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Tarabichi S, Lizcano JD, Abe EA, Goh GS, Baker CM, Parvizi J. Finding the Optimal Screening Test for Periprosthetic Joint Infection: A Prospective Study. J Arthroplasty 2024; 39:1919-1925.e2. [PMID: 38452860 DOI: 10.1016/j.arth.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Serological markers are often used as screening tools to avoid unnecessary joint aspiration in cases with a low probability of infection. This study aimed to determine the utility of standard-of-care serological tests as a screening tool for PJI in patients undergoing revision arthroplasty. METHODS This prospective study enrolled 502 patients undergoing revision hip or knee arthroplasty between May 2017 and August 2021. A PJI was defined using a modified definition of the 2018 International Consensus Meeting criteria. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. There were 82 patients undergoing reimplantation who were excluded. Additionally, 8 patients who had an inconclusive International Consensus Meeting score were also excluded. Of the 412 included patients, 317 (76.9%) underwent revision for aseptic failure, and 95 (23.1%) had PJI. Receiver operating characteristic curves were used to assess the diagnostic utility of each serological test. A pairwise comparison with Bonferroni correction was performed to determine whether the differences in areas under the curve (AUCs) between the tests were significant. Additional analyses were performed to find the threshold for each test that offered 100% sensitivity, allowing it to be the optimal screening test. RESULTS All 4 serological markers, D-dimer (AUC 0.860, sensitivity 81.3%, specificity 81.7%), CRP (AUC 0.862, sensitivity 90.4%, specificity 70.0%), ESR (AUC 0.833, sensitivity 73.9%, specificity 85.2%), and fibrinogen (AUC 0.798, sensitivity 74.7%, specificity 75.4%), demonstrated comparable accuracy for the diagnosis of PJI (all P > .05). When maximizing sensitivity to 100%, D-dimer demonstrated the highest specificity (AUC 0.860, specificity 40.2%), outperforming ESR (AUC 0.833, specificity 3.3%), fibrinogen (AUC 0.798, specificity 2.3%), and CRP (AUC 0.862, specificity 0%). A plasma D-dimer level of ≥ 244 ng/mL was identified as the optimal cutoff for use as a screening test. CONCLUSIONS Although plasma D-dimer demonstrated similar diagnostic accuracy as CRP, ESR, and fibrinogen, it outperformed all 3 aforementioned serological markers when used as a screening test for PJI. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Saad Tarabichi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Elizabeth A Abe
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts
| | - Colin M Baker
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Cleveland Clinic South Pointe, Cleveland, Ohio
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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Tarabichi S, Goh GS, Fraval A, Lizcano JD, Abe EA, Courtney PM, Namdari S, Parvizi J. Serum and Synovial Markers in the Diagnosis of Periprosthetic Joint Infection of the Hip, Knee, and Shoulder: An Algorithmic Approach. J Bone Joint Surg Am 2024; 106:1221-1230. [PMID: 38776388 DOI: 10.2106/jbjs.23.00669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
➤ No single test has demonstrated absolute accuracy for the diagnosis of periprosthetic joint infection (PJI).➤ Physicians rely on a combination of serological tests, synovial markers, and clinical findings plus clinical judgment to help to guide preoperative decision-making.➤ Several organizations have proposed criteria for the diagnosis of hip or knee PJI on which we now rely.➤ Given that shoulder arthroplasty has only recently become popular, it is possible that a shoulder-specific definition of PJI will be introduced in the coming years.➤ Although a number of serum and synovial markers have demonstrated high accuracy for the diagnosis of PJI of the hip and knee, further research is needed in order to identify markers that may be more suitable for the diagnosis of shoulder PJI and for the potential development and identification of specific serological tests as screening tools for PJI.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrew Fraval
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Elizabeth A Abe
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Surena Namdari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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Zou Z, Li H, Yu K, Ma K, Wang Q, Tang J, Liu G, Lim K, Hooper G, Woodfield T, Cui X, Zhang W, Tian K. The potential role of synovial cells in the progression and treatment of osteoarthritis. EXPLORATION (BEIJING, CHINA) 2023; 3:20220132. [PMID: 37933282 PMCID: PMC10582617 DOI: 10.1002/exp.20220132] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 06/15/2023] [Indexed: 11/08/2023]
Abstract
Osteoarthritis (OA), the commonest arthritis, is characterized by the progressive destruction of cartilage, leading to disability. The Current early clinical treatment strategy for OA often centers on anti-inflammatory or analgesia medication, weight loss, improved muscular function and articular cartilage repair. Although these treatments can relieve symptoms, OA tends to be progressive, and most patients require arthroplasty at the terminal stages of OA. Recent studies have shown a close correlation between joint pain, inflammation, cartilage destruction and synovial cells. Consequently, understanding the potential mechanisms associated with the action of synovial cells in OA could be beneficial for the clinical management of OA. Therefore, this review comprehensively describes the biological functions of synovial cells, the synovium, together with the pathological changes of synovial cells in OA, and the interaction between the cartilage and synovium, which is lacking in the present literature. Additionally, therapeutic approaches based on synovial cells for OA treatment are further discussed from a clinical perspective, highlighting a new direction in the treatment of OA.
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Affiliation(s)
- Zaijun Zou
- Department of Sports MedicineThe First Affiliated Hospital of Dalian Medical UniversityDalianLiaoningChina
| | - Han Li
- Department of Sports MedicineThe First Affiliated Hospital of Dalian Medical UniversityDalianLiaoningChina
| | - Kai Yu
- Department of Bone and JointCentral Hospital of Zhuang He CityDalianLiaoningChina
| | - Ke Ma
- Department of Clinical MedicineChina Medical UniversityShenyangLiaoningChina
| | - Qiguang Wang
- National Engineering Research Center for BiomaterialsSichuan UniversityChengduSichuanChina
| | - Junnan Tang
- Department of CardiologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouHenanChina
| | - Guozhen Liu
- School of MedicineThe Chinese University of Hong Kong (Shenzhen)ShenzhenGuangdongChina
| | - Khoon Lim
- Christchurch Regenerative Medicine and Tissue Engineering Group (CReaTE)Department of Orthopaedic Surgery and Musculoskeletal MedicineUniversity of OtagoChristchurchNew Zealand
| | - Gary Hooper
- Christchurch Regenerative Medicine and Tissue Engineering Group (CReaTE)Department of Orthopaedic Surgery and Musculoskeletal MedicineUniversity of OtagoChristchurchNew Zealand
| | - Tim Woodfield
- Christchurch Regenerative Medicine and Tissue Engineering Group (CReaTE)Department of Orthopaedic Surgery and Musculoskeletal MedicineUniversity of OtagoChristchurchNew Zealand
| | - Xiaolin Cui
- Department of Sports MedicineThe First Affiliated Hospital of Dalian Medical UniversityDalianLiaoningChina
- School of MedicineThe Chinese University of Hong Kong (Shenzhen)ShenzhenGuangdongChina
- Christchurch Regenerative Medicine and Tissue Engineering Group (CReaTE)Department of Orthopaedic Surgery and Musculoskeletal MedicineUniversity of OtagoChristchurchNew Zealand
| | - Weiguo Zhang
- Department of Sports MedicineThe First Affiliated Hospital of Dalian Medical UniversityDalianLiaoningChina
- Key Laboratory of Molecular Mechanisms for Repair and Remodeling of Orthopaedic DiseasesLiaoning ProvinceDalianLiaoningChina
| | - Kang Tian
- Department of Sports MedicineThe First Affiliated Hospital of Dalian Medical UniversityDalianLiaoningChina
- Key Laboratory of Molecular Mechanisms for Repair and Remodeling of Orthopaedic DiseasesLiaoning ProvinceDalianLiaoningChina
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Cutter B, Lum ZC, Giordani M, Meehan JP. Utility of D-dimer in total joint arthroplasty. World J Orthop 2023; 14:90-102. [PMID: 36998388 PMCID: PMC10044320 DOI: 10.5312/wjo.v14.i3.90] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 11/22/2022] [Accepted: 02/13/2023] [Indexed: 03/17/2023] Open
Abstract
As the number of patients receiving total joint replacements continues to rise, considerable attention has been directed towards the early detection and prevention of postoperative complications. While D-dimer has long been studied as a diagnostic tool in venous thromboembolism (VTE), this assay has recently received considerable attention in the diagnosis of periprosthetic joint infection (PJI). D-dimer values are substantially elevated in the acute postoperative period after total joint arthroplasty, with levels often exceeding the standard institutional cutoff for VTE (500 µg/L). The utility of D-dimer in detecting VTE after total joint replacement is currently limited, and more research to assess its value in the setting of contemporary prophylaxis protocols is warranted. Recent literature supports D-dimer as a good to excellent biomarker for the diagnosis of chronic PJI, especially when using serum sample technique. Providers should exercise caution when interpreting D-dimer levels in patients with inflammatory and hypercoagulability disorders, as the diagnostic value is decreased. The updated 2018 Musculoskeletal Infection Society criteria, which includes D-dimer levels > 860 µg/L as a minor criterion, may be the most accurate for diagnosing chronic PJI to date. Larger prospective trials with transparent lab testing protocols are needed to establish best assay practices and optimal cutoff values for D-dimer in the diagnosis of PJI. This review summarizes the most current literature on the value of D-dimer in total joint arthroplasty and elucidates areas for future progress.
