Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Apr 25;10(2):e24.00206.
doi: 10.2106/JBJS.OA.24.00206. eCollection 2025 Apr-Jun.

Comparative Diagnostic Value of Serological and Synovial Tests for Periprosthetic Joint Infections: A Comprehensive Analysis

Mars Yixing Zhao  1 , Samuel Girgis  2 , Thomas Goldade  2 , Evan Parchomchuk  2 , Michaela Nickol  1 , Johannes M van der Merwe  1
Affiliations

Comparative Diagnostic Value of Serological and Synovial Tests for Periprosthetic Joint Infections: A Comprehensive Analysis

Mars Yixing Zhao et al. JB JS Open Access. .

Abstract

Background: Prompt diagnosis of periprosthetic joint infections (PJIs) is crucial for providing optimal care. Currently, there are no gold-standard tests available. An ideal test would be simple to implement, cost-effective, and readily available. We aimed to determine the best single or combined serological or synovial markers for diagnosing PJIs.

Methods: There were 177 of 313 patients who had PJIs between April 2012 and March 2023 and a control group of 60 patients who were included in this retrospective review. The PJIs were diagnosed using Musculoskeletal Infection Society (MSIS) and European Bone and Joint Infection Society (EBJIS) criteria. Serum (C-reactive protein [CRP], white blood-cell [WBC] count, neutrophil-lymphocyte ratio [NLR], polymorphonuclear neutrophil percentage [PMN%]), and synovial fluid (WBC, NLR, PMN%) parameters were compared between the 2 groups. We determined the sensitivity, specificity, area under the curve (AUC), and cutoff values (COV) for each marker. We determined the best combination of markers to diagnose PJIs. There was no statistical significance between the demographic data of the control and treatment groups.

Results: The S-CRP had the highest AUC of 0.912 with a COV of 16.15 mg/dL (Sensitivity 79.6%, Specificity 97.8%). The combination of tests, S-CRP, synovial fluid (SF-WBC), and S-NLR demonstrated the highest AUC of 0.946 (Sensitivity 93%, Specificity 90.9%). The COV for SF-WBC was 5.75 cells/μL (AUC 0.803; Sensitivity 70.3%, Specificity 97.1%); S-NLR COV was 3.659 (AUC 0.803; Sensitivity 67.3%, Specificity 88%).

Conclusion: We found the combination of S-CRP, SF-WBC, and S-NLR to be valuable in diagnosing PJI with high sensitivities and specificities. It can be easily implemented by clinicians without additional cost or equipment. It is important to use this with a thorough clinical and physical examination as well as other modalities (i.e., MSIS/EBJIS criteria).

Level of evidence: Retrospective Comparative Study-Level III evidence. See Instructions for Authors for a complete description of levels of evidence.

PubMed Disclaimer

Conflict of interest statement

The authors have no conflicts of interest to declare. Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A791).

Figures

Fig. 1
Fig. 1
Patient inclusion and exclusion flowchart.
Fig. 2
Fig. 2
ROC: individual markers. CRP = C-reactive protein test, NLR = neutrophil-lymphocyte ratio, PMN = polymorphonuclear leucocytes, ROC = receiver operating characteristic curve, and WBC = white blood cells.
Fig. 3
Fig. 3
ROC: individual markers. NLR = neutrophil-lymphocyte ratio, PMN = polymorphonuclear leucocytes, ROC = receiver operating characteristic curve, and WBC = white blood cells.
Fig. 4
Fig. 4
ROC: combined markers. CRP = C-reactive protein test, NLR = neutrophil-lymphocyte ratio, ROC = receiver operating characteristic curve, S = serum, SF = synovial fluid, and WBC = white blood cells.
Fig. 5
Fig. 5
ROC: combined markers. PMN = polymorphonuclear leucocytes and ROC = receiver operating characteristic curve.
Fig. 6
Fig. 6
ROC: individual markers. ROC = receiver operating characteristic curve and WBC = white blood cells.
Fig. 7
Fig. 7
ROC: combined markers. ROC = receiver operating characteristic curve and NLR = neutrophil-lymphocyte ratio.
See this image and copyright information in PMC

Similar articles

See all similar articles

References

    1. World Medical Association. World medical association declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191-4. - PubMed
    1. Aslam M. Introducing Kolmogorov–Smirnov tests under uncertainty: an application to radioactive data. ACS Omega. 2020;5(1):914-7. - PMC - PubMed
    1. Balato G, Ascione T, Festa E, Di Gennaro D, Pandolfo G, Pagliano P. The diagnostic accuracy of neutrophils to lymphocytes ratio, platelets to lymphocytes ratio, monocytes to lymphocytes ratio, and platelets to mean platelet volume ratio in diagnosing periprosthetic knee infections. Are gender-specific cutoff values needed? J Arthroplasty. 2023;38(5):918-24. - PubMed
    1. Barton CB, Wang DL, An Q, Brown TS, Callaghan JJ, Otero JE. Two-stage exchange arthroplasty for periprosthetic joint infection following total hip or knee arthroplasty is associated with high attrition rate and mortality. J Arthroplasty. 2020;35(5):1384-9. - PubMed
    1. Berbari E, Mabry T, Tsaras G, Spangehl M, Erwin PJ, Murad MH, Steckelberg J, Osmon D. Inflammatory blood laboratory levels as markers of prosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am. 2010;92(11):2102-9. - PubMed

LinkOut - more resources