Aims. This study aimed to assess the performance of an automated multiplex polymerase chain reaction (mPCR) technique for rapid diagnosis of native joint septic arthritis. Patients and Methods. Consecutive patients with suspected septic arthritis undergoing aseptic diagnostic joint aspiration were included. The aspirate was used for analysis by mPCR and conventional microbiological analysis. A joint was classed as septic according to modified Newman criteria. Based on receiver operating characteristic (ROC) analysis, the area under the ROC curve (AUC) values of the mPCR and the synovial fluid culture were compared using the z-test. A total of 72 out of 76 consecutive patients (33 women, 39 men; mean age 64 years (22 to 92)) with suspected septic arthritis were included in this study. Results. Of 72 patients, 42 (58%) were deemed to have septic joints. The sensitivity of mPCR and synovial fluid culture was 38% and 29%, respectively. No significant differences were found between the AUCs of both techniques (p = 0.138). A strong concordance of 89% (Cohen’s kappa: 0.65) was shown. The mPCR failed to detect Staphylococcus aureus (n = 1) and Streptococcus pneumoniae (n = 1; no primer included in the mPCR), whereas the synovial fluid culture missed six microorganisms (positive mPCR: S. aureus (n = 2), Cutibacterium acnes (n = 3), coagulase-negative staphylococci (n = 2)). Conclusion. The automated mPCR showed at least a similar performance to the synovial fluid culture (the current benchmark) in diagnosing septic arthritis, having the great advantage of a shorter turnaround time (within five hours). Cite this article: Bone Joint J 2019;101-B:288–296

Aim. One of the most accurate and inexpensive tests in detection of prosthetic joint infection (PJI) is synovial fluid white blood cell (WBC) count and differential. Since leukocytes produce many different interleukins (IL) in situation of PJI, we hypothesized that ILs could be even more accurate in detection of PJI. The aim of the study was to test, if the synovial fluid IL-6 level is superior to WBC count and differential in detection of PJI. Methods. Unselected patients undergoing total hip or knee revision surgery were prospectively included. In perioperative assessment phase, WBC count, differential and IL-6 levels of synovial fluid were measured. Patients were labelled as positive or negative according to the predefined cut-off values for IL-6 (230pg/ml) and WBC count with differential (1,7 × 10. 9. WBC/ml with ≥65% of granulocytes). During the surgery, at least 4 intraoperative samples for microbiological and one for histopathological analysis were obtained. PJI was defined as presence of sinus tract, inflammation in histopathological samples, and growth of the same microorganism in at least two or more samples of periprosthetic tissue or synovial fluid. Binary diagnostic test was performed to check the diagnostic strength of both methods in detection of PJI. Results. 49 joints of 48 patients (mean age, 71 years; 53% females) undergoing artificial hip (n = 24) or knee (n = 25) revision surgery were included. 11 joints (22%) were infected. Sensitivity of synovial fluid WBC count with differential was 82%, specificity 97%, accuracy 94%, positive and negative predictive values were 90% and 95%, respectively. Sensitivity of IL-6 level was 73%, specificity 95%, accuracy 90%, positive and negative predictive values were 80% and 92%, respectively. There was a strong statistical agreement between both tests (Kappa value=0.749) and consequently there was no significant difference in detection of PJI comparing both tests (P=0.171). Conclusion. Our study revealed that synovial fluid IL-6 level is not superior to synovial fluid WBC count with differential in detecting PJI

Aim. Prosthetic joint infection (PJI) represents the second most frequent complication of total joint arthroplasty (TJA) with up to 20% of low-grade PJI treated as aseptic failure. Sensitive diagnostic criteria have been provided by EBJIS. However, to date there is no single test to reliably diagnose all PJIs. Studies of Mazzucco et al. and Fu et al. suggest that synovial fluid (SF) viscosity could be considered as an important marker for PJI. The primary aim of our study was to determine if SF viscosity is a more reliable diagnostic criterion of PJI than the SF cell count with differential (CCD), and the combined diagnostic value of SF viscosity and CCD. Method. We prospectively analysed the viscosity of SF samples obtained during TJA of hip and knee revisions. We sampled 2.5–5mL of SF for viscosity and CCD. Intraoperatively, 1mL of the sample was analysed for the CCD. The remaining SF was centrifuged for 4min at 7000rpm. The viscosity of the supernatant was determined on Ostwald viscometer as the time required to pass the viscometer at 20°C. During each surgery at least 5 microbiological and multiple histopathological samples were harvested, and explant sonication was performed. The diagnosis was based on EBJIS definition. The viscosity threshold for detecting PJI was set at 65 seconds. Results. Between December 2020 and January 2023, we analysed 65 knee and 47 hip TJA revision procedures. There were 55 septic and 57 aseptic diagnoses. As a diagnostic marker of PJI, SF viscosity achieved 100% sensitivity and 82.5% specificity, with area under the receiver operating characteristic curve (AUC) of 0.832 (95% CI 0.739, 0.925). The specificity and sensitivity of SF CCD were 98.2% and 78.2%, respectively, with AUC of 0.921 (95% CI 0.869, 0.974). Of the 10 cases incorrectly diagnosed as aseptic based on SF viscosity, 2 were acute traumas and 8 metalloses. The SF CCD in all these cases was <0.5. Of the 12 cases incorrectly diagnosed as aseptic based on SF CCD, 6 cases were culture negative, 4 C. acnes and 2 S. epidemidis isolates in microbiology. Taken together, SF viscosity and CCD achieved a combined AUC of 0.953 (95% CI 0.919, 0.987). Conclusions. Our study is the first to report that SF viscosity is more sensitive but slightly less specific for PJI than SF CCD. The study demonstrates diagnostic value of combining SF viscosity with CCD in decision making in TJA revision surgery

