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Kreinces JB, Ashkenazi I, Shichman I, Roof MA, Schwarzkopf R, Aggarwal VK. The James A. Rand Young Investigator's Award: Keeping It Simple: Are all Musculoskeletal Infection Society Tests Useful to Diagnose Periprosthetic Joint Infection? J Arthroplasty 2024; 39:S3-S7.e1. [PMID: 38810813 DOI: 10.1016/j.arth.2024.05.048] [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: 10/27/2023] [Revised: 05/18/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Current data evaluating the clinical value and cost-effectiveness of advanced diagnostic tests for periprosthetic joint infection (PJI) diagnosis, including alpha-defensin and synovial C-reactive protein (CRP), is conflicting. This study aimed to evaluate the adequacy of preoperative and intraoperative PJI workups without utilizing these tests. METHODS This retrospective analysis identified all patients who underwent revision total knee or hip arthroplasty (rTKA and rTHA, respectively) for suspected PJI between 2018 and 2020 and had a minimum follow-up of 2 years. Perioperative data and lab results were collected, and cases were dichotomized based on whether they met the 2018 Musculoskeletal Infection Society (MSIS) criteria for PJI. In total, 204 rTKA and 158 rTHA cases suspected of PJI were reviewed. RESULTS Nearly 100% of the cases were categorized as "infected" for meeting the 2018 MSIS criteria without utilization of alpha-defensin or synovial CRP (rTKA: n = 193, 94.6%; rTHA: n = 156, 98.7%). Most cases were classified as PJI preoperatively by meeting either the major MSIS or the combinational minor MSIS criteria of traditional lab tests (rTKA: n = 177, 86.8%; rTHA: n = 143, 90.5%). A subset of cases was classified as PJI by meeting combinational preoperative and intraoperative MSIS criteria (rTKA: 16, 7.8%; rTHA: 13, 8.2%). Only 3.6% of all cases were considered "inconclusive" using preoperative and intraoperative data. CONCLUSIONS Given the high rate of cases satisfying PJI criteria during preoperative workup using our available tests, the synovial alpha-defensin and synovial CRP tests may not be necessary in the routine diagnostic workup of PJI. We suggest that the primary PJI workup process should be based on a stepwise algorithmic approach with the most economical testing necessary to determine a diagnosis first. The use of advanced, commercialized, and costly biomarkers should be utilized only when traditional testing is indeterminate.
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Affiliation(s)
| | - Itay Ashkenazi
- NYU Langone, Adult Reconstructive Division, New York, New York; Division of orthopedic surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Ittai Shichman
- NYU Langone, Adult Reconstructive Division, New York, New York; Division of orthopedic surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | | | - Ran Schwarzkopf
- NYU Langone, Adult Reconstructive Division, New York, New York
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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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Xu H, Zhou J, Huang Q, Huang Z, Xie J, Zhou Z. Unreliability of Serum- or Plasma-based Assays of D-dimer or Fibrin (Fibrinogen) Degradation Product for Diagnosing Periprosthetic Joint Infection: A Prospective Parallel Study. Orthop Surg 2024; 16:29-37. [PMID: 37975182 PMCID: PMC10782268 DOI: 10.1111/os.13935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE The ability of D-dimer to diagnose periprosthetic joint infection (PJI) before revision hip or knee arthroplasty is still controversial, and the differences in diagnostic ability between serum- or plasma-based assays of D-dimer and fibrin (fibrinogen) degradation product (FDP) are uncertain. The prospective parallel study was performed to determine the ability of D-dimer to diagnose PJI before revision hip or knee arthroplasty, and the differences in diagnostic ability between serum- or plasma-based assays of D-dimer and FDP. METHODS Patients undergoing knee or hip arthroplasty at our institution were prospectively enrolled into the following groups: those without inflammatory diseases who were undergoing primary arthroplasty ("Prim" group), those with inflammatory arthritis who were undergoing primary arthroplasty ("Prim/Inflam"), those undergoing revision arthroplasty because of aseptic failure ("Rev/Asept"), or those undergoing revision arthroplasty because of PJI ("Rev/PJI"). The ability of preoperative levels of D-dimer or FDP in serum or plasma to diagnose PJI in each group was assessed using areas under receiver operating characteristic curves (AUCs) and other diagnostic performance indicators. The diagnostic performance of these assays was compared with that of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). RESULTS In the final analysis, Prim included 42 patients; Prim/Inflam, 40; Rev./Asept, 62; and Rev./PJI, 47. D-dimer assays led to AUCs of 0.635 in serum and 0.573 in plasma, compared to 0.593 and 0.607 for FDP. Even in combination with CRP or ESR, these assays failed to perform as well as the combination of CRP and ESR for diagnosing PJI. CONCLUSION Levels of D-dimer or FDP in serum or plasma, whether used alone or together with CRP or ESR, are unreliable for diagnosing PJI before revision arthroplasty.
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Affiliation(s)
- Hong Xu
- Department of Orthopedic surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Jing Zhou
- Department of Laboratory Medicine, West China HospitalSichuan UniversityChengduChina
| | - Qiang Huang
- Department of Orthopedic surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Zeyu Huang
- Department of Orthopedic surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Jinwei Xie
- Department of Orthopedic surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Zongke Zhou
- Department of Orthopedic surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
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Tarabichi S, Goh GS, Fernández-Rodríguez D, Baker CM, Lizcano JD, Parvizi J. Plasma D-Dimer Is a Promising Marker to Guide Timing of Reimplantation: A Prospective Cohort Study. J Arthroplasty 2023; 38:2164-2170.e1. [PMID: 37172794 DOI: 10.1016/j.arth.2023.04.065] [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: 01/31/2023] [Revised: 04/25/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Two-stage exchange arthroplasty remains the preferred surgical treatment for chronic periprosthetic joint infection. Currently, there is no single reliable marker to determine the optimal timing for reimplantation. The purpose of this prospective study was to assess the diagnostic utility of plasma D-dimer and other serological markers in predicting successful control of infection following reimplantation. METHODS This study enrolled 136 patients undergoing reimplantation arthroplasty between November 2016 and December 2020. Strict inclusion criteria were applied including the need for a two-week "antibiotic holiday" prior to reimplantation. A total of 114 patients were included in the final analysis. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. Treatment success was defined using the Musculoskeletal Infection Society Outcome-Reporting Tool. Receiver operating characteristic curves were used to assess the prognostic accuracy of each biomarker in predicting failure following reimplantation at a minimum 1-year follow-up. RESULTS Treatment failure occurred in 33 patients (28.9%) at a mean follow-up of 3.2 years (range, 1.0 to 5.7). Median plasma D-dimer was significantly higher in the treatment failure group (1,604 versus 631 ng/mL, P < .001), whereas median CRP, ESR, and fibrinogen were not significantly different between the success and failure groups. Plasma D-dimer demonstrated the best diagnostic utility (area under the curve [AUC] 0.724, sensitivity 51.5%, specificity 92.6%), outperforming ESR (AUC 0.565, sensitivity 93.3%, specificity 22.5%), CRP (AUC 0.541, sensitivity 87.5%, specificity 26.3%), and fibrinogen (AUC 0.485, sensitivity 30.4%, specificity 80.0%). Plasma D-dimer level of ≥1,604 ng/mL was identified as the optimal cutoff that predicted failure following reimplantation. CONCLUSION Plasma D-dimer was superior to serum ESR, CRP, and fibrinogen in predicting failure after the second stage of a two-stage exchange arthroplasty for periprosthetic joint infection. Based on the findings of this prospective study, plasma D-dimer may be a promising marker in assessing the control of infection in patients undergoing reimplantation surgery. LEVEL OF EVIDENCE Level II.
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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
| | - Diana Fernández-Rodríguez
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Plan de Estudios Combinados en Medicina (PECEM) MD/PhD, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Colin M Baker
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Tripathi S, Tarabichi S, Parvizi J, Rajgopal A. Current relevance of biomarkers in diagnosis of periprosthetic joint infection: an update. ARTHROPLASTY 2023; 5:41. [PMID: 37525262 PMCID: PMC10391917 DOI: 10.1186/s42836-023-00192-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/03/2023] [Indexed: 08/02/2023] Open
Abstract
With a significant rise in the number of arthroplasty procedures performed worldwide, the increasing revision burden posed by periprosthetic joint infection (PJI) is a matter of growing concern. In spite of various attempts to diagnose PJI, there are no defined tests that can be called a gold standard. Given the importance of early diagnosis in PJI, newer tests and biomarkers have been introduced to improve cumulative diagnostic accuracy. Novel biomarkers like calprotectin, lipocalcin, monocyte-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and platelet-to-mean platelet volume ratio have demonstrated a potential as diagnostic biomarkers for PJI. This article discusses the relevance of available and newly described diagnostic biomarkers to provide a perspective on the practical applicability in current medical practice, as well as highlights some recent advances in biomarkers for the diagnosis of PJI.
