Y. S. Lee, N. Fernando, H. Vahedi, A. F. Chen, Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA K.-H. Koo, Y. S. Lee, Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea N. Fernando, Department of Orthopedic Surgery, University of Washington School of Medicine, Seattle, WA, USA H. J. Kim, Institute for Evidence-based Medicine and Department of Preventive Medicine, Korea University College of Medicine, Seoul, South Korea.
Clin Orthop Relat Res. 2018 Oct;476(10):1972-1983. doi: 10.1097/01.blo.0000534680.87622.43.
There is no consensus on the appropriate marker to use when deciding to perform reimplantation after two-stage exchange arthroplasty for periprosthetic joint infection (PJI).
QUESTIONS/PURPOSES: What tests provide acceptable diagnostic value to guide appropriate timing of reimplantation in two-stage exchange arthroplasty for PJI?
A search of online databases (MEDLINE, EMBASE, OVID, and Cochrane database) was performed containing articles that provided sensitivity and specificity values for accuracy for predicting reimplantation of the hip and/or knee. Twelve articles were included for final analysis, which included data from 1047 patients. Data that described the diagnostic accuracy of markers for reimplantation were evaluated and categorized into four main entities according to diagnostic method (serologic, synovial, tissue, and diagnostic imaging). Twelve parameters were examined, including serum erythrocyte sedimentation (ESR) rate, serum C-reactive protein (CRP), serum white blood cell (WBC) count, synovial fluid Gram stain, synovial fluid culture, synovial fluid sonication culture, synovial fluid WBC, synovial fluid polymorphonucleocyte percentage (PMN%), tissue Gram stain, tissue culture, positron emission tomography scan, and leukocyte scan. Each of the included articles was independently analyzed for risk of bias and applicability by using QUADAS-2. Statistical heterogeneity was calculated by using the Cochran Q test, and an α of 0.10 was considered significant for heterogeneity.
Tissue culture (sensitivity 0.82 [0.72-0.90], specificity 0.91 [0.89-0.95], diagnostic odds ratio (DOR) 46.87 [95% confidence interval {CI}, 22.03-99.69], synovial fluid PMN% (sensitivity 0.77 [0.46-0.95], specificity 0.74 [0.67-0.81], DOR 11.27 [95% CI, 2.89-43.61]), and synovial fluid culture (sensitivity 0.64 [0.52-0.74], specificity 0.96 [0.93-0.98], DOR 27.07 [95% CI, 2.55-288.00]) showed relatively high diagnostic performance. Other parameters had poorer diagnostic accuracy: ESR (sensitivity 0.56 [0.40-0.72], specificity 0.60 [0.53-0.66], DOR 2.41 [95% CI, 0.60-9.72), CRP (sensitivity 0.53 [0.39-0.67], specificity 0.72 [0.66-0.78], DOR 2.25 [95% CI, 0.09-4.63), and synovial fluid WBC count (sensitivity 0.37 [0.19-0.58], specificity 0.49 [0.41-0.57], DOR 0.94 [95% CI, 0.06-14.74). However, interpretation is limited, because only two to three studies were available for each pooled analysis. Both risks of bias and applicability concerns were low in the four domains assessed in QUADAS-2.
This meta-analysis suggests that no single marker was superior to all the others, and none (when used alone) is likely sufficient to confirm control of infection after the first stage of a two-stage protocol for PJI. Therefore, the current approach using multiple tools rather than a single marker is essential. Additionally, further studies must be conducted so that pooled analysis can be performed using multiple studies to determine ideal markers for reimplantation.
Level III, diagnostic study.
对于假体周围关节感染（PJI）的两期翻修术，目前对于决定何时行再植入，尚无共识。
问题/目的：何种检查可提供可接受的诊断价值，以指导 PJI 两期翻修术时的合适再植入时机？
对在线数据库（MEDLINE、EMBASE、OVID 和 Cochrane 数据库）进行了检索，纳入了提供用于预测髋关节和/或膝关节再植入准确性的敏感性和特异性值的文章。最终纳入 12 篇文章进行分析，共包括 1047 例患者的数据。评估了描述标记物用于再植入的诊断准确性的数据，并根据诊断方法（血清学、滑膜、组织和诊断影像学）分为四个主要实体。共检查了 12 个参数，包括血清红细胞沉降率（ESR）、血清 C 反应蛋白（CRP）、血清白细胞（WBC）计数、滑膜液革兰氏染色、滑膜液培养、滑膜液超声培养、滑膜液白细胞、滑膜液多形核细胞百分比（PMN%）、组织革兰氏染色、组织培养、正电子发射断层扫描（PET）和白细胞扫描。使用 QUADAS-2 对每篇纳入的文章分别进行了偏倚风险和适用性分析。使用 Cochran Q 检验计算统计异质性，如果α值为 0.10，则认为存在显著异质性。
组织培养（敏感性 0.82 [0.72-0.90]，特异性 0.91 [0.89-0.95]，诊断比值比（DOR）46.87 [95%置信区间 {CI}，22.03-99.69]）、滑膜液 PMN%（敏感性 0.77 [0.46-0.95]，特异性 0.74 [0.67-0.81]，DOR 11.27 [95% CI，2.89-43.61]）和滑膜液培养（敏感性 0.64 [0.52-0.74]，特异性 0.96 [0.93-0.98]，DOR 27.07 [95% CI，2.55-288.00]）的诊断性能相对较高。其他参数的诊断准确性较差：ESR（敏感性 0.56 [0.40-0.72]，特异性 0.60 [0.53-0.66]，DOR 2.41 [95% CI，0.60-9.72]）、CRP（敏感性 0.53 [0.39-0.67]，特异性 0.72 [0.66-0.78]，DOR 2.25 [95% CI，0.09-4.63]）和滑膜液 WBC 计数（敏感性 0.37 [0.19-0.58]，特异性 0.49 [0.41-0.57]，DOR 0.94 [95% CI，0.06-14.74]）。但是，由于每种汇总分析仅可用 2-3 项研究，因此解释受到限制。QUADAS-2 评估的四个领域中，偏倚风险和适用性问题均较低。
这项荟萃分析表明，没有单一的标志物优于所有其他标志物，并且在 PJI 两期方案的第一阶段后，没有一种标志物（单独使用）足以确认感染得到控制。因此，目前采用多种工具而不是单一标志物的方法至关重要。此外，必须进行进一步的研究，以便可以使用多项研究进行汇总分析，以确定再植入的理想标志物。
III 级，诊断研究。
