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

  • Symposium: 2013 Hip Society Proceedings
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

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.

Questions/purposes

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.

Methods

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.

Results

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.

Conclusions

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.

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Fig. 1A–D

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Acknowledgments

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

Author information

Authors and Affiliations

  1. Midwest Orthopaedics, Rush University Medical Center, 1611 W Harrison Street, Suite 300, Chicago, IL, 60612, USA

    Paul H. Yi BA, Michael B. Cross MD, Mario Moric MS, Scott M. Sporer MD, MS, Richard A. Berger MD & Craig J. Della Valle MD

Authors
  1. Paul H. Yi BA
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  2. Michael B. Cross MD
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  3. Mario Moric MS
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  4. Scott M. Sporer MD, MS
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  5. Richard A. Berger MD
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  6. Craig J. Della Valle MD
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Corresponding author

Correspondence to Craig J. Della Valle MD.

Additional information

One of the authors certifies that he (CJDV), or a member of his or her immediate family, has or may receive payments or benefits, during the study period, an amount of USD 10,000 to USD 100,000 from Biomet, Inc (Warsaw, IN, USA), an amount of USD 10,000 to USD 100,000 from Smith & Nephew, Inc (Memphis, TN, USA), an amount of USD 10,000 to USD 100,000 from Stryker Orthopaedics (Mahwah, NJ, USA), and an amount of USD 10,000 to USD 100,000 from CD Diagnostics (Wynnewood, PA, USA). One of the authors certifies that he (SMS), or a member of his or her immediate family, has or may receive payments or benefits, during the study period, an amount of USD 10,000 to 100,000, from Zimmer, Inc (Warsaw, IN, USA), an amount of USD 10,000 to 100,00 from Cadence Health (Winfield, IL, USA), and an amount of USD 10,000 to USD 100,000 from Smith & Nephew, Inc. One of the authors certifies that he (RAB), or a member of his or her immediate family, has or may receive payments or benefits, during the study period, an amount of USD 100,001–USD 1,000,000 from Zimmer, Inc.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

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

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Yi, P.H., Cross, M.B., Moric, M. et al. The 2013 Frank Stinchfield Award: Diagnosis of Infection in the Early Postoperative Period After Total Hip Arthroplasty. Clin Orthop Relat Res 472, 424–429 (2014). https://doi.org/10.1007/s11999-013-3089-1

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  • DOI: https://doi.org/10.1007/s11999-013-3089-1

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