Aim. Synovial fluid D-lactate may be useful for diagnosing septic arthritis (SA) as this biomarker is almost exclusively produced by bacteria. We evaluated the performance of synovial fluid D-lactate and determined its optimal cut-off value for diagnosing SA. Method. Consecutive patients with suspicion of septic arthritis were prospectively included. They underwent joint aspiration and synovial fluid was collected for culture, leukocyte count and D-lactate concentration (by spectrophotometry). Youden's J statistic was used for determining optimal D-lactate cut-off value on the receiver operating characteristic (ROC) curve by maximizing sensitivity and specificity. Results. A total of 155 patients were included. Using institutional criteria, 21 patients (14%) were diagnosed with SA and 134 (86%) patients with aseptic arthropathy, out of which 43 (27%) had osteoarthrosis, 80 (52%) had rheumatic arthropathy and 11 (7%) reactive arthritis. The optimal cut-off of synovial fluid D-lactate to differentiate SA from aseptic cases was 0,035 mmol/l. Synovial fluid D-lactate had a sensitivity 90% (95% CI: 70–99%) and specificity 87% (95% CI: 80–92%) compared to leukocyte count with sensitivity 81% (95% CI: 60–95%) and specificity 83% (95% CI: 76–90%). Culture was positive in only 17 (80%) out of 21 patients with SA. Conclusions. The synovial fluid D-lactate showed high sensitivity and specificity for diagnosis of SA which was higher than the current gold standard of diagnosis (culture and leukocyte count). The high sensitivity makes this biomarker useful as a point-of-care screening test for SA

Aim. Periprosthetic joint infections (PJI) are severe complications after total joint arthroplasty (TJA). Up to now, a gold standard in the diagnostics of PJI is missing. Small extracellular vesicles (sEVs) are secreted by all types of cells and play a key role in immune response in presence of infection (1). In this prospective study, the diagnostic accuracy of sEVs in the synovial fluid to detect PJI of knee, hip and shoulder joints was investigated. We hypothesized increased surface markers of sEVs in PJI compared to aseptic complications (e.g. implant loosening, stress shielding related pain). Method. Synovial fluid from 48 patients with painful arthroplasty was examined. The distinction between aseptic and infectious cases was made on the basis of the 2018 Definition of Periprosthetic Hip and Knee Infection (2). 35 (72,9%) probands assigned to aseptic and 13 patients (27,1%) to PJI group. Immuno-fluorescence flow cytometry served to document the concentrations of CD9, CD63, CD66b, CD82 and HLA-DR on sEVs. Results. The concentration of CD9 surface marker on sEVs in synovial fluid was significantly lower (p=0.002) in PJI group than in aseptic group. In contrast, the levels of CD82 on sEVs in synovial fluid was significantly higher (p<0.0001) in the PJI group than in aseptic group. The concentrations of CD63, CD66b and HLA-DR on sEVs in synovial fluid did not differ significantly between the two cohorts (CD63: p=0.372; CD66b: p=0.634; HLA-DR: p=0.558). Conclusions. Overall, the significance of sEVs in the diagnostics of PJI is not well enough understood and the subject of current research and scientific discussion. Our data suggest, that CD82 and CD9 on sEVs in synovial fluid are promising biomarkers to differentiate between PJI and aseptic complications

