Archives of Orthopaedic and Trauma Surgery

, Volume 138, Issue 6, pp 871–878 | Cite as

Preoperative PCR analysis of synovial fluid has limited value for the diagnosis of periprosthetic joint infections of total knee arthroplasties

  • Bernd Fink
  • Markus Steurer
  • Sigrid Hofäcker
  • Peter Schäfer
  • Dieter Sandow
  • Philipp Schuster
  • Damian Oremek
Knee Arthroplasty


Preoperative diagnosis of periprosthetic joint infection (PJI) is important because of the therapeutic consequences. This prospective study was designed to answer the question, if preoperative PCR analysis of the synovial fluid in addition to the culture and the CRP analysis of the blood are helpful for the diagnosis of PJI in knee arthroplasties. Before revision CRP analysis of the blood, cultivation and PCR analysis of synovial fluid of 116 knee endoprostheses were performed. During revision surgery, five tissue samples of the periprosthetic tissue were cultured and five further samples subjected to histological analysis. These analyses of the periprosthetic tissue were used to verify the results of the preoperative diagnostic methods. Twenty-seven prostheses were identified as infected (prevalence 23.3%). The combined analyses of the joint fluid cultivation and the CRP blood level resulted in a sensitivity of 77.8%, a specificity of 95.5%, a positive-predictive value of 84.0%, a negative-predictive value of 93.4% and an accuracy of 91.4%. The PCR analysis of the synovial fluid resulted in a sensitivity of 55.6%, a specificity of 82.0%, a positive-predictive value of 48.4%, a negative-predictive value of 85.9% and an accuracy of 75.9%. The sensitivity for culture of the aspirate and PCR analysis in combination with an elevated CRP level was 85.2%, the specificity 82.0%, the positive-predictive value 58.9%, the negative-predictive value 94.8% and the accuracy 82.7%. The preoperative PCR analysis of synovial fluid has only limited value in addition to the standard culture analysis.


