The α-defensins (AD) present in synovial fluid have been regarded as constituting the most accurate periprosthetic joint infection (PJI) biomarker. The methods most commonly used for estimating AD as a biomarker are the qualitative Synovasure® PJI tests, based on the technique of lateral flow, and quantitative enzyme-linked immunosorbent assay (ELISA). Here, we propose a novel test based on detecting α-defensins in synovial fluid by high-performance liquid chromatography (HPLC). Synovial fluid was collected from 157 patients diagnosed with PJI, infectious arthritis (IA), arthrosis, reactive arthritis, and rheumatoid arthritis. AD concentrations in the fluid were determined by HPLC, and these same samples were used for additional diagnostic analyses. The results were statistically processed to calculate cutoff concentrations for PJI and IA. HPLC testing showed a sensitivity of 94% and a specificity of 92% for diagnosis of PJI, and a sensitivity of 97% and a specificity of 87% for diagnosis of IA. Using HPLC, we detected in synovial fluid a combination of three α-defensins: human neutrophil peptides HNP1, HNP2, and HNP3. All measured AD concentration values shown in this work refer to the sum of these three individual concentrations. Our study shows that the HPLC method meets the conditions for measuring precise concentrations of the sum of AD and can be recommended as part of a diagnostic array for PJI and IA diagnostics. By this method, we have verified that higher levels of AD in synovial fluid can also be seen in rheumatoid illnesses, crystal arthropathies, and reactive arthritis.

Department of Medical Chemistry and Clinical Biochemistry 2nd Faculty of Medicine Charles University Prague and Motol University Hospital 5 Úvalu 84 150 06 Prague 5 Czech Republic

Department of Orthopaedics 1st Faculty of Medicine Charles University Prague and Motol University Hospital 5 Úvalu 84 150 06 Prague 5 Czech Republic

Institute of Organic Chemistry and Biochemistry of the Czech Academy of Sciences Flemingovo nám 2 166 10 Prague 6 Czech Republic

Zobrazit více v PubMed

Deirmengian C., Kardos K., Kilmartin P., Cameron A., Schiller K., Parvizi J. Diagnosing periprosthetic joint infection. Has the era of the biomarker arrived? Clin. Orthop. Relat. Res. 2014;472:3254–3262. doi: 10.1007/s11999-014-3543-8. PubMed DOI PMC

Springer B.D. The diagnosis of periprosthetic joint infection. J. Arthroplast. 2015;30:908–911. doi: 10.1016/j.arth.2015.03.042. PubMed DOI

Ahn J.K., Huang B., Bae E.K., Park E.J., Hwang J.W., Lee J., Koh E.M., Cha H.S. The role of α-defensin-1 and related signal transduction mechanisms in the production of IL-6, IL-8 and MMPs in rheumatoid fibroblast-like synoviocytes. Rheumatology. 2013;52:1368–1376. doi: 10.1093/rheumatology/ket147. PubMed DOI

Deirmengian C., Kardos K., Kilmartin P., Cameron A., Schiller K., Parvizi J. Combined measurement of synovial fluid α-defensin and C-reactive protein levels: Highly accurate for diagnosing periprosthetic joint infection. J. Bone Jt. Surg. Am. 2014;96:1439–1445. doi: 10.2106/JBJS.M.01316. PubMed DOI

Deirmengian C., Kardos K., Kilmartin P., Cameron A., Schiller K., Booth R.E., Jr., Parvizi J. The alpha-defensin test for periprosthetic joint infection outperforms the leukocyte esterase test strip. Clin. Orthop. Relat. Res. 2015;473:198–203. doi: 10.1007/s11999-014-3722-7. PubMed DOI PMC

Frangiamore S.J., Gajewski N.D., Saleh A., Farias-Kovac M., Barsoum W.K., Higuera C.A. α-Defensin accuracy to diagnose periprosthetic joint infection—Best available test? J. Arthroplast. 2016;31:456–460. doi: 10.1016/j.arth.2015.09.035. PubMed DOI

Ganz T. Defensins: Antimicrobial peptides of innate immunity. Nat. Rev. Immunol. 2003;3:710–720. doi: 10.1038/nri1180. PubMed DOI

Lehrer R.I., Lu W. α-Defensins in human innate immunity. Immunol. Rev. 2012;245:84–112. doi: 10.1111/j.1600-065X.2011.01082.x. PubMed DOI

Wu Z., Ericksen B., Tucker K., Lubkowski J., Lu W. Synthesis and characterization of human α-defensins 4-6. J. Pept. Res. 2004;64:118–125. doi: 10.1111/j.1399-3011.2004.00179.x. PubMed DOI

Pupaibool J., Fulnecky E.J., Swords R.L., Jr., Sistrunk W.W., Haddow A.D. Alpha-defensin-novel synovial fluid biomarker for the diagnosis of periprosthetic joint infection. Int. Orthop. 2016;40:2447–2452. doi: 10.1007/s00264-016-3306-0. PubMed DOI

