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Incesoy MA, Demirkiran CB, Kaya HB, Geckalan MA, Tak AY, Elmali N, Yildiz F, Uzer G. Natural course of postoperative C-reactive protein and erythrocyte sedimentation rate in unilateral and simultaneous bilateral total knee arthroplasty. BMC Musculoskelet Disord 2025; 26:260. [PMID: 40087715 PMCID: PMC11907866 DOI: 10.1186/s12891-025-08523-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2025] [Accepted: 03/12/2025] [Indexed: 03/17/2025] Open
Abstract
BACKGROUND C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are valuable markers for detecting periprosthetic joint infection (PJI) post-total knee arthroplasty (TKA). However, their prolonged elevation after TKA diminishes diagnostic reliability. This study investigates CRP and ESR trends in unilateral (U-TKA) and simultaneous bilateral TKA (SB-TKA) patients, comparing their patterns. METHODS Between 2017 and 2023, preoperative and postoperative (weeks 2, 4, 6) CRP and ESR levels were assessed in U-TKA (32 patients) and SB-TKA (29 patients) groups for gonarthrosis. RESULTS Median preoperative CRP levels were 1.13 mg/dL (U-TKA) and 0.2 mg/dL (SB-TKA), with corresponding ESR levels of 13.50 mm/h and 10 mm/h. While CRP and ESR increased more in SB-TKA, differences were statistically insignificant (p > 0.05). Both groups showed significant differences in CRP and ESR values at all time points (p < 0.05). U-TKA patients reached CRP < 5 mg/dL and ESR < 30 mm/h by the 6th postoperative week. SB-TKA patients did not exhibit significantly higher CRP and ESR levels at various intervals compared to U-TKA patients (p > 0.05). CONCLUSION This study delineates postoperative CRP and ESR trends in U-TKA and SB-TKA for osteoarthritis. CRP values decreased below 5 mg/dL, and ESR values below 30 mm/h within 6 weeks in both groups. Statistically significant differences in CRP and ESR values were observed at all time points. No significant differences were found in CRP and ESR trends between both groups. These findings aid physicians in interpreting laboratory reports for PJI determination. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Mustafa Alper Incesoy
- Department of Orthopedics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey.
| | - Cemil Burak Demirkiran
- Department of Orthopedics, Kilis Prof. Dr. Alaeddin Yavaşca State Hospital, Kilis, Turkey
| | - Hakan Batuhan Kaya
- Department of Orthopedics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Muhammed Ali Geckalan
- Department of Orthopedics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Aysegul Yabaci Tak
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Nurzat Elmali
- Department of Orthopedics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Fatih Yildiz
- Department of Orthopedics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Gokcer Uzer
- Department of Orthopedics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
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Tarabichi S, Verhey JT, Lizcano JD, Abe EA, Cancio-Bello A, Tummala SV, Deckey DG, Jennings JM, Parvizi J, Courtney PM, Spangehl MJ, Bingham JS. Diagnostic Thresholds of Synovial Markers for Acute Periprosthetic Joint Infection: One Size Does Not Fit All. J Arthroplasty 2025:S0883-5403(25)00192-5. [PMID: 40023460 DOI: 10.1016/j.arth.2025.02.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Revised: 02/19/2025] [Accepted: 02/20/2025] [Indexed: 03/04/2025] Open
Abstract
BACKGROUND The diagnosis of periprosthetic joint infection (PJI), particularly during the early postoperative period, remains challenging. The purpose of this multicenter study was to assess the utility of synovial white blood cell (WBC) count and polymorphonuclear leukocyte percentage (PMN%) in the diagnosis of acute PJI at different time intervals after primary total joint arthroplasty (TJA). METHODS This retrospective study identified 225 patients who underwent a joint aspiration within 90 days of their primary TJA at three institutions. A PJI was defined as revision TJA for infection within 7 days of joint aspiration with two positive cultures isolating the same organism. Patients were considered aseptic if they had no reoperation for up to 1 year after arthrocentesis. Receiver operator characteristic curves were used to assess the utility of WBC count and PMN% in the diagnosis of acute PJI at zero to 15, 15 to 45, and 45 to 90 days. Youden's index was used to identify the optimal cutoffs at each time interval. A pairwise comparison was performed to compare the area under the curve (AUC) of the two markers. There were 214 patients included. Of these, 81 (37.9%) were infected and 133 (62.1%) were aseptic. RESULTS The optimal cutoff at zero to 15 days was 21,003 cells/μL for WBC count (AUC 0.937, sensitivity 88.0%, specificity 100%) and 92.0% for PMN% (AUC 0.638, sensitivity 56.0%, specificity 68.4%). Although the diagnostic threshold for WBC count decreased to 5,111 cells/μL at 15 to 45 days and to 2,503 cells/μL at 45 to 90 days, the cutoffs for PMN% did not downtrend in the same fashion (80% at 15 to 45 days; 86% at 45 to 90 days). Using pairwise comparison, the AUC for WBC count was higher than that of PMN% at 0 to 15 days (P = 0.002); however, there was no difference in AUCs at either 15 to 45 days (P = 0.438) or 45 to 90 days (P = 0.826). CONCLUSIONS Based on our findings, it appears that there may be a role for diagnostic thresholds for the identification of acute PJI that are specific to the timing of joint aspiration after primary TJA.