Aim. Prosthetic joint infection (PJI) presents the second most common complication of total joint arthroplasty (TJA). Accumulating evidence suggests that up to 20% of aseptic failures are low-grade PJI. However, there is still no single test to reliably diagnose all PJI. In his thesis, Mazzucco emphasized the viscosity differences between normal, osteoarthritic, and rheumatic synovial fluid. Similarly, a recent study by Fu et al. reported significantly lower viscosity in patients with PJI compared to the aseptic failure cohort. The primary aim of our study was to determine whether synovial fluid viscosity is a more reliable diagnostic criterion for PJI compared to the synovial fluid cell count with differential and serum C-reactive protein (CRP) levels. Method. We prospectively analyzed the viscosity of synovial fluid samples obtained during TJA of hip and knee joint revision procedures. We sampled 2.5–5 mL of synovial fluid for viscosity measurement. The samples were centrifuged (4 min at 7000 rpm) and the resulting supernatant was immediately transferred into the Ostwald viscometer. Viscosity was derived from the time required for a given volume of synovial fluid to pass the viscometer at 20 °C. The synovial fluid samples were also analysed for their cell count with differential and serum CRP was measured. The definite diagnosis of PJI was established on basis of EBJIS criteria. For the viscosity, the threshold for detecting PJI was set at 65 seconds. Results. Between December 2020 and March 2021, we analyzed 12 knee and 11 hip TJA revision samples. These included 14 septic and 9 aseptic synovial fluid samples. The average viscometer time in the PJI group was 31s (range 20–48s) compared to 247s (range 68–616s) in the group of aseptic revision procedures. The specificity and sensitivity of our viscosity measurements were 100%. The sensitivity and specificity of cell count was 100% and 85.7%, for the synovial fluid differential they were 100% and 85.7%, and for the CRP they were 88.9% and 71.4%, respectively. Conclusions. Our study is the first to report a significant difference in synovial fluid viscosity between the PJI and the aseptic cohort. It points towards the diagnostic superiority of viscosity measurements over conventional synovial fluid cell count, synovial fluid differential, and serum CRP levels. Albeit currently limited by small sample size, the study remains ongoing

Aim. The cut-off values for synovial fluid leukocyte count and neutrophils differential (%PMN) for differentiating aseptic from septic failure in total knee arthroplasties were already defined in the past. Our goal was to determine the cut-off values for synovial fluid leukocyte count and %PMN in failed total hip arthroplasties (THA). Method. Patients undergoing revision THA were prospectively included. In perioperative assessment phase, synovial fluid leukocyte count and %PMN were determined. During the surgery, at least 4 intraoperative samples for microbiological and one for histopathological analysis were obtained. Infection was defined as presence of sinus tract, inflammation in histopathological samples, and ≥2 tissue and/or synovial fluid samples growing the same microorganism. Exclusion criteria were systemic inflammatory diseases, revision surgery performed less than 3 months from index surgery and insufficient tissue sampling. Receiver operating characteristic (ROC) curves were constructed to assess the diagnostic performance and Youden's J statistic was computed to identify optimal cut-off values. Results. During the study period (between June 2006 and June 2011) 227 revision THAs were performed by the senior author. 31 patients were excluded. 196 patients (mean age, 69 years; 68% females) with THA failure were included. Aseptic failure was diagnosed in 150 patients (76,5%) and THA infection was diagnosed in 46 patients (23,5%). Synovial fluid leukocyte counts were significantly higher in the infected group (median, 5.50×10. 6. leukocytes/ml range, 0.05 to 143.9×10. 6. leukocytes/mL) than in the aseptic group (median, 0.23×10. 6. cells/ml; range, 0 to 21.3×10. 6. leukocytes/ml, P<0,0001). The %PMN was also significantly higher in the infected group (median, 83%; range, 6% to 97%) than in the aseptic group (median, 27,5%; range, 0% to 94%, P<0,0001). A synovial fluid leukocyte count of > 1.54×10. 6. leukocytes/ml, had a sensitivity of 63%, specificity of 95%, positive and negative predictive values of 78% and 89%, respectively. A synovial fluid %PMN of > 64%, had a sensitivity of 65%, specificity of 93%, positive and negative predictive values of 73% and 90%, respectively. Conclusion. The synovial fluid leukocyte count of > 1.54×10. 6. leukocytes/ml and %PMN of > 64% are useful and reliable tests for excluding THA infection, having a negative predictive value of around 90%. This tests and calculated cut-off values are highly recommended in the diagnostic process of failed THAs

Aim. To evaluate the analytical performance of synovial fluid D-lactate test for the diagnosis of PJI. Method. Consecutive patients undergoing diagnostic joint aspiration of prosthetic joint were prospectively included. PJI was diagnosed according to the proposed European Bone and Joint Infection Society (EBJIS) definition criteria. Synovial fluid was collected for culture, D-lactate measurement (by spectrophotometry, λ = 570 nm) and leukocyte count and differential (by flow cytometry). The receiver operating characteristic (ROC) analysis was performed to assess the diagnostic performance of D-lactate and leukocyte count. Results. Diagnostic joint aspiration was performed in 224 patients with prosthetic joints. PJI was diagnosed in 87 patients (39%). The optimal D-lactate cut-off value for diagnosing PJI was 1.2 mmol/l. The sensitivity of synovial fluid D-lactate was 97.7%, specificity 83.9%, whereas the sensitivity of synovial fluid leukocyte count was 87.5% with specificity 95.7%. Concentration of SF D-lactate was significantly higher in patients with PJI compared to aseptic loosening of prosthesis (median (range)) 2.33 (0.99–3.36) vs 0.77 (0.01–2.4), p<0.0001. We found positive correlation between D-lactate and erythrocytes in synovial fluid sample in the aseptic group (ρ = 0.339, p< 0.01). Conclusions. The synovial fluid D-lactate showed a good diagnostic performance for the diagnosis of PJI, which was comparable to the synovial fluid leukocyte count. Currently available (UV)-based method for detection of D-lactate showed low specificity (84%) due to influence of hemoglobin with the similar absorbance wavelengths (λ = 540 nm). More specific high-performance methods such as electro-chemical sensing system or lateral flow immunochromatographic assays should be implemented