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Affiliation(s)
- Saksham Tripathi
- Institute of Musculoskeletal Disorders and Orthopaedics, Medanta-The Medicity, Gurugram, HR, 122001, India.
| | - Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | - Ashok Rajgopal
- Institute of Musculoskeletal Disorders and Orthopaedics, Medanta-The Medicity, Gurugram, HR, 122001, India
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Pannu TS, Villa JM, Jimenez D, Riesgo AM, Higuera CA. Does Performance of D-Dimer for Diagnosis of Periprosthetic Joint Infection Change with the Virulence of Infecting Organism? J Arthroplasty 2023:S0883-5403(23)00546-6. [PMID: 37209907 DOI: 10.1016/j.arth.2023.05.022] [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] [Received: 12/01/2022] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023] Open
Abstract
INTRODUCTION The impact of the organism virulence on diagnostic accuracy of D-Dimer for periprosthetic joint infection (PJI) is unknown. Our objective was to assess if the performance of D-Dimer in PJI diagnosis changes with the virulence of the organism(s). METHODS Retrospective review of 143 consecutive revision total hip/knee arthroplasties (THA/TKAs) with D-Dimer ordered preoperatively. Operations were performed by 3 surgeons at a single institution (November 2017 through September 2020). There were 141 revisions with complete 2013-International Consensus Meeting (ICM)-criteria initially included. This criteria was used to classify revisions as aseptic vs. septic. Culture-negative septic revisions (n=8) were excluded, and 133 revisions (47-hips/86-knees; 67-septic/66-aseptic) were analyzed. Based on culture results, septic-revisions were categorized into 'low-virulence (LV/n=40)' or 'high-virulence (HV/n=27)'. The D-Dimer threshold (850-ng/mL) was tested against 2013-ICM-criteria ("standard") in identifying septic-revisions (LV/HV) from aseptic-revisions. Sensitivity, specificity, and positive/negative-predictive-values (PPV/NPV) were determined. Receiver-operating-characteristic-curve-analyses were performed. RESULTS Plasma D-Dimer showed high sensitivity (97.5%) and NPV (95.4%) in LV septic cases, which appeared to reduce by about 5% in HV septic cases (sensitivity=92.5% and NPV=91.3%). However, this marker had poor overall accuracy (LV=57%; HV=49.4%), low specificity (LV and HV=31.8%), and PPV (LV=46.4%; HV=35.7%) to diagnose PJI. The area under the curve (AUC) was 0.647 and 0.622 in LV and HV vs. aseptic revisions, respectively. CONCLUSION D-Dimer performs poorly to identify septic from aseptic revisions in the setting of LV/HV infecting organisms alike. However, it shows high sensitivity for PJI diagnosis in cases of low virulence organisms which might be missed by most diagnostic tests.
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Affiliation(s)
- Tejbir S Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida, 33331
| | - Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida, 33331
| | - Denise Jimenez
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida, 33331
| | - Aldo M Riesgo
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida, 33331
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida, 33331.
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Akgün D, Al-Muhtaresh F, Paksoy A, Lacheta L, Minkus M, Karczewski D, Moroder P. The role of serum D-Dimer for the diagnosis of periprosthetic shoulder infection. Arch Orthop Trauma Surg 2023; 143:1855-1860. [PMID: 35182199 PMCID: PMC10030413 DOI: 10.1007/s00402-022-04385-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 02/05/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION D-Dimer was recently identified as an additional biomarker in the diagnosis of hip and knee periprosthetic joint infection (PJI). Currently, there is only one study in literature dealing with the role of D-Dimer in the diagnosis of shoulder PJI. The purpose of this study was, therefore, to validate the sensitivity and specificity of D-Dimer in detecting shoulder PJI. MATERIALS AND METHODS All patients, who underwent septic or aseptic revision shoulder arthroplasty in our institution between November 2018 und March 2021, were analyzed. Our cohort consisted of 30 patients, of that 14 (47%) had a shoulder PJI according the last proposed criteria of the International Consensus Meeting. The diagnostic validity of serum D-Dimer regarding the detection of PJI was analyzed. RESULTS The mean D-Dimer level was significantly higher for the patients with shoulder PJI compared to patients with aseptic failure (1.44 ± 1 mg/l vs. 0.76 ± 0.6 mg/l, p = 0.025). Coagulase-negative staphylococci were the most commonly isolated pathogens, in 9/14 patients (64%), followed by Cutibacterium acnes in 5/14 patients (36%). According to the ROC analysis, a serum D-Dimer threshold of 0.75 mg/l had a sensitivity of 86% and a specificity of 56% for detection of a shoulder PJI. The area under curve was 0.74. A serum C-reactive protein (CRP) cutoff of 10 mg/l showed a sensitivity of 69% and a specificity of 88%. When both serum D-Dimer and CRP above the thresholds of 0.75 mg/l and 10 mg/l, respectively, were used to identify a PJI the sensitivity and specificity were 57% and 100%, respectively. CONCLUSIONS Serum D-Dimer showed a good sensitivity but a poor specificity for the diagnosis of shoulder PJI. Combination D-Dimer and CRP led to improvement of the specificity, however, at the cost of sensitivity. Thus, combination of both methods may be used as a confirmatory test in the diagnosis of shoulder PJI but not to rule out infection. LEVEL OF EVIDENCE Diagnostic level II.
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Affiliation(s)
- Doruk Akgün
- Center for Musculoskeletal Surgery, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Faisal Al-Muhtaresh
- Center for Musculoskeletal Surgery, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Alp Paksoy
- Center for Musculoskeletal Surgery, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Lucca Lacheta
- Center for Musculoskeletal Surgery, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Marvin Minkus
- Center for Musculoskeletal Surgery, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Daniel Karczewski
- Center for Musculoskeletal Surgery, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Philipp Moroder
- Center for Musculoskeletal Surgery, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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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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Wang R, Shi G, Zhang H, Wang T, Ren W, Jiao Q. Globulin and Albumin/Globulin Ratios as Potential Biomarkers for the Diagnosis of Acute and Chronic Peri-Prosthetic Joint Infections: A Retrospective Study. Surg Infect (Larchmt) 2023; 24:58-65. [PMID: 36706257 DOI: 10.1089/sur.2022.215] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background: Peri-prosthetic joint infection (PJI) is the most serious complication after prosthetic joint replacement. However, the diagnosis of PJI remains challenging for clinicians because of the lack of a gold standard. The purpose of this study was to investigate the diagnostic significance of serum globulin, albumin/globulin, and other biomarkers in acute and chronic periprosthetic infections. Patients and Methods: A retrospective study of 162 patients with PJI and aseptic loosening between January 2016 and March 2021 at our institution was performed in three groups. There were 20 patients with acute infection in group A, 36 patients with chronic infection in group B, and 106 patients with aseptic loosening in group C. Globulin, albumin/globulin, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), platelet count (PLT), mean platelet volume (MPV), d-dimer, and platelet count/mean platelet volume ratio (PMR) levels were recorded. The area under the curve (AUC) was used to measure the diagnostic value of globulin and albumin/globulin with other biomarkers for PJI. Results: Compared with the aseptic loosening group, the acute and chronic PJI group had higher levels of CRP, ESR, d-dimer, globulin, PLT, and PMR (p < 0.01) and lower levels of albumin/globulin and MPV (p < 0.01). The optimal cutoff, AUC, sensitivity, and specificity of CRP, albumin/globulin, ESR, and globulin were: CRP, 8.3 mg/L, 0.903, 78.57%, and 88.68%; albumin/globulin, 1.31, 0.899, 91.07%, and 73.58%; ESR, 32 mm/h, 0.888, 75.%, and 85.85%; globulin, 29.5 g/L, 0.880, 91.07%, and 72.64%. Conclusions: Globulin and albumin/globulin have excellent diagnostic value for acute and chronic PJI and are promising potential biomarkers for the diagnosis of PJI. The diagnostic performance of albumin/globulin is superior to that of ESR and similar to that of CRP.
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Affiliation(s)
- Renwei Wang
- Department of Orthopedic, Linfen Central Hospital, Linfen, Shanxi Province, China.,Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Guang Shi
- Department of Orthopedic, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong Province, P.R. China
| | - Hui Zhang
- Department of Orthopedic, Xi'an International Medical Center Hospital, Xi'an, Shaanxi Province, China
| | - Tao Wang
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Weiping Ren
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Qiang Jiao
- Department of Orthopedic, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
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Ciriello V, Ghannadian S, Saracco M, Logroscino G. Is Fibrinogen a Reliable Biomarker in the Diagnosis of Peri-Prosthetic Joint Infection? A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2022; 23:787-795. [PMID: 36269621 DOI: 10.1089/sur.2022.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: In recent years, several studies have identified closed correlations between the coagulation cascade and inflammatory mechanisms in infective diseases. Fibrinogen (PF) is emerging as promising biomarker for the diagnosis of peri-prosthetic joint infection (PJI). This study aims to investigate the diagnostic value of PF in diagnosing PJI and to explore potential causes influencing the diagnostic value of PF. Materials and Methods: PubMed, Embase, and Cochrane Library were searched regarding the role of fibrinogen as a biomarker in the diagnosis of PJI. Studies in English were included in the meta-analysis if they determined the diagnostic value of fibrinogen for PJI detection after hip or knee arthroplasty, applying the recognized diagnostic criteria for PJI. A quality evaluation of the studies included was performed. The pooled sensitivity, specificity, likelihood ratios and diagnostic odds ratio (DOR) and the area under the receiver operating characteristic curve (AUROC) were obtained using the statistical software STATA, version 17 (StataCorp, College Station, TX). Results: Ten studies (9 retrospective) were included in the study. Low publication bias was detected, but with high heterogeneity among them. Plasma fibrinogen showed a good diagnostic accuracy and clinical utility in PJI (sensitivity, 0.81 [95% confidence interval {CI}, 0.75-0.86]; specificity, 0.82 [95% CI, 0.76-0.86]; AUROC, 0.88 [95% CI, 0.85-0.91]; DOR, 19 [95% CI, 14-26]). Conclusions: The attempt to find an "ideal" biomarker is crucial to improve the sensitivity and specificity of the current diagnostic algorithms for PJI. The analysis performed in the current study indicates that plasma fibrinogen test is a valid biomarker for PJI diagnosis.