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Affiliation(s)
- Saad Tarabichi
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jens T Verhey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Juan D Lizcano
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Elizabeth A Abe
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Sailesh V Tummala
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | | | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
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Inoue D, Kabata T, Kajino Y, Yanagi Y, Ima M, Demura S. Is the natural course of perioperative laboratory testing effective in identifying wound-related complications following primary total hip arthroplasty? Arch Orthop Trauma Surg 2024; 145:75. [PMID: 39708180 DOI: 10.1007/s00402-024-05686-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 10/07/2024] [Indexed: 12/23/2024]
Abstract
INTRODUCTION Previous study did not clarify the correlation between the natural course of perioperative blood tests and occurrence of wound-related complications, including SSI, PJI, and delayed wound healing. This study aimed to investigate whether perioperative laboratory test is effective in identifying wound-related complications after THA. MATERIALS AND METHODS This retrospective, single-institutional study enrolled 1072 patients who underwent primary THAs. We identified all cases of perioperative wound-related complications, including surgical site infection (SSI), periprosthetic joint infection (PJI), and delayed wound healing. First, we investigated which factors influenced perioperative wound complications using multivariate analysis. Second, we did 2:1 case-control study between no complications and complication group by matching on age, BMI, diagnosis, ASA class, Charlson comorbidity index. The results of perioperative laboratory tests were compared between two groups. Third, we investigated whether there was an effective threshold for perioperative wound complications on serum CRP and D-dimer. RESULTS Twenty-six cases of THA, comprising SSI in 9 hips (0.8%), PJI in 10 hips (0.9%), and 7 hips with wound delay healing (0.7%), demonstrated perioperative wound-related complications. Multivariate analysis showed that ASA class, Charlson comorbidity index, and serum CRP values in 1 week postoperatively influenced perioperative wound complications, meanwhile serum D-dimer did not show the statistical difference. After case-control matching on patient factors, the result of any blood samples did not show statistical difference in complication group. Also, no significant threshold for detecting wound-related complications was found in serum CRP and D-dimer. CONCLUSION The main role of perioperative blood tests is to recognize preoperative patient factors in order to early detect of perioperative wound complications. Serum CRP values in 1 week postoperatively may play a supplemental role in taking care of perioperative wound complication.
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Affiliation(s)
- Daisuke Inoue
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Tamon Kabata
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Yoshitomo Kajino
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Yu Yanagi
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Musashi Ima
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Satoru Demura
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
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Ali KA, He L, Deng X, Pan J, Huang H, Li W. Assessing the predictive value of pre- and post-operative inflammatory markers in patients undergoing total knee arthroplasty. J Orthop Surg Res 2024; 19:614. [PMID: 39343946 PMCID: PMC11440765 DOI: 10.1186/s13018-024-05104-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 09/22/2024] [Indexed: 10/01/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Total Knee Arthroplasty (TKA) has proven highly effective in improving quality of life for patients with severe knee conditions. Despite advancements, surgical complications such as periprosthetic joint infections (PJIs) pose risks. The potential predictive value of pre- and post-operative inflammatory markers like neutrophil-to-lymphocyte ratio (NLR), D-dimer, and albumin levels on surgical outcomes is garnering attention. There is a growing interest in leveraging these markers to enhance patient selection and outcome prediction in the context of TKA.Focusing on the natural course of these markers, and the incidence of PJIs and to refine perioperative care strategies, improve patient outcomes, and identify high-risk patients for targeted intervention. METHODS The study included 94 patients who underwent total knee arthroplasty (TKA) between 2019 and 2023. Blood tests were conducted before surgery and at 1, 3, 7, and 15 days after surgery to assess various parameters including white blood cell count, neutrophils, lymphocytes, platelets, hemoglobin, C-reactive protein, D-dimers, total protein, albumin, and total cholesterol values and ratios. RESULTS Following total knee arthroplasty (TKA), key observations in blood markers included a sharp rise in white blood cell (WBC) counts from 5.81 to 10.22 (*10^9/L) on the first day post-surgery, with levels returning close to preoperative values by day-15. Neutrophil counts similarly increased from 3.46 to 8.50 (*10^9/L) on day-1, decreasing to 4.01 by day-15. Hemoglobin levels significantly decreased from 115.70 g/L to 90.62 by day-3 before improving to 100.30 by day-15. C-reactive protein (CRP) levels also saw a significant rise from 6.15 mg/L to a peak of 47.07 on day-3, then reducing to 10.55 by day-15, indicating a response to inflammation. CONCLUSION Following total knee arthroplasty (TKA), a significant initial postoperative increase in white blood cell count, neutrophils, and C-reactive protein levels, indicative of an acute inflammatory response, before returning towards baseline values by day 15. Hemoglobin levels displayed a notable dip post-surgery, gradually improving by the study's end. These patterns emphasize the dynamic nature of inflammatory and hematological responses after TKA, highlighting their potential role in predicting surgical outcomes and guiding postoperative care.
