It can be unnecessary to combine common synovial fluid analysis and alpha-defensin tests for periprosthetic joint infection diagnosis

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Abstract

Background

Periprosthetic joint infection is a serious complication after total joint arthroplasty. Despite that alpha-defensin was used as diagnostic test in the 2018 ICM (international consensus meeting) criteria, its position in the PJI diagnostic pipeline was controversial. Therefore, we performed a retrospective pilot study to identify whether synovial fluid alpha-defensin test was necessary when corresponding synovial fluid analysis (WBC count, PMN% and LE tests) was performed.

Methods

Between May 2015 and October 2018, a total of 90 suspected PJI patients who underwent revisions after TJA were included in this study. Based on the 2018 ICM criteria, the interobserver agreements between preoperative diagnostic results and postoperative diagnostic results and the interobserver reliability between preoperative diagnostic results and postoperative diagnostic results with or without synovial fluid alpha-defensin tests were calculated. After that, the ROC analysis, and the direct cost-effectiveness of adding alpha-defensin was performed.

Results

There were 48,16 and 26 patients in the PJI group, inconclusive group and non-PJI group, respectively. Adding the alpha-defensin tests into 2018 ICM criteria can’t change the preoperative diagnostic results, postoperative diagnostic results, and the concordance between preoperative and postoperative diagnostic results. Moreover, the Risk–benefit Ratio is over 90 per changed decision and the direct cost-effectiveness of alpha-defensin was more than $8370($93*90) per case.

Conclusions

Alpha-defensin assay exhibit high sensitivity and specificity for PJI detection as a standalone test based on the 2018 ICM criteria. However, the additional order of Alpha-defensin can’t offer additional evidence for PJI diagnosis when corresponding synovial fluid analysis was performed (synovial fluid WBC count, PMN% and LE strip tests).

Evidence level

Level II, Diagnostic study.

Related collections

Most cited references 19

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Interrater reliability: the kappa statistic

Mary L McHugh (2012)

The kappa statistic is frequently used to test interrater reliability. The importance of rater reliability lies in the fact that it represents the extent to which the data collected in the study are correct representations of the variables measured. Measurement of the extent to which data collectors (raters) assign the same score to the same variable is called interrater reliability. While there have been a variety of methods to measure interrater reliability, traditionally it was measured as percent agreement, calculated as the number of agreement scores divided by the total number of scores. In 1960, Jacob Cohen critiqued use of percent agreement due to its inability to account for chance agreement. He introduced the Cohen’s kappa, developed to account for the possibility that raters actually guess on at least some variables due to uncertainty. Like most correlation statistics, the kappa can range from −1 to +1. While the kappa is one of the most commonly used statistics to test interrater reliability, it has limitations. Judgments about what level of kappa should be acceptable for health research are questioned. Cohen’s suggested interpretation may be too lenient for health related studies because it implies that a score as low as 0.41 might be acceptable. Kappa and percent agreement are compared, and levels for both kappa and percent agreement that should be demanded in healthcare studies are suggested.

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Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America.

D R Osmon, E F Berbari, A Berendt … (2012)

These guidelines are intended for use by infectious disease specialists, orthopedists, and other healthcare professionals who care for patients with prosthetic joint infection (PJI). They include evidence-based and opinion-based recommendations for the diagnosis and management of patients with PJI treated with debridement and retention of the prosthesis, resection arthroplasty with or without subsequent staged reimplantation, 1-stage reimplantation, and amputation.

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Periprosthetic joint infection.

Bhaveen H Kapadia, Richard A Berg, Jacqueline Daley … (2016)

Periprosthetic joint infections are a devastating complication after arthroplasty and are associated with substantial patient morbidity. More than 25% of revisions are attributed to these infections, which are expected to increase. The increased prevalence of obesity, diabetes, and other comorbidities are some of the reasons for this increase. Recognition of the challenge of surgical site infections in general, and periprosthetic joint infections particularly, has prompted implementation of enhanced prevention measures preoperatively (glycaemic control, skin decontamination, decolonisation, etc), intraoperatively (ultraclean operative environment, blood conservation, etc), and postoperatively (refined anticoagulation, improved wound dressings, etc). Additionally, indications for surgical management have been refined. In this Review, we assess risk factors, preventive measures, diagnoses, clinical features, and treatment options for prosthetic joint infection. An international consensus meeting about such infections identified the best practices and further research needs. Orthopaedics could benefit from enhanced preventive, diagnostic, and treatment methods.

