Clinical Orthopaedics and Related Research®

, Volume 472, Issue 2, pp 424–429 | Cite as

The 2013 Frank Stinchfield Award: Diagnosis of Infection in the Early Postoperative Period After Total Hip Arthroplasty

  • Paul H. Yi
  • Michael B. Cross
  • Mario Moric
  • Scott M. Sporer
  • Richard A. Berger
  • Craig J. Della ValleEmail author
Symposium: 2013 Hip Society Proceedings



Diagnosis of periprosthetic joint infection (PJI) can be difficult in the early postoperative period after total hip arthroplasty (THA) because normal cues from the physical examination often are unreliable, and serological markers commonly used for diagnosis are elevated from the recent surgery.


The purposes of this study were to determine the optimal cutoff values for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), synovial fluid white blood cell (WBC) count, and differential for diagnosing PJI in the early postoperative period after primary THA.


We reviewed 6033 consecutive primary THAs and identified 73 patients (1.2%) who underwent reoperation for any reason within the first 6 weeks postoperatively. Thirty-six of these patients were infected according to modified Musculoskeletal Infection Society criteria. Mean values for the diagnostic tests were compared between groups and receiver operating characteristic curves generated along with an area under the curve (AUC) to determine test performance and optimal cutoff values to diagnose infection.


The best test for the diagnosis of PJI was the synovial fluid WBC count (AUC = 98%; optimal cutoff value 12,800 cells/μL) followed by the CRP (AUC = 93%; optimal cutoff value 93 mg/L), and synovial fluid differential (AUC = 91%; optimal cutoff value 89% PMN). The mean ESR (infected = 69 mm/hr, not infected = 46 mm/hr), CRP (infected = 192 mg/L, not infected = 30 mg/L), synovial fluid WBC count (infected = 84,954 cells/μL, not infected = 2391 cells/μL), and differential (infected = 91% polymorphonuclear cells [PMN], not infected = 63% PMN) all were significantly higher in the infected group.


Optimal cutoff values for the diagnosis of PJI in the acute postoperative period were higher than those traditionally used for the diagnosis of chronic PJI. The serum CRP is an excellent screening test, whereas the synovial fluid WBC count is more specific.

Level of Evidence

Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.


Synovial Fluid Early Postoperative Period Optimal Cutoff Periprosthetic Joint Infection Prosthetic Joint Infection 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Matthew Tetreault, Nicholas Ting, and Laura Quigley for their assistance in data collection.


