Clinical Significance Of Thromboelastography In Diagnosing Periprosthetic Joint Infection And Analyzing Reimplantation Timing For The Second-stage Revision

ObjectiveTo compare the value of thromboelastography(TEG)with CRP,ESR,and D-dimer in the diagnosis of periprosthetic joint infection(PJI)after total hip and knee arthroplasty,and to determine the clinical significance of TEG in analyzing reimplantation timing for the second-stage revision.MethodsFrom October 2017 to February 2021,138 patients who underwent revision arthroplasty were retrospectively included,PJI was defined by 2018 Musculoskeletal Infection Society(MSIS)criteria.Twenty-eight patients were diagnosed with PJI and the other 55 patients were included as aseptic loosen.The preoperative ESR,CRP,D-dimer,and TEG data of the two groups were collected.Receiver operating characteristic curves(ROC)were applied to evaluate the sensitivity,specificity,positive predictive value,negative predictive value,positive likelihood ratio,and negative likelihood ratio of each biomarker in PJI diagnosis.Diagnostic value of each biomarker was compared according to the area under the curve(AUC).The Youden biomarker was applied to determine these biomarkers’ optimal cutoff value for the diagnosis of PJI.Subgroup analyses were carried out to determine if the value of each biomarker differed in the diagnosis of periprosthetic infection of different joint.Then the diagnostic value of the pairwise combination of each biomarker was calculated.Spearman correlation analysis was applied to define the correlation between the inflammatory biomarker(ESR,CRP)and coagulation biomarker(D-dimer,TEG).Totally 17 PJI patients who underwent the two-stage revision were followed up,the outcome of the revision was defined by the Delphi consensus.And then the biomarkers before two stage revision were analyzed to evaluate their value in determining the reimplantation timing for the second-stage revision.ResultsAll biomarker levels except R in the periprosthetic infection group were significantly higher than in the aseptic loosening group(all p<0.05),while K level was significantly lower than in the aseptic loosening group.Among the diagnostic value of each biomarker,ESR exhibited the largest AUC with 0.899,while MA and E showed the highest sensitivity and specificity with 82.14%and 96.36%respectively.The subgroup analysis found that the diagnostic value of the same biomarker in the hip and knee joint was slightly different The sensitivity of ESR in the diagnosis of hip PJI was 100%,and the specificity of MA and E in the diagnosis of hip and knee PJI was 100%.When these biomarkers combined in pairs,the diagnostic value of CRP+A30 and CRP+E performed the best,with AUCs,sensitivity,and specificity were 0.953,89.29%,and 94.55%,respectively.Correlation analysis showed there existed a moderate negative correlation between K and ESR/CRP(-0.6≤r<-0.4),and a strong positive correlation between MA,A30,TPI,E and ESR(0.6≤r<0.8),while the positive correlation between D-dimer,Angle,CI and ESR were moderate(0.4≤r<0.6).And D-dimer showed a weak positive correlation with CRP(r=0.368),and all TEG except K showed a moderate positive correlation with CRP.At a mean follow-up of 17.12 months(17.12 ±8.24m),all 17 patients were infection-free.ESR,CRP,MA,A30,E showed valuable in determining the time of reimplantation,with their values all decreased below cut-off values before reimplantation.ConclusionThere is a certain positive correlation between the parameters of TEG(except K)and inflammatory biomarkers.TEG is a promising tool in diagnosing periprosthetic infection and determining the reimplantation timing for the second-stage revision.