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Affiliation(s)
- Brenden Cutter
- Department of Orthopedic Surgery, Valley Orthopedic Surgery Residency/Valley Consortium for Medical Education, Modesto, CA 95351, United States
| | - Zachary C Lum
- Department of Orthopaedics, Adult Reconstruction Division, University of California, Davis Medical Center, Sacramento, CA 95817, United States
| | - Mauro Giordani
- Department of Orthopaedics, Adult Reconstruction Division, University of California, Davis Medical Center, Sacramento, CA 95817, United States
| | - John P Meehan
- Department of Orthopaedics, Adult Reconstruction Division, University of California, Davis Medical Center, Sacramento, CA 95817, United States
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Tarabichi S, Goh GS, Baker CM, Chisari E, Shahi A, Parvizi J. Plasma D-Dimer Is Noninferior to Serum C-Reactive Protein in the Diagnosis of Periprosthetic Joint Infection. J Bone Joint Surg Am 2023; 105:501-508. [PMID: 36758110 DOI: 10.2106/jbjs.22.00784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Serological markers are often used as screening tools in the workup of patients with suspected PJI. This study aimed to determine the diagnostic utility of plasma D-dimer for PJI in a variety of clinical scenarios. METHODS This prospective study enrolled 502 patients undergoing revision hip or knee arthroplasty. PJI was defined per a modified version of the 2018 International Consensus Meeting (ICM) criteria. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. Receiver operating characteristic curves were used to assess the utility of each biomarker in the diagnosis of PJI. Pairwise comparison with Bonferroni correction was performed to determine whether the differences in areas under the curve (AUCs) between the markers were significant. RESULTS Of the 412 patients included, 317 (76.9%) did not have an infection (aseptic group) and 95 (23.1%) had an infection (PJI group). All 4 serological markers, D-dimer (AUC, 0.860; sensitivity, 81.3%; specificity, 81.7%), CRP (AUC, 0.862; sensitivity, 90.4%; specificity, 70.0%), ESR (AUC, 0.833; sensitivity, 73.9%; specificity, 85.2%), and fibrinogen (AUC, 0.798; sensitivity, 74.7%; specificity, 75.4%), demonstrated comparable accuracy for the diagnosis of PJI (all p > 0.05). When examining the performance of the different inflammatory markers in diagnosing infection caused by indolent organisms, D-dimer demonstrated the highest sensitivity at 93.8%. CONCLUSIONS We found that plasma D-dimer was noninferior to serum CRP and ESR in the diagnosis of PJI and may be a useful adjunct when screening patients undergoing revision total joint arthroplasty. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Miller MA, Hardy WR, Oest ME, Mann KA. Potential for supraphysiologic fluid shear stresses in a rat cemented knee replacement model. J Orthop Res 2023; 41:94-103. [PMID: 35332943 PMCID: PMC9509496 DOI: 10.1002/jor.25326] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/02/2022] [Accepted: 03/13/2022] [Indexed: 02/04/2023]
Abstract
The mechano-biologic environment associated with aseptic loosening of cemented joint replacements is not fully understood. The goal of this study was to use a preclinical rat knee arthroplasty model to explore the changes in cement-bone morphology and micromotion that occur with in vivo service. Narrow gaps between cement and bone under the tibial tray were present at early time points, and with even small magnitude micromotion, resulted in large micromotion-to-gap width ratios. These data were then used to develop models of fluid flow in the cement-bone gaps to estimate potential for high fluid shear stress (FSS). Modeling results revealed supraphysiologic (>4 Pa) FSS were possible, particularly for cases in which eccentric loading applied to the implant and if the fluid in the gap consisted of marrow or synovial fluid. The early, high FSS environment, could cause fluid-induced periprosthetic osteolysis locally, resulting in progressive loss of cement-bone fixation.
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Affiliation(s)
- Mark A Miller
- SUNY Upstate Medical University, Syracuse, New York, USA
| | | | - Megan E Oest
- SUNY Upstate Medical University, Syracuse, New York, USA
| | - Kenneth A Mann
- SUNY Upstate Medical University, Syracuse, New York, USA
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7
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Dilley JE, Seetharam A, Meneghini RM, Kheir MM. Synovial Fluid Absolute Neutrophil Count and Neutrophil-To-Lymphocyte Ratio are not Superior to Polymorphonuclear Percentage in Detecting Periprosthetic Joint Infection. J Arthroplasty 2023; 38:146-151. [PMID: 35843381 DOI: 10.1016/j.arth.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/08/2022] [Accepted: 07/08/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Serum and synovial biomarkers are currently used to diagnose periprosthetic joint infection (PJI). Serum neutrophil-to-lymphocyte ratio (NLR) has shown promise as an inexpensive test in diagnosing infection, but there are no reports of synovial NLR or absolute neutrophil count (ANC) for diagnosing chronic PJI. The purpose of this study was to investigate the diagnostic potential of both markers. METHODS A retrospective review of 730 patients who underwent total joint arthroplasty and subsequent aspiration was conducted. Synovial white blood cell (WBC) count, synovial polymorphonuclear percentage (PMN%), synovial NLR, synovial ANC, serum erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), serum WBC, serum PMN%, serum NLR, and serum ANC had their utility in diagnosing PJI examined by area-under-the-curve analyses (AUC). Pairwise comparisons of AUCs were performed. RESULTS The AUCs for synovial WBC, PMN%, NLR, and ANC were 0.84, 0.84, 0.83, and 0.85, respectively. Synovial fluid ANC was a superior marker to synovial NLR (P = .027) and synovial WBC (P = .003) but not PMN% (P = .365). Synovial NLR was inferior to PMN% (P = .006) but not different from synovial WBC (P > .05). The AUCs for serum ESR, CRP, WBC, PMN%, NLR, and ANC were 0.70, 0.79, 0.63, 0.72, 0.74, and 0.67, respectively. Serum CRP outperformed all other serum markers (P < .05) except for PMN% and NLR (P > .05). Serum PMN% and NLR were similar to serum ESR (P > .05). CONCLUSION Synovial ANC had similar performance to PMN% in diagnosing chronic PJI, whereas synovial NLR was a worse diagnostic marker. The lack of superiority to synovial PMN% limits the utility of these tests compared to established criteria.