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Affiliation(s)
- Khan Akhtar Ali
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - LingXiao He
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xinyue Deng
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jumei Pan
- Department of Hospice Care of Linfen Road Community Health Care Center, Jing An District, Shanghai, 200435, China
| | - Hui Huang
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Wenkai Li
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Zhao H, Li L, Wang HY, Ding L, Wang Y, Liu X, Tian S, Wang Y. Efficacy analysis of clinical serological indicators in the diagnosis of postoperative periprosthetic joint infection in patients with rheumatoid arthritis or osteoarthritis. INTERNATIONAL ORTHOPAEDICS 2024; 48:1945-1952. [PMID: 38581467 DOI: 10.1007/s00264-024-06171-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/01/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE To investigate the incidence of periprosthetic joint infection (PJI) in patients with rheumatoid arthritis (RA) or osteoarthritis (OA) after primary joint arthroplasty; to analyze the optimal cut-off values of clinical serum markers C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and D-dimer for the diagnosis of PJI in RA patients; and to explore their diagnostic efficacy and clinical significance. METHODS Clinical data of 15,702 patients with RA (578) or OA (15,124) who underwent total joint arthroplasty from 2013 to 2021 were retrospectively analyzed. Serum CRP, ESR, and D-dimer were recorded for each patient, and subject characteristic curves were used to determine the optimal threshold values of CRP, ESR, and D-dimer for RA-PJI and OA-PJI and to compare the areas under the curves to assess the diagnostic efficacy of the optimal threshold values of serologic indices for RA-PJI. RESULTS The five year incidence of PJI was 6.92% in RA patients and 0.67% in OA patients. The optimal thresholds of CRP, ESR, and D-dimer for the diagnosis of RA-PJI were respectively 13.85 mg/L, 33.02 mm/h, and 796.50 ng/mL. The sensitivities of the optimal thresholds were respectively 67.6%, 62.2%, and 56.8%, and the specificities were 74.7%, 60.4%, and 74.4%. CONCLUSION RA patients have a higher incidence of PJI than OA patients. The optimal thresholds for CRP, ESR, and d-dimer for the diagnosis of PJI were higher in RA patients than in OA patients, but the sensitivity and specificity of the diagnosis were not as good as in OA patients.
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Affiliation(s)
- Hengxin Zhao
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China
| | - Lianggang Li
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China
| | - Hong-Yu Wang
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China
| | - Lanfeng Ding
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China
| | - Yuanhe Wang
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China
| | - Xiaokai Liu
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China
| | - Shaoqi Tian
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China.
| | - Yan Wang
- Department of Gynecology, The Women and Children's Hospital of Qingdao, Tongfu Road 6, Qingdao, 266034, China.
