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Aseptic Synovitis Wolfgang Fitz and Richard D CHAPTER 24 Aseptic Synovitis Wolfgang Fitz and Richard D. Scott septic effusions are occasionally seen after total knee particulate cement debris, or hypersensitivity allergic Aarthroplasty, but their source is not well understood. reactions. Effusions immediately following total knee arthroplasty Joint fluid cell analysis is based on joints without (TKA) gradually disappear several weeks or a few months implants, based on the guidelines published by the Amer- after surgery, and even though frequent, they raise no ican College of Rheumatology8–10 (Table 24.1). It is con- significant clinical concern. A new onset of an effusion sidered to be normal with a white blood cell count (WBC) beyond the postoperative period of 1 year or more is of less than 200/mL, and less than 25% polymorphonu- infrequent and raises clinical concern. clear leukoctyes (PML).11 Osteoarthritic patients (nonin- Some minimal effusions occur gradually, most of the flammatory, group I) may have a WBC of <2000/ml with time without other symptoms, and may not even be <25% PML to be considered as normal, whereas inflam- noticed by the patient. The time between surgery and the matory arthritis (group II), such as rheumatoid, gouty, or onset of an effusion varies, and problems related to poly- pseudogouty arthritis, can have WBC ranging between ethylene wear increase with time. Several technical issues 2000 and 50000/mL with >50% PML, whereas the crite- that require consideration may play a role in accelerated ria for septic synovial fluid would be WBC >50000/ml polyethylene wear: the quality of polyethylene; the steril- with >75% of PML. The amount of WBC in inflamma- ization method;1–4 its shelf-life;5 the use of extruded versus tory arthritis is not associated with accelerated bone press-molded polyethylene;6 its thickness; third body degradation in normal joints.12 It has been shown that wear; mechanical problems that may lead to increased these guidelines apply for failed aseptic TKA, too.11 wear, such as backside wear; and designs that are too con- The most important differential diagnosis of an effu- forming, among others. Misalignment of components sion is infection, which must be ruled out in every case. and tissue balancing play important roles and have to be Aspiration of these joints provides easy access for further considered as contributors to excessive wear. Therefore, diagnostic studies and should be combined with basic the joint aspirate should be examined in addition to the blood workup and other diagnostic workups. The most normal work-up with polarized light microscopy for important differential diagnoses include gout and polyethylene wear debris.7 pseudogout. A significant challenge in TKA is the diag- However, catastrophic failures due to poor poly- nosis of a low-grade infection, in which aspirates remain ethylene quality, poor implant designs, or poor surgical aseptic. techniques usually represent no diagnostic but rather a surgical challenge. Some effusions have an acute onset with or without a LOW-GRADE INFECTION history of trauma. Some are accompanied by pain and some by a change in stability or alignment. The combi- The combination of pain and aseptic effusion should raise nation of effusion with pain and a change in alignment suspicion of an infection, which is sometimes difficult to is related to the loosening of the implant and is easy to diagnose. Whereas the diagnosis of an acute infection is diagnose. So far, no specific markers have been described relatively easy, based on the acute onset of effusion, for specific diagnosis, such as inflammation, metallosis, redness, swelling, systemic infectious symptoms (see 258 Chapter 24: Aseptic Synovitis 259 TABLE 24.1. Standard Workup for Aseptic Synovitis In addition to aspirate analyses, the serum level of Includes Serum Tests, Analysis of Synovial Fluid, and WBC, the determination of C-reactive protein levels, and Radiography. bone scans, among other analyses, may not significantly 11 Blood test improve the sensitivity of a suspected infected TKR. Erythrocyte sedimentation rates However, the combination of all these measures have not White blood cell counts been studied yet. C-reactive protein levels A low-grade infection may be present with an aseptic Synovial fluid analysis Aerobic and anaerobic cultures effusion. Microbial colonies produce a carbohydrate-rich Fungus cultures biofilm that encases the bacteria on the surface of the bio- Gram’s staining material, dispersing over the surface and between the Leukocyte counting implant-bone interface. The infectious process with clin- Glucose and protein level ical symptoms and positive aspirates does not start before Crystals Polarized light microscopy for polyethylene wear debris the bacteria leave the surface of