Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts.
J Arthroplasty. 2024 Aug;39(8):1919-1925.e2. doi: 10.1016/j.arth.2024.02.030. Epub 2024 Mar 6.
No single test has demonstrated absolute accuracy in the diagnosis of periprosthetic joint infection (PJI). Serological markers are often used as screening tools to avoid unnecessary joint aspiration in cases with a low probability of infection. This study aimed to determine the utility of standard-of-care serological tests as a screening tool for PJI in patients undergoing revision arthroplasty.
This prospective study enrolled 502 patients undergoing revision hip or knee arthroplasty between May 2017 and August 2021. A PJI was defined using a modified definition of the 2018 International Consensus Meeting criteria. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. There were 82 patients undergoing reimplantation who were excluded. Additionally, 8 patients who had an inconclusive International Consensus Meeting score were also excluded. Of the 412 included patients, 317 (76.9%) underwent revision for aseptic failure, and 95 (23.1%) had PJI. Receiver operating characteristic curves were used to assess the diagnostic utility of each serological test. A pairwise comparison with Bonferroni correction was performed to determine whether the differences in areas under the curve (AUCs) between the tests were significant. Additional analyses were performed to find the threshold for each test that offered 100% sensitivity, allowing it to be the optimal screening test.
All 4 serological markers, D-dimer (AUC 0.860, sensitivity 81.3%, specificity 81.7%), CRP (AUC 0.862, sensitivity 90.4%, specificity 70.0%), ESR (AUC 0.833, sensitivity 73.9%, specificity 85.2%), and fibrinogen (AUC 0.798, sensitivity 74.7%, specificity 75.4%), demonstrated comparable accuracy for the diagnosis of PJI (all P > .05). When maximizing sensitivity to 100%, D-dimer demonstrated the highest specificity (AUC 0.860, specificity 40.2%), outperforming ESR (AUC 0.833, specificity 3.3%), fibrinogen (AUC 0.798, specificity 2.3%), and CRP (AUC 0.862, specificity 0%). A plasma D-dimer level of ≥ 244 ng/mL was identified as the optimal cutoff for use as a screening test.
Although plasma D-dimer demonstrated similar diagnostic accuracy as CRP, ESR, and fibrinogen, it outperformed all 3 aforementioned serological markers when used as a screening test for PJI.
Level II.
目前尚无单项检测手段能对假体周围关节感染（PJI）的诊断具有绝对准确性。血清学标志物常用于筛选工具，以避免对低感染概率的病例进行不必要的关节抽吸。本研究旨在确定标准护理血清学检测作为接受翻修关节成形术患者 PJI 的筛选工具的效用。
本前瞻性研究纳入了 2017 年 5 月至 2021 年 8 月间进行翻修髋关节或膝关节成形术的 502 例患者。采用 2018 年国际共识会议标准的改良定义来定义 PJI。术前测量血浆 D-二聚体、红细胞沉降率（ESR）、C 反应蛋白（CRP）和纤维蛋白原。排除了 82 例进行再植入的患者。此外，也排除了 8 例国际共识会议评分不确定的患者。在纳入的 412 例患者中，317 例（76.9%）因无菌性失败而接受翻修，95 例（23.1%）患有 PJI。使用受试者工作特征曲线评估每种血清学检测的诊断效用。使用 Bonferroni 校正进行两两比较，以确定检测之间曲线下面积（AUC）的差异是否具有统计学意义。还进行了额外的分析，以找到每个检测的阈值，使它们能达到 100%的敏感性，从而成为最佳筛选检测。
所有 4 种血清学标志物，D-二聚体（AUC 0.860，敏感性 81.3%，特异性 81.7%）、CRP（AUC 0.862，敏感性 90.4%，特异性 70.0%）、ESR（AUC 0.833，敏感性 73.9%，特异性 85.2%）和纤维蛋白原（AUC 0.798，敏感性 74.7%，特异性 75.4%），对 PJI 的诊断均具有相当的准确性（均 P＞.05）。当最大程度地提高敏感性至 100%时，D-二聚体表现出最高的特异性（AUC 0.860，特异性 40.2%），优于 ESR（AUC 0.833，特异性 3.3%）、纤维蛋白原（AUC 0.798，特异性 2.3%）和 CRP（AUC 0.862，特异性 0%）。血浆 D-二聚体水平≥244ng/mL 被确定为用于筛选 PJI 的最佳截断值。
尽管 D-二聚体与 CRP、ESR 和纤维蛋白原的诊断准确性相似，但在用作 PJI 的筛选检测时，它优于上述 3 种血清学标志物。
2 级。