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Li Z, Song L, Qin B, Li K, Shi Y, Wang H, Wang H, Ma N, Li J, Wang J, Li C. A predictive nomogram for surgical site infection in patients who received clean orthopedic surgery: a retrospective study. J Orthop Surg Res 2024; 19:38. [PMID: 38183110 PMCID: PMC10770936 DOI: 10.1186/s13018-023-04473-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/14/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Surgical site infection (SSI) is a common and serious complication of elective clean orthopedic surgery that can lead to severe adverse outcomes. However, the prognostic efficacy of the current staging systems remains uncertain for patients undergoing elective aseptic orthopedic procedures. This study aimed to identify high-risk factors independently associated with SSI and develop a nomogram prediction model to accurately predict the occurrence of SSI. METHODS A total of 20,960 patients underwent elective clean orthopedic surgery in our hospital between January 2020 and December 2021, of whom 39 developed SSI; we selected all 39 patients with a postoperative diagnosis of SSI and 305 patients who did not develop postoperative SSI for the final analysis. The patients were randomly divided into training and validation cohorts in a 7:3 ratio. Univariate and multivariate logistic regression analyses were conducted in the training cohort to screen for independent risk factors of SSI, and a nomogram prediction model was developed. The predictive performance of the nomogram was compared with that of the National Nosocomial Infections Surveillance (NNIS) system. Decision curve analysis (DCA) was used to assess the clinical decision-making value of the nomogram. RESULTS The SSI incidence was 0.186%. Univariate and multivariate logistic regression analysis identified the American Society of Anesthesiology (ASA) class (odds ratio [OR] 1.564 [95% confidence interval (CI) 1.029-5.99, P = 0.046]), operative time (OR 1.003 [95% CI 1.006-1.019, P < 0.001]), and D-dimer level (OR 1.055 [95% CI 1.022-1.29, P = 0.046]) as risk factors for postoperative SSI. We constructed a nomogram prediction model based on these independent risk factors. In the training and validation cohorts, our predictive model had concordance indices (C-indices) of 0.777 (95% CI 0.672-0.882) and 0.732 (95% CI 0.603-0.861), respectively, both of which were superior to the C-indices of the NNIS system (0.668 and 0.543, respectively). Calibration curves and DCA confirmed that our nomogram model had good consistency and clinical predictive value, respectively. CONCLUSIONS Operative time, ASA class, and D-dimer levels are important clinical predictive indicators of postoperative SSI in patients undergoing elective clean orthopedic surgery. The nomogram predictive model based on the three clinical features demonstrated strong predictive performance, calibration capabilities, and clinical decision-making abilities for SSI.
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Affiliation(s)
- Zhi Li
- Department of Infection Management, North China Healthcare Group Xingtai General Hospital, Xingtai, Hebei, China
| | - Lihua Song
- Department of Infection Management, North China Healthcare Group Xingtai General Hospital, Xingtai, Hebei, China
| | - Baoju Qin
- Department of Infection Management, North China Healthcare Group Xingtai General Hospital, Xingtai, Hebei, China
| | - Kun Li
- Department of Infection Management, North China Healthcare Group Xingtai General Hospital, Xingtai, Hebei, China
| | - Yingtao Shi
- Operating Room, Xingtai General Hospital of North China Medical and Health Group, Xingtai, Hebei, China
| | - Hongqing Wang
- Department of Orthopedics, North China Healthcare Group Xingtai General Hospital, Xingtai, Hebei, China
| | - Huiwang Wang
- Department of Orthopedics, North China Healthcare Group Xingtai General Hospital, Xingtai, Hebei, China
| | - Nan Ma
- Department of Orthopedics, North China Healthcare Group Xingtai General Hospital, Xingtai, Hebei, China
| | - Jinlong Li
- Hebei Provincial Key Laboratory of Precision Medicine for Liver Cirrhosis and Portal Hypertension, Xingtai People's Hospital of Hebei Medical University, Xingtai, Hebei, China
| | - Jitao Wang
- Hebei Provincial Key Laboratory of Precision Medicine for Liver Cirrhosis and Portal Hypertension, Xingtai People's Hospital of Hebei Medical University, Xingtai, Hebei, China.
| | - Chaozheng Li
- Department of Infection Management, North China Healthcare Group Xingtai General Hospital, Xingtai, Hebei, China.
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Kılıçarslan K, Naldöven ÖF, Veizi E, Güven Ş, Çepni Ş, Fırat A. C-Reactive Protein and Erythrocyte Sedimentation Rates after Total and Unicompartmental Knee Arthroplasty-Less Implant Equals Quicker Normalization. J Long Term Eff Med Implants 2024; 34:49-55. [PMID: 38842232 DOI: 10.1615/jlongtermeffmedimplants.2023050965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Postoperative follow up after total or unicondylar knee arthroplasty (UKA) includes C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to scan for and possibly diagnose a periprosthetic joint infection (PJI). The aim of this study was to describe the postoperative changes in CRP and ESR values after UKA and compare them with values obtained after TKA. Patients operated on between 2020 and 2022 were eligible for this retrospective study. Inclusion criteria were patients with at least 4 postoperative visits associated with blood test screening for PJI, aged > 45, with uneventful follow-up for the first 90 days. Exclusion criteria were a history of chronic inflammatory disease, revision for any reason, and readmission for any reason. Blood samples were collected on the 3rd, 15th, and 30th postoperative days and once between the 45th and the 90th day. The mean and peak values were compared between the two groups. The study included 277 patients (243 TKAs and 34 UKAs). Mean age was significantly lower in the UKA group (67.2 ± 7.5 vs. 60.0 ± 5.9). On the 3rd and the 15th postoperative day, the UKA patients had significantly lower ESR and CRP levels. The levels normalized after the first month. While the TKA patients showed higher values, the trend normalized after the 30th day. CRP and ESR values rose significantly after TKA and persisted up to the 15th day postoperatively. CRP and ESR values normalized faster in patients undergoing UKA. Patients > 65 had higher CRP and ESR values during their routine follow-ups.
