Background: The European Bone and Joint Infection Society (EBJIS)/Musculoskeletal Infection Society (MSIS) criteria provide a framework for diagnosing hip periprosthetic joint infection, yet daily clinical application lacks a standardized algorithm.Since these criteria rely heavily on synovial fluid markers, surgeons encounter 2 primary dilemmas: the reliability of aspiration techniques (ultrasound vs fluoroscopy) and the economic trade-off between higher-cost proprietary assays and standard institutional laboratories.This cost-effectiveness analysis was conducted to identify the diagnostic pathway that maximizes clinical benefit while minimizing expenditure within the EBJIS/MSIS framework.Methods: A decision tree model simulated the diagnostic workup of a 67-year-old patient with suspected hip periprosthetic joint infection.Ten strategies were evaluated, comparing aspiration modality and laboratory method (institutional, point-of-care, and third-party analysis).The model incorporated 1-and 2-stage revision pathways and included dry tap scenarios.Accuracy inputs were derived from the literature, and costs reflected 2025 Medicare schedules.Sensitivity analyses tested robustness across diagnostic outcomes.Effectiveness was measured in quality-adjusted life years based on downstream surgical outcomes.Results: Ultrasound-guided aspiration with third-party synovial analysis was most cost-effective in both revision scenarios.Despite higher upfront costs of specialized testing, its superior sensitivity and specificity maximized quality-adjusted life years by reducing morbidity from misdiagnosis.Institutional testing was preferred only if sensitivity exceeded 90% and specificity 94%.In "dry tap" cases, intraoperative lateral flow alpha-defensin testing was favored over preoperative nuclear imaging.Surgical outcome utility most strongly influenced the results.Conclusions: Within the EBJIS/MSIS framework, prioritizing high-accuracy diagnostic tools maximizes value by reducing misaligned revision strategies.Diagnostic precision outweighed individual test cost in determining cost-effectiveness.
Diaz-Ledezma et al. (Sat,) studied this question.