Revisiting D-dimer in periprosthetic joint infection: a comprehensive systematic review and meta-analysis with subgroup and heterogeneity exploration

This systematic review and meta-analysis demonstrate that, based on low-to-moderate certainty evidence, D-dimer is best used as an initial triage tool or adjunctive rule-out test for PJI, particularly in lower-prevalence settings. Subgroup analyses and meta-regression suggest better diagnostic performance in serum assays, chronic infections, and knee PJI. High-certainty evidence supports the use of D-dimer in combination with C-reactive protein in a serial testing strategy to confirm PJI. Future studies should include large, prospective, multicenter diagnostic cohorts with rigorous methods, minimal missing data, and standardized laboratory reporting to strengthen the evidence base for D-dimer as a diagnostic criterion.