Aim. There is growing evidence that bacteria encountered in periprosthetic joint infections (PJI) form surface-attached biofilms on prostheses, as well as biofilm aggregates embedded in synovial fluid and tissues. However, models allowing the investigation of these biofilms and the assessment of their antimicrobial susceptibility in physiologically relevant conditions are currently lacking. To address this, we developed a synthetic synovial fluid (SSF) model and we validated this model in terms of growth, aggregate formation and antimicrobial susceptibility testing, using multiple PJI isolates. Methods. 17 PJI isolates were included, belonging to Staphylococcus aureus, coagulase negative staphylococci, Cutibacterium acnes, Pseudomonas aeruginosa, enterococci, streptococci, Candida species and Enterobacterales. Growth and aggregate formation in SSF, under microaerophilic or anaerobic conditions, were evaluated using light microscopy. The biofilm preventing concentration (BPC) and minimum biofilm inhibitory concentration (MBIC) of relevant antibiotics (doxycyclin, rifampicin and oxacillin) were determined for the staphylococcal strains (n=8). To this end, a high throughput approach was developed, using a fluorescent viability resazurin staining. BPC and MBIC values were compared to the minimum inhibitory concentration (MIC) obtained with conventional methods. Results. The SSF model allowed all isolates to grow well under microaerophilic or anaerobic conditions. When cultured in SSF, all isolates formed biofilm aggregates, varying in size and shape along different species. A susceptibility testing method based on measuring resazurin-derived fluorescence was successfully developed, allowing high throughput determination of the BPC and the MBIC in SSF. For all staphylococci cultured in SSF a reduced susceptibility to the tested antibiotics was observed when compared to susceptibility data obtained in general medium. For rifampicin and doxycyclin the BPC was consistently higher than the MIC (two- to fourfold dilution difference for rifampicin and four- to sixfold dilution difference for doxycyclin). For oxacillin the MIC equaled the BPC for two isolates, while for the other isolates the BPC was higher than the MIC (two- to fourfold dilution difference). Expectedly, the MBIC was higher than the BPC and differences with the MIC were even more pronounced for all antibiotics tested (differences of six- to fourteenfold dilutions were observed). Conclusion. Our data indicate that the in vitro SSF model could provide more insight in how PJI-related pathogens form biofilms in physiologically relevant conditions. The BPC and MBIC were consistently and substantially higher than MIC. This model could be a valuable addition to evaluate the antimicrobial susceptibility in biofilms in a PJI context. Sources of funding: FWO-Vlaanderen (grant G066523N)

Aim. Our goal is to assess diagnostic accuracy of synovial fluid testing in diagnosing prosthetic joint infection (PJI) as defined by the European Bone and Joint Infection Society (EBJIS). In addition to differential leukocyte count, simples and inexpensive biomarkers such as synovial fluid C-reactive protein (CRP), adenosine deaminase (ADA) and alpha-2-macrogloblulin(A2M) were also investigated and its possible role in increasing accuracy assessed. Method. Between January/2013 and December/2019 total hip or knee arthroplasty revision cases (regardless of preoperative diagnosis) were prospectively included provided enough synovial fluid for biomarker analysis was collected and at least four tissue samples, as well as the implant for sonication, were gathered for microbiological study. Definitive diagnosis was classified according to the new EBJIS PJI definition. Using receiver operating characteristic curves, we determined cutoff values as well as diagnostic accuracy for each marker. Results. Out of 364 revision arthroplasties performed, 102 fully respected inclusion criteria. There were 58 unlikely, 8 likely and 36 confirmed infections. Synovial fluid total leukocyte count, proportion of polymorphonuclear neutrophils (PMN), CRP, ADA and A2M were significantly different between groups. Area under the curve was 0.94 for total leucocyte count, 0.91 for proportion of PMN, 0.90 for CRP, 0.82 for ADA and 0.76 for A2M. Sensitivity, specificity, and predictive values for statistically optimal but also selected rule-in and rule-out cutoffs values are shown in Table 1. Interpreting a raised level of CRP(>2.7mg/L) or ADA(>60U/L) together with high leukocyte count (>1470 cells/μL) or proportion of PMN (>62.5%) significantly increases specificity and positive predictive value for affirming PJI. Conclusions. Differential leukocyte count cutoffs proposed by the EBJIS PJI definition are shown to perform well in ruling out (<1,500 cells/μL) and ruling in (>3,000 cells/μL) PJI. Adding simple and inexpensive biomarkers such synovial CRP or ADA is helpful in interpreting inconclusive results. For any tables or figures, please contact the authors directly

