Assessment and diagnosis of the acute hot joint: A systematic review and meta-analysis

Mrinalini Dey, Mariam Al-Attar, Leticia Peruffo, Ashley Coope, Sizheng Steven Zhao, Stephen Duffield, Nicola Goodson

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Prompt diagnosis of septic arthritis (SA) in acute native hot joints is essential to reduce unnecessary antibiotics and hospital admissions.

Aim: To evaluate the utility of SF and serum tests in differentiating causes of acute hot joints.

We performed a systematic literature review of diagnostic testing for in acute hot joints. Articles were included if studying ≥1 serum or SF test(s) for an acute hot joint, compared with clinical assessment and SF microscopy and culture. English-language articles only were included, without date restriction. The following were recorded for each test, threshold and diagnosis: sensitivity, specificity, positive/negative predictive values and likelihood ratios.
For directly comparable tests (i.e. identical fluid, test and threshold), bivariate random-effects meta-analysis was used to pool sensitivity, specificity and areas under curve (AUC).

8443 articles were identified, 49 ultimately included. Information on 28 distinct markers in SF and serum, differentiating septic from non-septic joints, was extracted. Most had been tested at multiple diagnostic thresholds, yielding a total of 27 serum markers and 156 SF markers.

Due to heterogeneity of study design, outcomes and thresholds, meta-analysis was possible for only eight SF tests, all differentiating septic from non-septic joints. Of these, leukocyte esterase had the highest pooled sensitivity (0.94 [0.70, 0.99]) with good pooled specificity (0.74 [0.67, 0.81]).

Our review demonstrates many single tests, individually with diagnostic utility but suboptimal accuracy for exclusion of native joint infection. A combination of several tests +/- stratification score is required to optimise rapid assessment of the hot joint.

Key messages:
1. Rapid exclusion of septic arthritis is required to improve patient outcomes and reduce unnecessary admissions and antibiotic-use.
2. Our review identified many biomarkers with individually good diagnostic utility but suboptimal accuracy to exclude septic arthritis.
3. A panel of synovial fluid and/or serum tests may optimise rapid assessment of hot joints.
Original languageEnglish
Pages (from-to)1740 -1756
Number of pages17
JournalRheumatology (Print)
Issue number5
Early online date20 Oct 2022
Publication statusPublished - 23 May 2023


  • septic arthritis
  • infectious arthritis
  • crystal arthritis
  • gout
  • hot joint
  • synovial fluid
  • biomarker
  • point-of-care testing


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