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Affiliation(s)
- Vincenzo Ciriello
- Department of Orthopaedics and Trauma, ASO "S. Croce e Carle", Cuneo, Italy
| | | | - Michela Saracco
- Department of Orthopaedics, "A. Gemelli" IRCCS University Hospital Foundation - Catholic University of the Sacred Heart, Rome, Italy.,Department of Orthopaedics and Trauma, "San Giovanni di Dio" Hospital, ASL Napoli2 Nord, Naples, Italy
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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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Paradoxical Behavior of Plasma d-Dimer From Explantation to Reimplantation in a Two-Stage Revision for Periprosthetic Joint Infection. J Arthroplasty 2022; 37:S977-S982. [PMID: 35158006 DOI: 10.1016/j.arth.2022.02.023] [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: 11/23/2021] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The variation of plasma d-dimer, an inflammatory marker, from pre-explantation to pre-reimplantation in two-stage revision remains unclear. Our objective was to evaluate delta-changes (Δ) in d-dimer, erythrocyte sedimentation rate (ESR), and C-reactive-protein (CRP), to ascertain whether these delta-changes are associated with the outcome of reimplantation. We hypothesized a decrease in d-dimer before reimplantation. METHODS A retrospective review was performed on a consecutive series of 95 two-stage revisions indicated for periprosthetic joint infection. Surgeries were performed by 3 surgeons at a single institution (2018-2020). The minimum follow-up was 1 year. The inclusion criteria comprised availability of d-dimer results at pre-explantation and pre-reimplantation. As a result, only 30 reimplantations were included. Success of reimplantation was defined by Musculoskeletal Infection Society outcome reporting tool: Tier 1/Tier 2 vs Tier 3/Tier 4. Nonparametric tests and Mann-Whitney U-tests were conducted to compare Δd-dimer% (pre-explantation value - pre-reimplantation value/pre-explantation value × 100). The bootstrapped receiver operating characteristic curve analyses with 2,000 replicates of 30 cases were conducted. RESULTS The median time between explantation and reimplantation was 86 days (interquartile range [IQR] = 77.7-138.5 days). Overall, a paradoxical median percent increase (Δd-Dimer% [INCREMENT] = 12.6%) in d-dimer was found from pre-explantation to pre-reimplantation (IQR = -28.06% to 77.3%). However, there was a percentage decrease in ESR (ΔESR% [DECREMENT] = -40%; IQR = -70.52% to 3.85%) and CRP (ΔCRP% [DECREMENT] = -75%; IQR = -87.43% to -61.34%). The changes in all these markers were not different between Musculoskeletal Infection Society Tier 1/2 and 3/4 outcomes (Δd-Dimer%, P = .146; ΔESR%, P = .946; ΔCRP%, P = .463). With area under curve of 0.676, Δd-dimer% (INCREMENT) appeared to be performing best in diagnosing infection control, which was nonexplanatory. CONCLUSION Plasma d-dimer paradoxically increases before reimplantation while other inflammatory markers (ESR/CRP) decrease, emphasizing that surgeons shall adopt caution using d-dimer to make clinical decisions.
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Zhang H, Xie S, Li Y, Li J, Deng P, Zeng H, Cao H, Liu M, Li J, Feng W, Ye P, Ge Y, Zeng J, Zeng Y. The potential performance of serum albumin to globulin ratio, albumin and globulin in the diagnosis of periprosthetic joint infection and prediction of reinfection following reimplantation. BMC Musculoskelet Disord 2022; 23:730. [PMID: 35907808 PMCID: PMC9338558 DOI: 10.1186/s12891-022-05533-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/05/2022] [Indexed: 12/02/2022] Open
Abstract
Background This study was conducted to evaluate the performance of serum albumin (ALB), globulin (GLO), and albumin to globulin ratio (AGR) in the diagnosis of PJI and prediction of reinfection following reimplantation in PJI patients who underwent two-stage revision. Methods We perform a retrospective data collection on identified patients who underwent revision arthroplasties in our institution from January 2010 to January 2020. A total of 241 patients were stratified into: group A (PJI), group B (aseptic loosening). Fifty-five patients who underwent two-stage revision in group A were assigned to group C. Group C was stratified into subgroup 1 (reinfection) and subgroup 2 (non-reinfection). Receiver operating characteristic curves were used to evaluate the utility of serum markers for diagnosing PJI and predicting reinfection following reimplantation. Results In the diagnosis of PJI, there were significant differences in the levels of ALB, GLO, and AGR between groups A and group B (P < 0.05). The AUC value of serum AGR (0.851) was similar to ESR (0.841) and CRP (0.866) (all p > 0.05). The AUC values of serum ALB and GLO were 0.757 and 0.753, respectively. As for predicting reinfection following reimplantation, the serum ALB in the non-reinfection group was higher than that in the reinfection group (p = 0.041). The AUC value of serum ALB was 0.7. Conclusion AGR was promising adjunct marker for the diagnosis of PJI, similar to CRP and ESR. ALB and GLO have an acceptable value for the diagnosis of PJI. ALB may be expected to be a kind of effective marker for predicting reinfection following reimplantation.
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Affiliation(s)
- Haitao Zhang
- The First Clinical of Medical School, Guangzhou University of Chinese Medicine, NO.12 Jichang Road, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Shuihua Xie
- The First Department of Orthopedics, Jiangxi Province Hospital of Integrated Chinese and Western Medicine, NO.90 Bayi Road, District Xihu, Nanchang, 330003, Jiangxi, China.
| | - YiJin Li
- The First Clinical of Medical School, Guangzhou University of Chinese Medicine, NO.12 Jichang Road, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Jiahao Li
- The First Clinical of Medical School, Guangzhou University of Chinese Medicine, NO.12 Jichang Road, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Peng Deng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, NO.16 Jichang Road, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Huiliang Zeng
- The Tenth Department of Orthopedics, Foshan Hospital of Chinese Medicine, NO.6 Qinren Road, District Chancheng, Foshan, 528000, Guangdong, China
| | - Houran Cao
- The Director of the Orthopedic Department of, Guangdong Province Hospital of Traditional Chinese Medicine, NO.111 Dade Road, District Yuexiu, Guangzhou, 510000, Guangdong, China
| | - Min Liu
- The Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, No.445 Bayi Avenue, Nanchang, 330000, Jiangxi, China
| | - Jie Li
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, NO.16 Jichang Road, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Wenjun Feng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, NO.16 Jichang Road, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Pengcheng Ye
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, NO.16 Jichang Road, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Yingjie Ge
- The First Clinical of Medical School, Guangzhou University of Chinese Medicine, NO.12 Jichang Road, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Jianchun Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, NO.16 Jichang Road, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Yirong Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, NO.16 Jichang Road, District Baiyun, Guangzhou, 510405, Guangdong, China.
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Muñoz-Mahamud E, Tornero E, Estrada J, Fernández-Valencia J, Martínez-Pastor J, Soriano Á. Usefulness of serum D-dimer and platelet count to mean platelet volume ratio to rule out chronic periprosthetic joint infection. J Bone Jt Infect 2022; 7:109-115. [PMID: 35620591 PMCID: PMC9128364 DOI: 10.5194/jbji-7-109-2022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/04/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Diagnosing periprosthetic joint infection (PJI) is challenging and usually requires the evaluation of several biomarkers. Our main aim was to evaluate the usefulness of D-dimer levels as well as the platelet count (PC) to mean platelet volume (MPV) ratio serum as biomarkers to rule out chronic knee and hip infection. Methods: The study enrolled a prospective cohort of 93 patients undergoing hip or knee revision. D-dimer values, PC to MPV ratio, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were preoperatively determined and evaluated as a predictor of PJI. The definitive diagnosis of PJI was established according to the 2018 International Consensus Meeting criteria. Results: A total of 24 (25.8 %) cases were postoperatively diagnosed with PJI. The median D-dimer value was significantly higher ( p < 0.001) for patients with PJI (1950 ng mL- 1 ) than for patients with aseptic failure (700 ng mL- 1 ). The area under the receiver operating characteristic curves for D-dimer, CRP and ESR was 0.820, 0.793 and 0.791 respectively. D-dimer ≥ 950 ng mL- 1 (91 % sensitivity, 64 % specificity), CRP ≥ 1.95 mg dL- 1 (61 % sensitivity, 90 % specificity) and ESR > 20 (74 % sensitivity, 82 % specificity) were identified as the values with the best balance between sensitivity and specificity. The mean PC to MPV ratio was 37.0 for PJI patients and 29.8 for patients in the aseptic revision cohort ( p = 0 .067). Conclusions: Serum D-dimer levels appear very unlikely to remain normal in the presence of chronic PJI. The 91 % sensitivity when considering 950 ng mL- 1 as the threshold highlights D-dimer as the most accurate initial test to rule out chronic PJI. Conversely, the PC to MPV ratio may be of limited value for accurately diagnosing PJI.
