Application and significance of joint puncture in the diagnosis and treatment of periprosthetic joint infection

doi:10.3969/j.issn.2095-4344.1945

Abstract

Abstract:

BACKGROUND: The diagnosis of periprosthetic joint infection is one of the difficulties and key points in clinical research. Joint puncture is a commonly used method in the preoperative diagnosis of periprosthetic joint infection, because it is simple and easy to spread. In recent years, synovial fluid examinations have been gradually used in clinical diagnosis, but there remain many disputed issues.

OBJECTIVE: To summarize latest research progress of synovial fluid analysis in the diagnosis of periprosthetic joint infection in and outside China.

METHODS: Publications in English and Chinese from 2008 to 2018 were searched by the first author for studies regarding joint puncture in the diagnosis of periprosthetic joint infection from the electronic databases of PubMed, Web of Science, and CNKI using the following keywords: periprosthetic joint infection, prosthetic joint infection, synovial fluid, joint puncture, and articular puncture. Five hundred and eighty-four articles were identified by the literature search. By reading the literature title, abstract and full text, 52 studies were included in our review paper.

RESULTS AND CONCLUSION: (1) Preoperative joint puncture is an indispensable part of the diagnosis of periprosthetic joint infection. (2) Until now, there is no single test that can diagnose periprosthetic joint infection alone; however, combining several examination methods can improve diagnostic accuracy. (3) Joint puncture under ultrasonic guidance has several advantages over fluoroscopy and standard methods. (4) Although several new methods have certain advantages in the diagnosis of periprosthetic joint infection, conventional testing of blood culture bottles and leukocyte counts still have an irreplaceable role in the diagnosis of periprosthetic joint infection.

Key words: arthroplasty, joint prosthesis, replacement, postoperative complications, infection, periprosthetic joint infection, joint puncture, synovial fluid, diagnose, methods

CLC Number:

R459.9|R604|R318

Li Cheng, Andrej Trampuz. Application and significance of joint puncture in the diagnosis and treatment of periprosthetic joint infection[J]. Chinese Journal of Tissue Engineering Research, 2019, 23(36): 5868-5874.

