A meta-analysis of synovial biomarkers in periprosthetic joint infection: Synovasure™ is less effective than the ELISA-based alpha-defensin test.

Ahmad, Sufian S; Hirschmann, Michael T; Becker, Roland; Shaker, Ahmed; Ateschrang, Atesch; Keel, Marius J B; Albers, Christoph E; Bütikofer, Lukas; Maqungo, Sithombo; Stöckle, Ulrich; Kohl, Sandro (2018). A meta-analysis of synovial biomarkers in periprosthetic joint infection: Synovasure™ is less effective than the ELISA-based alpha-defensin test. Knee surgery, sports traumatology, arthroscopy, 26(10), pp. 3039-3047. Springer 10.1007/s00167-018-4904-8

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PURPOSE (1) To determine the overall accuracy of synovial alpha-defensin, synovial C-reactive protein (sCRP), interleukin-6 (sIL-6), and leukocyte esterase (sLE) as diagnostic markers for periprosthetic joint infection (PJI) and (2) to independantly evaluate the accuracy of both the laboratory-based ELISA alpha-defensin test and the Synovasure™ alpha-defensin test kit. METHODS An EMBASE and MEDLINE (PubMed) database search was performed using a set of professionally set search terms. Two independent reviewers rated eligible articles. Sensitivity and specificity were meta-analysed using a bivariate random-effects model. RESULTS Accuracy values were extracted from 42 articles. Pooled sensitivity and specificity of the represented biomarkers were: alpha-defensin ELISA 0.97 (95% CI 0.91-0.99) and 0.97 (95% CI 0.94-0.98), respectively; Synovasure™ test kit assay 0.80 (95% CI 0.65-0.89) and 0.89 (95% CI 0.76-0.96), respectively; sLE 0.79 (95% CI 0.67-0.87) and 0.92 (95% CI 0.87-0.92), respectively; sIL-6 0.76 (95% CI 0.65-0.84) and 0.91 (95% CI 0.88-0.94), respectively; sCRP 0.86 (95% CI 0.81-0.91) and 0.90 (95% CI 0.86-0.93), respectively. CONCLUSION The labararory-based alpha-defensin ELISA test showed the highest ever reported accuracy for PJI diagnosis. However, this did not apply for the Synovasure™ alpha-defensin test, which was comparable in its overall diagnostic accuracy to sCRP, sIL-6 and sLE. The later biomarkers also did not yield an overall diagnostic accuracy higher than that previously reported for synovial white cell count (sWBC) or culture bacteriology. Based on current evidence, no synovial biomarker should be applied as a standalone diagnostic tool. Furthermore, the use of the laboratory-based alpha-defensin ELISA test should be encouraged, still, the Synovasure™ alpha-defensin test kit should be critically appreciated. LEVER OF EVIDENCE III.

Item Type:

Journal Article (Original Article)


04 Faculty of Medicine > Department of Orthopaedic, Plastic and Hand Surgery (DOPH) > Clinic of Orthopaedic Surgery
04 Faculty of Medicine > Pre-clinic Human Medicine > CTU Bern

UniBE Contributor:

Ahmad, Sufian; Shaker, Ahmed Mohamed Abd El Aziz; Keel, Marius; Albers, Christoph; Bütikofer, Lukas and Kohl, Sandro


600 Technology > 610 Medicine & health








Tanya Karrer

Date Deposited:

17 Apr 2018 11:08

Last Modified:

23 Oct 2019 14:45

Publisher DOI:


PubMed ID:


Uncontrolled Keywords:

Alpha defensin Alpha-defensin Biomarker Interleukin 6 Interleukin-6 Leukocyte esterase, CRP Synovasure Synovial Synovial CRP Synovial interleukin-6 α Defensin α-Defensin





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