Periprosthetic joint infection Knee arthroplasty Diagnosis PCR Culture 


  1. 1.
    Koh CK, Zeng I, Ravi S, Zhu M, Vince KG, Young SW (2017) Periprosthetic joint infection is the main cause of failure for modern knee arthroplasty: an analysis of 11,134 knees. Clin Orthop Relat Res 475:2194–2201CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Fehring TK, Griffin WL (1998) Revision of failed cementless total knee implants with cement. Clin Orthop Relat Res 356:34–38CrossRefGoogle Scholar
  3. 3.
    Saleh KJ, Rand JA, McQueen A (2003) Current status of revision total knee arthroplasty: how do we assess results? J Bone Jt Surg Am 85(Suppl 1):18–20CrossRefGoogle Scholar
  4. 4.
    Scuderi GR, Insall JN, Windosr RE, Moran MC (1989) Survivorship of cemented knee replacements. J Bone Jt Surg Br 71:798–803CrossRefGoogle Scholar
  5. 5.
    Hanssen AD (2002) Managing the infected knee: as good as it gets. J Arthroplast 17(4 Suppl 1):98–101CrossRefGoogle Scholar
  6. 6.
    Della Valle CJ, Zuckermann JD, Di Cesare PE (2004) Periprosthetic sepsis. Clin Orthop Relat Res 420:26–31CrossRefGoogle Scholar
  7. 7.
    Tsukayama DT, Estrada R, Gustilo RB (1996) Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Jt Surg Am 78:512–523CrossRefGoogle Scholar
  8. 8.
    Virolainen P, Lahteenmaki H, Hiltunen A, Sipola E, Meurman O, Nelimarkka O (2002) The reliability of diagnosis of infection during revision arthroplasties. Scan J Surg 91:178–181CrossRefGoogle Scholar
  9. 9.
    Trampuz A, Zimmerli W (2005) Prosthetic joint infections: update in diagnosis and treatment. Swiss Med Wkly 135:243–251PubMedGoogle Scholar
  10. 10.
    Munjal S, Phillips MJ, Krackow KA (2001) Revision total knee arthroplasty: planning, controversies, and management-infection. Instr Course Lect 50:367–377PubMedGoogle Scholar
  11. 11.
    Fink B, Makowiak C, Fuerst M, Berger I, Schäfer P, Frommelt L (2008) The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late peri-prosthetic infection of total knee replacements. J Bone Jt Surg Br 90:874–878CrossRefGoogle Scholar
  12. 12.
    Fink B, Lass R (2014) A diagnostic algorithm for painful total knee replacement. Z Orthop Unfall 152:189–202CrossRefPubMedGoogle Scholar
  13. 13.
    Cazanave C, Greenwood-Quaintance KE, Hanssen AE, Karau MJ, Schmidt SM, Gomez Urena EO, Mandrekar JN, Osmon DR, Lough LE, Pritt BS, Steckelberg JM, Patel R (2013) Rapid molecular microbiologic diagnosis of prosthetic joint infection. J Clin Micorobiol 51:2280–2287CrossRefGoogle Scholar
  14. 14.
    Ryu SY, Greenwood-Quaintance KE, Hanssen AD, Mandrekar JN, Patel R (2014) Low sensivity of periprosthetic tissue PCR for prosthetic knee infection diagnosis. Microbiol Infect Dis 79:448–453CrossRefGoogle Scholar
  15. 15.
    Schäfer P, Fink B, Sandow D, Margull A, Berger I, Frommelt L (2008) Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis 47:1403–1409CrossRefPubMedGoogle Scholar
  16. 16.
    Altschul SF, Gish W, Miller W, Myers EW, Lipman DJ (1990) Basic local alignment search tool. J Mol Biol 215:403–410CrossRefPubMedGoogle Scholar
  17. 17.
    Steinbrink K, Frommelt L (1995) Treatment of periprosthetic infection of the hip using one-stage exchange surgery. Orthopäde 24:335–343PubMedGoogle Scholar
  18. 18.
    Ince A, Rupp J, Frommelt L, Katzer A, Gille J, Löhr JF (2004) Is “aseptic” loosening of the prosthetic cup after total hip replacement due to nonculturable bacterial pathogens in patients with low-grade infection? Clin Infect Dis 39:1599–1603CrossRefPubMedGoogle Scholar
  19. 19.
    Atkins BL, Athanasou N, Deeks JJ, Crook DW, Simpson H, Peto TE, McLardy-Smith P, Berendt AR (1998) Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. J Clin Microbiol 36:2932–2939PubMedPubMedCentralGoogle Scholar
  20. 20.
    Pandey R, Drakouilakis E, Athanasou NA (1999) An assessment of the histological criteria used to diagnose infection in hip revision arthroplasty tissues. J Clin Pathol 52:118–123CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA, Wongworawat MD, Zalavras CG (2011) New definition of periprosthetic joint infection: from the workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 469:2992–2994CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Mirra JM, Amstutz HC, Matos M, Gold R (1976) The pathology of the joint tissues and its clinical relevance in prosthetic failure. Clin Orthop Relat Res 117:221–240Google Scholar
  23. 23.
    Mirra JM, Marder RA, Amstutz HC (1982) The pathology of failed total joint arthroplasty. Clin Orthop Relat Res 170:175–183Google Scholar
  24. 24.
    Feldman DS, Lonner JH, Desai P, Zuckerman JD (1995) The role of intraoperative frozen sections in revision total joint arthroplasty. J Bone Jt Surg Am 77:1807–1813CrossRefGoogle Scholar
  25. 25.
    Lonner JH, Desai P, Dicesare PE, Steiner G, Zuckerman JD (1996) The reliability of analysis of intraoperative frozen sections for identifying active infection during revision hip or knee arthroplasty. J Bone Jt Surg Am 78:1553–1558CrossRefGoogle Scholar
  26. 26.
    Heinecke A, Hultsch E, Repges R (eds) (1992) Medizinische Biometrie. Springer, BerlinGoogle Scholar
  27. 27.
