The role of synovial fluid analysis in the detection of periprosthetic hip and knee infections: a systematic review and meta-analysis
- 71 Downloads
This study tried to ascertain (1) the accuracy of synovial fluid white blood cell count and polymorphonucleate percentage in the diagnosis of periprosthetic hip and knee infections, (2) which test yielded superior test performance, and (3) the influence on diagnostic accuracy of study characteristics such as patient number, study design, study level, anatomic site, and threshold value.
A systematic search was conducted including papers assessing more effective cutoffs for synovial fluid tests, having comparative design, evaluating an exclusive cohort of hip or knee prostheses, including a clear definition of infected cases, and reporting sufficient data for the calculation of true-positive, false-positive, false-negative, and true-negative.
A total of 375 articles were collected and, given the inclusion criteria, ten manuscripts were included. These studies assessed 1155 hip prostheses (276 infected cases) and 1235 knee prostheses (401 infected cases). The specificity of synovial fluid white blood cell count was significantly increased by using the threshold value ≥ 3000 cell/μL (p = 0.006); the sensitivity of polymorphonucleate percentage was significantly higher in detecting knee infections (p = 0.034).
Both tests had a high specificity and sensitivity in detecting periprosthetic joint infections, and no clear superiority of one over the other existed. Furthermore, cutoff and anatomic site significantly influenced synovial fluid white blood cell count and polymorphonucleate percentage, respectively.
Synovial fluid analysis is adequate in differentiating patients with periprosthetic hip and knee infections. Our data confirms international guidelines suggesting the use of 3000 cell/μL as cutoff threshold for synovial fluid white blood cell count. Since an anatomic site effect has been demonstrated, the goal of future studies will be to identify different cutoffs for hip and knee prostheses.
KeywordsPeriprosthetic joint infections Synovial fluid analysis Synovial white blood cell count Infected hip prosthesis Infected knee prosthesis
The medical staff Marcello De Fine, Andrea Illuminati, Silvio Terrando, and Giovanni Pignatti of the General Orthopaedic Surgery Dept. - Bagheria-Palermo, Italy, Gianluca Giavaresi, MD of the Innovative Technology Platforms for Tissue Engineering, Theranostic and Oncology (Palermo, Italy), and Milena Fini, MD of the Laboratory of Preclinical and Surgical Studies of the Rizzoli Orthopedic Institute, all contributed to the present manuscript.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
This article does not need Institutional Review Board approval.
- 7.Della Valle C, Parvizi J, Bauer TW, Di Cesare PE, Evans RP, Segreti J, Spangehel M, Walters WC III, Keith M, Turkelson CM, Wies JL, Sluka P, Hitchcock K (2011) American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am 93:1355–1357. https://doi.org/10.2106/JBJS.9314ebo CrossRefPubMedGoogle Scholar
- 8.Ghanem E, Antoci V, Pulido L, Joshi A, Hozack W, Parvizi J (2009) The use of receiver operating characteristics analysis in determining erythrocyte sedimentation rate and C-reactive protein levels in diagnosing periprosthetic infection prior to revision total hip arthroplasty. Int J Infect Dis 13:e444–e449. https://doi.org/10.1016/j.ijid.2009.02.017 CrossRefPubMedGoogle Scholar
- 11.Sousa R, Massada M, Pereira A, Fontes F, Amorim I, Oliveira A (2011) Diagnostic accuracy of combined 99mTc-sulesomab and 99mTc-nanocolloid bone marrow imaging in detecting prosthetic joint infection. Nucl Med Commun 32:834–839. https://doi.org/10.1097/MNM.0b013e3283496695 CrossRefPubMedGoogle Scholar
- 15.Pandey R, Berendt AR, Athanasou NA (2000) Histological and microbiological findings in non-infected and infected revision arthroplasty tissues. The OSIRIS Collaborative Study Group. Oxford Skeletal Infection Research and Intervention Service. Arch Orthop Trauma Surg 120:570–574CrossRefPubMedGoogle Scholar
- 18.Ghanem E, Parvizi J, Burnett RSJ, Sharkey PF, Keshavarzi N, Aggarwal A, Barrack RL (2008) Cell count and differential of aspirated fluid in the diagnosis of infection at the site of total knee arthroplasty. J Bone Joint Surg Am 90(8):1637–1643. https://doi.org/10.2106/JBJS.G.00470 CrossRefPubMedGoogle Scholar
- 23.Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700CrossRefPubMedPubMedCentralGoogle Scholar
- 24.Deeks J, Boussyt P, Gatsonis C (2013) Cochrane handbook for systematic reviews of diagnostic test accuracy. Version 0.9. The Cochrane collaborationGoogle Scholar
- 26.R Core Team (2013) R: a language and environment for statistical computing. R Foundation for Statistical Computing. Vienna, Austria. URL http://www.R-project.org/
- 27.Doebler P (2015) mada: meta-analysis of diagnostic accuracy. R package version 0.5.7. URL https://CRAN.R-project.org/package=mada
- 29.Schiller I, Nandini D (2015) HSROC: joint meta-analysis of diagnostic test sensitivity and specificity with or without a gold standard reference test. R package version 2.1.8Google Scholar
- 41.Yi PH, Cross MB, Moric M, Levine BR, Sporer SM, Paprosky WG, Jacobs JJ, Della Valle CJ (2015) Do serologic and synovial tests help diagnose infection in revision hip arthroplasty with metal-on-metal bearings or corrosion? Clin Orthop 473(2):498–505. https://doi.org/10.1007/s11999-014-3902-5 CrossRefPubMedGoogle Scholar
- 43.Cipriano CA, Brown NM, Michael AM, Moric M, Sporer SM, Della Valle CJ (2012) Serum and synovial fluid analysis for diagnosing chronic periprosthetic infection in patients with inflammatory arthritis. J Bone Joint Surg Am 94(7):594–600. https://doi.org/10.2106/JBJS.J.01318 CrossRefPubMedGoogle Scholar
- 47.Lombardi AV, Barrack RL, Berend KR, Cuckler JM, Jacobs JJ, Mont MA, Schmalzried TP (2012) The Hip Society: algorithmic approach to diagnosis and management of metal-on-metal arthroplasty. J Bone Joint Surg Br 94(11 Suppl A):14–18. https://doi.org/10.1302/0301-620X.94B11.30680 CrossRefPubMedGoogle Scholar