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Affiliation(s)
- Julian E Dilley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Abhijit Seetharam
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael M Kheir
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
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Kuo FC, Lin PC, Yen SH, Tan TL, Wu CT, Wang JW. Which Minor Criteria is the Most Accurate Predictor for the Diagnosis of Hip and Knee Periprosthetic Joint Infection in the Asian Population? J Arthroplasty 2022; 37:2076-2081. [PMID: 35537614 DOI: 10.1016/j.arth.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/07/2022] [Accepted: 05/01/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate the diagnostic performance of minor criteria from the 2018 International Consensus Meeting (ICM) for the diagnosis of chronic periprosthetic joint infection (PJI) in an Asian population. METHODS We retrospectively reviewed 76 patients who underwent a revision knee or hip arthroplasty at an academic institution between September 2018 and December 2019. All major and minor 2018 ICM criteria were available for all patients included. Cases with at least 1 major criterion or score ≥6 in minor criteria were considered as infected. The diagnostic performance was evaluated by a receiver operative characteristic curve analysis and area under the curve (AUC) for each minor criterion. An AUC value of more than 0.9 was considered outstanding and 0.8-0.9 as excellent. RESULTS When using 2018 ICM threshold, the diagnostic performance ranked based on AUC was the following: alpha defensin (0.92), positive histology (0.83), leukocyte esterase (0.82), synovial white blood cell (0.81), serum erythrocyte sedimentation rate (0.78), synovial polymorphonuclear neutrophils (0.77), serum C-reactive protein (0.74), D-dimer (0.59), single positive culture (0.53), and positive intraoperative purulence (0.51). Alpha defensin was considered as an outstanding test among the 2018 ICM minor criteria. Positive histology, leukocyte esterase, and synovial white blood cell were considered as excellent tests. CONCLUSION Based on our findings, alpha-defensin has the best diagnostic performance in Asian population among the minor criteria of 2018 ICM.
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Affiliation(s)
- Feng-Chih Kuo
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; College of Medicine, Chang Gung University, Kaohsiung, Taiwan; Center for General Education, Cheng Shiu University, Kaohsiung, Taiwan
| | - Po-Chun Lin
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Shih-Hsiang Yen
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Timothy L Tan
- Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Cheng-Ta Wu
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jun-Wen Wang
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Tang H, Xu J, Yuan W, Wang Y, Yue B, Qu X. Reliable Diagnostic Tests and Thresholds for Preoperative Diagnosis of Non-Inflammatory Arthritis Periprosthetic Joint Infection: A Meta-analysis and Systematic Review. Orthop Surg 2022; 14:2822-2836. [PMID: 36181336 PMCID: PMC9627080 DOI: 10.1111/os.13500] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 02/06/2023] Open
Abstract
Objective The current diagnostic criteria for periprosthetic joint infection (PJI) are diverse and controversial, leading to delayed diagnosis. This study aimed to evaluate and unify their diagnostic accuracy and the threshold selection of serum and synovial routine tests for PJI at an early stage. Methods We searched the MEDLINE and Embase databases for retrospective or prospective studies which reported preoperative‐available assays (serum, synovial, or culture tests) for the diagnosis of chronic PJI among inflammatory arthritis (IA) or non‐IA populations from January 1, 2000 to June 30, 2022. Threshold effective analysis was performed on synovial polymorphonuclear neutrophils (PMN%), synovial white blood cell (WBC), serum C‐reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to find the relevant cut‐offs. Results Two hundred and sixteen studies and information from 45,316 individuals were included in the final analysis. Synovial laboratory‐based α‐defensin and calprotectin had the best comprehensive sensitivity (0.91 [0.86–0.94], 0.95 [0.88–0.98]) and specificity (0.96 [0.94‐0.97], 0.95 [0.89–0.98]) values. According to the threshold effect analysis, the recommended cut‐offs are 70% (sensitivity 0.89 [0.85–0.92], specificity 0.90 [0.87–0.93]), 4100/μL (sensitivity 0.90 [0.87–0.93], specificity 0.97 [0.93–0.98]), 13.5 mg/L (sensitivity 0.84 [0.78–0.89], specificity 0.83 [0.73–0.89]), and 30 mm/h (sensitivity 0.79 [0.74–0.83], specificity 0.78 [0.72–0.83]) for synovial PMN%, synovial WBC, serum CRP, and ESR, respectively, and tests seem to be more reliable among non‐IA patients. Conclusions The laboratory‐based synovial α‐defensin and synovial calprotectin are the two best independent preoperative diagnostic tests for PJI. A cut off of 70% for synovial PMN% and tighter cut‐offs for synovial WBC and serum CRP could have a better diagnostic accuracy for non‐IA patients with chronic PJI.
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Affiliation(s)
- Haozheng Tang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jialian Xu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei'en Yuan
- Ministry of Education Engineering Research Center of Cell & Therapeutic Antibody, School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - You Wang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Yue
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Goud A, Nützinger D, van der Bij A, Jenniskens K, Groenewold J, de Gast A, Bekkers JEJ. Synovial-Based Tests Outperform Serum Markers to Rule Out Infection in Total Knee Arthroplasty and Total Hip Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2022; 37:802-808.e5. [PMID: 34952165 DOI: 10.1016/j.arth.2021.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/22/2021] [Accepted: 12/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) provides successful results in most patients. Periprosthetic joint infection (PJI) accounts for up to 25% of failed TKAs needing revision. In clinical practice, consensus in diagnostic strategy for excluding or diagnosing PJI is still lacking. In this systematic review and meta-analysis, we aim to provide a simplified data-driven diagnostic strategy for aseptic knee and hip revision surgeons to rule out PJI in the outpatient clinic phase. METHODS A literature search in EMBASE, MEDLINE, PubMed, and Cochrane was conducted. Studies involving the diagnosis of PJI in patients with failed TKAs and total hip arthroplasties needing revision were identified. Only studies using the Musculoskeletal Infection Society criteria were included. Quality was assessed using MINORS criteria. Meta-analysis was performed for each diagnostic test identified in the included studies. Pooled estimates of diagnostic accuracy measures were calculated using a bivariate model and plotted in summary receiver-operator characteristic curves. Positive and negative predictive values were calculated in a hypothetical sample of patients with a given disease prevalence. RESULTS Twenty-four studies met the inclusion criteria, describing a total of 2974 patients. Quality scores ranged from 13 to 19. Meta-analysis could be performed on 7 unique diagnostic tests. Highest pooled sensitivity and specificity were demonstrated for α-defensin with values of 86% and 96.6%, respectively. α-defensin and white blood cell count in synovial fluid demonstrate highest negative predictive value values. CONCLUSIONS We recommend, in a clinical setting with low-intermediate prevalence of PJI, performing arthrocentesis and joint fluid analysis using α-defensin and/or white blood cell count before revision TKA and revision total hip arthroplasty surgery to rule out PJI.
