Sousa R, Serrano P, Gomes Dias J, Oliveira J C, Oliveira A
Centro Hospitalar do Porto, Hospital de Santo António, Largo Professor Abel Salazar; 4099-001 Porto, Portugal.
Administração Regional de Saúde do Norte, Rua Anselmo Braancamp, 144; 4000-078 Porto, Portugal.
Bone Joint J. 2017 Mar;99-B(3):351-357. doi: 10.1302/0301-620X.99B3.BJJ-2016-0684.R1.
AIMS: The aims of this study were to increase the diagnostic accuracy of the analysis of synovial fluid in the differentiation of prosthetic joint infection (PJI) by the addition of inexpensive biomarkers such as the levels of C-reactive protein (CRP), adenosine deaminase (ADA), alpha-2-macrogloblulin (α2M) and procalcitonin. PATIENTS AND METHODS: Between January 2013 and December 2015, synovial fluid and removed implants were requested from 143 revision total joint arthroplasties. A total of 55 patients met inclusion criteria of the receipt of sufficient synovial fluid, tissue samples and removed implants for analysis. The diagnosis of PJI followed the definition from a recent International Consensus Meeting to create two groups of patients; septic and aseptic. Using receiver operating characteristic curves we determined the cutoff values and diagnostic accuracy for each marker. RESULTS: There were 23 PJIs and 32 patients with aseptic loosening. The levels of total leucocyte count, proportion of polymorphonuclear leucocytes (PMNs), CRP, ADA and α2M in the synovial fluid were all significantly higher in those with a PJI than in those with aseptic loosening. The levels of procalcitonin were comparable in the two groups. Cutoff values for the optimal performance in the diagnosis of infection were: total leucocyte count > 1463 cells/μL (sensitivity (Sens) 100%, specificity (Spec) 71.9%, positive predictive value (PPV) 71.9%, negative predictive value (NPV) 100%); proportion of PMNs > 81% (Sens 78.3%, Spec 75.0%, PPV 69.2%, NPV 82.8%); CRP > 6.7mg/L (Sens 78.3%, Spec 93.8%, PPV 90.0%, NPV 85.7%); ADA > 61U/L (Sens 78.3%, Spec 96.9%, PPV 94.7%, NPV 86.1%) and α2M > 958 mg/L (Sens 47.8%, Spec 96.9%, PPV 91.7%, NPV 72.1%). The addition of a raised level of CRP or ADA to the total leukocyte count increased the specificity: total leukocyte count > 1463 cells/μL and CRP > 6.7mg/L (Sens 78.3%, Spec 100%, PPV 100%, NPV 86.5%) or with ADA > 61U/L (Sens 78.3%, Spec 96.9%, PPV 94.7%, NPV 86.1%). CONCLUSION: The total leucocyte count in the synovial fluid offers great negative predictive value in the diagnosis of PJI and the addition of more specific markers such as CRP and ADA improves the positive predictive value. Thus the addition of simple and inexpensive markers to the measurement of the leucocyte count in the synovial fluid may reduce the number of equivocal results which demand more expensive investigation. Cite this article: 2017;99-B:351-7.
目的：本研究的目的是通过添加诸如C反应蛋白（CRP）、腺苷脱氨酶（ADA）、α2-巨球蛋白（α2M）和降钙素原等廉价生物标志物，提高滑膜液分析在人工关节感染（PJI）鉴别诊断中的准确性。 患者与方法：2013年1月至2015年12月期间，从143例翻修全关节置换术中获取了滑膜液和取出的植入物。共有55例患者符合纳入标准，即获得了足够的滑膜液、组织样本和取出的植入物用于分析。PJI的诊断遵循最近一次国际共识会议的定义，将患者分为两组：感染组和无菌组。使用受试者工作特征曲线，我们确定了每个标志物的临界值和诊断准确性。 结果：有23例PJI患者和32例无菌性松动患者。PJI患者滑膜液中的白细胞总数、多形核白细胞（PMN）比例、CRP、ADA和α2M水平均显著高于无菌性松动患者。两组的降钙素原水平相当。诊断感染的最佳性能临界值为：白细胞总数>1463个/μL（敏感性（Sens）100%，特异性（Spec）71.9%，阳性预测值（PPV）71.9%，阴性预测值（NPV）100%）；PMN比例>81%（Sens 78.3%，Spec 75.0%，PPV 69.2%，NPV 82.8%）；CRP>6.7mg/L（Sens 78.3%，Spec 93.8%，PPV 90.0%，NPV 85.7%）；ADA>61U/L（Sens 78.3%，Spec 96.9%，PPV 94.7%，NPV 86.1%）和α2M>958mg/L（Sens 47.8%，Spec 96.9%，PPV 91.7%，NPV 72.1%）。在白细胞总数基础上增加升高的CRP或ADA水平可提高特异性：白细胞总数>1463个/μL且CRP>6.7mg/L（Sens 78.3%，Spec 100%，PPV 100%，NPV 86.5%）或ADA>61U/L（Sens 78.3%，Spec 96.9%，PPV 94.7%，NPV 86.1%）。 结论：滑膜液中的白细胞总数在PJI诊断中具有很大的阴性预测价值，添加CRP和ADA等更具特异性的标志物可提高阳性预测价值。因此，在滑膜液白细胞计数测量中添加简单且廉价的标志物可能会减少需要更昂贵检查的模棱两可结果的数量。引用本文：2017；99-B：351-7。
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