The Journal of Bone and Joint Surgery (American). 2007;89:1409-1416.
doi:10.2106/JBJS.D.02602
© 2007 The Journal of Bone and Joint Surgery, Inc.
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Use of Erythrocyte Sedimentation Rate and C-Reactive Protein Level to Diagnose Infection Before Revision Total Knee Arthroplasty

A Prospective Evaluation

Nelson V. Greidanus, MD, MPH, FRCSC1, Bassam A. Masri, MD, FRCSC1, Donald S. Garbuz, MD, MHSc, FRCSC1, S. Darrin Wilson, MBBCh, MD, FRCS1, M. Gavan McAlinden, MBBCh, MPH, MD, FRCS1, Min Xu, MSc1 and Clive P. Duncan, MD, MSc, FRCSC1

1 Department of Orthopaedics, University of British Columbia, Laurel Pavilion, 910 West 10th Avenue, Vancouver, BC V5Z 4E3, Canada. E-mail address for N.V. Greidanus: nelson.greidanus{at}vch.ca

Investigation performed at the Division of Lower Limb Reconstruction and Oncology, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Zimmer, Warsaw, Indiana) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Background: Despite the widespread use of several diagnostic tests, there is still no perfect test for the diagnosis of infection at the site of a total knee arthroplasty. The purpose of this study was to evaluate the diagnostic test characteristics of the erythrocyte sedimentation rate and C-reactive protein level for the assessment of infection in patients presenting for revision total knee arthroplasty.

Methods: One hundred and fifty-one knees in 145 patients presenting for revision total knee arthroplasty were evaluated prospectively for the presence of infection with measurement of the erythrocyte sedimentation rate and the C-reactive protein level. The characteristics of these tests were assessed with use of two different techniques: first, receiver-operating-characteristic curve analysis was performed to determine the optimal positivity criterion for the diagnostic test, and, second, previously accepted criteria for establishing positivity of the tests were used.

Results: A diagnosis of infection was established for forty-five of the 151 knees that underwent revision total knee arthroplasty. The receiver-operating-characteristic curves indicated that the optimal positivity criterion was 22.5 mm/hr for the erythrocyte sedimentation rate and 13.5 mg/L for the C-reactive protein level. Both the erythrocyte sedimentation rate (sensitivity, 0.93; specificity, 0.83; positive likelihood ratio, 5.81; accuracy, 0.86) and the C-reactive protein level (sensitivity, 0.91; specificity, 0.86; positive likelihood ratio, 6.89; accuracy, 0.88) have excellent diagnostic test performance.

Conclusions: The erythrocyte sedimentation rate and the C-reactive protein level provide excellent diagnostic test information for establishing the presence or absence of infection prior to surgical intervention in patients with pain at the site of a knee arthroplasty.

Level of Evidence: Diagnostic Level I. See Instructions to Authors for a complete description of levels of evidence.


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Letters to the Editor:

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Optimal Operating Points Determination
Zong-I Lin, M.D., et al.
JBJS Online, 17 Oct 2007 [Full text]
Optimal Operating Points Determination for ESR and CRP
Nelson V. Greidanus, et al.
JBJS Online, 22 Oct 2007 [Full text]