The graphical representation of cell count representation; a new procedure for the diagnosis of periprosthetic joint infections

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Bernd Fink 1,2,* , Marius Hoyka 1, Elke Weissbarth 1, Philipp Schuster 1,3 and Irina Berger 4
Department for Joint Replacement, Rheumatoid and General Orthopaedics, Orthopaedic Clinic Markgröningen, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany
Orthopaedic Department, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany
Department of Orthopedics and Traumatology, Clinic Nuremberg, Paracelsus Medical Private University, Nuremberg, Breslauer Straße 201, 90471 Nürnberg, Germany
Department of Pathology, Klinikum Kassel, Mönchebergstraße 41-43, 34125 Kassel, Germany
Author to whom correspondence should be addressed.


Aim: This study was designed to answer the question whether a graphical representation increase the diagnostic value of automated leucocyte counting of the synovial fluid in the diagnosis of periprosthetic joint infections (PJI).

Material and methods: Synovial aspirates from 322 patients (162 women, 160 men) with revisions of 192 total knee and 130 hip arthroplasties were analysed with microbiological cultivation, determination of cell counts and assay of the biomarker alpha-defensin (170 cases). In addition, microbiological and histological analysis of the periprosthetic tissue obtained during the revision surgery was carried out using the ICM classification and the histological classification of Morawietz and Krenn. The synovial aspirates were additionally analysed to produce dot plot representations (LMNE matrices) of the cells and particles in the aspirates using the hematology analyser ABX Pentra XL 80. Results: 112 patients (34.8%) had an infection according to the ICM criteria. When analysing the graphical LMNE matrices from synovia cell counting, four types could be differentiated: the type “wear particles” (I) in 28.3%, the type “infection” (II) in 24.8%, the “combined” type (III) in 15.5% and “indeterminate” type (IV) in 31.4%. There was a significant correlation between the graphical LMNE-types and the histological types of Morawietz and Krenn (p < 0.001 and Cramer test V value of 0.529). The addition of the LMNE-Matrix assessment increased the diagnostic value of the cell count and the cut-off value of the WBC count could be set lower by adding the LMNE-Matrix to the diagnostic procedure.

Conclusion: The graphical representation of the cell count analysis of synovial aspirates is a new and helpful method for differentiating between real periprosthetic infections with an increased leukocyte count and false positive data resulting from wear particles. This new approach helps to increase the diagnostic value of cell count analysis in the diagnosis of PJI.


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