Berger P., Van Cauter M., Driesen R., Neyt J., Cornu O., Bellemans J. Diagnosis of prosthetic joint infection with alpha-defensin using a lateral flow device: A multicentre study. Bone Jt. J. 2017;99:1176–1182. doi: 10.1302/0301-620X.99B9.BJJ-2016-1345.R2. PubMed DOI

Gehrke T., Lausmann C., Citak M., Bonanzinga T., Frommelt L., Zahar A. The accuracy of the alpha defensin lateral flow device for diagnosis of periprosthetic joint infection: Comparison with a gold standard. J. Bone Jt. Surg. Am. 2018;100:42–48. doi: 10.2106/JBJS.16.01522. PubMed DOI

Bonanzinga T., Zahar A., Dütsch M., Lausmann C., Kendoff D., Gehrke T. How reliable is the alpha-defensin immunoassay test for diagnosing periprosthetic joint infection? A prospective study. Clin. Orthop. Relat. Res. 2017;475:408–415. doi: 10.1007/s11999-016-4906-0. PubMed DOI PMC

Sigmund I.K., Holinka J., Gamper J., Staats K., Böhler C., Kubista B., Windhager R. Qualitative α-defensin test (Synovasure) for the diagnosis of periprosthetic infection in revision total joint arthroplasty. Bone Jt. J. 2017;99:66–72. doi: 10.1302/0301-620X.99B1.BJJ-2016-0295.R1. PubMed DOI

Sigmund I.K., Yermak K., Perka C., Trampuz A. Is the enzyme-linked immunosorbent assay more accurate than the lateral flow alpha defensin test for diagnosing periprosthetic joint infection? Clin. Orthop. Relat. Res. 2018;476:1645–1654. doi: 10.1097/CORR.0000000000000336. PubMed DOI PMC

Kanwar S., Al-Mansoori A.A., Chand M.R., Villa J.M., Suarez J.C., Patel P.D. What is the optimal criteria to use for detecting periprosthetic joint infections before total joint arthroplasty? J. Arthroplast. 2018;33:S201–S204. doi: 10.1016/j.arth.2018.02.072. PubMed DOI

Parvizi J., Gehrke T. Definition of periprosthetic joint infection. J. Arthroplast. 2014;29:1331. doi: 10.1016/j.arth.2014.03.009. PubMed DOI

Zmistowski B., Della Valle C., Bauer T.W., Malizos K.N., Alavi A., Bedair H., Booth R.E., Choong P., Deirmengian C., Ehrlich G.D., et al. Diagnosis of Periprosthetic Joint Infection. J. Orthop. Res. 2014;32:S98–S107. doi: 10.1016/j.arth.2013.09.040. PubMed DOI

de Saint Vincent B., Migaud H., Seneeville E., Loiez C., Pasquier G., Girard J., Putman S. Diagnostic accuracy of the alpha defensin lateral flow device (Synovasure) for periprosthetic infections in microbiologically complex situations: A study of 42 cases in a French referral centre. Orthop. Traumatol. Surg. Res. 2018;148:427–431. doi: 10.1016/j.otsr.2018.01.018. PubMed DOI

Kasparek M.F., Kasparek M., Boettner F., Faschingbauer M., Hahne J., Dominkus M. Intraoperative diagnosis of periprosthetic joint infection using a novel alpha-defensin lateral flow assay. J. Arthroplast. 2016;31:2871–2874. doi: 10.1016/j.arth.2016.05.033. PubMed DOI

Scholten R., Visser J., van Susante J.L.C., van Loon C.J.M. Low sensitivity of α-defensin (Synovasure) test for intraoperative exclusion of prosthetic joint infection. Acta Orthop. 2018;89:357–359. doi: 10.1080/17453674.2018.1444301. PubMed DOI PMC

Partridge D.G., Gordon A., Townsend R. False-positive synovial fluid alpha-defensin test in patient with acute gout affecting a prosthetic knee. Eur. J. Orthop. Surg. Traumatol. 2017;27:549–551. doi: 10.1007/s00590-017-1942-8. PubMed DOI

Paulsen F., Pufe T., Conradi L., Varoga D., Tsokos M., Papendieck J., Petersen W. Antimicrobial peptides are expressed and produced in healthy and inflamed human synovial membranes. J. Pathol. 2002;198:369–377. doi: 10.1002/path.1224. PubMed DOI

Ahmad S.S., Hirschmann M.T., Becker R., Shaker A., Ateschrang A., Keel M.J.B., Albers C.E., Buetikofer L., Maqungo S., Stöckle U., et al. A meta-analysis of synovial biomarkers in periprosthetic joint infection: Synovasure™ is less effective than the ELISA-based alpha-defensin test. Knee Surg. Sports Traumatol. Arthrosc. 2018;26:3039–3047. doi: 10.1007/s00167-018-4904-8. PubMed DOI

Synovial fluid alpha-defensins in Lyme arthritis-a useful marker