The Rule of Histology in the Diagnosis of Periprosthetic Infection: Specific Granulocyte Counting Methods and New Immunohistologic Staining Techniques may Increase the Diagnostic Value

Friedrich Boettner1, *, Gabriele Koehler2, Alexander Wegner4, Tom Schmidt-Braekling1, Georg Gosheger4, Christian Goetze3
1 Adult Reconstruction & Joint Replacement Division, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA
2 Gerhard-Domagk Institute of Pathology, University of Muenster, Muenster, Germany
3 Department of Orthopedics, Auguste Viktoria Hospital, Bad Oeynhausen, Germany
4 Department of Orthopedics and Tumor Orthopedics, University of Muenster, Muenster, Germany

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© Boettner et al.; Licensee Bentham Open

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution-Non-Commercial 4.0 International Public License (CC BY-NC 4.0) (, which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

* Address correspondence to this author at the Adult Reconstruction & Joint Replacement Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA; Tel: 212.774.2127; Fax: 212.774.2286; E-mail:



The current study investigates the diagnostic accuracy of the criteria described for frozen sections and whether modern leukocyte specific staining techniques including leukocyte peroxidase and Naphtol-AS-D-chloroacetate-esterase will improve the accuracy of the intra-operative histology.


77 patients undergoing revision total hip and knee arthroplasty were included in this retrospective study. Patients were grouped into septic and aseptic based on intraoperative cultures. Tissue samples were analyzed utilizing the Mirra, Feldman, Lonner, Banit and Athanasou criteria.


An experienced pathologist had a high specificity (96%), but rather low sensitivity (57%) diagnosing infection. By using the Banit-, Mirra-, or Athanasou-criteria the sensitivity is increased to 0.90. The Feldman- and Lonner-criteria have a lower sensitivity (0.48 and 0.38), however, an increased specificity of 0.96 and 0.98, respectively. The Banit cut off has the highest accuracy (86%). MPOX and NACE staining increased the sensitivity and accuracy up to 100% and 92% respectively.


Banit’s cut off is the most accurate histologic criteria to diagnose infection. Modern leukocyte specific staining techniques slightly improve the accuracy. The synovial fluid white blood cell count appears to be the most accurate intraoperative test.

Keywords: Deep Implant Infection, Diagnostic, Frozen Section, Histology.