    Saleh KJ, Clark CR, Rand JA, Brown GA (2003) Modes of failure and preoperative evaluation. J Bone Jt Surg Am 85(Suppl. 1):21–25CrossRefGoogle Scholar
  28. 28.
    Pellegrini VD Jr (1997) Management of the patient with an infected knee arthroplasty. Instr Course Lect 46:215–219PubMedGoogle Scholar
  29. 29.
    Simmons TD, Stern SH (1996) Diagnosis and management of the infected total knee arthroplasty. Am J Knee Surg 9:99–106PubMedGoogle Scholar
  30. 30.
    Tsukayama DT, Goldberg VM, Kyle R (2003) Diagnosis and management of infection after total knee arthroplasty. J Bone Jt Surg Am 85(Suppl.1):75–80CrossRefGoogle Scholar
  31. 31.
    Duff GP, Lachiewics PF, Kelly SS (1996) Aspiration of the knee joint before revision arthroplasty. Clin Orthop Relat Res 331:132–139CrossRefGoogle Scholar
  32. 32.
    Levitsky KA, Hozack WJ, Balderston RA, Rothman RH, Gluckman SJ, Maslack MM, Booth RE Jr (1991) Evaluation of the painful prosthetic joint. Relative value of bone scan, sedimentation rate, and joint aspiration. J Arthroplast 6:237–244CrossRefGoogle Scholar
  33. 33.
    Barrack RL (1997) The value of preoperative knee aspiration: don’t ask, don’t tell. Orthopedics 20:862–864PubMedGoogle Scholar
  34. 34.
    Mont MA, Waldman BJ, Hungerford DS (2000) Evaluation of preoperative cultures before second-stage reimplantation of a total knee prosthesis complicated by infection. A comparison-group study. J Bone Jt Surg Am 82:1552–1557CrossRefGoogle Scholar
  35. 35.
    Hischebeth GT, Randau TM, Buhr JK, Wimmer MD, Hoerauf A, Molitor E, Bekeredjian-Ding I, Gravius S (2016) Unyvero i60 implant ant tissue infection (ITI) multiplex PCR system in diagnosing periprosthetic joint infection. J Microbiol Methods 121:27–32CrossRefPubMedGoogle Scholar
  36. 36.
    Miyamae Y, Inaba Y, Kobayashi N, Choe H, Yukizawa Y, Ike H, Saito T (2013) Different diagnostic properties of C-reactive protein, real-time PCR, and histopathology of frozen and permanent sections in diagnosis of periprosthetic joint infection. Acta Orthop 84:524–529CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Zegaer BH, Ionnidis A, Babis GC, Ionnidou V, Kossyvakis A, Bersimis S, Papaparskevas J, Petinaki E, Pliatsika P, Chatzipanagiotou S (2014) Detection of bacteria bearing resistant biofilm forms, by using the unsiversal and specific PCR is still unhelpful in the diagnosis of periprosthetic joint infections. Front Med (Lausanne) 1:30Google Scholar
  38. 38.
    Mariani BD, Martin DS, Levine MJ, Booth RE Jr, Tuan RS (1996) Polymerase chain rection detection of bacterial infection in total knee arthroplasty. Clin Orthop Relat Res 331:11–22CrossRefGoogle Scholar
  39. 39.
    Bergin PF, Doppelt JD, Hamilton WG, Mirick GE, Jones AE, Sritulanondha S, Helm JM, Tuan RS (2010) Detection of periprosthetic infections with use of ribosomal RNA-based polymerase chain reaction. J Bone Jt Surg 92-A:654–663CrossRefGoogle Scholar
  40. 40.
    Kordelle J, Klett R, Stahl U, Hossain H, Schleicher I, Haas H (2004) Diagnostic of infection after total knee replacement. Z Orthop 142:337–343CrossRefPubMedGoogle Scholar
  41. 41.
    Kordelle J, Hossain H, Stahl U, Schleicher I, Haas H (2004) Usefulness of 16S rDNA-polymerase- chain-reaction (PCR) in the intraoperative detection of infection in revison of failed arthroplasties. Z Orthop Ihre Grenzgeb 142:571–576CrossRefPubMedGoogle Scholar
  42. 42.
    Panousis K, Grigoris P, Butchler I, Rana B, Reilly JH, Hamblen DL (2005) Poor predictive value of broad-rand PCR for the detection of arthroplasty infection in 92 cases. Acta Orthop 76:341–346PubMedCrossRefGoogle Scholar
  43. 43.
    Rak M, Barlic-Maganja D, Kavcic M, Trebse R, Cör A (2014) Comparison of molecular and culture method in diagnosis of prosthetic joint infection. FEMS Microbiol Lett 343:42–48CrossRefGoogle Scholar
  44. 44.
    Rak M, Barlic-Maganja D, Kavcic M, Trebse R, Cor A (2015) Identification of the same species in at least two intra-operative samples for prosthetic joint infection diagnsotics yields the best results with broad-range polymerase chain reaction. Int Orthop 39:975–979CrossRefPubMedGoogle Scholar
  45. 45.
    Rak M, Kavcic M, Trebse R, Cör A (2016) Detection of bacteria with molecular methods in prosthetic joint infection: sonication fluid better than periprosthetic tissue. Acta Orthop 87:339–345CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Suda A, Tinelli M, Beisemann ND, Weil Y, Khoury A, Bischel OE (2017) Diagnosis of periprosthetic joint infection using alpha-defensin test or multiplex-PCR: ideal diagnostic test still not found. Int Orthop 41:1307–1313CrossRefPubMedGoogle Scholar
  47. 47.
    Marin M, Garcia-Lechuz JM, Alonso P, Villanueva M, Alcala L, Gimeno M, Cercenado E, Sanchez-Somolinos (2012) Role of universal 16S rRNA gene PCR and sequencing in diagnosis of prosthetic joint infection. J Clin Microbiol 50:583–589CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department for Joint Replacement, Rheumatoid and General OrthopaedicsOrthopaedic Clinic MarkgröningenMarkgröningenGermany
  2. 2.Orthopaedic DepartmentUniversity Hospital Hamburg-EppendorfHamburgGermany
  3. 3.MVZ Labor LudwigsburgLudwigsburgGermany

Personalised recommendations