Comparative Diagnostic Accuracy of Image-Guided Aspiration Techniques for Periprosthetic Hip Infection: A Systematic Review

OBJECTIVES: Image-guided fluid aspiration is a key component in the diagnostic work-up of suspected prosthetic joint infection of the hip (PJI). Fluoroscopy, ultrasound (US), and computed tomography (CT) are frequently employed to guide aspiration; however, comparative evidence regarding their diagnostic performance and procedural outcomes remains limited. This study aimed to evaluate and compare the diagnostic accuracy and technical performance of these modalities. METHODS: A systematic review was conducted in accordance with PRISMA guidelines. PubMed, Embase, and CINAHL were searched for studies evaluating fluoroscopy-, US-, or CT-guided hip aspiration to aid PJI diagnosis. Outcomes of interest included diagnostic performance, dry tap rates, and procedural characteristics. Dry tap rates were pooled by modality using random-effects meta-analysis of proportions. Due to heterogeneity in reference standards, diagnostic accuracy outcomes were synthesised narratively. RESULTS: Ten studies comprising 1,574 hip aspirations were included (647 fluoroscopy, 831 US, 96 CT). Sensitivity ranged from 0.52-0.89 for US and 0.27-0.83 for fluoroscopy, with consistently high specificity (≥0.75) across modalities. CT-guided aspiration demonstrated sensitivity of 0.67 and specificity of 0.98 in a single study. Pooled dry tap rates were lower for US (17%, 95% CI 4-30%) compared with fluoroscopy (27%, 95% CI 9-45%), with substantial heterogeneity (I²>97%). CONCLUSIONS: Reported specificity is comparable between ultrasound- and fluoroscopy-guided hip aspiration for PJI. Ultrasound-guided aspiration demonstrates higher reported sensitivity and lower dry tap rates, although interpretation is limited by heterogeneity in reference standards. ADVANCES IN KNOWLEDGE: This review provides a focused synthesis of comparative evidence on imaging modalities for hip aspiration in PJI. It highlights a potential diagnostic and practical advantage of ultrasound-guided aspiration.