Aim. We report on the performance of a simple algorithm using a combination of synovial fluid White blood cell count(WBC), C-reactive protein(CRP) and α-Defensin(AD) tests to aid in the diagnosis of prosthetic joint infections. Methods. Sixty-six synovial fluid samples were collected prospectively in patients with suspected PJI (hip and knee). All samples were tested by: WBC counts (read manually) and CRP test (Alere-Afinion™ validated in-house); and on 37 of these with AD test. Synovial fluid samples were collected in 5 ml ethylenediaminetetraacetic acid (EDTA) tubes. Samples that were very viscous were pre-processed by the addition of 100µl of hyaluronidase solution. Grossly blood stained and clotted samples were excluded. A clinical diagnosis of infection was based IDSA definitions. 1. Cut offs of >3000 × 10. 6. cells/L for total synovial WBC count and >12mg/L for CRP were used to define infection. 2,3. . Results. Of 66 samples tested, 20 samples were categorised as clinically infected. Combination of WBC count and CRP yielded a sensitivity of 95% (95% CI: 75.13% to 99.87%) and specificity of 100% (95% CI: 92.29% to 100.00%). Only one patient, who had a chronic infection with S.epidermidis and S.warneri, had a CRP and WBC count that was falsely negative (<5mg/L and 93 × 10. 6. cells/L respectively). AD test was used on 37 samples (of which 20 were infected). Sensitivity of this test alone was 85.71% (95% CI: 63.66% to 96.95%) and specificity 87.5% (95% CI: 61.65% to 98.45%). There were 2 falsely positive AD test results (one of whom had a metal on metal prosthesis) and 3 false negative results (2 E.coli infections and one patient with chronic infection with S.epidermidis and S.warneri). Conclusion. Use of a combination of synovial fluid WBC count and CRP (both of which can be performed using simple and inexpensive laboratory tests), has a sensitivity of 95% and 100% specificity in the diagnosis of PJI. AD test may be useful on some occasions when near patient testing result may affect patient management

Aim. Bone and Joint Infections (BJIs) present with non-specific symptoms and can be caused by a wide variety of bacteria and fungi, including many anaerobes and microorganisms that can be challenging to culture or identify by traditional microbiological methods. Clinicians currently rely primarily on culture to identify the pathogen(s) responsible for infection. The BioFire. ®. FilmArray. ®. Bone and Joint Infection (BJI) Panel (BioFire Diagnostics, Salt Lake City, UT) was designed to detect 15 gram-positive (seven anaerobes), 14 gram-negative bacteria (one anaerobe), two yeast, and eight antimicrobial resistance (AMR) genes from synovial fluid specimens in an hour. The objective of this study was to evaluate the performance of an Investigational Use Only (IUO) version of the BioFire BJI Panel (BBJIP) compared to conventional used as reference methods. Method. In a monocentric study, leftover synovial fluid specimens were collected in a single institution including 4 hospitals and tested using conventional bacterial culture (Standard of Care (SoC)) according to routine procedures following French national recommendations. Specimen has been placed in a refrigerator (4°C) as soon as possible after collection and stored for less than or equal to 7 days before enrollment. Performance of the IUO version of the BBJIP was determined by comparison to SoC for species identification. Results. To date, 201 specimens have been collected and tested using BBJIP. A total of 39 pathogens were obtained in culture. Compared to SoC culture, the overall PPA was 89.7% (35 TP, 4 FN (SA, 1; Strepto Spp, 2; P. micra, 1) and the overall NPA was 99.7% with 16 FP for a total of 5374 bacterial targets screened. Two complementary molecular tests using home-made PCR are underway to definitively conclude about the FN et FP for BBJIP observed in the preset study. Conclusions. The BioFire BJI Panel appears as a promising, sensitive, specific, and robust test for rapid detection of 31 microorganisms (including anaerobes) and eight AMR genes in synovial fluid specimens. The number of pathogens and resistance markers included in the BioFire BJI Panel, together with a reduced time-to-result and increased diagnostic yield compared to culture, is expected to aid in the management of BJIs