the biomaterial and Radiographic analysis invade surrounding tissue, specifically bone tissue, Radiography thereby provoking local osteomyelitis. Sooner or later the Scintigraphy bacteria come into contact with the synovial fluid; the Gallium aspirate may become positive at this point. However, it Indium Technetium may take months or even years before the infection becomes manifest. During this phase, the synovial fluid may remain free of bacteria and testing may produce Chapter 16 for discussion) a low-grade infection may not false-negative test results. present with classical symptoms but rather with aseptic The contamination of the culture media, also may effusion and different levels of pain. Laboratory studies, lead to a false-positive diagnosis. Culture of both tissue including complete blood cell count, sedimentation rate, and synovial fluid may help reduce false-positive results. and C-reactive protein are useful in evaluating a suspected Repetitive aspirations every 2 to 4 weeks without the infected total knee replacement.13,14 Synovial fluid cul- administration of antibiotics are recommended, but it tures and white blood cell counts, including its differ- remains unclear when arthroscopic or open-tissue ential are commonly performed. The literature has sampling should be performed. demonstrated reliable specificity (80%–100%), but a vari- able sensitivity of 0% to 90% for aspirations in total hip arthroplasty.15–19 The use of white blood cell counts and GOUTY SYNOVITIS its differential was found to be helpful in a series of 79 failed TKR [11]. Only eight knees showed a white blood One of the most important differential diagnoses of an cell count >2000. The authors concluded that patients acute infected TKA is gouty or pseudogouty synovitis, with a primary diagnosis of osteoarthritis and a WBC since its treatment for this diagnosis may result in the <2000/mL and a differential of <50% PMLs of the syn- unnecessary removal of the implants. Its presentation ovial fluid had a greater than 98% negative predictive may be undistinguishable from an acute infected TKR value for excluding infection.11 with erythema, pain, redness, effusion, elevated erythro- The standard test for the detection of bacteria is cyte sedimentation rate (ESR), and fever. The crystals, arthrocentesis, followed by a Gram’s stain testing and which are either intracellular or extracellular, are usually culture, which actually fail to detect infection in 15% or visible with light microscopy under polarized light. His- even up to 50% of such cases. The percentage of false- tological examination of synovial tissue may be necessary negative test results from standard microbiologic assays to confirm the correct diagnosis under polarized light may be reduced significantly by the use of the polymerase [22]. Both conditions reveal a high WBC count ranging chain reaction (PCR).20 PCR testing results of 32 pre- from 50000 to 100000/mL in septic synovitis and from operative aspirates were all positive, whereas standard 20000 to 80000/mL in gouty arthritis.10 In the differen- microbiologic culturing assays performed preoperative tial WBC count for septic synovitis, the percentage of and intraoperative were positive in only 15 samples. PCR polymorphonuclear (PML) cells ranges from 75% to testing yielded no false-positive results in 21 negative 100% and is usually greater that 90%,10 whereas the per- control specimens obtained from aseptic joints. PCR may centage in gouty synovitis is usually slightly lower: 60% help to identify bacteria even under antibiotic therapy in to 90%. A careful clinical evaluation, including a medical the detection of both live and dead bacteria as recently history of previous gouty episodes, serum levels of uric shown,21 but its clinical use is still very limited. acid, assessment of the total WBC count and the PML cell 260 Revision Total Knee Arthroplasty count, and the presence or absence of monosodium urate synovial membrane consists of two types of synovio- crystals under light microscopy may provide the correct cytes.31 Synovial macrophages (type A) remove cellular diagnosis. and particulate debris from the synovial fluid, whereas The clinical presentation of pseudogouty synovitis synovial fibroblasts (type B) repair the damage of the syn- after TKA has been described as similar to that of septic ovial membrane. The activated synovial macrophages synovitis. In a series of 50 patients with a pseudogout produce a variety of inflammatory cytokines, such as attack, 14 patients were initially suspected or misdiag- interleukin (IL-1b, IL-6), tumor necrosis factor (TNF), 23 nosed as having septic arthritis. Only 1 of the 50 patients interferon, and prostaglandin (PGE2). IL-1b has been showed no calcium pyrophosphate dihydrate crystals shown to increase osteoclastic
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