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Imaging modalities demonstrate moderate and heterogeneous diagnostic accuracy for periprosthetic joint infection: A
Armita Armina Abedi1,2,3, Saad Tarabichi4, Andor Waltherus Johannes Maria Glaudemans5
1International Consensus on Orthopedic Infections Organization, Philadelphia, Pennsylvania, USA.
Purpose:
The diagnostic accuracy of imaging modalities in periprosthetic joint infections (PJIs) remains uncertain. This study assessed and compared the performance of different imaging techniques for diagnosing PJI.
Methods:
A systematic review and meta-analysis of studies published in PubMed and Embase (1 January 2000 to 1 March 2024) was conducted. Eligible studies included adults (≥18 years), applied a valid reference standard for PJI diagnosis, and provided sufficient data to construct 2 × 2 contingency tables. Imaging modalities included white blood cell scintigraphy (WBCS), FDG-PET/CT, antigranulocyte scintigraphy (AGS), bone scintigraphy (BS), magnetic resonance imaging (MRI), computed tomography (CT) and related combinations. Risk of bias was assessed using the QUADAS-2 tool. A bivariate random-effects model estimated pooled diagnostic odds ratios, sensitivities, and specificities with 95% confidence intervals (CIs).
Results:
Forty studies (1263 PJI cases, 4700 controls) were included. Pooled sensitivity and specificity were as follows: WBCS-SPECT/CT: 87.1% (95% CI, 31.7-99.0) and 94.1% (95% CI, 87.5-97.3); WBCS-BMS: 79.7% (95% CI, 58.3-91.7) and 94.2% (95% CI, 91.0-96.3); WBCS: 88.1% (95% CI, 73.8-95.1) and 80.0% (95% CI, 62.2-90.7); FDG-PET (±PET/CT): 88.1% (95% CI, 79.9-93.2) and 87.2% (95% CI, 76.3-93.5); BS-WBCS: 59.5% (95% CI, 43.2-73.9) and 96.6% (95% CI, 92.2-98.6); BS: 89.3% (95% CI, 80.9-94.2) and 74.1% (95% CI, 59.0-85.0); AGS: 89.1% (95% CI, 76.8-95.3) and 73.0% (95% CI, 63.1-81.0). No eligible studies were identified for MRI or CT. Substantial heterogeneity was observed.
Conclusion:
Diagnostic performance varied substantially, and no modality consistently demonstrated superior accuracy. WBCS showed the most stable results, particularly when combined with BS or BMS. Given the heterogeneity and variability in specificity, imaging should complement comprehensive diagnostic evaluation rather than be used in isolation.
Level Of Evidence:
2a-3a, systematic review and meta-analysis of retrospective cohort and case-control studies.
Insights
No single imaging technique consistently excels at diagnosing periprosthetic joint infections (PJIs). White blood cell scintigraphy (WBCS) demonstrated stable performance, especially when combined with bone scintigraphy (BS) or bone marrow scintigraphy (BMS).
Area of Science:
- Orthopedic Surgery
- Radiology
- Nuclear Medicine
Background:
- Periprosthetic joint infections (PJIs) pose a significant challenge in orthopedic care.
- The diagnostic accuracy of various imaging modalities for PJI remains uncertain, necessitating comparative analysis.
Purpose of the Study:
- To systematically review and compare the diagnostic performance of different imaging techniques for PJI.
- To assess the sensitivity and specificity of modalities like WBCS, FDG-PET/CT, AGS, and BS.
Main Methods:
- A systematic review and meta-analysis of studies from PubMed and Embase (2000-2024).
- Inclusion of studies with valid reference standards for PJI diagnosis in adults.
- Bivariate random-effects modeling to estimate pooled diagnostic performance metrics.
Main Results:
- Forty studies involving 1263 PJI cases and 4700 controls were analyzed.
- White blood cell scintigraphy (WBCS) showed high pooled sensitivity (88.1%) and specificity (80.0%).
- Combinations like WBCS with BS or BMS yielded strong diagnostic performance, though substantial heterogeneity was noted across studies.
Conclusions:
- Diagnostic accuracy varied significantly among imaging modalities for PJI.
- WBCS demonstrated the most consistent results, particularly when combined with BS or BMS.
- Imaging should supplement, not replace, comprehensive diagnostic evaluations for PJI due to performance variability.
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