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Synovial fluid analysis following menisectomya prospective study.

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95 1
BRIEF REPORT
SYNOVIAL FLUID ANALYSIS FOLLOWING MENISECTOMY:
A PROSPECTIVE STUDY
WILLIAM L. CLAYTON, ROBERT B. GIBBONS, KERRY A. RANDOLPH, and WILLIAM A. BULLEY
In 1953 Ropes and Bauer published their work
on synovial fluid analysis (l), an important advance in
the understanding of the synovial response to a variety
of stimuli. Recently, Krey and Bailen reviewed the extremes of leukocytosis in synovial fluid which may occur in a variety of disease states (2). We were prompted
to study the synovial fluid following routine, uncomplicated menisectomy after having seen two postoperative
patients whose dramatic synovial fluid leukocytosis suggested a septic process. A review of the literature failed
to reveal a systematic study of such patients.
Patients and Methods. In a prospective fashion,
synovial fluid was obtained from the knee joints of 19
healthy young men and 1 young woman who had undergone routine uncomplicated menisectomies. Fluid
was obtained 5 to 7 days after surgery in all patients.
None had received prophylactic antibiotics. Most patients were discharged on the eighth postoperative day,
but in 3 patients joint fluid was also obtained 9 to 10
days after surgery.
Synovial fluid was collected in EDTA for leukocyte count, differential, and crystal identification. Normal saline was used as the diluent, and cell counts were
determined as described by Cohen (3). White cell differentials were made by using Wright’s Giemsa stain. Examination for crystals was performed with an American
Optical polarizing microscope. Much clot tests were
carried out in plain fluid with a standard technique (3).
Glucose levels were determined by the automated
SMAC method, and all fluids were cultured for bacteria
From the Departments of Medicine, Orthopedic Surgery,
and Clinical Investigation, Madigan Army Medical Center, Tacoma,
Washington.
Address reprint requests to Dr. Robert B. Gibbons, Box 177,
Madigan Army Medical Center, Tacoma, WA 98431.
Submitted for publication September 25, 1980; accepted in
revised form February 2, 1981.
Arthritis and Rheumatism, Vol. 24, No. 7 (July 1981)
in thioglycolate broth, MacConkey’s medium, chocolate
agar, and blood agar. Laboratory determinations were
performed within 2 hours of synovial fluid aspiration.
With the exception of the glucose determinations and
bacteriologic cultures, all studies were carried out in the
rheumatology laboratory by one of the authors.
Results. Table 1 depicts the synovial fluid findings in 20 patients. All were relatively young and in
good health. All but one of the fluids were bloody or
blood-tinged when examined and had fair to poor mucin clots. No crystals were identified, and all cultured
fluids were sterile. Simultaneous blood glucose levels
were not obtained; however, none of the synovial fluid
glucose values was depressed.
In the fluids collected on days 5 through 7, the
leukocyte cell counts ranged from 450 mm3 to 117,200
mm3,with a mean value of 8,696 and a median value of
1,800 per cubic millimeter. The percent of polymorphonuclear cells ranged from 0 to 86 with a mean value of
20%.
When seen in the orthopedic clinic at the end of
30 days, all patients were doing well. The majority of
the patients had small, asymptomatic, persistent effusions, but arthrocenteses were not performed.
Discussion. The original work of Ropes and
Bauer describing the synovial fluid findings in patients
with a variety of systemic and localized disorders is a
hallmark in the understanding of synovial physiology.