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Author and article information

Contributors

Hao Li:

ORCID: http://orcid.org/0000-0003-4704-3174

lihao_969@qq.com

Rui Li: Ryanlee301@163.com

Niu Erlong:

ORCID: http://orcid.org/0000-0001-9093-8892

evilgenius1987@163.com

Wei Chai:

ORCID: http://orcid.org/0000-0001-8781-9745

chaiweiguanjie@sina.com

LiBo Hao:

ORCID: http://orcid.org/0000-0003-3052-8714

haolibo301@sina.com

Chi Xu:

ORCID: http://orcid.org/0000-0003-4211-0657

henyunale@163.com

Jun Fu:

ORCID: http://orcid.org/0000-0002-8692-6810

fujun301gk@163.com

Jiying Chen:

ORCID: http://orcid.org/0000-0001-8166-4658

chenjiyingpla@sina.com

Fangzheng Zhu: zhufangzheng262@sina.com

Journal

Journal ID (nlm-ta): BMC Musculoskelet Disord

Journal ID (iso-abbrev): BMC Musculoskelet Disord

Title: BMC Musculoskeletal Disorders

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2474

Publication date (Electronic): 29 June 2023

Publication date PMC-release: 29 June 2023

Publication date Collection: 2023

Volume: 24

Electronic Location Identifier: 529

Affiliations

[1 ]GRID grid.488137.1, ISNI 0000 0001 2267 2324, Medical School of Chinese PLA, ; Beijing, People’s Republic of China

[2 ]GRID grid.414252.4, ISNI 0000 0004 1761 8894, Department of Orthopedic Surgery, The First Medical Center, , Chinese PLA General Hospital, ; 28 Fuxing Road, Beijing, People’s Republic of China

[3 ]GRID grid.414252.4, ISNI 0000 0004 1761 8894, Senior Department of Orthopedics, , Fourth Medical Center of PLA General Hospital, ; Beijing, People’s Republic of China

[4 ]GRID grid.414252.4, ISNI 0000 0004 1761 8894, Department of Orthopedics, , 305 Hospital of PLA, ; Beijing, People’s Republic of China

[5 ]GRID grid.488137.1, ISNI 0000 0001 2267 2324, Department of Orthopaedics, , PLA Rocket Force Characteristics Medical Center, ; Beijing, 100088 China

Author information

Hao Li http://orcid.org/0000-0003-4704-3174

Niu Erlong http://orcid.org/0000-0001-9093-8892

Wei Chai http://orcid.org/0000-0001-8781-9745

LiBo Hao http://orcid.org/0000-0003-3052-8714

Chi Xu http://orcid.org/0000-0003-4211-0657

Jun Fu http://orcid.org/0000-0002-8692-6810

Jiying Chen http://orcid.org/0000-0001-8166-4658

Article

Publisher ID: 6594

DOI: 10.1186/s12891-023-06594-5

PMC ID: 10308702

SO-VID: 01ad4bc8-b18b-42ac-9e84-847459aeb1a9

License:

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 28 November 2022

Date accepted : 1 June 2023

Funding

Funded by: National Key Research and Development Program of China

Award ID: No.2020YFC2004900

Award Recipient : Jiying Chen

Custom metadata

ScienceOpen disciplines: Orthopedics

Keywords: periprosthetic joint infection,the 2018 icm criteria,alpha-defensin,total joint arthroplasty

Data availability:

ScienceOpen disciplines: Orthopedics

Keywords: periprosthetic joint infection, the 2018 icm criteria, alpha-defensin, total joint arthroplasty

It can be unnecessary to combine common synovial fluid analysis and alpha-defensin tests for periprosthetic joint infection diagnosis

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Abstract

Background

Methods

Results

Conclusions

Evidence level

Related collections

Orthopedics

Most cited references 19

Interrater reliability: the kappa statistic

Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America.

Periprosthetic joint infection.

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Contributors

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Funding

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