Fei Yang, Chenyu Zhao, Rong Huang, Hui Ma, Xiaohe Wang, Guodong Wang, Xiaowei Zhao

Scientific Reports, 11, Article number: 677 (2021)
DOI: 10.1038/s41598-020-80547-z

Summary by Leanne Ludwick, BS

As periprosthetic joint infection (PJI) is one of the most devastating complications following total hip and knee arthroplasty, early and accurate diagnosis of PJI is critical for infection management.^1–4 The recommendations for PJI diagnosis from the ICM include clinical symptoms, microbiology, and serum and synovial biomarkers, such as CRP and ESR.^5,6 Previous studies have shown that plasma fibrinogen (FIB), a coagulation-related indicator, is associated with the diagnosis of PJI.^7,8 However, further research is required to determine its diagnostic accuracy and potential utility as a biomarker for PJI. The purpose of this study was to determine if plasma FIB is an effective biomarker for PJI compared to other validated biomarkers and if so, establish the optimal cutoff and diagnostic values.

Yang et al. retrospectively reviewed the charts of 156 patients who underwent revision arthroplasty. Of which, 57 patients were undergoing revision for PJI (36.5%) and 99 patients were undergoing revision for aseptic mechanical failure (63.5%). They found plasma FIB to be significantly elevated in patients with PJI (5.23 (±1.12)) compared to non-PJI patients (3.41 (±0.72), p<0.001). Similarly, ESR, CRP, and serum WBC were also significantly higher in the PJI group compared to the non-PJI group (p<0.001). The ROC curves determined serum FIB, ESR, and CRP to be predictive of PJI with AUC values of 0.916 (95% CI 0.869–0.964), 0.822 (95% CI 0.752–0.893), and 0.901 (95% CI 0.861–0.960), respectively. Serum WBC count was not significantly able to predict PJI in this patient population (0.647, 95% CI 0.553-0.743). The authors determined the optimal cutoff of plasma FIB to be 4.20 g/L with a sensitivity, specificity, PPV, and NPV of 0.860, 0.900, 0.831, and 0.908, respectively.

Plasma FIB demonstrated significantly higher levels in PJI patients compared to non-PJI patients and resulted in the highest AUC compared to the traditional, validated PJI biomarkers. These findings warrant further investigation into the utility of plasma FIB as a biomarker for PJI diagnosis, especially since coagulation testing is a routine aspect of preoperative testing. Limitations of the study include its retrospective nature, failure to separately analyze acute and chronic PJI cases, and the strict inclusion and exclusion criteria that could affect the use of plasma FIB as a diagnostic tool in the general population.

References:

1. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic Burden of Periprosthetic Joint Infection in the United States. The Journal of Arthroplasty. 2012;27(8, Supplement):61-65.e1. doi:10.1016/j.arth.2012.02.022
2. Kurtz SM, Lau EC, Son M-S, Chang ET, Zimmerli W, Parvizi J. Are We Winning or Losing the Battle With Periprosthetic Joint Infection: Trends in Periprosthetic Joint Infection and Mortality Risk for the Medicare Population. The Journal of Arthroplasty. 2018;33(10):3238-3245. doi:10.1016/j.arth.2018.05.042
3. Izakovicova P, Borens O, Trampuz A. Periprosthetic joint infection: current concepts and outlook. EFORT Open Rev. 2019;4(7):482-494. doi:10.1302/2058-5241.4.180092
4. Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res. 2010;468(1):52-56. doi:10.1007/s11999-009-1013-5
5. Abdelaziz H, Rademacher K, Suero EM, et al. The 2018 International Consensus Meeting Minor Criteria for Chronic Hip and Knee Periprosthetic Joint Infection: Validation From a Single Center. The Journal of Arthroplasty. 2020;35(8):2200-2203. doi:10.1016/j.arth.2020.03.014
6. Parvizi J, Tan TL, Goswami K, et al. The 2018 Definition of Periprosthetic Hip and Knee Infection: An Evidence-Based and Validated Criteria. J Arthroplasty. 2018;33(5):1309-1314.e2. doi:10.1016/j.arth.2018.02.078
7. Li R, Shao H-Y, Hao L-B, et al. Plasma Fibrinogen Exhibits Better Performance Than Plasma D-Dimer in the Diagnosis of Periprosthetic Joint Infection: A Multicenter Retrospective Study. J Bone Joint Surg Am. 2019;101(7):613-619. doi:10.2106/JBJS.18.00624
8. Davalos D, Akassoglou K. Fibrinogen as a key regulator of inflammation in disease. Semin Immunopathol. 2012;34(1):43-62. doi:10.1007/s00281-011-0290-8