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Periprosthetic joint infection (hip)

102 citationsUpdated Sep 2026

Overview

Periprosthetic joint infection (PJI) remains a significant complication following hip arthroplasty, with the International Consensus on Periprosthetic Joint Infections providing a comprehensive framework to minimize care variations and reduce the burden of infection [1, 2]. This consensus process reached agreement on all but four of 207 questions regarding prevention, diagnosis, and treatment [2]. Although the consensus aims to improve research and outcomes, management remains challenging due to numerous unresolved problems and the need for further study on emerging diagnostic technologies and prevention protocols [3, 17]. The MSIS definition is currently used for diagnosing PJI [17]. While the prevalence of PJI as a cause of metal-on-metal hip arthroplasty failure was relatively high compared to other bearing combinations, the responsible organisms were similar to those in other combinations [5].

Treatment strategies vary based on patient factors and organism sensitivity. In North America, two-stage revision arthroplasty is the treatment of choice for chronic periprosthetic infection of the hip and knee [7]. However, one-stage revision using cementless implants may be appropriate for carefully selected patients with meticulous débridement and appropriate antibiotics [47]. Using cementless prostheses in two-stage revisions combined with specific local and systemic antibiotic therapy appears to eradicate infection and provide implant stability [9]. For patients with resistant staphylococci, evidence is variable and often limited by small, heterogeneous patient numbers [4]. A 2-stage reimplantation protocol with a standardized 1:8 minimal antibiotic serum bactericidal titer supports treatment efficacy, including for drug-resistant organisms [20]. Surgeons should be cautious using irrigation and débridement as a routine means to address PJI [25].

Eradication of PJI while minimizing patient morbidity continues to be a challenge [11]. Specific articulating antibiotic spacer designs allow for reliable eradication, low spacer-related complications, and improved functional outcomes [12]. Massive endoprostheses for hip and knee PJI describe an eradication rate of 72% with acceptable functional outcome [13]. Most hips and Gram-positive infections treated with chronic antibiotic suppression successfully avoided reoperation in studied cohorts [14]. No patient with an infected hip joint should be offered Girdlestone resection arthroplasty as the only alternative [21]. Preoperative antimicrobial prophylaxis may be administered safely in patients undergoing revision arthroplasty with planned microbiologic sampling without compromising diagnostic sensitivity [32]. The authors recommend against the routine use of synovial alpha-defensin, suggesting it be reserved for cases where PJI cannot be diagnosed or ruled out with standard testing [16].

Anatomy & Pathophysiology

Bony Anatomy

The hip is a multiaxial joint formed by the articulation between the pelvis and femur, connecting the axial skeleton and the lower extremity [79]. The hemipelvis comprises the ilium, ischium, and pubis, which unite at the triradiate cartilage within the concave acetabulum [79]. The acetabulum consists of an articular crescent-moon–shaped lunate surface and a nonarticular central fossa that serves as the attachment point for the ligamentum teres [79]. Inferiorly, the acetabulum is incomplete, forming a notch through which vital blood vessels and nerves pass to supply the joint [79]. The femoral head forms two-thirds of a sphere, with a small depression at its center from which the ligamentum teres extends to connect to the acetabular notch [79].

The neck-shaft angle of the femur averages 125° [79], with a mean adult value of 130° ± 7° [85]. Normal version, defined as the head-neck angle in the frontal plane, averages 15 to 20° [79], while the mean anteversion of the femoral neck is 10° ± 7° [85]. The proximal femur contains two prime trabecular groups: the principal tensile group and the principal compressive group [85]. The weakest area in the femoral neck is located in the Ward triangle [85]. The calcar femorale, a medial area of dense trabecular bone, transfers stress from the femoral shaft to the inferior portion of the femoral neck [85].

