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Prosthetic joint infection
Background
Overview
Definition
PJI is a clinical syndrome referring to an infection involving a joint prosthesis and adjacent tissue.
1
Pathophysiology
The most common infecting pathogens are bacteria, with coagulase-negative staphylococci and S. aureus accounting for the majority of infections. Pathogens that are less frequent include gram-negative bacilli, polymicrobial infection, and anaerobic infection.
2
Epidemiology
The incidence of PJI in the US is estimated at 150 cases per 100,000 person-years.
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Disease course
PJI causes clinical manifestations of joint pain, erythema, fever, wound drainage, sinus tract formation, and may be complicated by bacteremia.
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Prognosis and risk of recurrence
The 1-year mortality in patients with infection of a total hip arthroplasty is estimated at 8% (95% CI, 6-11%). The 1-year mortality rate in patients with infection of a total knee arthroplasty is estimated at 4.33% (95% CI, 3.14-5.51%).
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of prosthetic joint infection are prepared by our editorial team based on guidelines from the American Academy of Orthopaedic Surgeons (AAOS/AAHKS 2024), the American Academy of Orthopaedic Surgeons (AAOS 2020), the European Association of Nuclear Medicine (EANM/ESR/ESCMID/EBJIS 2019), the American Dental Association (ADA 2015), and the Infectious Diseases Society of America ...
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Screening and diagnosis
Indications for testing: as per IDSA 2013 guidelines, suspect PJI in patients with any of the following:
sinus tract or persistent wound drainage over a joint prosthesis
acute onset of a painful prosthesis
any chronic painful prosthesis at any time after prosthesis implantation.
B
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Timing of testing
Diagnostic criteria (definitive PJI)
Diagnostic criteria (highly probable PJI)
Classification and risk stratification
Diagnostic investigations
Laboratory tests
As per AAOS 2020 guidelines:
Obtain ESR, CRP and IL-6 to aid in the preoperative diagnosis of PJI.
A
Do not obtain peripheral blood leukocyte count and serum TNF-α to aid in the diagnosis of PJI.
D
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Diagnostic imaging
Diagnostic procedures
Synovial fluid analysis: as per AAOS 2020 guidelines, obtain the following synovial fluid tests to aid in the diagnosis of PJI:
leukocyte count and neutrophil percentage
aerobic and anaerobic bacterial cultures
leukocyte esterase
α-defensin
CRP
NAAT (such as PCR) for bacteria.
B
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Histopathology
Medical management
Antibiotic therapy following debridement, staphylococcal PJI
As per IDSA 2013 guidelines:
Complete 2-6 weeks of pathogen-specific intravenous antimicrobial therapy in combination with rifampin (300-450 mg PO BID) for patients with staphylococcal prosthetic-joint infection undergoing debridement, followed by:
rifampin plus a companion oral drug for a total of 3 months for a total hip arthroplasty infection
rifampin plus a companion oral drug for a total of 6 months for a total knee arthroplasty infection
A
Consider managing patients with total elbow, total shoulder, and total ankle arthroplasty infections using the same protocols as for patients with total hip arthroplasty infections.
C
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Antibiotic therapy following debridement (PJI due to other organisms)
Antibiotic therapy following exchange arthroplasty (PJI due to other organisms)
Antibiotic therapy following exchange arthroplasty (staphylococcal PJI)
Antibiotic therapy following resection arthroplasty
Antibiotic therapy following amputation
Antibiotic therapy for MRSA PJI
Surgical interventions
Exchange strategy
As per IDSA 2013 guidelines:
Use a two-stage exchange strategy in patients who are not candidates for a one-stage exchange, are medically able to undergo multiple surgeries, and are good candidates for reimplantation arthroplasty, based on the existing soft tissue and bone defects.
B
Consider a one-stage or direct exchange strategy in patients with a total hip arthroplasty infection who have a good soft tissue envelope, provided that the identity of the pathogens is known preoperatively and they are susceptible to oral antimicrobials with excellent oral bioavailability.
C
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Debridement and retention
Resection arthroplasty
Amputation
Preventative measures
Preoperative dental screening
As per AAHKS/AAOS 2024 guidelines:
Avoid obtaining dental screening before hip or knee replacement to reduce the risk of subsequent periprosthetic joint infections.
D
Consider delaying hip or knee replacement surgery based on the risk of transient bacteremia, the occurrence of an invasive surgical procedure, and treatment of an active dental infection
Situation
Guidance
Dental examination without probing, dental radiography or cone beam CT, denture adjustment procedures, clear orthodontic aligner (invisible braces) adjustment procedures, occlusal guard or bite splint adjustment
Same day
Oral hygiene procedures, including dental cleaning, dental prophylaxis using a rubber cup and handpiece (without scaling) or periodontal probing (without scaling and/or root planing)
1 day
Orthodontic procedures, including banding or debanding orthodontic fixes or removable appliances, archwire adjustment, orthodontic mini-implant removal, orthodontic separate placement
1 day
Other noninvasive procedures, including suture removal, anesthetic injection, crown and bridge placement, dental restorative procedures, rubber dam clamp or matrix band wedge between teeth, impression taking, endodontic treatment (root canal therapy)
1 day
Scaling and/or root planing with manual (hand instruments) or ultrasonic scaler
1 week
Dental extraction, including single, multiple, impacted third molar
3 weeks
Oral surgery, including dental implant surgery, periodontal surgery, cleft palate surgery, piezoelectric surgery, osteosynthesis plate removal
3 weeks
Treatment of active dental infection
3 weeks after resolution of active infection
E
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Preoperative decolonization
Antibiotic-loaded cement
Povidone-iodine lavage
Prophylaxis before dental procedures
Prophylaxis before revision surgery