Figures/Tables 1

2.1 关节穿刺关节穿刺是诊断假体周围感染常用的检查方法。但是，采用传统穿刺、超声或透视引导下穿刺，它们之间是否有差异? 2.1.1 膝关节穿刺 Wiler等[4]对66例(39例超声引导下穿刺，27例标记穿刺)需要膝关节穿刺的急诊科患者进行前瞻性随机对照研究，虽然结果显示膝关节超声引导下穿刺和标记穿刺在穿刺成功率(分别为95%和93%；P=1.0)以及获得关节液的量上无明显差异，但是超声引导下穿刺组的报告显示，患者产生更少的痛苦、医生更容易操作、总体操作时间更短。在初级医师组(关节穿刺经验少于10次)的报告中，超声引导下穿刺更容易操作并可以获得更多的关节液。Sibbitt等[5]的膝关节穿刺研究结果显示，在骨关节炎和类风湿关节炎的患者中，超声引导下穿刺相比传统穿刺方法，可以减少患者疼痛，获得更多关节液，穿刺的成功率更高。 2.1.2 髋关节穿刺对于髋关节置换术后感染的病例，Battaglia等[6]的研究显示，术前使用超声引导下穿刺和透视下穿刺的培养结果的敏感性分别为69%和27%；特异性分别为94%和75%；准确性分别为83%和40%。Randelli等[7]的研究结果也证明了使用超声引导下穿刺的培养结果优于透视下穿刺，超声引导下穿刺的敏感性和特异性为89%和94%；透视下穿刺的敏感性和特异性为60%和81%。作者在透视组中发现了40%假阴性，出现假阴性结果的原因可能是由于无法准确的将穿刺针推向有关节液的区域进行收集，所以获得的关节液少于超声穿刺，因此假阴性结果多于超声组。在髋关节使用超声引导下穿刺是一种有效、安全的辅助检查方法。而且，髋关节使用超声引导下穿刺的平均花费低于透视下穿刺。 2.2 关节液检查 2.2.1 白细胞计数以及中性粒细胞百分比白细胞计数及中性粒细胞百分比是关节液诊断假体周围感染的常用指标。国际共识会议把白细胞计数每微升>10 000个细胞或中性粒细胞百分比>90%(术后<6周的病例)、白细胞计数每微升> 3 000个细胞或中性粒细胞百分比>80%(术后> 6周的病例)作为诊断假体周围感染的次要标准之一[8]。欧洲骨与关节感染协会(European Bone and Joint Infection Society，EBJIS)把白细胞计数每微升>2 000个细胞或中性粒细胞百分比>70%(不包含术后6周内、风湿性关节病、假体周围骨折或脱位的病例)作为诊断假体周围感染的主要标准之一[9]。虽然这些指南提出了对诊断有帮助的临界值，但是目前对于最适用于诊断的临界值还没有统一的共识。Schinsky等[10]在髋关节翻修病例的研究中发现，白细胞计数> 4.2×109 L-1敏感性为84%，特异性为93%。中性粒细胞百分比>80%时，敏感性为84%，特异性为82%。作者认为当条件满足白细胞计数> 3×106 L-1，C-反应蛋白> 10 mg/L、血沉> 30 mm/h时，是最具有预测性的术前诊断方式，其敏感性和特异性分别为90%及91%。Dinneen等[11]的研究发现，在诊断髋膝关节假体周围感染时，白细胞计数>1.59×109 L-1、中性粒细胞百分比> 65%的敏感性和特异性分别为89.5%和91.3%、89.7%和86.6%。上述的这2项研究都排除了风湿性关节炎的病例，对于术后6周内、风湿性关节病、假体周围骨折或脱位的患者，要考虑白细胞计数的增高(假阳性)可能并非是感染所致[9]。2018年，德国Helios ENDO-Klinik对细胞计数在诊断髋、膝假体周围感染的价值进行评估，并把风湿性关节炎患者纳入研究中，其结果显示，髋膝关节白细胞计数为2.582×109 L-1(敏感性为80.6%、特异性为85.2%)、中性粒细胞百分比为66.1%(敏感性为80.6%、特异性为83.3%)时为最佳临界值；膝关节最佳临界值为白细胞计数为1.63×109 L-1(敏感性为83.6%、特异性为82.2%)、中性粒细胞百分比为60.5%(敏感性为80.3%、特异性为77.1%)；髋关节最佳临界值为白细胞计数在3.063×109 L-1(敏感性为78.1%、特异性为80.0%)、中性粒细胞百分比在66.1%(敏感性为82.2%、特异性为82.4%)，作者认为细胞计数在不同关节部位的临界值有差异，诊断标准应该进一步修订[12]。当白细胞计数与一些方法相结合时，其诊断价值可以进一步提升，Sousa等[13]发现关节液白细胞计数诊断假体周围感染的敏感性优于中性粒细胞百分比、C-反应蛋白、腺甙脱氨酶、α2-巨球蛋白及降钙素原(100% vs. 81%，78.3%，78.3%，47.8%)。