Ligaments and Capsule

The hip is surrounded by a dense fibrous capsule extending from the periphery of the acetabulum to the intertrochanteric line of the femoral neck [79]. This capsule enhances joint stability by preventing translation of the femoral head in the acetabulum [79]. The capsule attaches anteriorly and posteriorly along the periphery of the acetabulum outside the labrum [80]. Inferiorly, it attaches to the acetabular labrum [80]. On the femur, the capsule attaches anteriorly along the intertrochanteric crest [80]. Posteriorly, the attachment is partial, leaving the basicervical region of the femoral neck and the intertrochanteric region of the femur extracapsular [80].

Three main ligaments support the hip: Iliofemoral ligament: Y-shaped and the thickest and strongest of the three, it limits external rotation, while its lateral arm limits extension [79]. It becomes taut in full extension, preventing anterior dislocation and hyperextension [80]. Ischiofemoral ligament: Extends from the ischial margin of the acetabulum to the greater trochanter of the femur and restricts internal rotation motion [79]. Pubofemoral ligament: Extends from the obturator crest of the pubic bone to the femoral neck and acts to limit abduction of the joint [79].

Deep fibers from all three ligaments merge to form the zona orbicularis, which circumvents the femoral neck [79]. The twisted orientation of these ligaments provides a screw mechanism for the hip in full extension [80]. The ligamentum teres originates in the cotyloid fossa and attaches on the fovea of the femoral head [80].

Labrum

The acetabular labrum is a fibrocartilaginous ring that extends the articulating surface area and increases femoral head coverage [79]. Its triangular cross-section contributes to its ability to create a pressurized seal of the central compartment of the hip during loading [79]. Only the external one-third of the labrum contains blood vessels, leaving the majority of the structure avascular and limiting its healing ability following injury [79]. The labrum is highly innervated, with the presence of both mechanoreceptors and nociceptors [79]. It is absent in the area of the inferior acetabular notch, where the transverse acetabular ligament serves as the continuation of the labrum [79]. Labral functions include load transmission, maintenance of vacuum seal, regulation of synovial fluid hydrodynamics, and joint lubrication [76].

Muscles

The primary hip flexor muscles are the iliopsoas, rectus femoris, and sartorius muscles [83]. The gluteus maximus and hamstring muscles are the most important hip joint extensors [83]. The abductors of the hip are predominantly the gluteus medius and minimus muscles [83]. These muscles function together to maintain and abduct the femur during the stance phase of gait [83]. A Trendelenburg lurch is an attempt by the body to compensate for abductor weakness by bringing the center of gravity closer to the hip center [83]. Damage and/or weakness to the abductor muscles can occur during surgical approaches to the hip, affecting hip stability and potentially necessitating the use of constrained hip implants [83].

The external rotators of the hip include the obturator internus and externus, superior and inferior gemelli, quadratus femoris, and piriformis muscles [83]. The piriformis forms the reference structure for the posterior part of the hip, with structures identified by whether they originate above or below it [83]. The superior gluteal nerve and artery exit the pelvis above the piriformis muscle [83]. The pudendal nerve, internal pudendal artery, nerve to the obturator internus, posterior femoral cutaneous nerve, sciatic nerve, inferior gluteal nerve, inferior gluteal artery, and nerve to the quadratus femoris exit the pelvis below the piriformis [83]. In 10% of cases, the common peroneal component of the sciatic nerve can pass through the division in the piriformis [83]. Most often, the sciatic nerve passes below the piriformis and is situated on top of the short external rotators [83]. The most consistent internal rotators of the hip joint are the gluteus medius and tensor fascia latae muscles [83].

