识别叠加在结晶性关节病上的脓毒性关节炎：滑膜细胞计数是答案吗？
Identifying septic arthritis superimposed on crystalline arthropathy: Is synovial cell count the answer?
作者信息
Morgan Allison M, Ferati Sehar, Fong Chloe, Egol Kenneth
机构信息
Department of Orthopedic Surgery, New York University Langone Health, 1056 5th Avenue, New York, NY, 10028, USA.
出版信息
J Clin Orthop Trauma. 2025 Mar 24;65:102985. doi: 10.1016/j.jcot.2025.102985. eCollection 2025 Jun.
BACKGROUND
Septic arthritis (SA) is an orthopedic urgency with significant morbidity and potential mortality. Differentiating SA and crystalline arthritis (CA) is difficult as concurrent disease may exist. This study sought to identify the prevalence of and define diagnostic laboratory markers for SA in the setting of CA.
METHODS
A retrospective review was conducted of adult patients presenting to a single medical center between January 2012 and March 2023 with monosodium urate (MU) or calcium pyrophosphate (CPP) in synovial knee joint fluid of a native knee. Categorical variables were assessed using chi-square and Fisher exact tests. Receiver operating characteristic curves were computed, and diagnostic accuracy was determined from associated area under the ROC curve (AUC). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated and optimal diagnostic thresholds determined by Youden index.
RESULTS
225 knee aspirations were analyzed, 56.4 % CPP and 43.6 % MSU. There were 12 cases of superimposed SA (5.3 %), 11 culture confirmed and 1 suspected. Immunosuppression was associated with a higher incidence of SA (41.7 % versus 14.6 %, p = 0.0271). SA had a significantly higher mean synovial WBC (135,796 vs 22,510; p = 0.0007). There was no difference in percentage of PMNs between the septic and aseptic groups (90.6 % vs 69.7 %; p = 3.327). Of the 12 cases of concomitant SA, 10 (83.3 %) had a synovial WBC ≥50,000/mm3, compared to 21 (9.9 %) of the aseptic aspirations (p < 0.0001). Nine (75 %) aspirations in the septic group had ≥90 % PMNs, compared to 78 (36.6 %) in the aseptic group (p = 0.0123). The optimal diagnostic threshold for synovial WBC was 50,000/mm3 (91.7 % sensitivity, 90.1 % specificity, AUC = 0.960). The optimal synovial percentage of PMNs was 64 % (100 % sensitivity, 6.7 % specificity, AUC = 0.731).
CONCLUSION
In the setting of CA, synovial WBC may provide a useful diagnostic marker for SA with an optimal threshold of 50,000 cells/mm3.
背景
化脓性关节炎（SA）是一种骨科急症，具有较高的发病率和潜在死亡率。由于可能存在并发疾病，区分SA和晶体性关节炎（CA）较为困难。本研究旨在确定CA背景下SA的患病率并定义其诊断实验室标志物。
方法
对2012年1月至2023年3月期间在单一医疗中心就诊的成年患者进行回顾性研究，这些患者的天然膝关节滑膜液中存在尿酸钠（MU）或焦磷酸钙（CPP）。使用卡方检验和Fisher精确检验评估分类变量。计算受试者工作特征曲线，并根据ROC曲线下的相关面积（AUC）确定诊断准确性。计算敏感性、特异性、阳性预测值（PPV）和阴性预测值（NPV），并通过约登指数确定最佳诊断阈值。
结果
分析了225例膝关节穿刺样本，其中56.4%为CPP，43.6%为MSU。有12例并发SA（5.3%），11例经培养确诊，1例疑似。免疫抑制与SA的较高发病率相关（41.7%对14.6%，p = 0.0271）。SA的滑膜白细胞平均计数显著更高（135,796对22,510；p = 0.0007）。脓毒症组和无菌组之间的中性粒细胞百分比无差异（90.6%对69.7%；p = 3.327）。在12例并发SA的病例中，10例（83.3%）滑膜白细胞≥50,000/mm³，而无菌穿刺样本中有21例（9.9%）如此（p < 0.0001）。脓毒症组9例（75%）穿刺样本中性粒细胞≥90%，无菌组为78例（36.6%）（p = 0.0123）。滑膜白细胞的最佳诊断阈值为50,000/mm³（敏感性91.7%，特异性90.1%，AUC = 0.960）。中性粒细胞的最佳滑膜百分比为64%（敏感性100%，特异性6.7%，AUC = 0.731）。
结论
在CA背景下，滑膜白细胞可能为SA提供有用的诊断标志物，最佳阈值为50,000个细胞/mm³。
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