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Affiliation(s)
- Annemarie Goud
- Department of Orthopedic Surgery, Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands
| | - Don Nützinger
- Department of Orthopedic Surgery, Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands; Clinical Orthopedic Research Center Midden Nederland, Diakonessenhuis Utrecht/Zeist, Zeist, the Netherlands
| | - Akke van der Bij
- Department of Microbiology and Immunology, Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands
| | - Kevin Jenniskens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), University Utrecht, Utrecht, the Netherlands
| | - Joel Groenewold
- University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
| | - Arthur de Gast
- Clinical Orthopedic Research Center Midden Nederland, Diakonessenhuis Utrecht/Zeist, Zeist, the Netherlands
| | - Joris E J Bekkers
- Department of Orthopedic Surgery, Diakonessenhuis Utrecht/Zeist, Utrecht, the Netherlands; Clinical Orthopedic Research Center Midden Nederland, Diakonessenhuis Utrecht/Zeist, Zeist, the Netherlands
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11
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The accuracy of D-dimer in the diagnosis of periprosthetic infections: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:99. [PMID: 35172830 PMCID: PMC8848660 DOI: 10.1186/s13018-022-03001-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/04/2022] [Indexed: 01/24/2023] Open
Abstract
Background Periprosthetic joint infection (PJI) is a devastating complication after total hip arthroplasty (THA) or total knee arthroplasty (TKA). It is scarce and contradicting evidence supporting the use of serum D-dimer to diagnose PJI in revision THA and TKA. This systematic review and meta-analysis aimed to investigate the accuracy of D-dimer in the diagnosis of periprosthetic infections. Methods The PubMed, Embase, Web of Science were systematically searched from the inception dates to August 15, 2020. We included all diagnostic studies of D-dimer in the diagnosis of periprosthetic infections. The literature's quality was evaluated by the QUADAS-2 tool, and Stata16 and Revman5.3 software carried out the meta-analysis. Results Of 115 citations identified by the search strategy, 10 studies (comprising 1756 participants) met the inclusion criteria. The literature quality assessment results show that most of the literature is low-risk bias literature. The combined sensitivity of D-dimer in diagnosing periprosthetic infections was 0.81 (95% confidence interval [CI] 0.71–0.88), combined specificity was 0.74 (95% CI 0.61–0.84), combined positive likelihood ratio was 3.1 (95% CI 2.0–5.0), combined negative likelihood ratio 0.26 (95% CI 0.16–0.41), combined diagnosis odds ratio 12 (95% CI 5–27), area under the Summary Receiver Operator Characteristic Curve (SROC) is 0.85 (95% CI 0.81–0.88). The data are statistically significant. Conclusion D-dimer has a high diagnostic value in diagnosing PJI and has clinical significance in diagnosing periprosthetic infection. In addition, there are relatively few studies on the threshold of D-dimer, different sampling types, different laboratory detection methods, and different races, so more prospective trials with large samples, multi-centers, and scientific design should be carried out in the future. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03001-y.
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Del Giudice F, Barnes C. Rapid Temperature-Dependent Rheological Measurements of Non-Newtonian Solutions Using a Machine-Learning Aided Microfluidic Rheometer. Anal Chem 2022; 94:3617-3628. [PMID: 35167252 DOI: 10.1021/acs.analchem.1c05208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Biofluids such as synovial fluid, blood plasma, and saliva contain several proteins which impart non-Newtonian properties to the biofluids. The concentration of such protein macromolecules in biofluids is regarded as an important biomarker for the diagnosis of several health conditions, including cardiovascular disorders, joint quality, and Alzheimer's. Existing technologies for the measurements of macromolecules in biofluids are limited; they require a long turnaround time, or require complex protocols, thus calling for alternative, more suitable, methodologies aimed at such measurements. According to the well-established relations for polymer solutions, the concentration of macromolecules in solutions can also be derived via measurement of rheological properties such as shear-viscosity and the longest relaxation time. We here introduce a microfluidic rheometer for rapid simultaneous measurement of shear viscosity and longest relaxation time of non-Newtonian solutions at different temperatures. At variance with previous technologies, our microfluidic rheometer provides a very short turnaround time of around 2 min or less thanks to the implementation of a machine-learning algorithm. We validated our platform on several aqueous solutions of poly(ethylene oxide). We also performed measurements on hyaluronic acid solutions in the clinical range for joint grade assessment. We observed monotonic behavior with the concentration for both rheological properties, thus speculating on their use as potential rheo-markers, i.e., rheological biomarkers, across several disease states.
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Affiliation(s)
- Francesco Del Giudice
- Department of Chemical Engineering, Faculty of Science and Engineering, School of Engineering and Applied Science, Swansea University Fabian Way, Swansea, SA1 8EN, United Kingdom
| | - Claire Barnes
- Department of Biomedical Engineering, Faculty of Science and Engineering, School of Engineering and Applied Science, Swansea University Fabian Way, Swansea, SA1 8EN, United Kingdom
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Fernandez-Sampedro M, Sanlés-González I, García-Ibarbia C, Fañanás-Rodríquez N, Fakkas-Fernández M, Fariñas MC. The poor accuracy of D-dimer for the diagnosis of prosthetic joint infection but its potential usefulness in early postoperative infections following revision arthroplasty for aseptic loosening. BMC Infect Dis 2022; 22:91. [PMID: 35086474 PMCID: PMC8793264 DOI: 10.1186/s12879-022-07060-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 01/13/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND D-dimer was introduced in 2018 as an alternative biomarker for C-reactive protein (CRP) in the diagnostic of prosthetic joint infection (PJI) criteria of the Musculoskeletal Infection Society. We assessed the accuracy of plasma D-dimer for the diagnosis of early, delayed, and late PJI according to Infectious Diseases Society of America (IDSA) criteria, and whether persistently high levels of D-dimer in cases of aseptic loosening (AL) may be predictive of subsequent implant-related infection. METHODS A prospective study of a consecutive series of 187 revision arthroplasties was performed at a single institution. Septic (n = 39) and aseptic revisions (n = 141) were classified based on IDSA criteria. Preoperative assessment of CRP, erythrocyte sedimentation rate (ESR) and D-dimer was performed. Receiver operating curves were used to determine maximum sensitivity and specificity of the biomarkers. The natural progress of D-dimer for AL cases was followed up either until the date of implant-related infection at any time during the first year or 1 year after revision in patients without failure. Clinical outcomes for those AL cases included infection-related failure that required a new surgery or need for antibiotic suppression. RESULTS Preoperative D-dimer level was significantly higher in PJI cases than in AL cases (p = 0.000). The optimal threshold of D-dimer for the diagnosis of PJI was 1167 ng/mL. For overall diagnosis of PJI, C-reactive protein (CRP) achieved the highest sensitivity (84.6%), followed by erythrocyte sedimentation rate (ESR) and D-dimer (82% and 71.8%, respectively). Plasma D-dimer sensitivity was lower for all PJI types. When combinations of 2 tests were studied, the combined use of ESR and CRP achieved the best accuracy for all types of PJI (76.9%). 4.25% of AL cases had implant failure due to implant-related infection during the first year after the index revision arthroplasty, only the cases with early failure maintained high D-dimer levels. CONCLUSIONS Plasma D-dimer did not offer an improvement over the individual or combined diagnosis for any type of PJI according to IDSA criteria. Persistently raised levels of D-dimer after revision arthroplasty in AL cases might be used to effectively diagnose early postoperative infection.
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Affiliation(s)
- M Fernandez-Sampedro
- Infectious Diseases Department, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Av. Valdecilla s/n 39008, Santander, Spain.
