How Reliable Is the Alpha-defensin Immunoassay Test for Diagnosing Periprosthetic Joint Infection? A Prospective Study

Abstract

Background: A key issue in the treatment of periprosthetic joint infection (PJI) is the correct diagnosis. The main problem is lack of diagnostic tools able to diagnose a PJI with high accuracy. Alpha-defensin has been proposed as a possible solution, but in the current literature, there is a lack of independent validation.

Questions/purposes: We performed a prospective study to determine (1) what is the sensitivity, specificity, and positive and the negative predictive values of the alpha-defensin immunoassay test in diagnosing PJI; and (2) which clinical features may be responsible for false-positive and false-negative results?

Methods: Preoperative aspiration was performed in all patients presenting with a painful hip/knee arthroplasty, including both primary and revision implants. Metallosis, other inflammatory comorbidities, and previous/concomitant antibiotic therapy were not considered as exclusion criteria. An inadequate amount of synovial fluid for culture was an exclusion criterion. A total of 156 patients (65 knees, 91 hips) were included in this prospective study. At the time of revision, synovial fluid samples were taken to perform the alpha-defensin assay. During surgical débridement of tissue, samples for cultures and histologic evaluation were taken, and samples were cultured until positive or until negative at 14 days. A diagnosis of PJI was confirmed in 29 patients according to the International Consensus Group on PJI.

Results: The sensitivity of the alpha-defensin immunoassay was 97% (95% confidence interval [CI], 92%-99%), the specificity was 97% (95% CI, 92%-99%), the positive predictive value was 88% (95% CI, 81%-92%), and the negative predictive value was 99% (95% CI, 96%-99%). Among four false-positive patients, two had metallosis and one had polyethylene wear. The false-negative case presented with a draining sinus, and intraoperative cultures were also negative.

Conclusions: Alpha-defensin assay appears to be a reliable test, but followup evaluation is needed to estimate longer term performance of the test. The authors believe that alpha-defensin has demonstrated itself to be sufficiently robust that PJI diagnostic criteria now should include this test. Future studies are needed to compare the differences among the diagnostic capability of the available tests, in particular when metallosis is present, because metallosis may predispose the test to a false-positive result.

Level of evidence: Level I, diagnostic study.

Fig. 1

Intraoperative aspiration was performed through the capsule right before capsulotomy, avoiding admixture of blood. The knee is shown after soft tissue dissection.

Fig. 2

Workflow describing the features of the patients included in the study. Reproduced with permission from Silvia Bassini.

Fig. 3

Synovial fluid alpha-defensin values (logarithmic scale) for aseptic and PJI patients are shown separately. The line indicates the alpha-defensin diagnostic threshold of 1.0 (signal-to-cutoff ratio [S/CO]). The five white dots represent the misdiagnosed patients, being false-negative (in the PJI group) or false-positive (in the aseptic group).

Fig. 4

Preoperative AP radiograph of a patient with false-positive alpha-defensin value reveals polyethylene wear and osteolysis of the proximal femur at his right THA.