Acute pseudogout presenting as an exception to Musculoskeletal Infection Society criteria in total knee arthroplasty: a case report

In this case, a 78-year-old female with no previous medical history of crystalline arthropathy presented with pain, effusion, and erythema about a total knee arthroplasty (TKA) performed 13 years prior. Implementation of a novel synovial fluid alpha-defensin assay ruled out periprosthetic joint infection (PJI) despite a positive 2018 Musculoskeletal Infection Society (MSIS) minor criteria score of 8 points, a significant diagnostic differentiation which prevented secondary invasive debridement or joint irrigation intervention. Confirmatory histologic study was positive for calcium pyrophosphate crystals, indicative of acute pseudogout inflammation rather than PJI or septic arthritis manifestation. The patient was then conservatively managed medically for a pseudogout flare and had no evidence of infection with normal physical exam and laboratory study at one- and two-years post treatment, respectively. Given the predominantly clinical nature of current PJI assessment in-clinic coupled with notable risks associated with aggressive re-intervention in the setting of suspected infection, critical need exists for the maturation of sensitive, reliable empiric measures which may assist in guiding orthopaedic surgeon evaluation of patients presenting with inflammatory symptomology around a previous surgical site. In this case, we conclude that patients with a negative alpha-defensin assay alongside crystalline arthropathy on histology may be cautiously yet successfully treated non-operatively despite clinical MSIS criteria concerning for PJI.