| | - I Sanlés-González
- Infectious Diseases Department, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Av. Valdecilla s/n 39008, Santander, Spain
| | - C García-Ibarbia
- Internal Medicine Department, Hospital Universitario Marqués de Valdecilla, University of Cantabria, Santander, Spain
| | - N Fañanás-Rodríquez
- Clinical Analysis Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - M Fakkas-Fernández
- Orthopaedic Surgery Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - M C Fariñas
- Infectious Diseases Department, Hospital Universitario Marqués de Valdecilla, University of Cantabria, IDIVAL, Av. Valdecilla s/n 39008, Santander, Spain
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Yan J, Xie K, Jiang X, Han X, Wang L, Yan M. D-dimer for diagnosis of periprosthetic joint infection: A meta-analysis. J Orthop Sci 2021; 26:1036-1042. [PMID: 33127211 DOI: 10.1016/j.jos.2020.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/19/2020] [Accepted: 09/26/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The D-dimer test is easily available to detect periprosthetic joint infection (PJI). This study aimed to estimate the diagnostic accuracy of the D-dimer test in PJI diagnosis and identify possible independent factors affecting the diagnostic value of this test. METHODS MEDLINE and EMBASE databases identified literature until February 2020 that utilized the D-dimer test for PJI diagnosis. The pooled sensitivity, specificity, area under the curve (AUC), diagnostic odds ratio (DOR), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) were calculated to evaluate the diagnostic accuracy of the D-dimer test. Meta-regression and subgroup analyses were performed to assess potential heterogeneity. RESULTS The databases identified 243 records, and eight studies were included in the final analysis. The pooled sensitivity and specificity of the D-dimer test for PJI diagnosis were 0.78 (95% confidence interval [CI], 0.69-0.84) and 0.74 (95% CI, 0.85-0.99), respectively. The AUCs and DORs of the D-dimer test were 0.83 (95% CI, 0.79-0.86) and 10 (95% CI, 4-24), respectively. The PLR and NLR of the D-dimer test for PJI detection were 3.0 (95% CI, 1.9-4.8) and 0.30 (95% CI, 0.20-0.47), respectively. The results of the meta-regression and subgroup analyses indicated that studies that excluded patients with hypercoagulation disorder had higher sensitivity (0.85 vs 0.86) and specificity (0.83 vs 0.62). The sensitivity of the D-dimer test also improved in studies that excluded patients with inflammatory arthritis (0.81 vs 0.75). CONCLUSION The D-dimer test is a practical method for PJI diagnosis, especially in patients without history of hypercoagulation disorder and inflammatory arthritis.
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Affiliation(s)
- Jiren Yan
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Medical College, Soochow University, Suzhou, Jiangsu, China
| | - Kai Xie
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Xu Jiang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuequan Han
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liao Wang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengning Yan
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Sigmund IK, Puchner SE, Windhager R. Serum Inflammatory Biomarkers in the Diagnosis of Periprosthetic Joint Infections. Biomedicines 2021; 9:biomedicines9091128. [PMID: 34572314 PMCID: PMC8467465 DOI: 10.3390/biomedicines9091128] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/16/2021] [Accepted: 08/21/2021] [Indexed: 11/23/2022] Open
Abstract
Accurate preoperative diagnosis of periprosthetic joint infections (PJIs) can be very challenging, especially in patients with chronic PJI caused by low-virulence microorganisms. Serum parameters, such as serum C-reactive protein (CRP) or the erythrocyte sedimentation rate (ESR), are—among other diagnostic test methods—widely used to distinguish septic from aseptic failure after total hip or knee arthroplasty and are recommended by the AAOS in the preoperative setting. However, they are systemic parameters, and therefore, unspecific. Nevertheless, they may be the first and occasionally the only preoperative indication, especially when clinical symptoms are lacking. They are easy to obtain, cheap, and are available worldwide. In the last decade, different novel serum biomarkers (percentage of neutrophils, neutrophils to lymphocytes ratio, platelet count to mean platelet volume ratio, fibrinogen, D-Dimer, Il-6, PCT) were investigated to find a more specific and accurate serum parameter in the diagnosis of PJI. This article reviews the diagnostic value of established (serum CRP, ESR, WBC) and ‘novel’ serum inflammatory biomarkers (fibrinogen, D-dimer, interleukin-6 (IL-6), procalcitonin, percentage of neutrophils (%N), neutrophils to lymphocytes ratio (NLR), platelet count to mean platelet volume ratio (PC/mPV)) for the preoperative diagnosis of periprosthetic joint infections.
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Tian B, Cui L, Jiang W. The diagnostic effect of α-defensin, D-dimer, and IL-6 in periprosthetic joint infection: A systematic review and diagnostic meta-analysis. J Orthop Surg (Hong Kong) 2021; 28:2309499020971861. [PMID: 33225796 DOI: 10.1177/2309499020971861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is the most common complication after artificial joint replacement as previously reported. However, the main problem at present is its difficulty in diagnosis. This systematic review and meta-analysis aimed to compare the diagnostic accuracy of α-defensin, D-dimer, and interleukin-6 (IL-6) in clinical practice. METHOD Online databases were systematically searched until June 18th, 2020 with keywords and medical sub-headings terms. Studies mentioned the sensitivity and specificity of biological markers in detecting PJI were included in our study. The sensitivity, specificity, and diagnostic odds ratios (DORs) were obtained after integration. RESULTS A total of 34 studies with 1036 patients diagnosing as PJI were included for comparing α-defensin, D-dimer, and IL-6. The sensitivity and specificity of α-defensin for PJI were 0.88 and 0.96, and the DOR was 189 (95% CI 72-496), respectively. The sensitivity and specificity of D-dimer (0.82 and 0.72) and IL-6 (0.80 and 0.89) were lower than α-defensin. CONCLUSION The detection of α-defensin is a promising biomarker for diagnosing PJI. The optional cut-off needs to be curtained when using other biomarkers.
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Affiliation(s)
- Baozhong Tian
- Bone surgery, Affiliated Hospital of Jilin Medical University, Jilin City, China
| | - Liwen Cui
- Changyi District Center for Disease Control and Prevention, Jilin City, China
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Zheng QY, Li R, Ni M, Ren P, Ji QB, Sun JY, Li JC, Chen JY, Zhang GQ. What Is the Optimal Timing for Reading the Leukocyte Esterase Strip for the Diagnosis of Periprosthetic Joint Infection? Clin Orthop Relat Res 2021; 479:1323-1330. [PMID: 33492869 PMCID: PMC8133206 DOI: 10.1097/corr.0000000000001609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/24/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The leucocyte esterase (LE) strip test often is used to diagnose periprosthetic joint infection (PJI). In accordance with the manufacturer's directions, the LE strip test result is read 3 minutes after exposing it to joint fluid, but this has not been supported by robust research. Moreover, we have noted that the results of the LE strip test might change over time, and our previous studies have found that centrifugation causes the results of the LE strip test to degrade. Still, there is no evidence-based recommendation as to when to read the LE strip test to maximize diagnostic accuracy, in general, and the best reading times for the LE strip test before and after centrifugation need to be determined separately, in particular. QUESTIONS/PURPOSES (1) What is the optimal timing for reading LE strip test results before centrifugation to diagnose PJI? (2) What is the optimal timing for reading LE strip test results after centrifugation to diagnose PJI? METHODS This study was a prospective diagnostic trial. In all, 120 patients who were scheduled for revision arthroplasty and had signs of infection underwent joint aspiration in the outpatient operating room between July 2018 and July 2019 and were enrolled in this single-center study. For inclusion, patients must have had a diagnosis of PJI or nonPJI, valid synovial fluid samples, and must not have received antibiotics within 2 weeks before arthrocentesis. As such, 36 patients were excluded; 84 patients were included for analysis, and all 84 patients agreed to participate. The 2018 International Consensus Meeting Criteria (ICM 2018) was used for the classification of 49 patients with PJI (score ≥ 6) and 35 without PJI (score ≤ 2). The classification was used as the standard against which the different timings for reading LE strips were compared. All patients without PJI were followed for more than 1 year, during which they did not report the occurrence of PJI. All patients were graded against the diagnostic criteria regardless of their LE strip test results. In 83 patients, one drop of synovial fluid (50 μL) was applied to LE strips before and after centrifugation, and in one patient (without PJI), the sample was not centrifuged because the sample volume was less than 1.5 mL. The results of the strip test were read on an automated colorimeter. Starting from 1 minute after centrifugation, these strips were automatically read once every minute, 15 times (over a period of 16 minutes), and the results were independently recorded by two observers. Results were rated as negative, ±, 1+, and 2+ upon the machine reading. Grade 2+ (dark purple) was used as the threshold for a positive result. An investigator who was blinded to the study performed the statistics. Optimal timing for reading the LE strip before and after centrifugation was determined by using receiver operative characteristic (ROC) analysis. The specificity, sensitivity, and positive predictive and negative predictive values were calculated for key timepoints. RESULTS Before centrifugation, the area under the curve was the highest when the results were read at 5 minutes (0.90 [95% CI 0.83 to 0.98]; sensitivity 0.88 [95% CI 0.75 to 0.95]; specificity 0.89 [95% CI 0.72 to 0.96]). After centrifugation, the area under the curve was the highest when the results were read at 10 minutes (0.92 [95% CI 0.86 to 0.98]; sensitivity 0.65 [95% CI 0.50 to 0.78]; specificity 0.97 [95% CI 0.83 to 1.00]). CONCLUSION The LE strip test results are affected by time and centrifugation. For samples without centrifugation, we found that 5 minutes after application was the best time to read LE strips. We cannot deny the use of centrifuges because this is an effective way to solve the sample-mingling problem at present. We recommend 10 minutes postapplication as the most appropriate time to read LE strips after centrifugation. Multicenter and large-sample size studies are warranted to further verify our conclusion. LEVEL OF EVIDENCE Level II, diagnostic study.