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Affiliation(s)
| | - Ömer Faruk Naldöven
- Department of Orthopedics and Traumatology, Ankara City Hospital, 06000 Ankara, Turkey
| | - Enejd Veizi
- Department of Orthopedics and Traumatology, Ankara City Hospital, 06000 Ankara, Turkey
| | - Şahan Güven
- Department of Orthopedics and Traumatology, Ankara City Hospital, 06000 Ankara, Turkey
| | - Şahin Çepni
- Department of Orthopedics and Traumatology, Ankara City Hospital, 06000 Ankara, Turkey
| | - Ahmet Fırat
- Department of Orthopedics and Traumatology, Ankara City Hospital, 06000 Ankara, Turkey
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Yang L, Wu BY, Wang CF, Li HW, Bian WW, Ruan H. Indicators and medical tests to identify lower limb swelling causes after total knee arthroplasty: a Delphi study with multidisciplinary experts. J Orthop Surg Res 2023; 18:573. [PMID: 37543607 PMCID: PMC10403920 DOI: 10.1186/s13018-023-03980-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/04/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Lower limb swelling after total knee arthroplasty (TKA) hinders surgical effectiveness. The poor results of studies on swelling interventions are due to the lack of a classification of swelling causes through appropriate medical tests. A gold standard is missing. This study aimed to clarify the causes of TKA postoperative swelling and how to identify them through indicators and medical tests by consulting a wide range of experts from multiple disciplines. METHOD The Delphi method was used. A first draft of the index was prepared based on a systematic search of the literature. A total of 11 experts from several disciplines were invited to evaluate the rationality of the indicators and suggest modifications. After two rounds of consultation, the experts reached a consensus, and the consultation was stopped. RESULTS The response rate of the 11 experts was 100%, and the authoritative Cr was 0.896. Kendall's W values for opinion coordination of the two rounds of consultation were 0.262 and 0.226, respectively (P < 0.001). Among the final indicators, there were 4 primary indicators for swelling cause classification (inflammatory response, poor venous return, joint hematoma, muscle damage, and healing), 19 secondary and 19 tertiary indicators. CONCLUSION The indications obtained by systematic literature review and multidisciplinary expert consultation are reliable and scientific. Multiple causes of lower extremity swelling after TKA were identified. Blood test indicators can reflect an inflammatory response, suggest poor venous return, and reflect muscle damage and healing progress. Ultrasound scans are needed to identify underlying thrombotic or valvular problems, joint hematomas, and muscle damage. These tests help clinicians and researchers determine the cause of swelling after TKA and take appropriate management.
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Affiliation(s)
- Lin Yang
- Department of Nursing, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- School of Nursing, Shanghai JiaoTong University, Shanghai, China
| | - Bei-Ying Wu
- Department of Nursing, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Cai-Feng Wang
- Department of Nursing, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Hui-Wu Li
- Department of Orthopedic, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Wei-Wei Bian
- Department of Nursing, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.
| | - Hong Ruan
- Department of Nursing, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.