虽然一些新的方法并不优于传统的白细胞计数检查，但是作者发现当白细胞计数结合C-反应蛋白时，特异性从71.9%提升至100%；与腺甙脱氨酶结合时，特异性提升至96.9%。 2.2.2 血培养瓶培养由于关节液在血培养瓶中培养的结果优于普通培养基，目前血培养瓶培养已成为关节液细菌培养的常用培养方式。邹国友等[14]的研究结果显示，髋膝关节假体周围感染的关节液在血培养瓶中的细菌检出率高于常规培养(74.1% vs. 45.1%，P=0.003)。这种方法不仅能提高关节液细菌培养的检出率，而且也适用于组织培养。作者认为，与普通培养基相比，血培养瓶培养的污染率更低、操作更方便。Font-Vizcarra等[15]的研究结果显示关节液血培养瓶培养的敏感性为86%、特异性为100%，相比拭子培养和组织培养，关节液在血培养瓶中获得的结果优于拭子培养和组织培养的结果，作者同时对急、慢性假体周围感染以及不同的关节部位进行分类，结果显示关节液在急性假体周围感染的敏感性高于慢性假体周围感染(91.39% vs. 78.94%)，但是特异性相同(100%)。在不同感染部位(髋、膝关节)的假体周围感染，关节液培养结果的阳性率没有明显差异。 2.2.3 C-反应蛋白 Parvizi等[16]于2012年首次发表了关节液C-反应蛋白诊断假体周围感染(14例膝关节和6例髋关节)的研究。当临界值在9.5 mg/L时，敏感性为85%、特异性为95%。作者发现在感染和无菌性松动之间的关节液C-反应蛋白均值差异有显著性意义。之后，Vanderstappen等[17]的研究提供了膝关节的不同临界值，膝关节液C-反应蛋白临界值在1.8 mg/L时，敏感性和特异性分别为100%和84.9%。当临界值在2.8 mg/L时，敏感性和特异性分别为90.9%及93.9%。Ronde-Oustau等[18]也对膝关节C-反应蛋白在假体周围感染的诊断价值进行研究，作者认为当C-反应蛋白>2.78 mg/L时，可能为感染 (敏感性为100%，特异性为82%) ，而C-反应蛋白> 5.37 mg/L时，很有可能是感染(敏感性为90% 特异性为91%)。作者还提出，当临界值低于2.78 mg/L时，可以排除假体周围感染。Tetreault等[19]对髋、膝关节C-反应蛋白的诊断价值进行评估，髋、膝关节C-反应蛋白临界值在6.6 mg/L时，敏感性和特异性分别为88%和85%。在髋关节，C-反应蛋白临界值在8.5 mg/L时的敏感性和特异性分别为87%和86%，而膝关节C-反应蛋白临界值在 14.1 mg/L时，敏感性和特异性分别为82%和93%。由于C-反应蛋白检查操作简单、价格便宜，血清C-反应蛋白也常用于假体周围感染的检测，Tetreault及Vanderstappen等的研究发现，关节液C-反应蛋白与血清C-反应蛋白相比，并没有显示出优势[17，19]。 2.2.4 分子生物学 1995年Levine等[20]首次发表了PCR在膝关节假体周围感染的应用之后，分子生物学技术逐渐开始应用于假体周围感染的诊断。 Melendez等[21]对PCR电喷质谱电离与传统的关节液培养进行对比，结果发现关节液培养的敏感性(86% vs. 81%)与特异性(100% vs. 95%)均高于PCR电喷质谱电离，在先前接受过抗生素治疗的9例假体周围感染患者中，PCR电喷质谱电离培养阳性8例，而关节液培养均为阳性。Melendez等[22]对PCR电喷质谱电离、实时荧光定量PCR以及普通关节液的培养结果分析显示，PCR电喷质谱电离的敏感性高于关节液培养、实时荧光定量PCR，关节液的的特异性高于实时荧光定量PCR及PCR电喷质谱电离。在48例30 d内接受抗生素的假体周围感染患者中，关节液培养的敏感性高于PCR(P < 0.000 1)。作者不推荐PCR常规使用或代替普通培养，它可以适当的应用于某些怀疑感染但是培养结果为阴性的病例进行快速检测。核糖体RNA也是近年来分子生物学研究的热点，郑忠等[23]对16S核糖体RNA、23S核糖体RNA在膝关节假体周围感染的诊断进行测试，结果显示两者诊断假体周围感染的敏感性与特异性的差异均无显著性意义。Fink等[24]对假体周围感染患者的术前16S/18S核糖体RNA的研究结果显示，PCR的敏感性和特异性分别为55.6%、82%，低于血培养瓶培养的结果(74%和96.6%)。作者认为这种检测方法假阳性率较高，而且价格昂贵，所以不推荐作为临床常规检查工具，它仅适用于不能停用抗生素治疗且需要快速诊断的病例。Huang等[25]对关节液、组织培养、超声裂解液进行普通培养和16S核糖体RNA的检测结果显示，超声裂解普通培养、关节液PCR、超声裂解PCR敏感性相近(分别为83.0%，83.0%和84.9%)。