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Updated: Jun 25, 2025
Novel Diagnostics in Revision Arthroplasty: Implant Sonication and Multiplex Polymerase Chain Reaction
Published on: December 3, 2017
The James A. Rand Young Investigator's Award: Keeping It Simple: Are all Musculoskeletal Infection Society Tests
Jason B Kreinces1, Itay Ashkenazi2, Ittai Shichman2
1NYU Langone, Adult Reconstructive Division, New York, New York.
Background:
Current data evaluating the clinical value and cost-effectiveness of advanced diagnostic tests for periprosthetic joint infection (PJI) diagnosis, including alpha-defensin and synovial C-reactive protein (CRP), is conflicting. This study aimed to evaluate the adequacy of preoperative and intraoperative PJI workups without utilizing these tests.
Methods:
This retrospective analysis identified all patients who underwent revision total knee or hip arthroplasty (rTKA and rTHA, respectively) for suspected PJI between 2018 and 2020 and had a minimum follow-up of 2 years. Perioperative data and lab results were collected, and cases were dichotomized based on whether they met the 2018 Musculoskeletal Infection Society (MSIS) criteria for PJI. In total, 204 rTKA and 158 rTHA cases suspected of PJI were reviewed.
Results:
Nearly 100% of the cases were categorized as "infected" for meeting the 2018 MSIS criteria without utilization of alpha-defensin or synovial CRP (rTKA: n = 193, 94.6%; rTHA: n = 156, 98.7%). Most cases were classified as PJI preoperatively by meeting either the major MSIS or the combinational minor MSIS criteria of traditional lab tests (rTKA: n = 177, 86.8%; rTHA: n = 143, 90.5%). A subset of cases was classified as PJI by meeting combinational preoperative and intraoperative MSIS criteria (rTKA: 16, 7.8%; rTHA: 13, 8.2%). Only 3.6% of all cases were considered "inconclusive" using preoperative and intraoperative data.
Conclusions:
Given the high rate of cases satisfying PJI criteria during preoperative workup using our available tests, the synovial alpha-defensin and synovial CRP tests may not be necessary in the routine diagnostic workup of PJI. We suggest that the primary PJI workup process should be based on a stepwise algorithmic approach with the most economical testing necessary to determine a diagnosis first. The use of advanced, commercialized, and costly biomarkers should be utilized only when traditional testing is indeterminate.
Insights
Advanced diagnostic tests for periprosthetic joint infection (PJI) may not be necessary. Standard preoperative and intraoperative workups effectively diagnose PJI, making costly biomarkers potentially redundant for routine cases.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Diagnostic Medicine
Background:
- Conflicting data exists on the clinical value and cost-effectiveness of advanced periprosthetic joint infection (PJI) diagnostic tests like alpha-defensin and synovial C-reactive protein (CRP).
- Evaluating PJI diagnostic adequacy without these advanced tests is crucial for optimizing patient care and resource allocation.
Purpose of the Study:
- To assess the effectiveness of standard preoperative and intraoperative diagnostic workups for periprosthetic joint infection (PJI).
- To determine if advanced biomarkers (alpha-defensin, synovial CRP) are essential for routine PJI diagnosis.
Main Methods:
- Retrospective analysis of revision total knee (rTKA) and hip arthroplasty (rTHA) cases with suspected PJI (2018-2020).
- Minimum 2-year follow-up, collection of perioperative data and lab results.
- Dichotomization of cases based on 2018 Musculoskeletal Infection Society (MSIS) criteria for PJI.
Main Results:
- Nearly 100% of cases met 2018 MSIS criteria for PJI without advanced tests (rTKA: 94.6%, rTHA: 98.7%).
- Most PJI cases were diagnosed preoperatively using traditional lab tests (rTKA: 86.8%, rTHA: 90.5%).
- Only 3.6% of cases were deemed inconclusive using standard preoperative and intraoperative data.
Conclusions:
- Synovial alpha-defensin and CRP tests may not be required for routine PJI diagnosis.
- A stepwise, economical diagnostic approach is recommended, utilizing advanced tests only when traditional methods are indeterminate.
- Standard PJI workup is adequate for most revision arthroplasty cases.
