Reliable Diagnostic Tests and Thresholds for Preoperative Diagnosis of Non‐Inflammatory Arthritis Periprosthetic Joint Infection: A Meta‐analysis and Systematic Review

• Published in: Orthopaedic surgery 2022-11, Vol.14 (11), p.2822-2836
• Main Authors: Tang, Haozheng, Xu, Jialian, Yuan, Wei'en, Wang, You, Yue, Bing, Qu, Xinhua
• Format: Article
• Language: English
• Subjects: Accuracy; Arthritis; Biomarkers; Diagnosis; Diagnostic tests; Infections; Joint surgery; Laboratories; Lymphocytes; Meta-analysis; Periprosthetic joint infection; Review; Serum and synovial test; Systematic review; Threshold effect; Total joint arthroplasty
• ISSN: 1757-7853; 1757-7861
• DOI: 10.1111/os.13500

Objective The current diagnostic criteria for periprosthetic joint infection (PJI) are diverse and controversial, leading to delayed diagnosis. This study aimed to evaluate and unify their diagnostic accuracy and the threshold selection of serum and synovial routine tests for PJI at an early stage. Methods We searched the MEDLINE and Embase databases for retrospective or prospective studies which reported preoperative‐available assays (serum, synovial, or culture tests) for the diagnosis of chronic PJI among inflammatory arthritis (IA) or non‐IA populations from January 1, 2000 to June 30, 2022. Threshold effective analysis was performed on synovial polymorphonuclear neutrophils (PMN%), synovial white blood cell (WBC), serum C‐reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to find the relevant cut‐offs. Results Two hundred and sixteen studies and information from 45,316 individuals were included in the final analysis. Synovial laboratory‐based α‐defensin and calprotectin had the best comprehensive sensitivity (0.91 [0.86–0.94], 0.95 [0.88–0.98]) and specificity (0.96 [0.94‐0.97], 0.95 [0.89–0.98]) values. According to the threshold effect analysis, the recommended cut‐offs are 70% (sensitivity 0.89 [0.85–0.92], specificity 0.90 [0.87–0.93]), 4100/μL (sensitivity 0.90 [0.87–0.93], specificity 0.97 [0.93–0.98]), 13.5 mg/L (sensitivity 0.84 [0.78–0.89], specificity 0.83 [0.73–0.89]), and 30 mm/h (sensitivity 0.79 [0.74–0.83], specificity 0.78 [0.72–0.83]) for synovial PMN%, synovial WBC, serum CRP, and ESR, respectively, and tests seem to be more reliable among non‐IA patients. Conclusions The laboratory‐based synovial α‐defensin and synovial calprotectin are the two best independent preoperative diagnostic tests for PJI. A cut off of 70% for synovial PMN% and tighter cut‐offs for synovial WBC and serum CRP could have a better diagnostic accuracy for non‐IA patients with chronic PJI. This work provides additional insights and brand‐new evidences to the diagnostic accuracy of traditional and novel tests in early diagnosis of periprosthetic joint infection (PJI), especially the threshold selection. The results could attract more attentions on finding reliable cut‐offs and further influence the update of present criteria, which might provide significant meanings to the diagnosis and therapy strategy of PJI.