Although one would expect hemorrhagic fluid to be
present following surgical trauma to the synovial space,
we had observed 2 patients prior to this study with persistent effusions, pain, and elevated synovial fluid leukocyte counts consistent with a septic process. Similar patients have been observed by other rheumatologists and
orthopedic surgeons with whom we have been associated (personal communications). In most cases, it appears that the synovial fluids were visually examined
BRIEF REPORTS
952
Table 1. Clinical characteristics and synovial fluid parameters of 20 uncomplicated, postoperative
menisectomy patients
Patient
Age/sex
5
6
6
9
2
3
25/M
25/M
24/M
4
5
6
38/M
21/M
21/M
5
7
8
9
10
11
29/M
36/M
18/M
22/M
22/M
5
12
13
14
28/M
19/M
20/F
15
32/M
20/M
20/M
18/M
17/M
30/M
1
16
17
18
19
20
5
6
9
5
5
5
6
10
5
5
7
Appearance
Mucin clot
Thin, bloody
Thin, bloody
Thin, bloody
Thin, yellow
Thin, bloody
Thin, bloody
Thin, bloody
Thin, bloody
Bloody
Bloody
Bloody
Thin, bloody
Bloody
Thin, bloody
Thin, bloody
Thin, bloody
Thin, bloody
Fair
Fair
Poor
Poor
Fair
Fair
Poor
Poor
Fair
Fair
Poor
Fair
Poor
Fair
Poor
Poor
Spontaneous
clot
Good
Fair
Fair
Poor
Poor
Poor
Bloody
Thin, bloody
Bloody
Bloody
Thin, bloody
Thin, bloody
Leukocyte
count*
825 (0)
1,600 (12)
3,000 (40)
2,950 (53)
450 (84)
850 (5)
1,500 (16)
3,500 (15)
1,850 (10)
1,300 (12)
3,300 (10)
1,800 (8)
1,450 (8)
5,900 (0)
900 ( 5 )
24,000 (12)
117,200 (86)
4,000 (13)
1,850 (2)
3,850 (48)
2,150 (1 1)
1,100 (8)
950 (12)
Glucoset
Culture
69
79
93
ND
105
60
115
ND
87
No growth
No growth
No growth
No growth
No growth
No growth
No growth
ND
No growth
No growth
No growth
No growth
No growth
No growth
No growth
No growth
No growth
102
ND
106
90
90
75
69
88
89
113
74
94
79
84
No growth
No growth
No growth
No growth
No growth
No growth
* Numbers in parentheses indicate percent polymorphonuclear leukocytes.
t ND = not done.
and cultured, but cell counts and differential cell determinations were not performed. We had not found a
controlled study of such patients, and consequently in
the setting of a persistent effusion with a high leukocyte
count, we have recommended initial antibiotic therapy
based on the presumption of sepsis.
Our study was designed to define the range of
the response of synovial fluid following routine, uncomplicated menisectomy as a form of surgical trauma
in a population of otherwise healthy patients. In the
early postoperative period, our findings show that most
effusions are hemorrhagic, with poor to fair mucin clots
and normal glucose values. In 13 of the 20 patients, the
leukocyte counts were found to be in the category of
group 1 (noninflammatory) fluids. Five patients had
values which varied from 2,950 to 5,900 mm3. In two
patients (patients 13 and 14), the leukocyte counts were
strikingly elevated (24,000 and 117,200, respectively).
Although Ropes and Bauer did not study synovial fluid following surgical trauma, they did describe
the changes seen within the first 3 months following
closed trauma (1). Their evaluation of 25 such patients
demonstrated leukocyte cell counts which varied from
100 to 7,500 cells/mm3 with a mean of 1,540. A median
value was not reported. The mean polymorphonuclear
cell count was 17%. These values are somewhat lower
than those from our patients. However, if patients 13
and 14 in our own group were excluded, the mean cell
count would be 1,818, similar to that of the Ropes and
Bauer series.
The reason for the dramatic synovial fluid reactions in patient 14, and the somewhat lesser but significant response of patient 13, is unknown. Both had uncomplicated postoperative recoveries, and cultures of
the synovial fluids were sterile. We believe that the subsequent clinical course of each patient precludes bacterial infection.
Only 3 patients were available for a second arthrocentesis at day 9 or 10. Total leukocyte cell counts
were variable, but not substantially different from the
values obtained on the earlier examinations. Based
upon our findings, we recommend that antibiotic therapy should be withheld pending the results of synovial
fluid culture in the postoperative patient with an elevated synovial fluid leukocyte count without other signs
of a septic process. The organisms generally responsible
for postoperative infections in a normal host are not fastidious, and can generally be cultured on routine labo-
BRIEF REPORTS
ratory media. However, a marked synovial fluid leukocyte response is unusual following uncomplicated,
elective menisectomy, and should be cause for concern.
This finding and/or the presence of recurrent effusions
should be carefully evaluated by synovial fluid analysis
and culture.
Acknowledgment. T h e authors thank Mrs.
Dianna Mize for her technical and secretarial assistance.
953
REFERENCES
1. Ropes MW, Bauer W: Synovial Fluid Changes in Joint
Disease. Cambridge, Harvard University Press, 1953, pp
79- 82
2. Krey PR, Bailen DA: Synovial fluid leukocytosis: a study
of extremes. Am J Med 67:436-442, 1979
3. Cohen AS, Brandt KD, Krey PR: Laboratory Diagnostic
Procedures in the Rheumatic Diseases. Second edition.
Boston, Little, Brown, & Co., 1975, pp 1-62
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menisectomya, prospective, stud, following, analysis, synovial, fluid
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