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Accuracy of diagnostic tests for prosthetic joint infection: a systematic review

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

There are few evidence-based recommendations on the most effective methods for diagnosing prosthetic joint infections (PJIs), and the potency of tests in relation to each other also remains vague. This systematic review aimed to (1) identify systematic reviews reporting accuracies of available approaches for diagnosing PJI, (2) critically appraise their quality and bias, and (3) compare the available approaches in terms of accuracy for diagnosing PJI.

Methods

PubMed and EMBASE databases were searched for meta-analyses reporting accuracies of different diagnostic modalities for PJIs. Thirteen systematic reviews met the inclusion and exclusion criteria, and their data were extracted and tabulated by two reviewers in duplicate and independent manners.

Results

The 13 articles reported diagnostic accuracy from 278 clinical studies comprising 27,754 patients and evaluating 13 diagnostic tests grouped into 7 broad categories. Implant sonication had the highest positive likelihood ratio (17.2), followed by bacteriology (15.3) and synovial fluid differentiated cytology (13.3). The highest negative likelihood ratio was for interleukin (IL)-6 serum marker (0.03) followed by synovial fluid cytology and differentiation (0.12 and 0.13, respectively).

Conclusion

The diagnostic tests that are most likely to rule out PJI include serum IL-6, serum C-reactive protein, and synovial fluid cytology. On the other hand, the diagnostic test that is most likely to confirm PJI is implant sonication. Nuclear imaging showed low overall accuracy as diagnostic tests for PJI. The findings of this study could enable clinicians to confirm or rule out PJIs using the most accurate, rapid, least invasive, and cost-effective tools available, thereby enabling fast treatment before formation of resistant biofilms and degradation of patient conditions.

Level of evidence

Systematic review, Level IV.

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References

  1. Abou El-Khier NT, El Ganainy Ael R, Elgeidy A, Rakha SA (2013) Assessment of interleukin-6 and other inflammatory markers in the diagnosis of Egyptian patients with periprosthetic joint infection. Egypt J Immunol 20(2):93–99

    PubMed  Google Scholar 

  2. Benito N, Franco M, Ribera A, Soriano A, Rodriguez-Pardo D, Sorli L, Fresco G, Del Toro MD, Guio L, Sanchez-Rivas E, Bahamande A, Riera M, Esteban J, Etxaburu JM, Martinez-Alvarez J, Jover-Saenz A, Duenas C, Ramos A, Sobrino B, Euba G, Morata L, Pigrau C, Coll P, Mur I, Ariza J (2016) Time trends in the etiology of prosthetic joint infections: a multicenter cohort study. Clin Microbiol Infect. doi:10.1016/j.cmi.2016.05.004

    PubMed  Google Scholar 

  3. Berbari E, Mabry T, Tsaras G, Spangehl M, Erwin PJ, Murad MH, Steckelberg J, Osmon D (2010) Inflammatory blood laboratory levels as markers of prosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am 92(11):2102–2109

    Article  PubMed  Google Scholar 

  4. Bereza PL, Ekiel A, Augusciak-Duma A, Aptekorz M, Wilk I, Kusz DJ, Wojciechowski P, Martirosian G (2013) Identification of silent prosthetic joint infection: preliminary report of a prospective controlled study. Int Orthop 37(10):2037–2043

    Article  PubMed  PubMed Central  Google Scholar 

  5. Bozic KJ (2015) The role of the payment system in improving value in healthcare. J Arthroplasty 30(3):341–342

    Article  PubMed  Google Scholar 

  6. Brammen L, Palestro C, Sinzinger H (2015) Radionuclide imaging: past, present and future outlook in the diagnosis of infected prosthetic joints. Hell J Nucl Med 18(Suppl 1):95–102

    PubMed  Google Scholar 

  7. Della Valle C, Parvizi J, Bauer TW, Dicesare PE, Evans RP, Segreti J, Spangehl M, Watters WC 3rd, Keith M, Turkelson CM, Wies JL, Sluka P, Hitchcock K (2010) Diagnosis of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg 18(12):760–770