作者发现关节液PCR技术不能准确的识别多重细菌感染以及真菌感染，但是可通过超声裂解培养来解决。Kuo等[26]采用关节液16S/28S核糖体RNA诊断假体周围感染，其敏感性和特异性略高于普通培养基培养(100%>92%，99.5%>98.4%)，由于采用血平板培养基的方式没有血培养瓶的结果理想，这可能是PCR培养的结果高于普通培养的原因[14，27]。虽然加入28S核糖体RNA改善了真菌培养的结果，但是对于多重细菌感染，普通培养检测到5例，而PCR技术仅检测到其中1例多重感染中的一种细菌[27]。Morgenstern等[28]的研究发现，与普通血培养瓶培养相比，多重PCR能够改善低毒力(痤疮丙酸杆菌及凝固酶阴性葡萄球菌等)感染的诊断，检测到比普通培养更多的多重细菌感染(4例 vs. 2例)。虽然多重PCR具有一定的优势，但是还无法代替传统的诊断方法，其敏感性低于传统的白细胞计数/中性粒细胞百分比的结果(60% vs. 86%)。 2.2.5 白细胞酯酶白细胞酯酶(Leukocyte esterase，LE)试纸是一种操作简便、价格便宜、可提供实时检测结果的方法，临床常用于尿路感染的诊断。2011年Parvizi等[29]首次发表了LE试纸在假体周围感染诊断的应用，以试纸显示“++”为标准时，敏感性为80.6%、特异性为100%。Colvin等[30]以美国骨科医师学会(American Academy of Orthopaedic Surgeons，AAOS)的标准诊断评估假体周围感染，当结果以“++”为阳性时，敏感性、特异性分别为100%和97%。有1篇由4名不同的外科医生参与的来自韩国的多中心研究报告结果显示，当使用骨骼肌肉感染协会(Musculoskeletal Infection Society，MSIS)的诊断标准时，LE试纸显示“++”在诊断膝关节假体周围感染的敏感性为84%、特异性为100%。LE试纸“+”为诊断标准时，自动读数与医生主观判断的差异可达到10%。因此，当以“+”为阳性结果时，外科医生应该仔细筛选是否为感染[31]。来自韩国的多中心研究虽然采用3种不同的LE试纸(Arkray，Siemens，Roche Diagnostics)对假体周围感染进行评估，但是并没有描述不同的试纸条是否会影响诊断结果。李睿等[32]对Combur 10 Test ®M Roche(德国)和AUTION Sticks 10PA Arkray(日本)这2种试纸条进行对比分析。结果显示，这2种试纸条对于假体周围感染的诊断结果无显著性差异。但是，作者发现德国的试纸覆盖有较厚的过滤膜，会影响肉眼判断，有时需要手动处理后才可以进一步明确结果，因此，更推荐使用AUTION Sticks 10PA Arkray诊断假体周围感染。Deirmengian等[33]对Roche和Siemens的2种LE试纸的评估结果显示，Roche的LE试纸的敏感性为72.44%、特异性为97.29；Siemens的LE试纸的敏感性为80.31%、特异性为97.08%。作者认为根据以往的研究结果显示，LE试纸诊断假体周围感染的敏感性较低(66%-84%)，不应该作为排除假体周围感染的方法。但是它的特异性较高，可以作为一种二次确诊假体周围感染的指标。而Nelson等[34]发现，以MSIS为诊断标准时，LE试纸在诊断肩关节假体周围感染的结果并不理想，其敏感性和特异性较低(分别为30%和67%)。 LE试纸诊断假体周围感染时，存在一定的缺点：①在判断是否存在感染时只能通过主观判断，没有一个客观的指标；②当穿刺获取的关节液中混有血液时，将不能判断结果[30，35]。为了使混有血液的关节液能够评估假体周围感染，有学者发现离心后可以帮助判断结果[36]。Li等[37]对关节液离心前、后的LE试纸结果进行分析，作者发现离心后的样本颜色会变浅。离心前，以LE试纸“++”为标准时，其敏感性为97.7%、特异性为97%。离心后，以LE试纸“+”或“++”为标准时，其敏感性为92.5%、特异性为100%。Ruangsomboon等[38]对离心后上清液取样深度是否有差异进行研究，LE试纸“++”为阳性时，2，4，6 mm深度的敏感性相同(94.1%)，2 mm和4 mm深度的特异性更高(89.6% vs. 72.4%)。作者发现离心后<2 mm液面取样时，LE试纸“++”或以上最适合诊断假体周围感染。 2.2.6 α防御素 α防御素是近年来研究较多的诊断假体周围感染的生物标记物，Deirmengian等[39]的研究结果表明，α防御素比LE试纸更敏感(100% vs. 68.8%)。