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Diagnostic accuracy of synovial fluid, blood markers, and microbiological testing in chronic knee prosthetic infections

  • Orthopaedic Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

This retrospective study was undertaken to define cut-off values for synovial fluid (SF) leukocyte count and neutrophil percentage for differentiating aseptic failure and periprosthetic joint infection (PJI) and to evaluate the diagnostic accuracy of blood inflammatory markers, and microbiological testing according to the criteria proposed by the International Consensus Meeting (ICM) of Philadelphia.

Methods

All patients who underwent revision total knee arthroplasty from January 2010 to July 2015 were included: we identified and classified 31 PJIs and 136 aseptic joints. The diagnostic performance of single test was assessed by receiver operating characteristic curve analyses. The sensitivity and specificity were calculated for each of the cut-off values and the area under the curve (AUC) was calculated.

Results

The median SF leukocyte count as well as the neutrophil percentage and inflammatory markers were significantly higher in patients with PJI than in those with aseptic failure (p < 0.001). A leukocyte count of > 2.8 × 103/μL had a sensitivity of 83.8% and a specificity of 89.7% whereas a neutrophil percentage of > 72% yielded a marginally higher sensitivity of 84% and a specificity of 91%. Applying the ICM criteria we found a significant correlation between all these diagnostic measures and PJI (p < 0.001) except for a single positive culture. The most accurate criterion of the ICM was the synovial neutrophil differential (AUC = 0.89; 95% CI 0.81–0.97), followed by SF leukocyte count (AUC = 0.86; 95% CI 0.78–0.94), increased inflammatory markers (AUC = 0.85; 95% CI 0.76–0.93), and two positive periprosthetic cultures (AUC = 0.84; 95% CI 0.73–0.94). The presence of sinus tract communicating with the joint and a single positive culture showed unfavourable diagnostic accuracy (AUC = 0.60, 95% CI 0.47–0.72; AUC = 0.49, 95% CI 0.38–0.61, respectively)

Conclusions

The present study highlights the adequate ability of fluid cell count and neutrophil differential to distinguish between PJI and aseptic loosening. The clinical utility of fluid analysis in diagnosing infection can be improved by evaluation of other diagnostic criteria.

Level of evidence

Level I Diagnostic Study.

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Author information

Authors and Affiliations

  1. Department of Public Health, School of Medicine, Federico II University, Via S. Pansini, Naples, Italy

    Giovanni Balato

  2. Orthopedic Unit, IFCA Institute, Florence, Italy

    Vincenzo Franceschini, Alfredo Lamberti & Andrea Baldini

  3. Department of Infectious Diseases, D. Cotugno Hospital, AORN Dei Colli, Naples, Italy

    Tiziana Ascione

  4. Department of Laboratory Medicine, IFCA Clinic, Florence, Italy

    Fiamma Balboni

Authors
  1. Giovanni Balato
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  2. Vincenzo Franceschini
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  3. Tiziana Ascione
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  4. Alfredo Lamberti
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  5. Fiamma Balboni
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  6. Andrea Baldini
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Correspondence to Giovanni Balato.

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Balato, G., Franceschini, V., Ascione, T. et al. Diagnostic accuracy of synovial fluid, blood markers, and microbiological testing in chronic knee prosthetic infections. Arch Orthop Trauma Surg 138, 165–171 (2018). https://doi.org/10.1007/s00402-017-2832-6

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  • DOI: https://doi.org/10.1007/s00402-017-2832-6

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