  1. 1.
    Bauer TW, Parvizi J, Kobayashi N, Krebs V. Diagnosis of periprosthetic infection. J Bone Joint Surg Am. 2006;88:869–882.PubMedCrossRefGoogle Scholar
  2. 2.
    Bedair H, Ting N, Jacovides C, Saxena A, Moric M, Parvizi J, Della Valle CJ. The Mark Coventry Award: diagnosis of early postoperative TKA infection using synovial fluid analysis. Clin Orthop Relat Res. 2011;469:34–40.PubMedCrossRefGoogle Scholar
  3. 3.
    Berend KR, Lombardi AV Jr, Morris MJ, Bergeson AG, Adams JB, Sneller MA. Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality. Clin Orthop Relat Res. 2012 Sep 15 [Epub ahead of print].Google Scholar
  4. 4.
    Bilgen O, Atici T, Durak K, Karaeminoğullari, Bilgen MS. C-reactive protein values and erythrocyte sedimentation rates after total hip and total knee arthroplasty. J Int Med Res. 2001;29:7–12.PubMedCrossRefGoogle Scholar
  5. 5.
    Boettner F, Cross MB, Nam D, Kluthe T, Schulte M, Goetze C. Functional and emotional results differ after aseptic vs septic revision hip arthroplasty. HSS J. 2011;7:235–238.PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91:128–133.PubMedCrossRefGoogle Scholar
  7. 7.
    Cahill JL, Shadbolt B, Scarvell JM, Smith PN. Quality of life after infection in total joint replacement. J Orthop Surg (Hong Kong). 2008;16:58–65.Google Scholar
  8. 8.
    Cipriano CA, Brown NM, Michael AM, Moric M, Sporer SM, Della Valle CJ. Serum and synovial fluid analysis for diagnosing chronic periprosthetic infection in patients with inflammatory arthritis. J Bone Joint Surg Am. 2012;94:594–600.PubMedCrossRefGoogle Scholar
  9. 9.
    Della Valle CJ, Sporer SM, Jacobs JJ, Berger RA, Rosenberg AG, Paprosky WG. Preoperative testing for sepsis before revision total knee arthroplasty. J Arthroplasty. 2007;22:90–93.Google Scholar
  10. 10.
    Garvin KL, Hanssen AD. Infection after total hip arthroplasty. Past, present, and future. J Bone Joint Surg Am. 1995;77:1576–1588.PubMedGoogle Scholar
  11. 11.
    Ghanem E, Parvizi J, Burnett RSJ, Sharkey PF, Keshavarzi N, Aggarwal A, Barrack RL. Cell count and differential of aspirated fluid in the diagnosis of infection at the site of total knee arthroplasty. J Bone Joint Surg Am. 2008;90:1637–1643.PubMedCrossRefGoogle Scholar
  12. 12.
    Hanssen AD, Spangehl MJ. Treatment of the infected hip replacement. Clin Orthop Relat Res. 2004:420:63–71.PubMedCrossRefGoogle Scholar
  13. 13.
    Kersey R, Benjamin J, Marson B. White blood cell counts and differential in synovial fluid of aseptically failed total knee arthroplasty. J Arthroplasty. 2000;15:301–304.PubMedCrossRefGoogle Scholar
  14. 14.
    Kurtz SM, Ong KL, Schmier J, Mowat F, Saleh K, Dybvik E, Kärrholm J, Garellick G, Havelin LI, Furnes O, Malchau H, Lau E. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89(Suppl 3):144–151.PubMedCrossRefGoogle Scholar
  15. 15.
    Larsson S, Thelander U, Friberg S. C-reactive protein (CRP) levels after elective orthopedic surgery. Clin Orthop Relat Res. 1992;275:237–242.PubMedGoogle Scholar
  16. 16.
    Laupacis A, Bourne R, Rorabeck C, Feeny D, Wong C, Tugwell P, Leslie K, Bullas R. The effect of elective total hip replacement on health-related quality of life. J Bone Joint Surg Am. 1993;75:1619–1626.PubMedGoogle Scholar
  17. 17.
    Malchau H, Herberts P, Ahnfelt L. Prognosis of total hip replacement in Sweden. Follow-up of 92,675 operations performed 1978-1990. Acta Orthop Scand. 1993;64:497–506.PubMedCrossRefGoogle Scholar
  18. 18.
    Mason JB, Fehring TK, Odum SM, Griffin WL, Nussman DS. The value of white blood cell counts before revision total knee arthroplasty. J Arthroplasty. 2003;18:1038–1043.PubMedCrossRefGoogle Scholar
  19. 19.
    Parvizi J, Della Valle CJ. AAOS Clinical Practice Guideline: diagnosis and treatment of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg. 2010;18:771–772.PubMedGoogle Scholar
  20. 20.
    Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA, Wongworawat MD, Zalavras CG. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469:2992–2994.PubMedCrossRefGoogle Scholar
  21. 21.
    Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90:1869–1875.Google Scholar
  22. 22.
    Spangehl MJ, Masri BA, O’Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999;81:672–683.PubMedGoogle Scholar
  23. 23.
    Tetreault MW, Wetters NG, Aggarwal V, Mont M, Parvizi J, Della Valle CJ. The Chitranjan Ranawat Award: Should prophylactic antibiotics be withheld before revision surgery to obtain appropriate cultures? Clin Orthop Relat Res. 2013 Apr 30 [Epub ahead of print].Google Scholar
  24. 24.
    Trampuz A, Hanssen AD, Osmon DR, Mandrekar J, Steckelberg JM, Patel R. Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med. 2004;117:556–562.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Paul H. Yi
    • 1
  • Michael B. Cross
    • 1
  • Mario Moric
    • 1
  • Scott M. Sporer
    • 1
  • Richard A. Berger
    • 1
  • Craig J. Della Valle
    • 1
    Email author
  1. 1.Midwest OrthopaedicsRush University Medical CenterChicagoUSA

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