部分炎症指标对膝关节假体周围感染的诊断价值

The diagnostic value of some inflammatory markers for knee joint periprosthetic joint infection

目的探讨红细胞沉降率与C反应蛋白的比值(erythrocyte sedimentation rate/C reactive protein,ECR)、纤维蛋白原和D-二聚体对人工膝关节置换术后假体周围感染的诊断价值。方法回顾性收集2017年1月至2021年12月在新疆医科大学第一附属医院关节外科进行人工膝关节翻修术的患者205例,男62例、女143例,年龄(66.9±9.5)岁(范围26~84岁)。假体周围感染(periprosthetic joint infection,PJI)122例,包括急性感染43例、慢性感染79例(慢性感染中13例合并类风湿关节炎进行单独分析);非PJI者83例,包括无菌性松动73例、假体脱位8例、关节僵硬2例。术前检查红细胞沉降率、C反应蛋白、白细胞计数、纤维蛋白原、D-二聚体水平,以受试者工作特征(receiver operating characteristic,ROC)曲线计算指标的灵敏度与特异度,根据曲线下面积(area under curve,AUC)比较不同炎症标志物的诊断价值。结果急性PJI组ECR、红细胞沉降率、C反应蛋白、纤维蛋白原、D-二聚体水平分别为2.47±2.91、50(38,62)mm/1 h、31.6(13.9,79.3)mg/L、(4.25±0.94)g/L、763(453,1157)ng/ml,慢性PJI组为3.06±2.95、50(34,64)mm/1 h、20.4(12.7,43.3)mg/L、(4.19±0.91)g/L、586(317,1122)ng/ml,分别与非PJI组6.20±4.64、22(15,34)mm/1 h、4.6(2.7,7.74)mg/L、(3.10±0.59)g/L、363(181,591)ng/ml比较差异均有统计学意义(P<0.05)。急性PJI组ECR、红细胞沉降率、C反应蛋白、纤维蛋白原、D-二聚体的AUC分别为0.82、0.85、0.90、0.88、0.76;最佳临界值分别为2.89、37.00 mm/1 h、13.6 mg/L、3.86 g/L、443.0 ng/ml,灵敏度分别为76.7%、79.1%、76.7%、69.8%、82.4%,特异度分别为79.5%、78.3%、94.0%、90.4%、63.8%。慢性PJI组ECR、红细胞沉降率、C反应蛋白、纤维蛋白原、D-二聚体、白细胞计数的AUC分别为0.77、0.82、0.87、0.85、0.67、0.63;最佳临界值分别为2.91、33.00 mm/1 h、10.9 mg/L、4.01g/L、558.5 ng/ml、5.575×10^(9)/L,灵敏度分别为68.2%、78.8%、81.8%、63.6%、57.9%、75.8%,特异度分别为79.5%、73.5%、88.0%、95.2%、72.5%、49.4%。结论纤维蛋白原对膝关节PJI的诊断价值较高,其次为ECR,D-二聚体诊断膝关节PJI的价值最低。

Objective To investigate the diagnostic value of erythrocyte sedimentation rate/C-reactive protein(ECR),fibrinogen and D-dimer in periprosthetic infection after artificial knee replacement.Methods A total of 205 patients,including 62 males and 143 females,aged 66.9±9.5 years(range 26-84 years),who underwent revision of artificial knee joint at Department of Joint Surgery,The First Affiliated Hospital of Xinjiang Medical University from January 2017 to December 2021 were retrospectively collected.122 cases of periprosthetic joint infection(PJI),including 43 cases of acute infection;79 cases of chronic infection(13 cases of chronic infection combined with rheumatoid arthritis were analyzed separately);there were 83 cases without PJI,including 73 cases of aseptic loosening,8 cases of prosthesis dislocation and 2 cases of joint stiffness.Erythrocyte sedimentation rate,C-reactive protein,white blood cell count,fibrinogen and D-dimer levels were examined before surgery,and the sensitivity and specificity of the indicators were calculated using the receiver operating characteristic(ROC)curve.The diagnostic value of different inflammatory markers was compared according to the area under curve(AUC).Results The levels of ECR,erythrocyte sedimentation rate,C-reactive protein,fibrinogen,and D-dimer in acute PJI group were 2.47±2.91,50(38,62)mm/1 h,31.6(13.9,79.3)mg/L,4.25±0.94 g/L,763(453,1157)ng/ml,respectively.The chronic PJI group was 3.06±2.95,50(34,64)mm/1 h,20.4(12.7,43.3)mg/L,4.19±0.91 g/L,586(317,1122)ng/ml,and the non-PJI group was 6.20±4.64,22(15,34)mm/1 h,4.6(2.7,7.74)mg/L,3.10±0.59 g/L and 363(181,591)ng/ml were statistically significant(P<0.05).The AUC of ECR,erythrocyte sedimentation rate,C-reactive protein,fibrinogen,and D-dimer in the acute PJI group were 0.82,0.85,0.90,0.88,and 0.76,respectively.The optimal critical values were 2.89,37.00 mm/1 h,13.6 mg/L,3.86 g/L,and 443.0 ng/ml,respectively,with sensitivity of 76.7%,79.1%,76.7%,69.8%,and 82.4%,and specificity of 79.5%,78.3%,94.0%,94.0%,90.4%,and 63.8%,respectively.The AUC of ECR,erythrocyte sedimentation rate,C-reactive protein,fibrinogen,D-dimer,and white blood cell count in the chronic PJI group were 0.77,0.82,0.87,0.85,0.67,and 0.63,respectively.The optimal critical values are 2.91,33.00 mm/1 h,10.9 mg/L,4.01 g/L,558.5 ng/ml,and 5.575×10^(9)/L,respectively,with sensitivity of 68.2%,78.8%,81.8%,63.6%,57.9%,and 75.8%,and specificity of 79.5%,73.5%,88.0%,95.2%,72.5%,and 49.4%,respectively.Conclusion Fibrinogen has a higher diagnostic value for knee joint PJI,followed by ECR,and D-dimer has the lowest diagnostic value for knee joint PJI.