Neurovascular Anatomy

In adulthood, the major blood supply to the femoral head is from the medial femoral circumflex and lateral epiphyseal arteries [88]. The medial femoral circumflex artery is the main blood supply to the femoral head and terminates in the posterior aspect of the extracapsular arterial ring [85]. The lateral femoral circumflex artery gives rise to the anterior aspect of the arterial ring [85]. The ascending cervical arteries originate from the extracapsular arterial ring and are divided into four distinct groups based on their anatomic relationship to the femoral neck: lateral, medial, posterior, and anterior [85]. The lateral group of ascending branches is the main blood supply to the femoral head [85]. These ascending branches give off multiple perforator vessels to the femoral neck and terminate in the subsynovial arterial ring located at the margin of the articular surface of the femoral head [85]. The lateral epiphyseal artery penetrates the femoral head and is believed to be the dominant blood supply to the femoral head from this system [85]. Fractures that disrupt the ascending blood flow to the lateral epiphyseal vessel have an increased risk of osteonecrosis [85]. The artery of the ligamentum teres arises from either the obturator or medial femoral circumflex artery and does not provide sufficient blood supply to maintain the viability of the femoral head [85].

The common femoral vessels are the most commonly reported extrapelvic vascular structures that are injured during total hip arthroplasty [88]. The most common mechanism of injury to the common femoral vessels is errant retractor placement anterior to the acetabulum [88]. The profundus or deep femoral artery arises from the lateral aspect of the common femoral artery approximately 3.5 cm below the inguinal ligament [88]. The lateral circumflex artery arises from the lateral side of the proximal profundus femoris artery [88]. The medial circumflex artery most commonly comes from the posteromedial profundus femoris artery but may also come directly from the femoral artery [88].

The superior gluteal vessels are branches of the posterior division of the internal iliac artery and are closest to the hip as they exit from the sciatic notch [88]. Superior gluteal artery injury can occur with the placement of screws in the region of the sciatic notch [88]. The inferior gluteal vessels and internal vessels are branches of the anterior division of the internal iliac artery and exit the pelvis between the piriformis and coccygeus muscles [88]. These vessels can be injured by screws in the posterior column that are at least 5 mm past the bony margin [88].

Pathophysiology of Infection

Biofilms are defined as a microbially derived sessile community, characterized by cells that are irreversibly attached to a substratum or interface or to each other, embedded in a matrix of extracellular polymeric substances that they have produced, and exhibit an altered phenotype with respect to growth rate and gene transcription [33]. Biofilm bacteria display characteristics that affect the identification of the causative organisms and antimicrobial therapy compared to free-floating bacteria [33]. Treatment of biofilm bacteria is much more challenging compared to planktonic bacteria [33]. Specifically, 100-1000 times the standard concentration of cell wall active antibiotics is required when treating biofilm bacteria [33]. Staphylococcal invasion at the surgical site followed by adherence to the prosthesis frequently results in biofilm formation [143]. The biofilm matrix supports the three-dimensional organization of bacteria while also actively suppressing proinflammatory microbicidal responses [143]. Biofilm products cause macrophage polarization toward an anti-inflammatory phenotype and the recruitment of myeloid-derived suppressor cells [143].

The pathogen spectra of periprosthetic and native joint infections differ considerably [19]. The overall risk for implant-associated infection in orthopedic surgery is below 1%-2% [33]. Periprosthetic joint infections occur in 1%-2% of primary total hip and knee arthroplasty cases [41]. There is an increased prevalence of periprosthetic joint infection in revision arthroplasty cases [41]. Septic revision accounts for 7.5% of all revision surgeries in total hip arthroplasty [33]. The annual cost of infected revision total joint arthroplasty to US hospitals has been projected to exceed $1.62 billion by 2020 [30]. The costs of periprosthetic joint infection exceeded $900 million in 2012 and are projected to exceed $1.6 billion by 2020 [41].

The management of periprosthetic joint infection remains difficult primarily due to the evolution of resistance by the infecting organisms [41]. Cure rates for periprosthetic joint infection have essentially stalled in the last two decades using methods of antimicrobial cement joint spacers and parenteral antimicrobial agents [146]. Microbiota have responded to increasing antimicrobial pressures with adaptive mechanisms beyond traditional antimicrobial resistance genes [146]. The exact mechanism by which joint contamination becomes an infection is still poorly understood [138].

