Diagnosing Periprosthetic Joint Infection in Inflammatory Arthritis: Assumption Is the Enemy of True Understanding

Abstract

Background: Despite concern over the interpretation of serum and synovial fluid tests to screen and diagnose periprosthetic joint infection (PJI) in patients with inflammatory arthritis, only a single study has investigated this area. We aimed to assess accuracy of clinical and laboratory markers for PJI diagnosis in the context of underlying inflammatory arthritis.

Methods: This multicenter study was conducted on total joint arthroplasty patients at 3 different centers between 2001 and 2016. PJI was defined based on Musculoskeletal Infection Society criteria. Acute PJI cases were excluded. Patients operated for a diagnosis other than infection, who did not subsequently fail at 1-year follow-up, were considered aseptic revisions. Serum C-reactive protein and erythrocyte sedimentation rate, synovial white blood cell and differential, as well as alpha-defensin and results of frozen section were documented.

Results: In total, 1220 patients undergoing revision total joint arthroplasty (567 PJI, 653 aseptic) were included. Fifty-five septic patients and 61 in the aseptic group had inflammatory arthritis. Although mean levels of serum C-reactive protein and synovial white blood cell in inflammatory arthritis patients were significantly higher compared to patients without inflammatory arthritis, there were no significant differences in PJI patients. The thresholds associated with increased risk for PJI in patients with and without inflammatory arthritis were similar and closely resembled traditional cut-points.

Conclusion: We demonstrate higher baseline immune upregulation in aseptic revision cases with inflammatory arthritis, but no significant differences are seen for PJI. Conventional PJI thresholds for serum and synovial diagnostic markers should be adhered to. Assumptions about inflammatory arthritis patients needing differential diagnostic protocols should be avoided.

Keywords: diagnosis; inflammatory arthritis; laboratory markers; periprosthetic joint infection; total joint arthroplasty.