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The Mark Coventry Award: Diagnosis of Early Postoperative TKA Infection Using Synovial Fluid Analysis

  • Symposium: Papers Presented at the Annual Meetings of the Knee Society
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Synovial fluid white blood cell count is useful for diagnosing periprosthetic infections but the utility of this test in the early postoperative period remains unknown as hemarthrosis and postoperative inflammation may render standard cutoff values inaccurate.

Questions/purposes

We evaluated the diagnostic performance of four common laboratory tests, the synovial white blood cell count, differential, C-reactive protein, and erythrocyte sedimentation rate to detect infection in the first 6 weeks after primary TKA.

Methods

We reviewed 11,964 primary TKAs and identified 146 that had a knee aspiration within 6 weeks of surgery. Infection was diagnosed in 19 of the 146 knees by positive cultures or gross purulence. We compared demographic information, time from surgery, and the laboratory test values between infected and noninfected knees to determine if any could identify infection early postoperatively. Receiver operating characteristic curves were constructed to determine optimal cutoff values for each of the test parameters.

Results

Synovial white blood cell count (92,600 versus 4200 cells/μL), percentage of polymorphonuclear cells (89.6% versus 76.9%), and C-reactive protein (171 versus 88 mg/L) were higher in the infected group. The optimal synovial white blood cell cutoff was 27,800 cells/μL (sensitivity, 84%; specificity, 99%; positive predictive value, 94%; negative predictive value, 98%) for diagnosing infection. The optimal cutoff for the differential was 89% polymorphonuclear cells and for C-reactive protein 95 mg/L.

Conclusions

With a cutoff of 27,800 cells/μL, synovial white blood cell count predicted infection within 6 weeks after primary TKA with a positive predicted value of 94% and a negative predictive value of 98%. The use of standard cutoff values for this parameter (~ 3000 cells/μL) would have led to unnecessary reoperations.

Level of Evidence

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

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Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA

    Hany Bedair MD

  2. Massachusetts General Hospital, Boston, MA, USA

    Hany Bedair MD

  3. The Center for Adult Joint Reconstruction, 2014 Washington Street, Newton, MA, 02462, USA

    Hany Bedair MD

  4. Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA

    Nicholas Ting BA & Craig J. Della Valle MD

  5. Department of Anesthesia, Rush University Medical Center, Chicago, IL, USA

    Mario Moric MS

  6. Department of Orthopaedic Surgery, Thomas Jefferson University School of Medicine, Philadelphia, PA, USA

    Christina Jacovides BA, Arjun Saxena MD & Javad Parvizi MD

Authors
  1. Hany Bedair MD
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  2. Nicholas Ting BA
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  3. Christina Jacovides BA
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  4. Arjun Saxena MD
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  5. Mario Moric MS
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  6. Javad Parvizi MD
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  7. Craig J. Della Valle MD
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Corresponding author

Correspondence to Hany Bedair MD.

Additional information

Dr. Parvizi is a consultant for Stryker Orthopaedics (Mahwah, NJ). Dr. Della Valle is a consultant for Smith and Nephew Inc (Memphis, TN), Biomet Inc (Warsaw, IN), and Kinamed Inc (Camarillo, CA) and receives research/institutional support from Zimmer Inc (Warsaw, IN).

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at Rush University Medical Center and Thomas Jefferson University School of Medicine.

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Bedair, H., Ting, N., Jacovides, C. et al. The Mark Coventry Award: Diagnosis of Early Postoperative TKA Infection Using Synovial Fluid Analysis. Clin Orthop Relat Res 469, 34–40 (2011). https://doi.org/10.1007/s11999-010-1433-2

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  • DOI: https://doi.org/10.1007/s11999-010-1433-2

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