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Affiliation(s)
- Qing-yuan Zheng
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Rui Li
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Ming Ni
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Peng Ren
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Quan-bo Ji
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Jing-yang Sun
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Jun-cheng Li
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Ji-ying Chen
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Guo-qiang Zhang
- Q.-Y. Zheng, J.-Y. Sun, J.-C. Li, Medical School of Chinese People’s Liberation Army General Hospital, Beijing, China
- Q.-Y. Zheng, M. Ni, P. Ren, Q.-B. Ji, J.-Y. Sun, J-C. Li, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
- R. Li, M. Ni, J.-Y. Chen, G.-Q. Zhang, Department of Orthopedics, the Fourth Medical Center, Chinese People’s Liberation Army General Hospital, Beijing, China
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Balato G, De Franco C, Balboni F, De Matteo V, Ascione T, Baldini A, Lippi G. The role of D-dimer in periprosthetic joint infection: a systematic review and meta-analysis. ACTA ACUST UNITED AC 2021; 9:3-10. [PMID: 34013679 DOI: 10.1515/dx-2021-0032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/19/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The current literature on diagnosis of periprosthetic joint infection (PJI) provides controversial evidence on the diagnostic accuracy of D-dimer. Therefore, this critical literature search and meta-analysis was aimed to summarize the diagnostic accuracy of D-dimer for diagnosing PJI. CONTENT We searched MEDLINE, Scopus, and Web of Science, for studies on D-dimer for diagnosing PJI, according to the PRISMA flowchart. QUADAS was used for assessing study quality. Sensitivity, specificity, positive (PLR) and negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were analyzed using bivariate diagnostic random-effects model. The area under the receiver-operating curve (AUC-ROC) was calculated. Subgroup analysis and univariate meta-regression were carried out for detecting potential sources of heterogeneity. SUMMARY We included 12 articles, totaling 1,818 patients (539 with PJI). The pooled sensitivity and specificity of D-dimer for diagnosing PJI were 0.739 (95% CI: 0.616-0.833) and 0.785 (95% CI: 0.679-0.863). The pooled PLR, NLR, DOR were 3.359 (95% CI, 2.340-4.821), 0.295 (95% CI, 0.180-0.484), and 11.787 (95% CI, 5.785-24.018). The cumulative ROC plot displayed an AUC of 0.688 (95% CI, 0.663-0.713; p<0.001). No threshold effects could be observed. The type of blood sample was identified as possible source of heterogeneity for DOR (p=0.01). OUTLOOK Evidence emerged from this meta-analysis suggests that D-dimer displays sufficient diagnostic accuracy to rule out PJI. The type of blood sample (plasma vs. serum) and the study design could influence the results in terms of DOR and sensitivity. However, further perspective studies would be needed to validate its potential diagnostic usefulness.
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Affiliation(s)
- Giovanni Balato
- Department of Public Health, Orthopedic Unit, Federico II University Naples, Naples, Italy
| | - Cristiano De Franco
- Department of Public Health, Orthopedic Unit, Federico II University Naples, Naples, Italy
| | - Fiamma Balboni
- Laboratory Service, Istituto Fiorentino Cura e Assistenza IFCA Florence, Florence, Italy
| | - Vincenzo De Matteo
- Department of Public Health, Orthopedic Unit, Federico II University Naples, Naples, Italy
| | - Tiziana Ascione
- Department of Medicine, Service of Infectious Disease, Cardarelli Hospital Naples, Naples, Italy
| | - Andrea Baldini
- Orthopedic Unit, Istituto Fiorentino Cura e Assistenza IFCA Florence, Florence, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Different diagnostic performance of plasma fibrinogen and D-dimer in periprosthetic joint infection: a propensity score matched study. BMC Musculoskelet Disord 2021; 22:422. [PMID: 33962585 PMCID: PMC8106205 DOI: 10.1186/s12891-021-04282-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 04/20/2021] [Indexed: 01/04/2023] Open
Abstract
Background Fibrinogen (Fbg) and D-dimer have been used as biomarkers for the diagnosis of periprosthetic joint infection (PJI). However, previous research has reported conflicting results on the diagnostic value of D-dimer in comparison to Fbg, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Aim This study aimed to: (1) determine the optimal threshold of plasma Fbg and D-dimer in the diagnosis of PJI and compare their diagnostic value to that of CRP and ESR; and (2) investigate whether Fbg and D-dimer perform differently than CRP and ESR as diagnostic indicators for different types of PJI. Methods A total of 115 revision cases after total hip arthroplasty (THA) and total knee arthroplasty (TKA) were identified. Based on demographic characteristics, 25 culture-positive cases were matched to 50 culture-negative cases using propensity score matching. Sensitivity, specificity, receiver operating characteristics (ROC), negative predictive value (NPV), and positive predictive value (PPV) were calculated and compared. Results The optimal thresholds were 2.72 mg/L for D-dimer, 3.655 g/L for Fbg, 12.64 mg/L for CRP, and 27 mm/h for ESR. Levels of plasma Fbg, D-dimer, CRP, and ESR were significantly higher in the culture-positive group than the culture-negative group. Fbg, D-dimer, CRP, and ESR showed sensitivity of 0.92, 0.56, 0.92, and 0.88, respectively, and showed specificity of 0.84, 0.96, 0.94, and 0.80, respectively. The ROC curve showed that CRP has the highest area under the curve (AUC) (0.94), followed by Fbg (0.90), ESR (0.87), and D-dimer (0.81). Conclusions Plasma Fbg exhibited a similar diagnostic performance compared to CRP and ESR in predicting culture-positive results in PJI. Plasma D-dimer showed high specificity but low sensitivity. In our study, Fbg and D-dimer did not show better diagnostic performance with different pathogens and different types of PJI. Further studies are required to investigate the difference between serum D-dimer and plasma D-dimer in the arthroplasty population.