Staphylococcus aureus is the most frequently isolated organism in periprosthetic joint infections. The mechanism by which synovial fluid (SF) kills bacteria has not yet been elucidated, and a better understanding of its antibacterial characteristics is needed. We sought to analyze the antimicrobial properties of exogenous copper in human SF against S. aureus. SF samples were collected from patients undergoing total elective knee or hip arthroplasty. Different S. aureus strains previously found to be sensitive and resistant, UAMS-1 and USA300 WT, respectively, were used. We performed in-vitro growth and viability assays to determine the capability of S. aureus to survive in SF with the addition of 10µM of copper. We determined the minimum bactericidal concentration of copper (MBC-Cu) and evaluated the sensitivity to killing, comparing WT and CopAZB-deficient USA300 strains. UAMS-1 evidenced a greater sensitivity to SF when compared to USA300 WT, at 12 (p=0.001) and 24 hours (p=0.027). UAMS-1 significantly died at 24 hours (p=0.017), and USA300 WT survived at 24 hours. UAMS-1 was more susceptible to the addition of copper at 4 (p=0.001), 12 (p=0.005) and 24-hours (p=0.006). We confirmed a high sensitivity to killing with the addition of exogenous copper on both strains at 4 (p=0.011), 12 (p=0.011), and 24 hours (p=0.011). Both WT and CopAZB-deficient USA300 strains significantly died in SF, evidencing a MBC-Cu of 50µM against USA300 WT (p=0.011). SF has antimicrobial properties against S. aureus, and UAMS-1 was more sensitive than USA300 WT. The addition of 10µM of copper was highly toxic for both strains, confirming its bactericidal effect. We evidenced CopAZB-proteins involvement in copper effluxion by demonstrating the high sensitivity of the mutant strain to lower copper concentrations. Thus, we propose CopAZB-proteins as potential targets and the use of exogenous copper as possible treatment alternatives against S. aureus

Background. The diagnosis of Periprosthetic Joint Infection (PJI) is a considerable challenge in total joint arthroplasty. The mainstay for diagnosis of PJI is a combination of serological markers, including C-reactive protein (CRP), along with joint aspirate for white cell count, differential and culture. The aim of this study was to examine the use of synovial fluid CRP in the diagnosis of PJI. Material & Methods. Synovial fluid samples were collected prospectively from patients undergoing primary and revision knee arthroplasty. Samples were assessed for CRP, cell count and differential. Three groups were analyzed; those undergoing primary knee arthroplasty, aseptic knee arthroplasties and infected arthroplasties. Demographic data, along with associated medical co-morbidities, were collected,. Statistical analysis was performed. Synovial fluid CRP was correlated with serum CRP values. Sensitivity and specificity were calculated. Results. 50 synovial fluid samples were collected from 50 patients. Synovial fluid CRP was 0.3 +/− 0.4 in native knees, 0.2 +/− 0.5 in aseptic knee arthroplasties, 4.3+/−4.1 in patients with infected knee arthroplasties. Synovial fluid CRP was significantly higher in septic total knee arthroplasties by comparison to both aseptic total knees (p< 0.001) and native knees (p=0.006). The specificity was 100% and the sensitivity was 89% at a CRP of 1. Conclusion. While this is preliminary data, synovial fluid CRP was found to be significantly elevated in patients with infected total knee arthroplasties. This test is easily performed under routine hospital laboratory conditions without specific, expensive assays. We believe synovial CRP assay holds great promise as a new, potentially low-cost, diagnostic marker for PJI

Aim. To evaluate a panel of peripheral blood and synovial fluid biomarkers for the identification of periprosthetic joint infection PJI. Method. Peripheral blood and synovial fluid measurements of CD64, IL-1a, IL-1b, IL-6, IL-8, IL-10, IL-17, Alpha Defensin and CRP were made on samples collected from patients with suspected PJI using a combination of flow cytometry (CD64), ELISA (Alpha Defensin) and MSD Electrochemiluminescence (IL-1a, IL-1b, IL-6, IL-8, IL-10, IL-17). Receiver operating characteristic (ROC) curves which combine sensitivity and specificity were created for each marker using GraphPad PRISM statistical software. The diagnosis of infection was based on MSIS major criteria. Results. A total of 35 infections were identified (12 acute, 23 chronic). The best performing peripheral blood biomarker in both acute and chronic PJI was CRP with an area under the curve (AUC) of 0.88 (sensitivity 83%, specificity 94%) in acute infection and 0.82 in chronic infection (sensitivity 80%, specificity 85%). In synovial fluid the best performing acute infection marker was CRP with an AUC of 0.94 (sensitivity 87.5%, specificity 95%) and in chronic cases was Alpha defensin with an AUC of 0.98 (sensitivity 100%, specificity 85%). Conclusions. CRP measured in peripheral blood shows excellent diagnostic characteristics in both acute and chronic cases. This is also replicated in synovial fluid from acute PJIs but not in chronic infection where Alpha defensin showed the best performance

