Thermogenic diagnosis of periprosthetic joint infection by microcalorimetry of synovial fluid

Christian Morgenstern, Nora Renz, Sabrina Cabric, Elena Maiolo, Carsten Perka, Andrej Trampuz, Christian Morgenstern, Nora Renz, Sabrina Cabric, Elena Maiolo, Carsten Perka, Andrej Trampuz

Abstract

Background: Synovial fluid culture is the standard investigation for the preoperative diagnosis of periprosthetic joint infection (PJI). However, the culture has limited sensitivity and requires several days until result. We evaluated the value of isothermal microcalorimetry for real-time diagnosis of PJI based on heat produced by microbial growth in synovial fluid.

Methods: Patients undergoing aspiration of prosthetic hip or knee joint before revision surgery were prospectively included between 2014 and 2015. The performance of microcalorimetry was compared to synovial fluid culture using McNemar's chi-squared test. Pearson's correlation coefficient was calculated for synovial fluid leukocyte count and microcalorimetric heat.

Results: Of 107 included patients (58 knee and 49 hip prosthesis), PJI was diagnosed in 46 patients (43%) and aseptic failure in 61 patients (57%) according to institutional criteria. In 26 PJI cases (56%) the pathogen grew in synovial fluid and intra-operative cultures. The sensitivity of synovial fluid culture and microcalorimetry was both 39% and the results were concordant in 98 patients (92%). In patients with PJI, microcalorimetry missed 4 pathogens which grew in synovial fluid culture, whereas culture missed 4 pathogens detected by microcalorimetry. A linear correlation (r = 0.366) was found between leukocyte count and microcalorimetric heat in synovial fluid (p < 0.001). The median time to positivity of microcalorimetry was 9 h (range, 1-64 h) vs. 3 days for cultures (range, 1-14 days).

Conclusion: Microcalorimetry of synovial fluid allows thermogenic diagnosis of periprosthetic joint infection in synovial fluid. The diagnostic performance of synovial fluid microcalorimetry is comparable to culture and delivers results considerably faster.

Trial registration: This prospective study was registered on August 21, 2015 with the public clinical trial identification NCT02530229.

Keywords: Joint arthroplasty; Microcalorimetry; Periprosthetic joint infection; Synovial fluid.

Conflict of interest statement

C.M. and S.C. report no conflict of interests. N.R. and E.M. report a grant from the PRO-IMPLANT Foundation. C.P. reports personal fees from DePuy/Synthes, personal fees from Smith&Nephew, grants from Aesculap, personal fees from Zimmer/Biomet, personal fees from Link, all outside of the submitted work and A.T. reports research grants from Zimmer/Biomet and Heraeus medical and personal fees, all outside of the submitted work.

Figures

Fig. 1
Fig. 1
Example of a microcalorimetry curve of an aseptic patient. Note the characteristic inverse exponential decay of heat until reaching baseline (dashed line)
Fig. 2
Fig. 2
Examples of microcalorimetric signals of patients with PJI. The microorganisms mentioned in the legend were found in synovial fluid culture. CNS: coagulase-negative staphylococci
Fig. 3
Fig. 3
Positive linear association of peak heat values measured with microcalorimetry with leukocyte count in synovial fluid (p = 0.003) for aseptic calorimetry curves

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