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Zhang Q, Dong J, Zhou D, Liu F. Circulating D-Dimer versus Fibrinogen in the Diagnosis of Peri-Prosthetic Joint Infection: A Meta-Analysis. Surg Infect (Larchmt) 2021; 22:200-210. [PMID: 32345131 DOI: 10.1089/sur.2019.298] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Circulating D-dimer and fibrinogen are both emerging as promising biomarkers for the diagnosis of peri-prosthetic joint infection (PJI), but their clinical values still remain disputable. This study aims to evaluate and compare the accuracy of circulating D-dimer and fibrinogen in the diagnosis of suspected PJI. Methods: We conducted a comprehensive literature search in PubMed, EMBASE, and the Cochrane Library to retrieve diagnostic accuracy studies in which PJI was investigated with circulating D-dimer or fibrinogen from the time of database inception to August 1, 2019. The pooled sensitivity, specificity, likelihood ratios and diagnostic odds ratio (DOR), summary receiver operating characteristic (sROC) curves, and area under the sROC curve (AUC) were constructed using a meta-analysis framework. Results: Seven eligible studies (1,374 patients) were included in the quantitative analysis. The mean levels of circulating D-dimer and fibrinogen were all significantly higher in patients with PJI. The plasma fibrinogen illustrated relatively higher sensitivity (0.84, 95% confidence interval [CI]: 0.78-0.98) and specificity (0.80, 95% CI: 0.76-0.84) than circulating D-dimer (0.74, 95% CI: 0.69-0.78; 0.66, 95% CI: 0.62-0.69, respectively) for the diagnosis of PJI. The pooled DOR of D-dimer, fibrinogen, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) to diagnose PJI was 7.00 (95% CI, 2.50-19.59), 12.40 (95% CI, 5.85 to 26.28), 10.71 (95% CI, 7.76 to 14.78) and 16.22 (95% CI 11.71-22.46), respectively, while the pooled AUC was 0.84 (95% CI, 0.77-0.90), 0.87 (95% CI, 0.85-0.89), 0.82 (95% CI, 0.78-0.85) and 0.87 (95% CI, 0.86-0.88), respectively. Conclusions: This meta-analysis reveals that it could be concluded that plasma fibrinogen is an excellent biomarker for diagnosing PJI, comparable to serum CRP and ESR, while the diagnostic value of circulating D-dimer is only moderate. Large-scale, prospective studies are still needed to confirm current findings.
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Affiliation(s)
- Qingyu Zhang
- Department of Orthopaedics, Shandong Provincial Hospital affiliated to Shandong University, Shandong, China
| | - Jinlei Dong
- Department of Orthopaedics, Shandong Provincial Hospital affiliated to Shandong University, Shandong, China
| | - Dongsheng Zhou
- Department of Orthopaedics, Shandong Provincial Hospital affiliated to Shandong University, Shandong, China
| | - Fanxiao Liu
- Department of Orthopaedics, Shandong Provincial Hospital affiliated to Shandong University, Shandong, China
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21
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Plasma fibrinogen in the diagnosis of periprosthetic joint infection. Sci Rep 2021; 11:677. [PMID: 33436902 PMCID: PMC7803950 DOI: 10.1038/s41598-020-80547-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 12/11/2020] [Indexed: 12/23/2022] Open
Abstract
Periprosthetic joint infections (PJIs) have become the most catastrophic complication for patients after arthroplasty. Although previous studies have found that many biomarkers have good performance for diagnosing PJI, early diagnosis remains challenging and a gold standard is lacking. This study aimed to investigate the diagnostic accuracy of plasma fibrinogen (FIB) in detecting PJI compared to other traditional biomarks (CRP, WBC and ESR). A total of 156 patients (including 57 PJI and 99 non-PJI patients) who underwent revision arthroplasty were retrospectively reviewed from 01/2014 to 01/2020. The diagnostic criteria of PJI were mainly based on the definition from the evidence-based definition for periprosthetic joint infection in 2018. The optimal plasma FIB predictive cutoff was 4.20 g/L, the sensitivity of the plasma fibrinogen was 0.860, the specificity was 0.900, the positive predictive value (PPV) was 0.831, and the negative predictive value (NPV) was 0.908. The area under the curve (AUC) value of plasma fibrinogen was 0.916 (95% CI 0.869-0.964), and the CRP, ESR and WBC levels had AUCs of 0.901, 0.822 and 0.647, respectively. Plasma FIB demonstrated better diagnostic strength compared with that of other serum biomarkers before revision arthroplasty. It represents a new horizon for the diagnosis of PJI due to the diagnosis values and cost-effective features.
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Chen X, Li H, Zhu S, Wang Y, Qian W. Is D-dimer a reliable biomarker compared to ESR and CRP in the diagnosis of periprosthetic joint infection? Bone Joint Res 2020; 9:701-708. [PMID: 33399473 PMCID: PMC7640940 DOI: 10.1302/2046-3758.910.bjr-2020-0172.r2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Aims The diagnosis of periprosthetic joint infection (PJI) has always been challenging. Recently, D-dimer has become a promising biomarker in diagnosing PJI. However, there is controversy regarding its diagnostic value. We aim to investigate the diagnostic value of D-dimer in comparison to ESR and CRP. Methods PubMed, Embase, and the Cochrane Library were searched in February 2020 to identify articles reporting on the diagnostic value of D-dimer on PJI. Pooled analysis was conducted to investigate the diagnostic value of D-dimer, CRP, and ESR. Results Six studies with 1,255 cases were included (374 PJI cases and 881 non-PJI cases). Overall D-dimer showed sensitivity of 0.80 (95% confidence interval (CI) 0.69 to 0.87) and specificity of 0.76 (95% CI 0.63 to 0.86). Sub-group analysis by excluding patients with thrombosis and hyper-coagulation disorders showed sensitivity of 0.82 (95% CI 0.70 to 0.90) and specificity of 0.80 (95% CI 0.70 to 0.88). Serum D-dimer showed sensitivity of 0.85 (95% CI 0.76 to 0.92), specificity of 0.83 (95% CI 0.74 to 0.90). Plasma D-dimer showed sensitivity of 0.67 (95% CI 0.60 to 0.73), specificity of 0.58 (95% CI 0.45 to 0.72). CRP showed sensitivity of 0.78 (95% CI 0.72 to 0.83), specificity of 0.81 (95% CI 0.72 to 0.87). ESR showed sensitivity of 0.68 (95% CI 0.63 to 0.73), specificity of 0.83 (95% CI 0.78 to 0.87). Conclusion In patients without thrombosis or a hyper-coagulation disorder, D-dimer has a higher diagnostic value compared to CRP and ESR. In patients with the aforementioned conditions, D-dimer has higher sensitivity but lower specificity compared to ESR and CRP. We do not recommend the use of serum D-dimer in patients with thrombosis and hyper-coagulation disorders for diagnosing PJI. Serum D-dimer may perform better than plasma D-dimer. Further studies are needed to compare serum D-dimer and plasma D-dimer in arthroplasty patients. Cite this article: Bone Joint Res 2020;9(10):701–708.
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Affiliation(s)
- Xi Chen
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Hairui Li
- Department of Plastic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Shibai Zhu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Yiou Wang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Wenwei Qian
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
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Wang Y, Man Z, Yuan T, Cao H, Sun S. Reliability of d-Dimer Determination in Diagnosis of Peri-Prosthetic Joint Infection: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2020; 22:374-382. [PMID: 32897817 DOI: 10.1089/sur.2020.212] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Surgeons continue to seek indicators for the diagnosis of peri-prosthetic joint infection (PJI), which is a serious complication after total joint arthroplasty (TJA). Many recent studies have assessed the value of d-dimer in diagnosing PJI because of the close relation between the d-dimer value and inflammation. However, the conclusions from different studies are still disputed. Methods: We searched for studies published from 2011 to March 2020 using online databases and screened studies based on the inclusion criteria. Diagnostic parameters of d-dimer, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were calculated, including the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and the area under the curve (AUC). In addition, univariate meta-regression and subgroup analyses were performed to identify sources of heterogeneity. Results: A total of nine studies with 431 Patients with PJI were included. The pooled sensitivity, specificity, DOR, and AUC of d-dimer were 0.82 (95% confidence interval [CI], 0.73-0.89), 0.73 (95% CI, 0.58-0.83), 12 (95% CI, 5-30), and 0.85 (95% CI, 0.82-0.88), respectively. In addition, the sensitivity, specificity, and AUC of CRP were 0.78 (95% CI, 0.73-0.83), 0.80 (95% CI, 0.73-0.86) and 0.85 (95% CI, 0.81-0.87), respectively, whereas those of ESR were 0.68 (95% CI, 0.60-0.74), 0.83 (95% CI, 0.75-0.88), and 0.80 (95% CI, 0.76-0.83), respectively. Conclusions: d-dimer determination had similar performance to CRP and ESR in the diagnosis of PJI and may be a good addition to the current diagnostic criteria.
