Diagnosis of Periprosthetic Joint Infection using Alpha-Defensin Test or Multiplex-PCR: Ideal Diagnostic Test Still not Found

Arnold Suda 1 Nils Beisemann 2 Yoram Weil 3 Amal Khoury 3 Marco Tinelli 2 Oliver Bischel 2
1Department of Septic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
2Department of Trauma and Orthopaedics, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
3Department of Orthopaedics, Hadassah Medical Center, Jerusalem, Israel

Background: Diagnosing periprosthetic infection remains a challenge. Multiplex-PCR and biomarkers such as alpha-defensin are potentially useful and fast methods for detecting periprosthetic infection. This study compared these new methods with clinical assessment, conventional microbiological methods and histopathological examination.

Methods: 30 consecutive patients with removal of Total Hip Arthroplasty (THA) or Total Knee Replacement (TKR) at a single center and under a single surgeon between April and June 2016 were included in this study. Patients were classified according to the Musculoskeletal Infection Society Score (MSIS) for infected joints. Punction fluid and tissue specimens were taken for conventional microbiological examination, alpha-defensin test was performed, a synovial membrane specimen was used for multiplex-PCR and histopathological examination was carried out.

Results: 28 patients (17 men and 11 women) with 30 joints and a mean age of 67.7 years (range 39 to 88) were included in this study. The alpha-defensin test and multiplex-PCR showed a sensitivity of 76.9% vs. 30.8% and a specificity of 82.4% vs. 100% respectively. We found a significant difference between the positive and negative results (p=0.0023). The conventional microbiological methods were not significantly different from the alpha-defensin test (p=0.244) with a sensitivity of 84.6% and a specificity of 100% but did differ significantly from the multiplex PCR (p=0.0030). There was a significant difference between MSIS classification and multiplex PCR (p=0.0007).

Conclusions: Neither alpha-defensin test nor multiplex-PCR could detect periprosthetic infection immediately and reliably. Multiplex-PCR was suitable for detecting the non-infected but not the truly infected. Alpha-defensin test was helpful but showed no satisfactory results.

Conventional microbiological methods remain the most reliable for periprosthetic infection diagnosis. Limitations of this study are the small study population, use of just one specimen of synovial membrane for multiplex-PCR, and antibiotic therapy prior to testing of all patients.

An ideal method for diagnosing periprosthetic infection was not found and a change in clinical practice using biomarkers and multiplex-PCR cannot be reputably recommended.