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Affiliation(s)
- Ernesto Muñoz-Mahamud
- Department of Orthopedics and Trauma Surgery, Hospital Clinic of
Barcelona, University of Barcelona, Barcelona, Spain
| | - Eduard Tornero
- Department of Orthopedics and Trauma Surgery, Hospital Clinic of
Barcelona, University of Barcelona, Barcelona, Spain
| | - José A. Estrada
- Department of Orthopedics and Trauma Surgery, Hospital Clinic of
Barcelona, University of Barcelona, Barcelona, Spain
| | - Jenaro A. Fernández-Valencia
- Department of Orthopedics and Trauma Surgery, Hospital Clinic of
Barcelona, University of Barcelona, Barcelona, Spain
| | - Juan C. Martínez-Pastor
- Department of Orthopedics and Trauma Surgery, Hospital Clinic of
Barcelona, University of Barcelona, Barcelona, Spain
| | - Álex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona,
University of Barcelona, Barcelona, Spain
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16
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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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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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Which International Consensus Meeting Preoperative Minor Criteria is the Most Accurate Marker for the Diagnosis of Periprosthetic Joint Infection in Hip and Knee Arthroplasty? J Arthroplasty 2021; 36:3728-3733. [PMID: 34281702 DOI: 10.1016/j.arth.2021.06.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The accurate preoperative diagnosis of periprosthetic joint infection (PJI) is critical. The aim of this study was to evaluate the diagnostic accuracy and performance of the 2018 International Consensus Meeting (ICM) preoperative minor criteria for the diagnosis of chronic PJI in total hip and knee arthroplasty. METHODS We retrospectively reviewed 260 patients that underwent a revision knee or hip arthroplasty at our institution between 2015 and 2017. All major and minor 2018 ICM criteria (except erythrocyte sedimentation rate, D-dimer) were available for all patients included. Cases with at least 1 major criterion were considered as infected. Receiver operative characteristic curve analysis was performed for preoperative minor criteria. RESULTS The diagnostic performance of the preoperative minor criteria ranked as per the area under the curve was PMN% (0.926), alpha defensin (0.922), white blood cell count (0.916), leukocyte esterase (0.861), and serum C-reactive protein (0.860). Increasing the PMN % cutoff from 70% to 77.8% improves the diagnostic accuracy (86.5% vs 90.8%). The highest diagnostic performance was achieved by combining all 5 preoperative parameters, and at current ICM thresholds, the diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive were 93.5%, 95.4%, 92.1%, 89.7%, and 96.5%, respectively. CONCLUSION The diagnostic performance of preoperative minor criteria was outstanding (PMN%, alpha defensin, white blood cell count) or excellent (leukocyte esterase, serum C-reactive protein). PMN% showed the best diagnostic utility (area under the curve) and should have an increased weight-adjusted score in the ICM scoring system.
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Abstract
Periprosthetic joint infection (PJI) is one of the most dreadful complications after THA and TKA. Though prevention is of utmost importance in PJI management, the last decade has seen many remarkable developments in PJI diagnosis, including the introduction of several standardized PJI diagnostic definitions and biomarkers. Depending on the specific clinical situation, a myriad of treatment options for PJI are offered. Our review aims to summarize the pertinent information on PJI diagnosis and synthesize literature on the different treatment methods currently used in clinical practice. One of the most accepted PJI diagnostic definitions was developed by the Musculoskeletal Infection Society (MSIS) in 2011, later modified in the 2013 International Consensus Meeting (ICM). After promising results from studies, alpha-defensins and D-dimer were recently incorporated into the 2018 ICM PJI definition. The management choices for PJI include irrigation and debridement (DAIR), one-stage exchange arthroplasty, or two-stage exchange arthroplasty, to name a few. While two-stage revision has traditionally been the treatment of choice in the United States, there has been a growing body of evidence framing one-stage revision as a comparable choice. One-stage revision should be offered in patients meeting strict selection criteria: no sinus tract, proper soft tissue available for wound closure, appropriate bone stock, a favorable identifiable organism with encouraging antibiotic sensitivities (for cement and oral suppression later), and robust immunological status. DAIR can be considered in case of early infections with sensitive infecting organisms. Patients with multiple unsuccessful revisions or those who refuse further surgical intervention for PJI can be offered antibiotic suppression. If nothing seems to work, salvage procedures (resection arthroplasty and arthrodesis) are available as a last resort. Further research is encouraged to improve on diagnostic capabilities and develop evidence on the best treatment of choice for PJI.
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Affiliation(s)
- Tejbir S. Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida 2950 Cleveland Clinic Blvd. Weston 33331 FL USA
| | - Jesus M. Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida 2950 Cleveland Clinic Blvd. Weston 33331 FL USA
| | - Carlos A. Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida 2950 Cleveland Clinic Blvd. Weston 33331 FL USA
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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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21
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Xu H, Xie J, Wang D, Huang Q, Huang Z, Zhou Z. Plasma levels of D-dimer and fibrin degradation product are unreliable for diagnosing periprosthetic joint infection in patients undergoing re-revision arthroplasty. J Orthop Surg Res 2021; 16:628. [PMID: 34666806 PMCID: PMC8524877 DOI: 10.1186/s13018-021-02764-0] [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: 08/16/2021] [Accepted: 09/30/2021] [Indexed: 02/08/2023] Open
Abstract
Background The preoperative diagnosis of periprosthetic joint infection (PJI) in patients undergoing re-revision arthroplasty is crucial, so we evaluated whether plasma levels of D-dimer and fibrin degradation product (FDP) could aid such diagnosis. Methods We retrospectively analyzed data on patients who underwent re-revision hip or knee arthroplasty at our institute during 2008–2020. Patients were stratified into those who experienced PJI or not, based on 2013 International Consensus Meeting Criteria. Plasma levels of D-dimer and FDP as well as levels of the traditional inflammatory biomarkers C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and interleukin-6 were compared between the groups. The ability of these biomarkers to diagnose PJI was assessed based on the area under the receiver operating characteristic (AUC) curve, for which predictive cut-offs were optimized based on the Youden index. Results Based on a cut-off of 0.80 mg/L, D-dimer gave an AUC of 0.595, high sensitivity of 85.7% but poor specificity of 47.8%. Based on a cut-off of 2.80 mg/L, FDP gave an AUC of 0.550, poor sensitivity of 56.5% and poor specificity of 52.9%. CRP, ESR and interleukin-6 showed much better diagnostic ability, with AUCs > 0.82. The combination of CRP and interleukin-6 gave an AUC of 0.877, high sensitivity of 91.7% and acceptable specificity of 78.3%. Conclusions Plasma levels of D-dimer and FDP may be inappropriate for diagnosing PJI in patients undergoing re-revision arthroplasty, whereas the combination of serum CRP and interleukin-6 may be effective.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Jinwei Xie
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Duan Wang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Qiang Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Zongke Zhou
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, China.
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22
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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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23
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Yuan T, Wang Y, Sun S. Thromboelastography parameters in diagnosing periprosthetic joint infection and predicting reimplantation timing. BMC Musculoskelet Disord 2021; 22:689. [PMID: 34388995 PMCID: PMC8364122 DOI: 10.1186/s12891-021-04578-x] [Citation(s) in RCA: 3] [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: 01/20/2021] [Accepted: 08/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Coagulation-related biomarkers are drawing new attention in the diagnosis of periprosthetic joint infection (PJI). The thromboelastography (TEG) assay provides a comprehensive assessment of blood coagulation; therefore, it could be a promising test for PJI. This study aims to assess the value of TEG in diagnosing PJI and to determine the clinical significance of TEG in analysing reimplantation timing for second-stage revision. METHODS From October 2017 to September 2020, 62 patients who underwent revision arthroplasty were prospectively included. PJI was defined by the 2011 Musculoskeletal Infection Society criteria, in which 23 patients were diagnosed with PJI (Group A), and the remaining 39 patients were included as having aseptic loosening (Group B). In group A, 17 patients completed a two-stage revision in our centre. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), D-dimer, and TEG parameters (clotting time, α-angle, MA [maximum amplitude], amplitude at 30 min, and thrombodynamic potential index) were measured preoperatively in all included patients. In addition, receiver operating characteristic curves were used to evaluate the diagnostic value of these biomarkers. RESULTS ESR (area under curve [AUC], 0.953; sensitivity, 81.82; specificity, 94.87) performed best for PJI diagnosis, followed by MA (AUC, 0.895; sensitivity, 82.61; specificity, 97.44) and CRP (AUC, 0.893; sensitivity, 82.61; specificity, 94.74). When these biomarkers were combined in pairs, the diagnostic value improved compared with any individual biomarker. The overall success rate of the two-stage revision was 100%. Furthermore, ESR and MA were valuable in determining the time of reimplantation, and their values all decreased below the cut-off values before reimplantation. CONCLUSION TEG could be a promising test in assisting PJI diagnosis, and a useful tool in judging the proper timing of reimplantation.
