Plasma D-dimer found noninferior to serum CRP in diagnosis of PJI
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Published results showed plasma D-dimer was noninferior to serum C-reactive protein and erythrocyte sedimentation rate in the diagnosis of periprosthetic joint infection.
“This study demonstrated that plasma D-dimer had comparable diagnostic accuracy to traditional inflammatory markers, such as CRP and [erythrocyte sedimentation rate] ESR, in the diagnosis of PJI,” Saad Tarabichi, MD, postdoctoral research fellow at Rothman Orthopaedic Institute, told Healio. “Furthermore, we found that D-dimer may help improve diagnostic confidence in a number of clinical scenarios.”
Tarabichi and colleagues preoperatively measured plasma D-dimer, ESR, CRP and fibrinogen among 502 patients undergoing revision hip or knee arthroplasty. Researchers used receiver operating characteristic curves to assess the utility of each biomarker in the diagnosis of PJI, which was defined per a modified version of the 2018 International Consensus Meeting criteria. Researchers also performed pairwise comparison with Bonferroni correction to determine whether the differences in areas under the curve between the markers were significant.
Of the 412 patients included in the study, researchers found 76.9% did not have an infection and 23.1% had an infection. Results showed plasma D-dimer, CRP, ESR and fibrinogen all demonstrated comparable accuracy for the diagnosis of PJI.
“In a subanalysis of patients with a diagnosis of PJI caused by indolent organisms, D-dimer outperformed CRP and ESR and demonstrated a sensitivity of 93.8%,” Tarabichi said.
Perspective
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I commend Javad Parvizi, MD, FRCS, and colleagues on a well-designed study. There has been some debate in the literature about the usefulness of plasma D-dimer when compared with serum D-dimer; some studies demonstrate higher sensitivity of serum D-dimer. The combination of elevated CRP, ESR and D-dimer have the highest sensitivity in diagnosing infection. While CRP and ESR are the gold standard, these can be falsely low in the case of chronic infections and indolent organisms. This is when plasma D-dimer may be useful.
More research is needed to determine whether the plasma D-dimer should be a routine test ordered alongside CRP and ESR, or if it is only needed in situations where these markers are low in a clinically suspected PJI. As always, the cost of the test must be weighed against its utility. Because CRP and ESR are accurate in most cases, the D-dimer may need to be reserved as a second-line test when faced with normal CRP and ESR for indolent and chronic infections. It is helpful that the study’s cut-off level of the D-dimer was 471 ng/mL for indolent organisms, and serum CRP, ESR and D-dimer levels were not affected by usage of preoperative oral antibiotics.
Reference:
Wang R, et al. J Orthop Surg Res. 2022;doi:10.1186/s13018-022-03001-y.
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