Objectives. The efficacy of Gram-stain microscopy for diagnosis of septic arthritis is fundamentally limited by an inherent false-negative rate of 25–50%. The aim of this study was to calculate the sensitivity of Gram-stain microscopy of synovial fluid collected in heparinised containers and to investigate if this collection method improves diagnostic value. Methods. 12-year retrospective study of patients undergoing synovial fluid analysis between 1998 and 2010. Gram-stain result was correlated with culture result and clinical diagnosis. The formula sensitivity = number of true positives/(number of true positives + number of false negatives) was used for analysis. Results. 602 cases of culture proven septic arthritis analysed with Gram-stain microscopy were identified over this time period. All samples were collected in heparinised containers. The most common joint affected was the knee in 390 cases. 568 cases were correctly identified by Gram-stain microscopy as positive and 34 were falsely identified as negative giving a false-negative rate of 5.6%, and a sensitivity value of 94%. Conclusion. This is the largest study investigating the efficacy of Gram-stain microscopy in the literature. We report a sensitivity of 94% for Gram-stain microscopy, far higher than previously reported (50–75%). No direct comparison was made to non-heparinised synovial fluid samples however we hypothesise that anticoagulation of our samples is directly responsible for this increased sensitivity. Based on these findings Gram-stain microscopy of anticoagulated synovial fluid samples is still a valuable investigation for suspected septic arthritis

Aim. Surgical and antimicrobial treatment of periprosthetic joint infections (PJI) depends largely on the causative pathogen. We assessed the pathogen detection rates and the concordance of preoperative synovial fluid culture and culture of intraoperative samples harvested during revision surgery in patients with PJI. Method. Culture-positive PJI cases treated at our institution from 02/2011 to 07/2018, for which culture results from preoperative (synovial fluid) and intraoperative samples (periprosthetic tissue, synovial or sonication fluid) were available, were retrospectively assessed. For organisms belonging to the resident skin flora (coagulase-negative staphylococci, cutibacteria and corynebacteria) significant growth was considered, if the identical pathogen grew in ≥2 samples or >50 cfu/ml sonication fluid. For other pathogens (S. aureus, streptococci, enterococci, fungi and gram-negative rods) or patients under antimicrobials, any growth was considered positive. We determined the pathogen detection rate in preoperative and intraoperative cultures and compared it in different subgroups using Fisher's exact test. Furthermore, we assessed the concordance of preoperative and intraoperative cultures. Results. We included 167 culture-positive PJI cases (76 hip and 91 knee joints). Coagulase-negative staphylococci (n=55, 33%), Staphylococcus aureus (n=34, 20%) and streptococci (n=22, 13%) were the most common pathogens. In 17 cases (10%) polymicrobial infection was found. The pathogen(s) grew in synovial fluid in 105 cases and in intraoperative samples in 146 cases (63% vs. 87%, p<0.001). 49 patients received antibiotics before aspiration and/or surgery. No differences were observed comparing hip and knee prostheses, primary and revision prostheses or patients receiving or not receiving antibiotics before sampling. Congruent results of preoperative and intraoperative cultures were found in 85 cases (concordance 51%). In 14 cases (8%), the pathogen was detected preoperatively only, in 59 cases (35%) the pathogen was found intraoperatively only; in 3 cases an additional pathogen was found preoperatively, in 6 cases an additional organism was found intraoperatively. Pathogen detection was significantly better in intraoperative compared to preoperative cultures in low-virulent pathogens (87% vs 36%, p<0.001), polymicrobial infections (88% vs. 47%, p<0.001) and delayed/late PJI (>3months; 92% vs 64%, p<0.001). There was no difference regarding detection rate of high-virulent pathogens (88% vs 83%) and in early postoperative PJI (<3 months, 91% vs. 73%). Conclusions. As concordance of preoperative and intraoperative microbiological results was 51%, surgical and antimicrobial treatment should not be selected based on preoperative synovial fluid cultures only. An additional pathogen was found intraoperatively in 39%

The diagnosis of prosthetic-joint infection (PJI) is challenging, as bacteria adhere on implant and form biofilm. Therefore, current diagnostic methods, such as preoperative culture of joint aspirate have limited sensitivity with false-negative results. Aim. To evaluate the performance of measurement synovial fluid (SF) D-lactate (as a pathogen-specific marker) for the diagnosis of PJI and estimate of treatment success. Method. 224 patients undergoing removal knee or hip prosthesis were included in the study between January 2015 and March 2017. 173 patients of this group had aseptic loosening of prosthesis and 87 were diagnosed with PJI. Prior to surgery, synovial fluid routine culture, D-lactate test, leukocyte count and neutrophils (%) were performed for each patient. In order to evaluate a treatment success, the measurement of SF D-lactate before second two-stage exchange procedure (after treatment) was implemented in 30 patients. Diagnosis of PJI was established according to modified Zimmerli criteria. Results. Of 87 patients with infection of prosthetic joints, 61 (70%) had positive synovial fluid cultures, including Staphylococcus spp. (70%), Streptococcus spp. (10%), Enterococcus spp. (6%), Anaerobes (6%), Enterobacteriacae (4%), P. aeruginosa (2%), C. parapsilosis (2%). There was no significant difference in SF D-lactate levels due to different bacterial strains. The optimal D-lactate cut off was 1,2 mmol/l (sensitivity = 98%, specificity = 84%, PPV = 79%, NPV = 98%, AUC 0,99). Concentration of SF D-lactate was significantly higher in patients with PJI compared to aseptic loosening of prosthesis (median (range)) 2.33 (0.99–3.36) vs 0.77 (0.01–2.4), p<0.0001.D-lactate has better sensitivity for diagnosis of PJI (98%), compared to leukocytes (80%) and neutrophils % (89%), p<0.0001). The concentration of D-lactate decreased below cut off within four weeks after revision surgery (after treatment) in all patients except of three, showing relapse of infection (p<0.0001). Conclusions. The measurement of synovial fluid D-lactate demonstrated high analytical performance in the diagnosis of PJI, it is a reliable pathogen specific marker. D-lactate has the best sensitivity as independent diagnostic method and could be implemented for the evaluation of treatment success