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Affiliation(s)
- Tao Yuan
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
| | - Yi Wang
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
| | - Shui Sun
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China. .,Department of Joint Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
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24
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Jungwirth-Weinberger A, Oezel L, Morgenstern R, Shue J, Hanreich C, Sama AA, Boettner F. D-Dimer Levels Are Not Elevated in SARS-CoV-2 IgG Positive Patients Undergoing Elective Orthopedic Surgery. J Clin Med 2021; 10:jcm10163508. [PMID: 34441803 PMCID: PMC8397049 DOI: 10.3390/jcm10163508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION In acute COVID-19, D-Dimer levels can be elevated and those patients are at risk for thromboembolic events. This study aims to investigate differences in preoperative D-Dimer levels in SARS-CoV-2 IgG positive and negative patients undergoing primary total knee and total hip replacement (TJA) or spine surgery. METHODS D-Dimer levels of 48 SARS-CoV-2 IgG positive and 718 SARS-CoV-2 IgG negative spine surgery patients were compared to those of 249 SARS-CoV-2 IgG positive and 2102 SARS-CoV-2 IgG negative TJA patients. Patients were assigned into groups based on D-Dimer levels as follows: <200 ng/mL, 200-400 ng/mL, and >400 ng/mL D-Dimer Units (DDU). RESULTS D-Dimer levels did neither differ significantly between SARS-CoV-2 IgG positive spine surgery patients and TJA patients (p = 0.1), nor between SARS-CoV-2 IgG negative spine surgery and TJA patients (p = 0.7). In addition, there was no difference between SARS-CoV-2 IgG positive and negative spine surgery patients and SARS-CoV-2 IgG positive and negative TJA patients (p = 0.3). CONCLUSIONS There is no difference in D-Dimer levels between SARS-CoV-2 IgG positive and negative patients and there does not seem to be any difference for different orthopedic specialty patients. Routine testing of D-Dimer levels is not recommended for patients undergoing elective orthopedic surgery.
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Affiliation(s)
- Anna Jungwirth-Weinberger
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA or (A.J.-W.); (R.M.); (C.H.)
- Orthopaedics and Traumatology, Cantonal Hospital Baden, Im Ergel 1, CH-5404 Baden, Switzerland
| | - Lisa Oezel
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; (L.O.); (J.S.); (A.A.S.)
| | - Rachelle Morgenstern
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA or (A.J.-W.); (R.M.); (C.H.)
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; (L.O.); (J.S.); (A.A.S.)
| | - Carola Hanreich
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA or (A.J.-W.); (R.M.); (C.H.)
| | - Andrew A. Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; (L.O.); (J.S.); (A.A.S.)
| | - Friedrich Boettner
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA or (A.J.-W.); (R.M.); (C.H.)
- Correspondence: ; Tel.: +1-212-774-2127
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25
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Khalifa AA, Farouk OA. Total hip arthroplasty periprosthetic infection management, the dilemma remains. JOURNAL OF MUSCULOSKELETAL SURGERY AND RESEARCH 2021; 5:139-141. [DOI: 10.25259/jmsr_85_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Ahmed A. Khalifa
- Department of Orthopedics, Qena Faculty of Medicine and University Hospital, South Valley University, Qena,
| | - Osama A. Farouk
- Department of Orthopedics and Traumatology, Assiut University Hospitals, Assiut, Egypt,
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26
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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 2021; 103:1251-1258. [PMID: 34048412 DOI: 10.2106/jbjs.21.00311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Thomas K Fehring
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.,Atrium Musculoskeletal Institute, Charlotte, North Carolina
| | | | | | | | - Jesse E Otero
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.,Atrium Musculoskeletal Institute, Charlotte, North Carolina
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27
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Xu H, Xie J, Zhou J, Wang X, Wang D, Huang Z, Zhou Z. Ability of plasma-based or serum-based assays of D-dimer and FDP for diagnosing periprosthetic joint infection: protocol for a prospective single-centre, parallel comparative study. BMJ Open 2021; 11:e046442. [PMID: 34215605 PMCID: PMC8256792 DOI: 10.1136/bmjopen-2020-046442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Several studies have evaluated the diagnostic values of D-dimer and fibrin degradation product (FDP) for detecting periprosthetic joint infection (PJI), but their conclusions have been inconsistent. More importantly, whether the diagnostic value of these two biomarkers differs depending on whether they are assayed in plasma or serum is unclear. METHODS AND ANALYSIS This prospective single-centre, parallel comparative study will involve patients planning to undergo revision hip or knee arthroplasty due to an aseptic mechanical failure or PJI. After the patients provide written informed consent, their serum and plasma will be sampled and assayed for D-dimer and FDP. The diagnostic value of these two biomarkers in plasma and serum will be compared with one another and with the value of two traditional inflammatory markers (C reactive protein and erythrocyte sedimentation rate) used to diagnose PJI according to the 2013 International Consensus Meeting criteria. Diagnostic value will be assessed in terms of area under receiver operating characteristic curves, sensitivity, specificity, as well as positive and negative predictive values, all calculated based on the optimal cut-off determined from the Youden index. ETHICS AND DISSEMINATION This study was approved by the Ethics Committee of our hospital (approval no. 2020-859). Written informed consent will be obtained from all patients before enrollment. Study findings will be disseminated widely through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000038547), and it is ongoing.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Jinwei Xie
- Department of Orthopaedic Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Jing Zhou
- Department of Laboratory Medicine, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Xing Wang
- Department of Orthopaedic Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Duan Wang
- Department of Orthopaedic Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Zongke Zhou
- Department of Orthopaedic Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
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Pannu TS, Villa JM, Engh C, Patel A, Levine BR, Piuzzi NS, Higuera CA, Riesgo AM. Plasma D-dimer Does Not Anticipate the Fate of Reimplantation in Two-stage Exchange Arthroplasty for Periprosthetic Joint Infection: A Preliminary Investigation. Clin Orthop Relat Res 2021; 479:1458-1468. [PMID: 33830953 PMCID: PMC8208420 DOI: 10.1097/corr.0000000000001738] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/26/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Inflammatory markers such as the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels have always been a part of the diagnostic criteria for periprosthetic joint infection (PJI), but they perform poorly anticipating the outcome of reimplantation. D-dimer has been reported in a small series as a potential marker to measure infection control after single-stage revisions to treat PJI. Nonetheless, its use to confirm infection control and decide the proper timing of reimplantation remains uncertain. QUESTIONS/PURPOSES (1) What is the best diagnostic threshold and accuracy values for plasma D-dimer levels compared with other inflammatory markers (ESR and CRP) or what varying combinations of these tests are associated with persistent infection after reimplantation? (2) Do D-dimer values above this threshold, ESR, CRP, and varying test combinations at the time of reimplantation indicate an increased risk of subsequent persistent infection after reimplantation? METHODS We retrospectively studied the electronic medical records of all 53 patients who had two-stage revisions for PJI and who underwent plasma D-dimer testing before reimplantation at one of two academic institutions from November 22, 2017 to December 5, 2020. During that period, all patients undergoing two-stage revisions also had a D-dimer test drawn. The minimum follow-up duration was 1 year. We are reporting at this early interval (rather than the more typical 2-year time point) because of the poorer-than-expected performance of this diagnostic test. Of these 53 patients, 17% (9) were lost to follow-up before 1 year and could not be analyzed; the remaining 44 patients (17 hips and 27 knees) were studied here. The mean follow-up was 503 ± 135 days. Absence or persistence of infection after reimplantation were defined according to the Delphi criteria. The conditions included in these criteria were: (1) control of infection, as characterized by a healed wound without fistula, drainage, or pain; (2) no subsequent surgical intervention owing to infection after reimplantation; and (3) no occurrence of PJI-related mortality. The absence of any of the aforementioned conditions until the final follow-up examination was deemed a persistent infection after reimplantation. Baseline patient characteristics were not different between patients with persistent infection (n = 10) and those with absence of it after reimplantation (n = 34) as per the Delphi criteria. Baseline patient characteristics evaluated were age, gender, self-reported race (white/Black/other) or ethnicity (nonHispanic/Hispanic), BMI, American Society of Anesthesiologists (ASA) status, smoking status(smoker/nonsmoker), and joint type (hip/knee). The optimal D-dimer threshold to differentiate between persistence of infection or not after reimplantation was calculated using the Youden index. A receiver operating characteristic curve analysis was performed to test the accuracy of D-dimer, ESR, CRP, and their combinations to establish associations, if any, with persistent infection after reimplantation. A Kaplan-Meier survival analysis (free of infection after reimplantation) with a log-rank test was performed to investigate if D-dimer, ESR, and CRP were associated with absence of infection after reimplantation. Survival or being free of infection after reimplantation was determined as per Delphi criteria. Alpha was set at p < 0.05. RESULTS In the receiver operating characteristic curve analysis, with an area under the curve of 0.62, D-dimer showed low accuracy and did not anticipate persistent infection after reimplantation. The optimal D-dimer threshold differentiating between persistence of infection or not after reimplantation was 3070 ng/mL. When using this threshold, D-dimer demonstrated a sensitivity of 90% (95% CI 55.5% to 99.7%) and negative predictive value of 94% (95% CI 70.7% to 99.1%), but low specificity (47% [95% CI 29.8% to 64.9%]) and positive predictive value (33% [95% CI 25.5% to 42.2%]). Although D-dimer showed the highest sensitivity, the combination of D-dimer with ESR and CRP showed the highest specificity (91% [95% CI 75.6% to 98%]) defining the persistence of infection after reimplantation. Based on plasma D-dimer levels, with the numbers available, there was no difference in survival free from infection after reimplantation (Kaplan-Meier survivorship free from infection at minimum 1 year in patients with D-dimer below 3070 ng/mL versus survivorship free from infection with D-dimer above 3070 ng/mL: 749 days [95% CI 665 to 833 days] versus 615 days [95% CI 471 to 759 days]; p = 0.052). Likewise, there were no associations between high ESR and CRP levels and persistent infection after reimplantation, but the number of events was very small, and insufficient power is a concern with this analysis. CONCLUSION In this preliminary series, with the numbers available, D-dimer alone had poor accuracy and was not associated with survival free from infection after reimplantation in patients who underwent two-stage exchange arthroplasty. D-dimer alone might be used to establish that PJI is unlikely, and the combination of D-dimer, ESR, and CRP should be considered to confirm PJI diagnosis in the setting of reimplantation.Level of Evidence Level IV, diagnostic study.
