Diagnostic Test Analysis of Intraoperative Direct Sonication in Detecting Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis.

Periprosthetic joint infection (PJI) remains a challenging complication after arthroplasty. Intraoperative direct sonication (sonicating explanted components or periprosthetic tissue in the operating room and inoculating processed fluid into blood culture bottles) may improve pathogen detection by disrupting biofilm. We conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of this test for suspected PJI. We searched CENTRAL, MEDLINE (PubMed), and Embase (ProQuest) on June 10, 2025, without language restrictions, and screened trial registries (ICTRP, ClinicalTrials.gov), organizational websites/guidelines, citations, and conference abstracts. Eligible studies evaluated intraoperative direct sonication against a predefined reference standard and reported or allowed reconstruction of 2×2 data. Two reviewers independently performed study selection, data extraction, and QUADAS-2 risk-of-bias assessment. We synthesized sensitivity and specificity using hierarchical models. We also generated forest plots and an SROC (summary receiver operating characteristic) curve. The search yielded 1,910 records plus 124 from other sources; six studies met the inclusion criteria. After confirming cohort overlap, four unique datasets remained; two studies (n=479) used the MSIS 2011 criteria and were pooled. Risk of bias was generally low; one study had unclear patient selection. Summary sensitivity and specificity were 88.7% (95% CI, 82.9-92.7) and 83.1% (95% CI, 73.5-89.7), respectively. Intraoperative direct sonication showed promising diagnostic performance for suspected PJI, but the current pooled evidence is based on only two studies using the Musculoskeletal Infection Society (MSIS) reference standard. Larger, multicenter studies using consistent reference standards are needed to refine accuracy estimates and define its role in diagnostic pathways.