Aim. Our goal is to increase diagnostic accuracy of synovial fluid testing in differentiating prosthetic joint infection(PJI) by more exhaustively studying simple and inexpensive biomarkers. For that purpose, we sought to determine: 1) if synovial fluid C-reactive protein(CRP), alpha-2-macrogloblulin(A2M), procalcitonin and adenosine deaminase(ADA) concentrations are different between infected and aseptic cases; 2) performance and optimal cutoff values of each marker; 3) whether any such test may help improve diagnostic performance of traditional leukocyte count. Method. Between January/2013 and December/2015 total hip or knee arthroplasty revision cases (regardless of preoperative diagnosis) were prospectively included provided enough synovial fluid for biomarker analysis was collected and at least four tissue samples as well as the implant for sonication were gathered for microbiological study. Definitive diagnosis was classified as infection or aseptic on the basis of the recent International Consensus Meeting definition of PJI. Using receiver operating characteristic curves, we determined cutoff values as well as sensitivity and specificity for each marker. Results. Fifty-five out of 143 revision arthroplasties fully respected the inclusion criteria. Two supposedly aseptic cases were ultimately classified as infected resulting in 32 aseptic and 23 infected cases available for analysis. Total leukocyte count, proportion of PMN, C-reactive protein, ADA and alpha-2-macroglobulin but not procalcitonin were significantly different between both groups. Cutoff values for optimal performance in the diagnosis of infection were: total leukocyte count >1,463 cells/μL; proportion of PMN >81%; CRP >6.7mg/L and ADA >61U/L. Conclusions. Synovial fluid leukocyte count offers great negative predictive value and interpreting it together with other more specific markers such as C-reactive protein and ADA is helpful in improving its positive predictive value. These simple and inexpensive markers may reduce the number of equivocal synovial fluid results requiring more expensive investigation

We studied twelve parameters (physical appearance, mucin clot, fibrin clot, white cell count, differential count, red blood cell count, gram stain for bacteria, crystal microscopy, aerobic bacterial culture, anaerobic bacterial culture and ratio between synovial sugar and blood sugar) in over 300 samples of synovial fluid from patients with a variety of suspected pathologies (e.g. infection, inflammatory disease, infection adjacent to a joint, aseptic loosening of a prosthesis). The diagnosis of infection was further established using clinical signs, radiological features, full blood count, C-reactive protein and iron profile. Many of the patients came to surgery. This of course created further opportunity to establish or rule out the diagnosis of infection with greater certainty. Nine of the features of synovial fluid were analysed statistically, including turbidity, diminished viscosity, mucin clot, fibrin clot, total white cell count, polymorphs greater than 60%, bacteria observed on direct microscopy, bacteria yielded by culture and concentration of synovial sugar less than 40% of the simultaneous blood sugar. The positive or negative features of infection were determined to be true or false in the light of the cumulative overall features of infection. The data so obtained was analysed to establish sensitivity, specificity, positive predictive value, negative predictive value and accuracy. The mass of data so obtained cannot be meaningfully expressed in such a brief abstract. Important examples are when culturing synovial fluid there were 44% false negatives or no growth and 56% true positives. Looking at the ratio between synovial sugar and blood sugar we found that taking 40% as the critical value, this was 62% sensitive, the specificity was 89%, the accuracy was 73%, the positive predictive value was 89%, the negative predictive value was 62.4%. However we went further and separated those who were definitely infected or probably infected i.e. Groups 4 & 5 from those who were probably or definitely NOT infected according to the sum of clinical laboratory and radiological parameters. When thus separated the predictive value of a positive result was 100% in Group 4 & 5 and 0% in Group 1 & 2. The predictive value of a negative result in Group 1 & 2 was 98.7% accurate and 22.4% in Group 4 & 5