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Affiliation(s)
- Yi Wang
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Zhentao Man
- Department of Joint Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Tao Yuan
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Huan Cao
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Shui Sun
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Joint Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
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Zhang H, Sun X, Xin P, Zhu X, Jie K, Cao H, Feng W, Zeng Y, Lv Y, Chen J, Li J, Zeng J, Zeng Y. Diagnostic accuracy of D-dimer in periprosthetic joint infection: a diagnostic meta-analysis. J Orthop Surg Res 2020; 15:334. [PMID: 32807236 PMCID: PMC7430004 DOI: 10.1186/s13018-020-01853-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/31/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is one of the most devastating complications after total joint replacement (TJA). Up to now, the diagnosis of PJI is still in a dilemma. As a novel biomarker, whether D-dimer is valuable in the diagnosis of PJI remains controversial. This meta-analysis attempts to determine the diagnostic accuracy of D-dimer in PJI. METHODS Relevant literature was retrieved from PubMed, Embase, Web of Science, and Cochrane Library (from database establishment to April 2020). Literature quality was evaluated using Revman (version 5.3). The random effect model was used in the Stata version 14.0 software to combine sensitivity, specificity, likelihood ratio (LR), diagnostic odds ratio (DOR), summary receiver operating characteristic (SROC) curve, and area under SROC (AUC) to evaluate the diagnostic value of overall D-dimer for PJI. Meta regression and subgroup analysis were performed according to the threshold, the study design, the sample size, the diagnostic gold standard, the country of study, and the type of sample. RESULTS A total of 9 studies were included in this study, including 1592 patients. The pooled sensitivity and specificity of D-dimer for PJI diagnosis are 0.82 (95% CI, 0.72~0.89) and 0.73 (95% CI, 0.58~0.83), respectively. The pooled positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 2.99 (95% CI, 1.84~4.88) and 0.25 (95% CI, 0.15~0.41), respectively. The pooled AUC and diagnostic odds ratios were 0.85 (95% CI, 0.82~0.88) and 12.20 (95% CI, 4.98~29.86), respectively. CONCLUSION D-dimer is a promising biomarker for the diagnosis of PJI, which should be used in conjunction with other biomarkers or as an adjunct to other diagnostic methods to enhance diagnostic performance.
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Affiliation(s)
- Haitao Zhang
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Xiaobo Sun
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China.,Ganzhou Hospital of Traditional Chinese Medicine, Xijin Road 16#, District Zhanggong, Ganzhou, Jiangxi, China
| | - Pengfei Xin
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Xingyang Zhu
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Ke Jie
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Houran Cao
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Wenjun Feng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Yuqing Zeng
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Yan Lv
- The First Affiliated Hospital of Nanchang University, 17 Yongwai Street, Nanchang, 330006, China
| | - Jinlun Chen
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Jie Li
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Jianchun Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Yirong Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China.
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Li C, Margaryan D, Ojeda-Thies C, Perka C, Trampuz A. Meta-analysis of serum and/or plasma D-dimer in the diagnosis of periprosthetic joint infection. J Orthop Surg Res 2020; 15:298. [PMID: 32762703 PMCID: PMC7409706 DOI: 10.1186/s13018-020-01808-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/21/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The purpose of this meta-analysis was to evaluate the diagnostic value of D-dimer in detecting periprosthetic joint infection (PJI). METHODS A systematic search and screening of relevant studies was performed in the databases PubMed, Web of Science, and Embase using the following medical subject headings (MeSH) or keywords: "arthroplasty or joint prosthesis or joint replacement or periprosthetic joint or prosthetic joint", "infection or infectious or infected", and "D-dimer or serum D-dimer or plasma D-dimer or fibrin degradation products". Data were subsequently analysed and processed using Meta-Disc. RESULTS Seven studies with 1285 patients were included in this meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 0.75 (95% confidence interval [CI] 0.70-0.79), 0.69 (95% CI 0.66-0.72), 3.01 (95% CI 1.84-4.93), 0.32 (95% CI 0.19-0.53), and 10.20 (95% CI 3.63-28.64), respectively. Subgroup analyses showed that the use of serum D-dimer had better sensitivity and specificity than plasma D-dimer for the diagnosis of PJI. CONCLUSIONS Serum D-dimer was shown to have a better diagnostic value than plasma D-dimer for the diagnosis of PJI. Further research is required for clarification.
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Affiliation(s)
- Cheng Li
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Donara Margaryan
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | | | - Carsten Perka
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany.
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26
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Lu G, Li T, Ye H, Liu S, Zhang P, Wang W. D-dimer in the diagnosis of periprosthetic joint infection: a systematic review and meta-analysis. J Orthop Surg Res 2020; 15:265. [PMID: 32677991 PMCID: PMC7364596 DOI: 10.1186/s13018-020-01761-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/23/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND D-dimer, a coagulation-related indicator, has recently been used as a tool for the diagnosis of periprosthetic joint infection (PJI), but its reliability is uncertain. The purpose of this systematic review and meta-analysis was to explore the accuracy of D-dimer in the diagnosis of PJI after joint arthroplasty. METHODS We systematically searched the MEDLINE, EMBASE, and Cochrane databases for relevant literature about D-dimer in the diagnosis of PJI. QUADAS-2 was used to assess the risk of bias and clinical applicability of each included study. We used the bivariate meta-analysis framework to pool the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the SROC curve (AUC). Univariate meta-regression and subgroup analyses were performed to explore the sources of heterogeneity. RESULTS We included 8 eligible studies. The pooled diagnostic sensitivity and specificity were 0.82 (95% CI, 0.70-0.89) and 0.70 (95% CI, 0.55-0.82), respectively. The pooled PLR, NLR, and DOR were 2.7 (95% CI, 1.7-4.4), 0.26 (95% CI, 0.15-0.46), and 10 (95% CI, 4-25), respectively. The AUC was 0.83 (95% CI, 0.8-0.86). Serum D-dimer might have higher diagnostic accuracy than plasma D-dimer for PJI (pooled sensitivity: 0.88 vs 0.67; pooled specificity: 0.76 vs 0.61). CONCLUSIONS D-dimer has limited performance for the diagnosis of PJI.
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Affiliation(s)
- Guangxu Lu
- Department of Logistics University of PAP, Tianjin, 300309, China.,Department of Orthopedics, Characteristic Medical Center of PAP, Tianjin, 300162, China.,Department of Orthopedics, Er Quan Hospital of PAP, Wuxi, 214000, China
| | - Tong Li
- Department of Orthopedics, Characteristic Medical Center of PAP, Tianjin, 300162, China
| | - Haoqi Ye
- Department of Logistics University of PAP, Tianjin, 300309, China
| | - Shujin Liu
- Department of Logistics University of PAP, Tianjin, 300309, China.,Department of Orthopedics, Characteristic Medical Center of PAP, Tianjin, 300162, China
| | - Peng Zhang
- Department of Orthopedics, Characteristic Medical Center of PAP, Tianjin, 300162, China
| | - Wenliang Wang
- Department of Orthopedics, Characteristic Medical Center of PAP, Tianjin, 300162, China.
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Fehring TK, Fehring KA, Hewlett A, Higuera CA, Otero JE, Tande AJ. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2020; 102:1222-1229. [PMID: 32675671 PMCID: PMC7431136 DOI: 10.2106/jbjs.20.00363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | | | | | | | - Jesse E. Otero
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina
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