    Article  PubMed  Google Scholar 

  8. Di Cesare PE, Chang E, Preston CF, Liu CJ (2005) Serum interleukin-6 as a marker of periprosthetic infection following total hip and knee arthroplasty. J Bone Joint Surg Am 87(9):1921–1927

    Article  PubMed  Google Scholar 

  9. Elgeidi A, Elganainy AE, Abou Elkhier N, Rakha S (2014) Interleukin-6 and other inflammatory markers in diagnosis of periprosthetic joint infection. Int Orthop 38(12):2591–2595

    Article  PubMed  Google Scholar 

  10. Fink B, Gebhard A, Fuerst M, Berger I, Schafer P (2013) High diagnostic value of synovial biopsy in periprosthetic joint infection of the hip. Clin Orthop Relat Res 471(3):956–964

    Article  PubMed  Google Scholar 

  11. Fink B, Makowiak C, Fuerst M, Berger I, Schafer P, Frommelt L (2008) The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late peri-prosthetic infection of total knee replacements. J Bone Joint Surg Br 90(7):874–878

    Article  CAS  PubMed  Google Scholar 

  12. Font-Vizcarra L, Garcia S, Martinez-Pastor JC, Sierra JM, Soriano A (2010) Blood culture flasks for culturing synovial fluid in prosthetic joint infections. Clin Orthop Relat Res 468(8):2238–2243

    Article  PubMed  PubMed Central  Google Scholar 

  13. Frangiamore SJ, Saleh A, Kovac MF, Grosso MJ, Zhang X, Bauer TW, Daly TM, Ricchetti ET, Iannotti JP (2015) Synovial fluid interleukin-6 as a predictor of periprosthetic shoulder infection. J Bone Joint Surg Am 97(1):63–70

    Article  PubMed  Google Scholar 

  14. Gallo J, Kolar M, Dendis M, Loveckova Y, Sauer P, Zapletalova J, Koukalova D (2008) Culture and PCR analysis of joint fluid in the diagnosis of prosthetic joint infection. New Microbiol 31(1):97–104

    PubMed  Google Scholar 

  15. Gallo J, Raska M, Dendis M, Florschutz AV, Kolar M (2004) Molecular diagnosis of prosthetic joint infection. A review of evidence. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 148(2):123–129

    Article  CAS  PubMed  Google Scholar 

  16. Gbejuade HO, Lovering AM, Webb JC (2015) The role of microbial biofilms in prosthetic joint infections. Acta Orthop 86(2):147–158

    Article  PubMed  PubMed Central  Google Scholar 

  17. Gemmel F, Van den Wyngaert H, Love C, Welling MM, Gemmel P, Palestro CJ (2012) Prosthetic joint infections: radionuclide state-of-the-art imaging. Eur J Nucl Med Mol Imaging 39(5):892–909

    Article  CAS  PubMed  Google Scholar 

  18. Glas AS, Lijmer JG, Prins MH, Bonsel GJ, Bossuyt PM (2003) The diagnostic odds ratio: a single indicator of test performance. J Clin Epidemiol 56(11):1129–1135

    Article  PubMed  Google Scholar 

  19. Gollwitzer H, Dombrowski Y, Prodinger PM, Peric M, Summer B, Hapfelmeier A, Saldamli B, Pankow F, von Eisenhart-Rothe R, Imhoff AB, Schauber J, Thomas P, Burgkart R, Banke IJ (2013) Antimicrobial peptides and proinflammatory cytokines in periprosthetic joint infection. J Bone Joint Surg Am 95(7):644–651

    Article  PubMed  Google Scholar 

  20. Grosso MJ, Frangiamore SJ, Saleh A, Kovac MF, Hayashi R, Ricchetti ET, Bauer TW, Iannotti JP (2014) Poor utility of serum interleukin-6 levels to predict indolent periprosthetic shoulder infections. J Shoulder Elbow Surg 23(9):1277–1281

    Article  PubMed  Google Scholar 

  21. Gundtoft PH, Pedersen AB, Schonheyder HC, Overgaard S (2016) Validation of the diagnosis ‘prosthetic joint infection’ in the Danish Hip Arthroplasty Register. Bone Joint J 98-b(3):320–325

