Synovial Cytokines and the MSIS Criteria Are Not Useful for Determining Infection Resolution After Periprosthetic Joint Infection Explantation
Synovial Cytokines and the MSIS Criteria Are Not Useful for Determining Infection Resolution After Periprosthetic Joint Infection Explantation
Salvatore J. Frangiamore 0
Marcelo B. P. Siqueira 0
Anas Saleh 0
Thomas Daly 0
Carlos A. Higuera 0
Wael K. Barsoum 0
0 S. J. Frangiamore, M. B. P. Siqueira, A. Saleh, T. Daly, C. A. Higuera (&), W. K. Barsoum Department of Orthopaedic Surgery, Cleveland Clinic , 9500 Euclid Avenue/A41, Cleveland, OH 44195 , USA
Background Diagnosing periprosthetic joint infection (PJI) requires a combination of clinical and laboratory parameters, which may be expensive and difficult to
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One of the authors certifies that he (CAH), or a member of his
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the study period, an amount of USD 10,000 to USD 100,000 from
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100,001 to USD 1,000,000 from Myoscience (Fresno, CA, USA), and
an amount of USD 100,001 to USD 1,000,000 from CD Diagnostics
(Claymont, DE, USA). One of the authors certifies that he (WKB), or
a member of his immediate family, has or may receive payments or
benefits, during the study period, an amount of USD 100,001 to USD
1,000,000 from Stryker, an amount of USD 100,000 to USD
1,000,000 from Exatech (Gainesville, FL, USA), an amount of USD
10,000 to USD 100,000 from Custom Orthopaedic Solutions
(Cleveland, OH, USA), and an amount of USD 10,000 to USD
100,000 from KEF Healthcare (Dubai, UAE).
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interpret. Synovial fluid cytokines have been shown to
accurately differentiate septic from aseptic failed total knee
(TKA) and hip (THA) arthroplasties. However, after
firststage explantation, there is still no reliable test to rule out
PJI before a second-stage reimplantation procedure.
Questions/purposes (1) Which synovial fluid cytokines
have the highest diagnostic accuracy for PJI? (2) Which
cytokine shows the greatest decrease associated with the
resolution of infection in the same patient between
explantation and subsequent reimplantation of an infected
arthroplasty? (3) What is the accuracy of synovial fluid
cytokines and the Musculoskeletal Infection Society
(MSIS) criteria to rule out PJI after first-stage explantation?
(4) What are the most studied synovial fluid cytokines for
diagnosing PJI as reported in the literature and what are
their cumulative diagnostic accuracy?
Methods Between May 2013 and March 2014, 104
patients with painful THA and TKA evaluated for possible
PJI were included in our study. Of these, 90 (87%) had
cytokine levels measured from synovial fluid samples
collected as part of this prospective study (n = 33 hips, n =
57 knees). A second group of 35 patients (n = 36 samples)
who presented during the same time period with an
antibiotic spacer also had synovial cytokines measured
before second-stage reimplantation. For the first group of
90 patients, the MSIS definition classified each joint at the
time of surgery as infected (n = 31) or not infected (n = 59)
and was used as the standard to test the accuracy in
diagnosing PJI. Of the 35 patients with synovial marker data
before second-stage surgery, 15 patients had cytokine
measurements both at explantation and reimplantation and
were used to quantify the change between stages. The
reimplantation group had a minimum 1-year followup
(with four [11%] patients lost to followup) and was
classified into successful or failed treatment based on
Delphibased consensus data and was used to test the accuracy in
detecting infection resolution at reimplantation.
Results Interleukin (IL)-1b and interferon-c
demonstrated the highest diagnostic utility (area under the curve
0.92, 0.91, respectively); IL-1b and IL-6 had the highest
sensitivities (0.90 [95% confidence interval {CI}, 0.74–
0.98] and 0.81 [0.63–0.93]). As a measure of infection
resolution, IL-1b had the greatest decrease (12.4-fold; level
at explantation: 232.4 [range, 23.1–1545.7]; level at
reimplantation: 18.8 (range 1.2–298.9); mean difference: 325.5
[95% CI, 65.0–596.0]; p = 0.0001), and IL-6 had a near (...truncated)