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Vosáhlo J, Salus A, Smolko M, Němcová B, Nordmeyer V, Mikles M, Rau SM, Erik Johansen O. Oral enzyme combination with bromelain, trypsin and the flavonoid rutoside reduces systemic inflammation and pain when used pre- and post-operatively in elective total hip replacement: a randomized exploratory placebo-controlled trial. Ther Adv Musculoskelet Dis 2023; 15:1759720X231186875. [PMID: 37529332 PMCID: PMC10387799 DOI: 10.1177/1759720x231186875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/20/2023] [Indexed: 08/03/2023] Open
Abstract
Background Early mobilization after total hip replacement (THR) is key for fast recovery but is often limited by pain. Oral enzyme combinations (OECs) have demonstrated anti-inflammatory and pain-relieving effects. Objectives and design This prospective, randomized, double-blind, placebo-controlled exploratory trial evaluated the effects of pre- and post-operative use of OEC (90 mg bromelain, 48 mg trypsin, 100 mg rutoside) following elective THR, on post-operative recovery. Methods Candidates for primary elective cementless THR owing to osteoarthritis were eligible for participation [age ⩾50 years, body mass index 25-35 kg/m2, C-reactive protein (CRP) ⩽6 mg/L]. Following randomization to OEC or placebo, intervention started pre-operatively and continued onwards until day 42. Main outcomes included post-operative CRP levels (days 1-7), self-reported hip pain at rest (by 0-10 cm visual analogue scale on post-operative days 1-42), post-operative analgesic use [by cumulative analgesic consumption score (CACS) days 7-42], tolerability and adverse events. Results Patients (N = 34) were recruited from a tertiary orthopaedic hospital in the Czech Republic, of whom 33 completed the study (OEC/placebo: n = 15/18). Baseline characteristics across the groups were comparable. Compared with placebo, the OEC group had numerically lower CRP levels on post-operative days 1-7, including peak level [mean (standard deviation) OEC versus placebo: 81.4 (28.3) versus 106.7 (63.3) mg/L], which translated into a significant 32% lower CRP area under the curve (p = 0.034). The OEC group reported significantly less pain during post-operative days 1-7 versus placebo (analysis of variance treatment × visit [F(4) = 3.989]; p = 0.005). Analgesic use was numerically reduced as assessed through an accumulated CACS. No deleterious effects on haemorheological parameters were observed in either group. Conclusions Pre- and post-operative use of OEC significantly reduced CRP levels and patient self-reported pain. OEC may be an efficacious and safe treatment option to facilitate post-operative recovery following THR. Trial registration EudraCT number 2016-003078-41.
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Affiliation(s)
- Jiří Vosáhlo
- Orthopaedic and Traumatology Department, Jihlava Hospital, Jihlava, Czech Republic
| | - Adam Salus
- Orthopaedic and Traumatology Department, Jihlava Hospital, Jihlava, Czech Republic
| | - Michael Smolko
- Orthopaedic and Traumatology Department, Jihlava Hospital, Jihlava, Czech Republic
| | - Barbora Němcová
- Rehabilitation Department, Jihlava Hospital, Jihlava, Czech Republic
| | - Veit Nordmeyer
- Clinical Department for Trauma Surgery, University Hospital Tulln, Tulln, Austria
| | - Milos Mikles
- Clinical Department for Trauma Surgery, University Hospital Tulln, Tulln, Austria
| | | | - Odd Erik Johansen
- Nestlé Health Science, Avenue Nestle 55, Vevey, Vaud 1800, Switzerland
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10
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Bae JK, Seo JS, Shin SK, Kim SJ, Kim JH. Does COVID-19 Infection within 1 Week after Total Knee Arthroplasty Affect Patients' Early Clinical Outcomes? A Matched Case-Control Study. J Clin Med 2023; 12:4496. [PMID: 37445528 DOI: 10.3390/jcm12134496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/25/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
Recent studies have reported the impact of previous COVID-19 infection on the early clinical outcome after total knee arthroplasty (TKA). However, the timing of infection before the surgery was not constant and a study on patients with COVID-19 infection within 1 week after TKA is lacking. This study aimed to determine the effect of COVID-19 infection within one week after TKA on the postoperative outcomes and to compare the early clinical outcomes to those who were not infected with COVID-19 before and after surgery. No significant differences were observed between the two groups in terms of clinical outcomes or complications. The length of the hospital stay (LOS) was significantly longer for the COVID-19 group than for the non-COVID-19 group (p < 0.05). The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were higher for the study group on postoperative days 9 and 12 than for those in the control group (p < 0.05). However, D-dimer levels were not significantly different between the two groups. We should cautiously consider that COVID-19 infection within 1 week after TKA may be associated with increased ESR, CRP levels, and length of hospital stay, but they are not associated with the worsening of early clinical outcomes or the occurrence of complications.
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Affiliation(s)
- Jung-Kwon Bae
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul 02053, Republic of Korea
| | - Jae-Sung Seo
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul 02053, Republic of Korea
| | - Seong-Kee Shin
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul 02053, Republic of Korea
| | - Seo-Jin Kim
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul 02053, Republic of Korea
| | - Jun-Ho Kim
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea
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11
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Cutter B, Lum ZC, Giordani M, Meehan JP. Utility of D-dimer in total joint arthroplasty. World J Orthop 2023; 14:90-102. [PMID: 36998388 PMCID: PMC10044320 DOI: 10.5312/wjo.v14.i3.90] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 11/22/2022] [Accepted: 02/13/2023] [Indexed: 03/17/2023] Open
Abstract
As the number of patients receiving total joint replacements continues to rise, considerable attention has been directed towards the early detection and prevention of postoperative complications. While D-dimer has long been studied as a diagnostic tool in venous thromboembolism (VTE), this assay has recently received considerable attention in the diagnosis of periprosthetic joint infection (PJI). D-dimer values are substantially elevated in the acute postoperative period after total joint arthroplasty, with levels often exceeding the standard institutional cutoff for VTE (500 µg/L). The utility of D-dimer in detecting VTE after total joint replacement is currently limited, and more research to assess its value in the setting of contemporary prophylaxis protocols is warranted. Recent literature supports D-dimer as a good to excellent biomarker for the diagnosis of chronic PJI, especially when using serum sample technique. Providers should exercise caution when interpreting D-dimer levels in patients with inflammatory and hypercoagulability disorders, as the diagnostic value is decreased. The updated 2018 Musculoskeletal Infection Society criteria, which includes D-dimer levels > 860 µg/L as a minor criterion, may be the most accurate for diagnosing chronic PJI to date. Larger prospective trials with transparent lab testing protocols are needed to establish best assay practices and optimal cutoff values for D-dimer in the diagnosis of PJI. This review summarizes the most current literature on the value of D-dimer in total joint arthroplasty and elucidates areas for future progress.