    Article  CAS  PubMed  Google Scholar 

  22. Hsu W, Hearty TM (2012) Radionuclide imaging in the diagnosis and management of orthopaedic disease. J Am Acad Orthop Surg 20(3):151–159

    Article  PubMed  Google Scholar 

  23. Jin H, Yuan L, Li C, Kan Y, Hao R, Yang J (2014) Diagnostic performance of FDG PET or PET/CT in prosthetic infection after arthroplasty: a meta-analysis. Q J Nucl Med Mol Imaging 58(1):85–93

    CAS  PubMed  Google Scholar 

  24. Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89(4):780–785

    Article  PubMed  Google Scholar 

  25. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J (2012) Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 27(8 Suppl):61–65.e61

    Google Scholar 

  26. Kurtz SM, Ong KL, Lau E, Bozic KJ (2014) Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am 96(8):624–630

    Article  PubMed  Google Scholar 

  27. Kwee TC, Kwee RM, Alavi A (2008) FDG-PET for diagnosing prosthetic joint infection: systematic review and metaanalysis. Eur J Nucl Med Mol Imaging 35(11):2122–2132

    Article  PubMed  Google Scholar 

  28. Marmor S, Bauer T, Desplaces N, Heym B, Roux AL, Sol O, Roge J, Mahe F, Desire L, Aegerter P, Ghout I, Ropers J, Gaillard JL, Rottman M (2016) Multiplex antibody detection for noninvasive genus-level diagnosis of prosthetic joint infection. J Clin Microbiol 54(4):1065–1073

    Article  PubMed  PubMed Central  Google Scholar 

  29. Matar WY, Jafari SM, Restrepo C, Austin M, Purtill JJ, Parvizi J (2010) Preventing infection in total joint arthroplasty. J Bone Joint Surg Am 92(Suppl 2):36–46

    Article  PubMed  Google Scholar 

  30. Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7):e1000097

    Article  PubMed  PubMed Central  Google Scholar 

  31. Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hanssen A, Wilson WR (2013) Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 56(1):e1–e25

    Article  PubMed  Google Scholar 

  32. Ouyang Z, Li H, Liu X, Zhai Z, Li X (2014) Prosthesis infection: diagnosis after total joint arthroplasty with three-phase bone scintigraphy. Ann Nucl Med 28(10):994–1003

    Article  PubMed  Google Scholar 

  33. Pakos EE, Trikalinos TA, Fotopoulos AD, Ioannidis JP (2007) Prosthesis infection: diagnosis after total joint arthroplasty with antigranulocyte scintigraphy with 99mTc-labeled monoclonal antibodies–a meta-analysis. Radiology 242(1):101–108

    Article  PubMed  Google Scholar 

  34. Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Wongworawat MD, Fehring TK, Osmon DR, Barrack RL, Berend KR, Esterhai JL, Gioe TJ, Kurtz SM, Masri BA, Spangehl MJ, Segreti J (2011) New definition for periprosthetic joint infection. J Arthroplasty 26(8):1136–1138

    Article  Google Scholar 

  35. Parvizi J, Gehrke T (2014) Definition of periprosthetic joint infection. J Arthroplasty 29(7):1331

    Article  PubMed  Google Scholar 

  36. Parvizi J, Gehrke T, Chen AF (2013) Proceedings of the international consensus on periprosthetic joint infection. Bone Joint J 95-b(11):1450–1452

    Article  CAS  PubMed  Google Scholar 

  37. Peel TN, Dylla BL, Hughes JG, Lynch DT, Greenwood-Quaintance KE, Cheng AC, Mandrekar JN, Patel R (2016) Improved diagnosis of prosthetic joint infection by culturing periprosthetic tissue specimens in blood culture bottles. MBio 7(1):e01776–01715

    Article  Google Scholar 

  38. Qu X, Zhai Z, Li H, Li H, Liu X, Zhu Z, Wang Y, Liu G, Dai K (2013) PCR-based diagnosis of prosthetic joint infection. J Clin Microbiol 51(8):2742–2746

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Qu X, Zhai Z, Liu X, Li H, Wu C, Li Y, Li H, Zhu Z, Qin A, Dai K (2014) Evaluation of white cell count and differential in synovial fluid for diagnosing infections after total hip or knee arthroplasty. PLoS One 9(1):e84751

