard is lacking. This study aimed to investigate the diagnostic accuracy of plasma fibrinogen (FIB) in detecting PJI compared to other traditional biomarks (CRP, WBC and ESR). A total of 156 patients (including 57 PJI and 99 non-PJI patients) who underwent revision arthroplasty were retrospectively reviewed from 01/2014 to 01/2020. The diagnostic criteria of PJI were mainly based on the definition from the evidence-based definition for periprosthetic joint infection in 2018. The optimal plasma FIB predictive cutoff was 4.20 g/L, the sensitivity of the plasma fibrinogen was 0.860, the specificity was 0.900, the positive predictive value (PPV) was 0.831, and the negative predictive value (NPV) was 0.908. The area under the curve (AUC) value of plasma fibrinogen was 0.916 (95% CI 0.869–0.964), and the CRP, ESR and WBC levels had AUCs of 0.901, 0.822 and 0.647, respectively. Plasma FIB demonstrated better diagnostic strength compared with that of other serum biomarkers before revision arthroplasty. It represents a new horizon for the diagnosis of PJI due to the diagnosis values and cost-effective features.

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