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Affiliation(s)
- Brenden Cutter
- Department of Orthopedic Surgery, Valley Orthopedic Surgery Residency/Valley Consortium for Medical Education, Modesto, CA 95351, United States
| | - Zachary C Lum
- Department of Orthopaedics, Adult Reconstruction Division, University of California, Davis Medical Center, Sacramento, CA 95817, United States
| | - Mauro Giordani
- Department of Orthopaedics, Adult Reconstruction Division, University of California, Davis Medical Center, Sacramento, CA 95817, United States
| | - John P Meehan
- Department of Orthopaedics, Adult Reconstruction Division, University of California, Davis Medical Center, Sacramento, CA 95817, United States
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D-Dimer, Erythrocyte Sedimentation Rate, and C-Reactive Protein Sensitivities for Periprosthetic Joint Infection Diagnosis. J Arthroplasty 2022; 38:914-917. [PMID: 36529198 DOI: 10.1016/j.arth.2022.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND There is contradicting evidence on the diagnostic value of inflammatory biomarkers for periprosthetic joint infection (PJI). We sought to quantify the sensitivity of D-dimer for acute and chronic PJI diagnosis and evaluate D-dimer lab values in the 90-day postoperative window in a control cohort of primary joint arthroplasty patients for comparison. METHODS An institutional database was queried for patients undergoing revision procedures for PJI after total hip arthroplasty (THA) and total knee arthroplasty (TKA) from 2014 to present. CRP, ESR, and D-dimer were collected within 90 days pre and postoperatively and sensitivities for the diagnosis of PJI were calculated. The control group included patients who underwent a negative diagnostic workup for deep venous thrombosis (DVT) or pulmonary embolus (PE) and had a D-dimer lab collected within 90 days postoperatively from primary total joint arthroplasty (TJA). RESULTS A total of 604 PJI patients were identified, and 81 patients had D-dimer, ESR, and CRP collected. There were 50/81 acute PJI patients and 31/81 chronic PJI patients who had median D-dimer values of 2,136.5 ng/mL [interquartile range (IQR): 1,642-3,966.5] and 3,336 ng/mL [IQR: 1,976-5,594]. Only the chronic PJI group had significantly higher D-dimer values when compared to the control cohort (P = .009). The sensitivity of D-dimer was calculated to be 92% and 93.5% in the acute and chronic PJI groups, respectively. CONCLUSION Serum D-dimer may not have high diagnostic utility for acute PJI, especially in the setting of recent surgery; however, it still may be useful for patients who have chronic PJI.
