Comparing the Diagnostic Value of Serum D-Dimer to CRP and IL-6 in the Diagnosis of Chronic Prosthetic Joint Infection

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.

The change in plasma D-dimer does not help to guide the timing of reimplantation in two stage exchange for periprosthetic joint infection

“…While the median concentrations of 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 (IQR, 4–9 pg/ml), p < 0.001) were significantly higher prior to first stage surgery compared to the planned second stage reimplantation. 43% of patients (13/30) had a D-dimer above 2850 ng/ml prior to reimplantation which was the calculated threshold in the diagnosis of PJI at our institutional laboratory in patients undergoing revision arthroplasty 10 .…”

“…Furthermore, the previous orthopedic literature on D-dimers has recently been criticized for basic methodological errors such as failure to report the specific laboratory standard used and the correct unit used with Moser et al 21 suggesting an individual cut-off for each institution as the levels of D-dimer are expected to vary greatly. This has been done for the present cohort 10 however it remains uncertain whether it is useful for low-volume centers to gather a sufficient number of patients in order to calculate a reliable individual cut-off value. Lastly, it has been shown that some biomarkers and there behavior following surgery for PJI could predict further intervention or be associated with adverse outcome 22 .…”

“…The change in the respective serum marker was calculating subtracting the value prior to first stage surgery from the value prior to reimplantation (an expected drop with a negative sign). Furthermore, a calculated threshold of 2850 ng/ml from a previous study using the same laboratory kit in patients undergoing revision arthroplasty was evaluated 10 . During the study period (July 2019 to June 2020) we performed complete two stage revision in 35 patients and in 30 patients preoperative D-dimers were taken at both stages (STROBE diagram, Fig.…”

“…Serum D-dimer is a novel parameter that has been included in the criteria by the Musculoskeletal Infection Society (MSIS) in 2018 8 and the findings from International consensus meeting (ICM) 9 for the diagnosis of PJI. Several studies have investigated the diagnostic accuracy of D-dimer in distinguishing aseptic complication and PJI with conflicting results and a reported sensitivity of 38–96% 10 – 12 and a specificity of 32–94% 10 , 11 , 13 . The value of D-dimer prior to reimplantation in a two-stage exchange has only been investigated sporadically with one study recommending its use 14 and one 15 finding a limited accuracy.…”

Synovial pH Is As Specific As Synovial Leukocyte Count But Less Sensitive For The Diagnosis of Chronic Prosthetic Joint Infection

“…PJI continues to affect a remarkable number of patients who undergo TJA but the accurate diagnosis is still challenging in daily clinical practise and the search for potential serological and synovial biomarkers is ongoing [17][18][19]. This study evaluates synovial pH as a potential novel marker for chronic PJI.…”