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Affiliation(s)
- Tejbir S. Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Jesus M. Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Charles Engh
- Midwest Orthopaedics at Rush University Medical Center, Chicago, IL, USA
| | - Arpan Patel
- Midwest Orthopaedics at Rush University Medical Center, Chicago, IL, USA
| | - Brett R. Levine
- Midwest Orthopaedics at Rush University Medical Center, Chicago, IL, USA
| | - Nicolas S. Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Carlos A. Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Aldo M. Riesgo
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Xu H, Shang G, Wang Y, Xiang S. Plasma fibrinogen is a reliable marker for diagnosing periprosthetic joint infection and determining the timing of second-stage revision. Int J Infect Dis 2021; 108:220-225. [PMID: 34089882 DOI: 10.1016/j.ijid.2021.05.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES We investigated the diagnostic value of fibrinolytic markers for periprosthetic joint infection (PJI), determined their relationship with culture results, and evaluated whether these markers could assess infection control and determine the timing of second-stage reimplantation. DESIGN/METHODS This single-center-retrospective study included 206 patients who underwent revision hip or knee arthroplasty (PJI group, n = 79; aseptic loosening [AL] group, n = 127). The plasma levels of fibrinogen, d-dimer, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were compared, and receiver operating characteristic curves were constructed. Subgroup analysis within the PJI group was also performed. RESULTS The plasma levels of fibrinogen, d-dimer, ESR, and CRP were significantly lower in the AL group, with an area under the curve of 0.848, 0.669, 0.865, and 0.841, respectively. The plasma level of d-dimer was significantly lower in patients with culture-negative PJI. In patients with residual infection, the levels of all the markers had not significantly changed, while noticeably decreased plasma levels of fibrinogen, ESR, and CRP were detected in patients with successful second-stage reimplantation. CONCLUSIONS Plasma fibrinogen is a promising marker for diagnosing PJI and evaluating persistent infection. Decreased plasma levels of d-dimer in patients with PJI might be linked with negative culture results.
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Affiliation(s)
- Hao Xu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Guangqian Shang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yingzhen Wang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Shuai Xiang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, 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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A retrospective comparison of thromboelastography and conventional coagulation parameters for periprosthetic joint infection diagnosis and reimplantation timing. Clin Chim Acta 2021; 519:118-125. [PMID: 33895127 DOI: 10.1016/j.cca.2021.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/24/2021] [Accepted: 04/16/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE The diagnostic significance of coagulation parameters in periprosthetic joint infection (PJI) is currently attracting increasing attention. We assessed the diagnostic accuracy of thromboelastography (TEG) for PJI and compared the values of various coagulation indicators for PJI diagnosis and reimplantation timing. METHODS We enrolled 250 patients undergoing revision for aseptic failure (Group A), revision for PJI (Group B), or reimplantation (Group C) during 2013-2020. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), representative coagulation-related indicators (reaction time [R], clotting time [K], angle and maximum amplitude [MA]) of TEG and routine coagulation indicators, including fibrinogen, D-dimer, fibrin degradation product (FDP), platelets count (PC), mean platelet volume (MPV), distribution width (PDW) and plateletcrit (PCT) as well as PC/MPV ratio(PVR)were measured preoperatively. Receiver operating characteristic (ROC) curves were used to evaluate the utility of all tested indicators for assessing infection. RESULTS All the indicators showed significant differences between groups A and B (P < 0.05) and, except for D-dimer, FDP, MPV and R, between groups B and C (P < 0.05). Similar differences were also observed in biomarkers before first-stage revision and second-stage reimplantation. ROC curves showed that fibrinogen, K, angle and MA outperformed the other coagulation indicators, with areas under the curve of 0.864 to 0.893 and threshold values of 3.55 g/L, 1.2 min, 72.4 deg and 69.1 mm, respectively. The multiple tests of TEG indices (K, angle and MA) and traditional inflammatory markers (CRP and ESR) or conventional coagulation indicators (fibrinogen, PC and PVR) had good sensitivity and specificity for PJI diagnosis, and the diagnostic values of TEG and platelet-associated indicators (PC and PVR) varied in the different subgroups. CONCLUSION TEG was closely related to PJI and could serve as a valuable technique for identifying residual infection before reimplantation. Fibrinogen showed high diagnostic accuracy for PJI and effectively guided the timing of reimplantation.
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Ackmann T, Schwarze J, Gosheger G, Schmidt-Braekling T, Schneider KN, Dieckmann R, Klingebiel S, Moellenbeck B, Theil C. The change in plasma D-dimer does not help to guide the timing of reimplantation in two stage exchange for periprosthetic joint infection. Sci Rep 2021; 11:7323. [PMID: 33795812 PMCID: PMC8016946 DOI: 10.1038/s41598-021-86890-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 03/22/2021] [Indexed: 11/12/2022] Open
Abstract
D-dimer has been included in the criteria by the Musculoskeletal Infection Society in 2018 as a novel parameter to diagnose prosthetic joint infection (PJI). However, it is unclear how D-dimer levels change in between stages of a two-stage exchange. We prospectively investigated 30 patients who underwent a two-stage exchange using a spacer for PJI. D-Dimer, CRP and IL-6 were collected before first and second stage surgery and the difference (Δ) in between stages was calculated. The levels of plasma D-Dimer did not change from first to second stage surgery (2770 ng/ml (IQR, 1600–3770 ng/ml) versus 2340 ng/ml (IQR, 1270–4100 ng/ml); p = 0.8) while CRP (4.0 mg/dl (IQR, 1.7–5.5 mg/dl) versus 0.6 mg/dl (IQR, 0.5–0.8 mg/dl); p < 0.001) and IL-6 (21 pg/ml (IQR, 10–29 pg/ml) versus 6 pg/ml (4–9 pg/ml); p < 0.001) decreased. The ΔD-dimer between both stages was 300 ng/ml (range: − 2820 to 4280 ng/ml), the median ΔCRP was − 3.4 mg/dl (IQR, − 1.2 to − 4.8 mg/dl) and ΔIL-6 was − 13 pg/ml (IQR, − 4 to − 20 pg/ml). In 15 of 30 cases (50%) the D-dimer level increased between both stages, whereas the level of CRP (93%; 28/30) and IL-6 (96%; 28/29) decreased in most patients. As the level of serum D-dimers varies greatly, lacks a uniform decrease and does not identify persisting infection, surgeons should be cautious when using it at the timing of reimplantation.
