Abstract
BackgroundD-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.MethodsA 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.ResultsPreoperative 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.ConclusionsPlasma 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.
Highlights
In recent years, several scientific societies have developed criteria to standardize definitions for prosthetic joint infection (PJI) [1,2,3,4]
Plasma D-dimer did not offer an improvement over the individual or combined diagnosis for any type of PJI according to Infectious Diseases Society of America (IDSA) criteria
The main peripheral blood parameters used for the preoperative diagnosis of PJI include primarily 2 serological markers, serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
Summary
Several scientific societies have developed criteria to standardize definitions for prosthetic joint infection (PJI) [1,2,3,4]. Relevant studies that used MSIS or ICM criteria addressing the evaluation of D-dimer for the diagnosis of PJI reach different conclusions [7,8,9,10,11,12]. This may be due to the different methodologies used among the studies and, because the thresholds of serological markers may vary, depending on the heterogeneity of the definitions, the time of infection, different D-dimer assays, and/or the infecting organism, more work is needed to further validate their role in the diagnosis of PJI [6]. 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
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