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Wu Y, Zhou J, Liu R, Zeng Y, Sun K, Li M, Peng L, Xu J, Shen B. What Is the Normal Trajectory of C-Reactive Protein, Erythrocyte Sedimentation Rate, Plasma Fibrinogen and D-Dimer after Two-Stage Exchange for Periprosthetic Joint Infection? Orthop Surg 2022; 14:2987-2994. [PMID: 36193876 PMCID: PMC9627072 DOI: 10.1111/os.13533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 07/21/2022] [Accepted: 09/07/2022] [Indexed: 11/29/2022] Open
Abstract
Objective C‐reactive protein (CRP), erythrocyte sedimentation rate (ESR), plasma fibrinogen and D‐Dimer are used as diagnostic biomarkers of prosthetic joint infection (PJI) after total joint arthroplasty (TJA). The purpose of the study was to investigate the normal trajectory of CRP, ESR, plasma fibrinogen and D‐Dimer at different time points after two‐stage exchange arthroplasty for PJI. Methods We studied 53 patients undergoing two‐stage exchange for PJI at five time points: preoperatively (T0), duration of hospital stays (T1), 30 days (T2), 30–90 days (T3), and 90–180 days (T4) after surgery. The medical records of all patients were well documented and carefully reviewed. The Shapiro–Wilk test was utilized to compare the normal distribution for continuous variables, and the nonnormally distributed data were used for Friedmann's one‐way repeat measures analysis of variances. Post hoc Dunnett's test was used to compare each pair of data to find differences from baseline. Results Compare with T0 point, the levels of CRP and ESR increased significantly and reached peak values at T1 point (all P < 0.001), with median values of 56.40 mg/L (range, 5.54–161.0 mg/L) and 49.00 mm/h (range, 13.00–113.0 mm/h), respectively. In addition, the levels of plasma fibrinogen and D‐Dimer increased significantly and reached peak values at T1 point (all P < 0.001), with median values of 4.13g/L (range, 2.27–6.80 mg/L) and 4.00 mg/L (range, 0.19–14.01 mg/L), respectively. CRP and ESR rapidly declined at the T2 point with significantly compared with T0 point (P = 0.001 and P < 0.001). The levels of CRP, ESR, plasma fibrinogen and D‐Dimer returned to preoperative levels of 5.23 mg/L (range, 1.01–21.70 mg/L), 19.00 mm/h (range, 6.00–60.00 mm/h), 3.38g/L (range, 1.71–5.10 g/L) and 2.33 mm/h (range, 0.19–6.87 mg/L) at T4 point, and there was no significant difference compared with T0 point (all P > 0.05). Conclusions The study demonstrated the normal trajectory of CRP, ESR, plasma fibrinogen and D‐Dimer at five time points in patients who underwent two‐stage exchange for PJI. Thus, the results have the possibility of providing signs of infection after the patient receives two‐stage exchange arthroplasty for PJI, which can benefit from early treatment.
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Affiliation(s)
- Yuangang Wu
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Jinhan Zhou
- Core Facilities of West China Hospital, Sichuan University, Chengdu, China
| | - Ran Liu
- Engineering Research Center of Medical Information Technology, Ministry of Education, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Zeng
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Kaibo Sun
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Mingyang Li
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Linbo Peng
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Jiawen Xu
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Bin Shen
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
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14
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Paradoxical Behavior of Plasma d-Dimer From Explantation to Reimplantation in a Two-Stage Revision for Periprosthetic Joint Infection. J Arthroplasty 2022; 37:S977-S982. [PMID: 35158006 DOI: 10.1016/j.arth.2022.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The variation of plasma d-dimer, an inflammatory marker, from pre-explantation to pre-reimplantation in two-stage revision remains unclear. Our objective was to evaluate delta-changes (Δ) in d-dimer, erythrocyte sedimentation rate (ESR), and C-reactive-protein (CRP), to ascertain whether these delta-changes are associated with the outcome of reimplantation. We hypothesized a decrease in d-dimer before reimplantation. METHODS A retrospective review was performed on a consecutive series of 95 two-stage revisions indicated for periprosthetic joint infection. Surgeries were performed by 3 surgeons at a single institution (2018-2020). The minimum follow-up was 1 year. The inclusion criteria comprised availability of d-dimer results at pre-explantation and pre-reimplantation. As a result, only 30 reimplantations were included. Success of reimplantation was defined by Musculoskeletal Infection Society outcome reporting tool: Tier 1/Tier 2 vs Tier 3/Tier 4. Nonparametric tests and Mann-Whitney U-tests were conducted to compare Δd-dimer% (pre-explantation value - pre-reimplantation value/pre-explantation value × 100). The bootstrapped receiver operating characteristic curve analyses with 2,000 replicates of 30 cases were conducted. RESULTS The median time between explantation and reimplantation was 86 days (interquartile range [IQR] = 77.7-138.5 days). Overall, a paradoxical median percent increase (Δd-Dimer% [INCREMENT] = 12.6%) in d-dimer was found from pre-explantation to pre-reimplantation (IQR = -28.06% to 77.3%). However, there was a percentage decrease in ESR (ΔESR% [DECREMENT] = -40%; IQR = -70.52% to 3.85%) and CRP (ΔCRP% [DECREMENT] = -75%; IQR = -87.43% to -61.34%). The changes in all these markers were not different between Musculoskeletal Infection Society Tier 1/2 and 3/4 outcomes (Δd-Dimer%, P = .146; ΔESR%, P = .946; ΔCRP%, P = .463). With area under curve of 0.676, Δd-dimer% (INCREMENT) appeared to be performing best in diagnosing infection control, which was nonexplanatory. CONCLUSION Plasma d-dimer paradoxically increases before reimplantation while other inflammatory markers (ESR/CRP) decrease, emphasizing that surgeons shall adopt caution using d-dimer to make clinical decisions.
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