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Affiliation(s)
- Thomas Ackmann
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
| | - Jan Schwarze
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Georg Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Tom Schmidt-Braekling
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Kristian Nikolaus Schneider
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Ralf Dieckmann
- Department of Orthopedic Surgery, Barmherzige Brüder Hospital, 54292, Trier, Germany
| | - Sebastian Klingebiel
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Burkhard Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Christoph Theil
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
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Xu H, Xie JW, Yang JL, Huang ZY, Pei FX. Role of D-dimer and Fibrinogen in the Diagnosis of Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis. Orthop Surg 2021; 13:692-700. [PMID: 33682337 PMCID: PMC8126916 DOI: 10.1111/os.12969] [Citation(s) in RCA: 10] [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: 10/25/2020] [Revised: 01/15/2021] [Accepted: 01/28/2021] [Indexed: 02/05/2023] Open
Abstract
The diagnostic potential of D-dimer and fibrinogen to detect periprosthetic joint infection (PJI) of the hip and knee is not well-understood. The aim of this study was to determine whether D-Dimer and fibrinogen can be used as effective biomarkers to screen PJI. A systematic review of the literature indexed in Web of Science, PubMed, Cochrane Library, Embase, and Google Scholar databases was performed. All studies using D-dimer levels in serum or plasma, or fibrinogen levels in plasma, for the diagnosis of PJI were included. Meta-analysis estimates, including sensitivity, specificity, diagnostic odds ratios (DOR), and the area under the summary receiver operating characteristic curve (AUSROC), were calculated using a random-effects model, and used to assess the diagnostic accuracy of these biomarkers. A total of nine studies were analyzed, and their quality was considered to be acceptable. D-dimer gave a limited diagnostic value if serum and plasma combined: sensitivity (0.77, 95% confidence interval [CI] [0.63 to 0.87]), specificity (0.67, 95% CI [0.54 to 0.78]), DOR (6.81, 95% CI [2.67 to 17.37]), and AUSROC (0.78, 95% CI [0.74 to 0.82]). Plasma D-dimer levels were associated with less satisfactory sensitivity (0.65, 95% CI 0.57 to 0.71), specificity (0.58, 95% CI 0.50 to 0.66), DOR (2.52, 95% CI 1.64 to 3.90), and AUSROC (0.65, 95% CI 0.61 to 0.69). Serum D-dimer levels showed higher corresponding values of 0.89 (95% CI 0.79 to 0.94), 0.76 (95% CI 0.55 to 0.89), 24.24 (95% CI 10.07 to 58.32), and 0.91 (95% CI 0.88 to 0.93). Plasma fibrinogen showed acceptable corresponding values of 0.79 (95% CI 0.70 to 0.85), 0.73 (95% CI 0.57 to 0.85), 10.14 (95% CI 6.16 to 16.70), and 0.83 (95% CI 0.79 to 0.86). Serum D-dimer may be an effective marker for the diagnosis of PJI in hip and knee arthroplasty patients, and it may show higher diagnostic potential than plasma fibrinogen. Plasma D-dimer may have limited diagnostic potential.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Jin-Wei Xie
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Jing-Li Yang
- College of Earth and Environmental Sciences, School of Public Health, Lanzhou University, Lanzhou, China
| | - Ze-Yu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fu-Xing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Chen Y, Qin L, Gong X, Wang J, Huang W, Hu N. Response to Letter to the Editor on "Combined Measurement of D-Dimer and C-Reactive Protein Levels: Highly Accurate for Diagnosing Chronic Periprosthetic Joint Infection". J Arthroplasty 2021; 36:e6. [PMID: 33187857 DOI: 10.1016/j.arth.2020.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/21/2020] [Indexed: 02/02/2023] Open
Affiliation(s)
- Yuelong Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Leilei Qin
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuan Gong
- Outpatient Department, Chongqing General Hospital, Chongqing, China
| | - Jiawei Wang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ning Hu
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Pannu TS, Villa JM, Riesgo AM, Higuera CA. Letter to the Editor on "Combined Measurement of D-Dimer and C-Reactive Protein Levels: Highly Accurate for Diagnosing Chronic Periprosthetic Joint Infection". J Arthroplasty 2021; 36:e5. [PMID: 33187855 DOI: 10.1016/j.arth.2020.09.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/21/2020] [Indexed: 02/02/2023] Open
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Grzelecki D, Walczak P, Grajek A, Szostek M, Dudek P, Bartosz P, Olewnik Ł, Czubak-Wrzosek M, Marczak D, Tyrakowski M. Elevated plasma D-dimer concentration has higher efficacy for the diagnosis of periprosthetic joint infection of the knee than of the hip-A single-center, retrospective study. J Orthop Res 2021; 39:291-298. [PMID: 33098596 DOI: 10.1002/jor.24897] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 10/07/2020] [Accepted: 10/21/2020] [Indexed: 02/04/2023]
Abstract
The aim of this study is to evaluate the value of D-dimers in the diagnosis of periprosthetic joint infection (PJI). The analysis was performed for revision total hip (rTHA) and revision total knee arthroplasty (rTKA) together and separately with two thresholds, one calculated by statistical methods and the second adopted from the ICM 2018 definition. The study group comprised 133 patients who underwent rTHA or rTKA: 68 patients diagnosed according to the ICM 2018 definition (PJI group) and 65 with aseptic implant loosening, instability, malposition, or implant failure with the exclusion of infection (aseptic revision total joint arthroplasty or arTJA group). Mean D-dimer concentrations were 0.36 ± 0.25 μg/ml in the arTJA group and 0.87 ± 0.78 μg/ml in the PJI group (p < .001). For rTHA and rTKA together, the sensitivity and specificity of the evaluation were 75% and 73.8% according to the calculated cut-off value (0.45 μg/ml), and 33.8% and 95.4% based on the ICM 2018 threshold (0.85 μg/ml). Separately, for rTHA, sensitivity and specificity were 62.5% and 62.1% for the calculated value (0.43 μg/ml) and 6.3% and 96.6% for the ICM 2018 threshold; for rTKA, sensitivity was 86.1% and specificity was 88.9% for the calculated threshold (0.48 μg/ml) and 58.3% and 94.4% for the ICM 2018 value. Our findings indicate that plasma D-dimers have potential as markers of knee PJI, but moderate to low value for hip PJI.
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Affiliation(s)
- Dariusz Grzelecki
- Department of Orthopedics and Rheumoorthopedics, Centre of Postgraduate Medical Education, Otwock, Poland
| | - Piotr Walczak
- Department of Orthopedics, Centre of Postgraduate Medical Education, Otwock, Poland
| | - Aleksandra Grajek
- Central Laboratory of Professor Adam Gruca's Hospital, Otwock, Poland
| | - Marta Szostek
- Central Laboratory of Professor Adam Gruca's Hospital, Otwock, Poland
| | - Piotr Dudek
- Department of Orthopedics and Rheumoorthopedics, Centre of Postgraduate Medical Education, Otwock, Poland
| | - Paweł Bartosz
- Department of Orthopedics, Centre of Postgraduate Medical Education, Otwock, Poland
| | - Łukasz Olewnik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Lodz, Poland
| | - Maria Czubak-Wrzosek
- Department of Spine Disorders and Orthopedics, Centre of Postgraduate Medical Education, Otwock, Poland
| | - Dariusz Marczak
- Department of Orthopedics and Rheumoorthopedics, Centre of Postgraduate Medical Education, Otwock, Poland
| | - Marcin Tyrakowski
- Department of Spine Disorders and Orthopedics, Centre of Postgraduate Medical Education, Otwock, Poland
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Fibrinogen performs better than D-dimer for the diagnosis of periprosthetic joint infection: a meta-analysis of diagnostic trials. J Orthop Surg Res 2021; 16:30. [PMID: 33422082 PMCID: PMC7796531 DOI: 10.1186/s13018-020-02109-3] [Citation(s) in RCA: 3] [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: 10/25/2020] [Accepted: 11/19/2020] [Indexed: 11/10/2022] Open
Abstract
Purpose D-dimer and fibrinogen, both belonging to coagulation parameters, are controversial for the diagnosis of periprosthetic joint infection (PJI). This meta-analysis was conducted to compare their diagnostic accuracies for PJI by synthesizing currently available evidence. Methods Cochrane Library, MEDLINE, Web of Science, and Embase up to March 1, 2020, and other relevant articles were searched. Five hundred and eighty-one articles were identified after initial research, and 11 studies were included finally. No threshold effects were found between studies. The pooled sensitivity, specificity, and positive and negative likelihood ratio were reported to evaluate the diagnostic performance with heterogeneity analysis. Z test statistics was used to analyze the difference of diagnostic performance between D-dimer and fibrinogen. Results The pooled sensitivity, specificity, and positive and negative likelihood ratio of D-dimer for PJI were 0.79 (95% [CI], 0.72–0.85), 0.77 (0.67–0.84), 3.38 (2.21–5.18), and 0.27 (0.18–0.41), respectively. As for fibrinogen, the pooled sensitivity, specificity, and positive and negative likelihood ratio for PJI were 0.75 (0.68–0.80), 0.85 (0.82–0.88), 5.12 (4.22–6.22), and 0.30 (0.23–0.37), respectively. Great heterogeneity was found in studies for D-dimer, and univariate meta-regression analysis revealed that number of involved joints, disease spectrum, comorbidities influencing D-dimer, and sample sources were the source of heterogeneity. Z test found that the pooled specificity of fibrinogen was significantly higher than D-dimer (0.85 ± 0.01 versus 0.77 ± 0.04, p = 0.03). The pooled positive likelihood ratio of fibrinogen was significantly higher than D-dimer (5.12 ± 0.51 versus 3.38 ± 0.74, p = 0.03). Conclusion Based on currently available evidence, the meta-analysis suggests that fibrinogen performs better than D-dimer as a rule-in diagnostic tool for its higher specificity. However, more prospective trials with larger size are still needed to provide further confirmation. Trial registration This meta-analysis was prospectively registered on PROSPERO (International prospective register of systematic reviews), and the registering number was CRD42020177176.
