International Orthopaedics

, Volume 42, Issue 5, pp 983–994 | Cite as

The role of synovial fluid analysis in the detection of periprosthetic hip and knee infections: a systematic review and meta-analysis

  • Marcello De Fine
  • Gianluca Giavaresi
  • Milena Fini
  • Andrea Illuminati
  • Silvio Terrando
  • Giovanni Pignatti
Review Article



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.


Periprosthetic 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.

Ethical approval

This article does not need Institutional Review Board approval.


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Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  • Marcello De Fine
    • 1
  • Gianluca Giavaresi
    • 1
  • Milena Fini
    • 1
  • Andrea Illuminati
    • 1
  • Silvio Terrando
    • 1
  • Giovanni Pignatti
    • 1
  1. 1.IRCCSRizzoli Orthopaedic InstituteBolognaItaly

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