Factors to Consider When Assessing the Diagnostic Accuracy of Synovial Leukocyte Count in Periprosthetic Joint Infection

Ottink, Karsten D.; Strahm, Carol; Muller-Kobold, Anneke; Sendi, Parham; Wouthuyzen-Bakker, Marjan

doi:10.7150/jbji.34854

Cited by 28 publications

(22 citation statements)

References 77 publications

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“…Values above this threshold may suggest infection, especially in PJI of the knee. 30 In addition, there is a high level of consensus and literature support for a cut-off value of 3,000 cells/µl and a percentage of PMNs above 80% to confirm a PJI in the hip and knee. 30 It must be noted that these cut-off levels can be affected by other conditions, 30 and may not be appropriate for other joints, particularly in the upper limbs.…”

Section: Diagnostic Categoriesmentioning

confidence: 99%

The EBJIS definition of periprosthetic joint infection

McNally

Sousa

Wouthuyzen-Bakker

et al. 2021

The Bone & Joint Journal

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Aims The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition. Methods This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance. Results This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI. Conclusion The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice. Cite this article: Bone Joint J 2021;103-B(1):18–25.

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Section: Diagnostic Categoriesmentioning

confidence: 99%

The EBJIS definition of periprosthetic joint infection

McNally

Sousa

Wouthuyzen-Bakker

et al. 2021

The Bone & Joint Journal

Self Cite

363

300

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“…However, while the sensitivity and specificity of individual tests and a combination of tests is high, there are challenging cases that don’t fulfil the criteria for infection, but present with a high suspicion for PJI 8 . Despite the high sensitivity and specificity of synovial markers there are cases of a dry tap, clotted specimens or blood contamination of the aspirate, which have been described in up to 36% that greatly impair the quality of synovial analysis 10 , 11 . Moreover even if all necessary diagnostic parameters according to the MSIS Criteria have been analyzed an inconclusive score (“possibly infected”) (2–5 points) may occur and further investigation is recommended in these cases 8 .…”

Section: Introductionmentioning

confidence: 99%

Poor performance of open incisional biopsy for the microbiological diagnosis of periprosthetic knee joint infection

Schwarze

Moellenbeck

Gosheger

et al. 2021

Sci Rep

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The accurate preoperative diagnosis of periprosthetic joint infection (PJI) of total knee arthroplasty (TKA) can be difficult despite the use of a combination of serum and synovial markers. In such inconclusive cases, incisional open biopsy might be considered. This study investigates the usefulness of biopsies in patients with inconclusive diagnostic findings. We retrospectively identified 63 patients who underwent incisional biopsy for chronic PJI in the operation theatre following TKA revision between 2010 and 2018 after inconclusive preoperative diagnostics for PJI. In all cases, 5 independent biopsies were taken. Results from open biopsy for PJI were analyzed for diagnostic accuracy using the intraoperative results from following revision surgery as gold standard. 27 patients (43%) had a positive culture taken during biopsy. 15 cases (24%) met the diagnostic criteria for a chronic PJI. Most common organisms were Coagulase-negative staphylococci (67%) and Cutibacterium acnes (30%). Compared to the findings during revision surgery, biopsies showed a sensitivity of 47% and a specificity of 77% for PJI. Open incisional biopsy following inconclusive serum- and synovial diagnostics for low grade PJI may be considered for identification of microorganisms. Due to its low sensitivity and moderate specificity found in the present cohort, microbiological analysis should be combined with additional diagnostic markers and histological investigation.Level of Evidence. Retrospective cohort study (Level III).

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“…In this context, it makes also sense that its specificity of 82% appears to be quite reliable. Especially in low-grade infections the number of white blood cells in the synovial fluid has gained more attention recently with suggested limits indicative for infection being drastically lowered to values such as 3000/µl [13,20,23], depending also on the joint [20]. Microbiological culture from joint aspirate does not seem to provide sufficient diagnostic information: With 0% sensitivity not a single infection could be diagnosed by this method.…”

Section: Discussionmentioning

confidence: 99%

The significance of synovial biopsy in the diagnostic workup of the low-grade periprosthetic joint infection of shoulder arthroplasty

Mederake

Hofmann

Fink

2021

Arch Orthop Trauma Surg

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Introduction A common reason for painful shoulder arthroplasties and revision surgery is a low-grade periprosthetic joint infection (PJI). Diagnosing a low-grade infection is, however, a major diagnostic challenge. This applies even more to the shoulder, which differs from other large joints in terms of clinical features and microbiological spectrum. Aim of this study was to evaluate the diagnostic value of the synovial biopsy in the diagnostic workup of low-grade PJI of the shoulder. Materials and methods A retrospective evaluation was conducted on 56 patients receiving revision surgery on their shoulder arthroplasty. A standardized preoperative workup was performed comprising CRP value, leukocyte blood count, synovial fluid microbiological analyses and leukocyte count from joint aspiration, and five synovial biopsy samples for bacteriologic and histologic analysis obtained through an arthroscopic approach. During revision surgery, five samples of periprosthetic tissue were harvested for bacteriologic and histologic analyses. The MSIS-Criteria 2014 were used to evaluate the diagnostic results. Results In total, 15 of 56 revised prostheses turned out as PJI (27%). When applying our diagnostic workup, we obtained a sensitivity of 67% with a specificity of 95%. When performing a subgroup analysis on those patients that had received diagnostic biopsy, a sensitivity of 100% and a specificity of 83% could be achieved. With a sensitivity and specificity of 90% and 83%, respectively, the biopsy is the single method with the highest diagnostic value. Conclusions The sensitivity of only 67% of our standard workup emphasizes the difficulty to adequately diagnose low-grade infections after shoulder arthroplasty. The excellent specificity of 95% ensures, however, that non-infected prostheses are not incorrectly explanted. This study highlights that synovial biopsy has a high diagnostic value and should be done prior to complex revision surgeries to raise sensitivity in diagnosing a PJI.

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Factors to Consider When Assessing the Diagnostic Accuracy of Synovial Leukocyte Count in Periprosthetic Joint Infection

Cited by 28 publications

References 77 publications

The EBJIS definition of periprosthetic joint infection

The EBJIS definition of periprosthetic joint infection

Poor performance of open incisional biopsy for the microbiological diagnosis of periprosthetic knee joint infection

The significance of synovial biopsy in the diagnostic workup of the low-grade periprosthetic joint infection of shoulder arthroplasty

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