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Jiang Q, Xu C, Chai W, Zhou YG, Fu J, Chen JY. The 2018 New Definition of Periprosthetic Joint Infection is Valuable for Diagnosis of Persistent Infection at Reimplantation in Patients without Synovial Fluid. J Arthroplasty 2021; 36:279-285. [PMID: 32792204 DOI: 10.1016/j.arth.2020.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/02/2020] [Accepted: 07/11/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Diagnosis of persistent infection at reimplantation of 2-stage exchange revision is a challenging problem. The aim of our study is to evaluate the performance of the 2018 new definition and Musculoskeletal Infection Society (MSIS) criteria in determining the persistent infection at reimplantation in patients without synovial fluid. METHODS We retrospectively reviewed 150 patients who underwent 2-stage exchange revision from 2014 to 2018. Two models were used to define persistent infection-model 1: identical major criteria of the MSIS criteria and new definition and model 2: identical major criteria of 2 criteria and/or subsequent infection after reimplantation. The predictive accuracy of the new definition and MSIS criteria was compared by using receiver operating characteristic curves. RESULTS The receiver operating characteristic curves showed that the new definition had good performance in determining the persistent infection, with the area under the curve (AUC) of 0.871 in model 1 and 0.835 in model 2. The optimal threshold for aggregate scores in new definition was 4. The MSIS criteria had limited diagnostic value in both model 1 (AUC = 0.708) and model 2 (AUC = 0.664). In model 1, the sensitivity and specificity were 86.96% and 84.25% in new definition, and 47.83% and 93.70% in MSIS criteria in patients without synovial fluid. In model 2, the sensitivity and specificity were 78.57% and 85.25% in new definition, and 39.29% and 93.44% in MSIS criteria. CONCLUSION The 2018 new definition of PJI is valuable in the diagnosis of persistent infection, which can improve diagnostic accuracy compared with the MSIS criteria in patients without synovial fluid.
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Affiliation(s)
- Qiao Jiang
- Medical School of Chinese PLA, Beijing, People's Republic of China; Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China; Medical College, Nankai University, Tianjin, People's Republic of China
| | - Chi Xu
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Wei Chai
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Yong-Gang Zhou
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Jun Fu
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Ji-Ying Chen
- Medical School of Chinese PLA, Beijing, People's Republic of China; Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China; Medical College, Nankai University, Tianjin, People's Republic of China
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Comparing the Diagnostic Value of Serum D-Dimer to CRP and IL-6 in the Diagnosis of Chronic Prosthetic Joint Infection. J Clin Med 2020; 9:jcm9092917. [PMID: 32927683 PMCID: PMC7563505 DOI: 10.3390/jcm9092917] [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] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 12/31/2022] Open
Abstract
Introduction: D-dimer is a diagnostic criterion for periprosthetic joint infection (PJI) of the Musculoskeletal Infection Society (MSIS) in 2018. The aim of this study was to evaluate the serum D-dimer values in comparison to C-reactive protein (CRP) and interleukin-6 (IL-6) for the diagnosis of PJI. Materials and Methods: We included 119 patients (50 women, 69 men; 71 knees, 48 hips) undergoing revision arthroplasty with preoperative assessment of CRP, IL-6, and serum D-dimer. Cases were classified as infected or aseptic based on the MSIS criteria of 2018. Receiver operating curves and Youden’s index were used to define an ideal cut-off value and sensitivity and specificity for the individual parameters, and respective combinations were calculated using cross-tables. Results: The median D-dimer level (2320 vs. 1105 ng/mL; p < 0.001), the median CRP level (4.0 vs. 0.5 mg/dL; p < 0.001), and the median IL-6 level (21.0 vs. 5.0 pg/mL; p < 0.001) were significantly higher in the group of PJI compared to the group with aseptic failure. The calculated optimal cut-off values were 2750 ng/mL (AUC 0.767) for D-dimer, 1.2 mg/dL (AUC 0.914) for CRP, and 10.0 pg/mL (AUC 0.849) for IL-6. D-dimer showed a sensitivity of 38% and specificity of 94%, whereas the CRP and IL-6 had sensitivities of 88% and 76%, and specificities of 87% and 92%, respectively. Conclusion: In comparison with CRP and IL-6, serum D-dimer showed low sensitivity and specificity in our cohort. While CRP and IL-6 combination had the highest sensitivity, a combination of Il-6 and D-dimer or CRP and IL-6 had the highest specificity.
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Pearson LN, Moser KA, Schmidt RL. D-Dimer Varies Widely Across Instrument Platforms and is Not a Reliable Indicator of Periprosthetic Joint Infections. Arthroplast Today 2020; 6:686-688. [PMID: 32875020 PMCID: PMC7451938 DOI: 10.1016/j.artd.2020.07.014] [Citation(s) in RCA: 5] [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: 04/21/2020] [Revised: 06/22/2020] [Accepted: 07/10/2020] [Indexed: 11/05/2022] Open
Abstract
The D-dimer test is a component of the modified scoring criteria for periprosthetic joint infection (PJI). The performance of the D-dimer test varies greatly among laboratories because of the lack of standardization. Laboratories may use different assays and will produce widely varying results for the same sample. This study used published proficiency testing data from 3903 laboratories to demonstrate the variability in D-dimer results and estimate the misclassification rate of patients using the proposed cutoff for the test as a component of PJI criteria. Given the variability in D-dimer results, a clinically significant percentage of patients are likely to be misclassified. The data illustrate that a universal cutoff for this marker in the context of assessment for PJI is not appropriate. Each site must conduct a study to determine an appropriate cutoff for their unique testing platform.
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Affiliation(s)
- Lauren N Pearson
- Department of Pathology, ARUP Laboratories & University of Utah, Salt Lake City, UT, USA
| | - Karen A Moser
- Department of Pathology, ARUP Laboratories & University of Utah, Salt Lake City, UT, USA
| | - Robert L Schmidt
- Department of Pathology, ARUP Laboratories & University of Utah, Salt Lake City, UT, USA
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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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Wu H, Meng Z, Pan L, Liu H, Yang X, Yongping C. Plasma Fibrinogen Performs Better Than Plasma d-Dimer and Fibrin Degradation Product in the Diagnosis of Periprosthetic Joint Infection and Determination of Reimplantation Timing. J Arthroplasty 2020; 35:2230-2236. [PMID: 32376167 DOI: 10.1016/j.arth.2020.03.055] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The accurate and timely diagnosis of periprosthetic joint infection (PJI) is challenging, and no single biomarker can definitively confirm infection before revision arthroplasty. The coagulation cascade has been linked closely to infection. This study was performed to determine the value of plasma d-dimer, plasma fibrinogen, and plasma fibrin degradation product (FDP) for the diagnosis of PJI and timing of reimplantation. METHODS We retrospectively enrolled 136 patients who underwent revision surgery from January 2008 to December 2019. They were assigned to 3 groups: aseptic failure (group A), PJI (group B), and reimplantation (group C). Receiver operating characteristic curves were constructed to estimate the value of plasma fibrinogen, plasma d-dimer, plasma FDP, erythrocyte sedimentation rate (ESR), and serum C-reactive protein (CRP) for PJI diagnosis and reimplantation timing. RESULTS All biomarker levels were significantly higher in group B than in group A (P < .05), and plasma fibrinogen, CRP, and ESR values were significantly higher in group B than in group C (all P < .05). The receiver operating characteristic curves showed that the areas under the curve of plasma fibrinogen, plasma d-dimer, plasma FDP, CRP, and ESR were 0.848, 0.914, 0.728, 0.737, and 0.868, respectively, and the threshold values for plasma fibrinogen, plasma d-dimer, and plasma FDP were 3.61 g/L, 0.41 mg/L, and 3.55 mg/L, respectively. CONCLUSION Plasma fibrinogen exhibits good value for the diagnosis of PJI and can be an indicator of residual infection before reimplantation in 2-stage arthroplasty. Plasma d-dimer and FDP are of limited value for PJI diagnosis and cannot be used to determine the timing of reimplantation.
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Affiliation(s)
- Hao Wu
- Department of Orthopedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Zhichao Meng
- Department of Orthopedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Liping Pan
- Department of Orthopedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Heng Liu
- Department of Orthopedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Xin Yang
- Department of Orthopedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Cao Yongping
- Department of Orthopedics, Peking University First Hospital, Beijing, People's Republic of China
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Sharfman ZT, Gelfand Y, Shah P, Holtzman AJ, Mendelis JR, Kinon MD, Krystal JD, Brook A, Yassari R, Kramer DC. Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications. Asian Spine J 2020; 14:742-759. [PMID: 32718133 PMCID: PMC7595828 DOI: 10.31616/asj.2019.0369] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/17/2020] [Indexed: 12/18/2022] Open
Abstract
Spinal epidural abscess (SEA) is a rare condition associated with significant morbidity and mortality. Despite advances in diagnostic medicine, early recognition of SEAs remains elusive. The vague presentation of the disease, coupled with its numerous risk factors, the diagnostic requirement for obtaining advanced imaging, and the necessity of specialized care constitute extraordinary challenges to both diagnosis and treatment of SEA. Once diagnosed, SEAs require urgent or emergent medical and/or surgical management. As SEAs are a relatively rare pathology, high-quality data are limited and there is no consensus on their optimal management. This paper focuses on presenting the treatment modalities that have been successful in the management of SEAs and providing a critical assessment of how specific SEA characteristics may render one infection more amenable to primary surgical or medical interventions. This paper reviews the relevant history, epidemiology, clinical presentation, radiology, microbiology, and treatment of SEAs and concludes by addressing the medicolegal implications of delayed treatment of the disease.
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Affiliation(s)
- Zachary Tuvya Sharfman
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yaroslav Gelfand
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pryiam Shah
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ari Jacob Holtzman
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Joseph Roy Mendelis
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Merritt Drew Kinon
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jonathan David Krystal
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Allan Brook
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Reza Yassari
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David Claude Kramer
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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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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