Shahi等[40]的研究发现，对于2周内接受抗生素治疗的患者，并没有影响α防御素的诊断结果。在接受抗生素治疗的病例中，α防御素的敏感性高于血沉、C-反应蛋白及关节液中性粒细胞百分比、关节液细菌培养(100% vs. 69%，79.3%，79.3%，70%)。Kasparek等[41]发现，α防御素在诊断髋膝关节假体周围感染方面的诊断价值至少和术中冰冻切片相当，α防御素的敏感性高于术中冰冻切片 (67% vs. 58%)；术中冰冻切片的特异性高于α防御素(96% vs. 93%)。Renz等[42]首次采用MSIS、美国感染协会(Infectious Diseases Society of America，IDSA)、欧洲骨与关节感染协会(The European Bone and Joint Infection Society，EBJIS)3种诊断标准定义假体周围感染后，对α防御素进行评估。结果显示，α防御素有较高的特异性(>95%)，但是敏感性较低(54%-86%)。作者认为α防御素虽然不能作为筛查假体周围感染的诊断方法，但是可以作为假体周围感染的确证试验。对于风湿免疫性疾病、金属病的患者应该警惕可能会出现假阳性的结果以及低毒力感染造成的假阴性结果[41，43-45]。但是，当关节液C-反应蛋白与α防御素联合使用时，可以改善假阳性的培养结果。Deirmengian等[46]的研究发现，当α防御素与C-反应蛋白关节液(3.0 mg/L)相结合时，敏感性为97%、特异性为100%。在这项研究中，感染组有32%的系统免疫性疾病、27%的接受过抗生素治疗。结果显示99%的无菌性松动或感染的病例被诊断。Stone等[47]的研究显示，当α防御素与C-反应蛋白关节液(3.0 mg/L)相结合时，敏感性为73%，特异性为99.3%。当α防御素或C-反应蛋白关节液(3.0 mg/L)阳性时，敏感性为91.9%、特异性为79.5%。 Frangiamore等[48]有关α防御素在一、二期阶段诊断髋膝关节假体周围感染的结果显示，α防御素在一期阶段诊断假体周围感染的敏感性为100%、特异性为98%；在二期阶段诊断假体周围感染的敏感性为67%、97%。虽然二期阶段的敏感性明显低于一期阶段的结果，但是，α防御素的结果要优于同组的血清C-反应蛋白与血沉的敏感性(0%和33%)。二期置换前对假体周围感染的评估是目前诊断的难点，以往的研究表明，关节液细胞计数、关节液细菌培养、白细胞酯酶在二期阶段的敏感性较低(10%，6%和26.3%)[49，50]。α防御素可能是一种比较适合二期阶段假体周围感染诊断的方法，但是还需要更多的研究来证明其诊断价值[51]。 2.2.7 其他为了进一步提高假体周围感染诊断的准确性，许多学者对各种新的生物标记物进行测试。白细胞介素6是近年来诊断假体周围感染的热点，根据以往的研究结果显示，其敏感性为87%-90%、特异性在95%-100%[52-54]。关节液和血液白细胞介素6都可以用于假体周围感染的诊断，Randau等[55]的研究结果发现，在髋膝关节假体周围感染，关节液白细胞介素6比血清白细胞介素6、C-反应蛋白以及白细胞计数更准确。2016年，Wimmer等[56]首次报道了一种新的白细胞介素6侧流免疫层析技术装置在假体周围感染诊断的应用，作者发现这种检查的特异性较高。Randau 等[55]的研究结果也发现白细胞介素6在诊断假体周围感染方面的特异性为85.71%-97.62%。但是这种方法可能不适用于金属对金属严重磨损、关节液中出现絮状脓液的病例。多数关节液标记物都是与髋、膝关节假体周围感染相关，Frangiamore等[57]对9种生物标记物(白细胞介素2，6，8，10，12，1β，粒细胞巨噬细胞集落刺激因子、干扰素γ和肿瘤坏死因子α)在肩关节假体周围感染的诊断价值进行评估，肿瘤坏死因子α、白细胞介素6以及白细胞介素2的组合结果优于任何生物标记物单独使用的结果。由于肩关节假体周围感染的常见致病菌为痤疮丙酸杆菌感染。作者发现在痤疮丙酸杆菌感染的病例中，白细胞介素2，6，8，10，1β显著增高。钙卫蛋白也是近年来一种新的诊断假体周围感染的方法，Wouthuyzen等[58]用一种基于钙卫蛋白的快速检测的工具(Quantum Blue®)诊断慢性假体周围感染，其敏感性为86.7%、特异性为91.7%。虽然这种方法快捷方便(15 min内获得结果)、价格便宜(20欧元)，但是对于低毒力感染、样本采集前使用抗生素治疗的患者，可能会造成假阴性的结果。 "

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