    Article  PubMed  PubMed Central  Google Scholar 

  40. Qu X, Zhai Z, Wu C, Jin F, Li H, Wang L, Liu G, Liu X, Wang W, Li H, Zhang X, Zhu Z, Dai K (2013) Preoperative aspiration culture for preoperative diagnosis of infection in total hip or knee arthroplasty. J Clin Microbiol 51(11):3830–3834

    Article  PubMed  PubMed Central  Google Scholar 

  41. Sharma R, Vannabouathong C, Bains S, Marshall A, MacDonald SJ, Parvizi J, Bhandari M (2011) Meta-analyses in joint arthroplasty: a review of quantity, quality, and impact. J Bone Joint Surg Am 93(24):2304–2309

    Article  PubMed  Google Scholar 

  42. Tande AJ, Patel R (2014) Prosthetic joint infection. Clin Microbiol Rev 27(2):302–345

    Article  PubMed  PubMed Central  Google Scholar 

  43. Topolski MS, Chin PY, Sperling JW, Cofield RH (2006) Revision shoulder arthroplasty with positive intraoperative cultures: the value of preoperative studies and intraoperative histology. J Shoulder Elbow Surg 15(4):402–406

    Article  PubMed  Google Scholar 

  44. Tsaras G, Maduka-Ezeh A, Inwards CY, Mabry T, Erwin PJ, Murad MH, Montori VM, West CP, Osmon DR, Berbari EF (2012) Utility of intraoperative frozen section histopathology in the diagnosis of periprosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am 94(18):1700–1711

    Article  PubMed  Google Scholar 

  45. Villacis D, Merriman JA, Yalamanchili R, Omid R, Itamura J, Rick Hatch GF 3rd (2014) Serum interleukin-6 as a marker of periprosthetic shoulder infection. J Bone Joint Surg Am 96(1):41–45

    Article  PubMed  Google Scholar 

  46. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J (2003) The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 3:25

    Article  PubMed  PubMed Central  Google Scholar 

  47. Xing D, Ma X, Ma J, Wang J, Chen Y, Yang Y (2013) Use of anti-granulocyte scintigraphy with 99mTc-labeled monoclonal antibodies for the diagnosis of periprosthetic infection in patients after total joint arthroplasty: a diagnostic meta-analysis. PLoS One 8(7):e69857

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Yuan K, Chen HL, Cui ZM (2014) Diagnostic accuracy of C-reactive protein for periprosthetic joint infection: a meta-analysis. Surg Infect (Larchmt) 15(5):548–559

    Article  Google Scholar 

  49. Zhai Z, Li H, Qin A, Liu G, Liu X, Wu C, Li H, Zhu Z, Qu X, Dai K (2014) Meta-analysis of sonication fluid samples from prosthetic components for diagnosis of infection after total joint arthroplasty. J Clin Microbiol 52(5):1730–1736

    Article  PubMed  PubMed Central  Google Scholar 

  50. Zhao X, Guo C, Zhao GS, Lin T, Shi ZL, Yan SG (2013) Ten versus five polymorphonuclear leukocytes as threshold in frozen section tests for periprosthetic infection: a meta-analysis. J Arthroplasty 28(6):913–917

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Bern University Hospital, Inselspital, Bern, Switzerland

    Sufian S. Ahmad, Ahmed Shaker & Sandro Kohl

  2. Department of Medical Research, Alliance Scientifique SAS, Lyon, France

    Mo Saffarini

  3. Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA

    Antonia F. Chen

  4. Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland-Bruderholz, Basel, Switzerland

    Michael T. Hirschmann

Authors
  1. Sufian S. Ahmad
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  2. Ahmed Shaker
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  3. Mo Saffarini
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  4. Antonia F. Chen
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  5. Michael T. Hirschmann
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  6. Sandro Kohl
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Correspondence to Sufian S. Ahmad.

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Ahmad, S.S., Shaker, A., Saffarini, M. et al. Accuracy of diagnostic tests for prosthetic joint infection: a systematic review. Knee Surg Sports Traumatol Arthrosc 24, 3064–3074 (2016). https://doi.org/10.1007/s00167-016-4230-y

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