Classification

International Consensus on Periprosthetic Joint Infections: This consensus process aimed to minimize variations in care and reduce the burden of infection, reaching agreement on all but four of 207 questions regarding the prevention, diagnosis, and treatment of periprosthetic joint infection [2]. The initiative has focused the community and should lead to better research and outcomes [1].

MSIS Definition: The Musculoskeletal Infection Society (MSIS) definition for diagnosing periprosthetic joint infection is detailed in orthopaedic infection literature, which also highlights the need for further study on emerging diagnostic technologies and prevention protocols [17].

Clinical Setting Classification: A classification scheme based on four clinical settings was used to guide the treatment of infections after total hip arthroplasty [67]. Other classification schemes, such as those defining early infection as occurring within three months, subacute within one year, and late after one year, did not fulfill the role of guiding therapy in the studied series [67].

Other Considerations: The orthopedic community should consider a probability and likelihood paradigm to create a PJI diagnostic definition, as probably not a single definition might be suited for all situations [35]. The diagnosis of peri-prosthetic bone and joint infections relies on converging information from clinical, laboratory, and imaging assessments [36]. Clinical findings like a sinus tract serve as major criteria for the diagnosis of peri-prosthetic bone and joint infections [36]. The workup of patients with painful joint and suspected late periprosthetic joint infection should follow a systematic approach including laboratory tests and aspiration of the joint [10]. Synovial fluid analysis is adequate in differentiating patients with periprosthetic hip and knee infections [31]. Biomarkers perform differently according to the selected PJI definitions [38]. The authors recommend against the routine use of synovial alpha-defensin and suggest it be reserved for cases where PJI cannot be diagnosed or ruled out with standard testing [16]. The cutoff level for the 2018 International Consensus Meeting Minor Criteria seems to be different between the hip and knee [37]. The change in serum Interleukin-6 between stages does not appear to identify subsequent PJI in patients who have two-stage revision for periprosthetic joint infection [23]. Sonication of retrieved implants improves sensitivity in the diagnosis of periprosthetic joint infection [15]. Fluorescence In Situ Hybridization (FISH) represents a fast and reliable tool for detecting PJI in periprosthetic membranes, especially in combination with clinical and histopathological classification [137].

The prevalence of PJI as a cause of metal-on-metal hip arthroplasty failure was relatively high compared to other hip bearing combinations [5]. The organisms responsible for PJI in metal-on-metal hip arthroplasties were similar to those in other combinations [5]. The prevalence of multiple periprosthetic joint infections has decreased compared with historical reports [27]. The decrease in prevalence of multiple periprosthetic joint infections is likely due to higher rates of 2-stage revisions and fewer patients treated with I&D [27].

A specific articulating antibiotic spacer design allows for reliable PJI eradication, low spacer-related complications, and reliable improvement in functional outcomes [12]. Massive endoprostheses used for managing periprosthetic joint infections of the hip and knee describe a PJI eradication rate of 72% with acceptable functional outcome [13]. A 2-stage reimplantation protocol with a standardized 1:8 minimal antibiotic serum bactericidal titer supports the efficacy for the treatment of periprosthetic infections of the hip, including those caused by drug-resistant organisms [20]. Partial component-retained two-stage reconstruction could be an alternative treatment option for chronic infection after an uncemented total hip arthroplasty with a radiographically and clinically well-fixed component in selected patients who are not immunocompromised and are infected by a low-virulence organism [22]. Treatment of infection at the site of a hip arthroplasty with 2-stage revision using cementless components and an articulated spacer yields recurrence rates similar to revisions where at least one of the components at the second stage is fixed with antibiotic-loaded cement [70].

Biofilms are fundamental with respect to the pathogenesis and persistence of PJIs [33]. The costs of PJI exceeded $900 million in 2012 and are projected to exceed $1.6 billion by 2020 [41]. There has been a shift in treatment approach from urgent surgical procedures to preoperative patient optimization and establishment of an accurate diagnosis prior to surgical planning and treatment [41]. Antibiotics combined with 1 or 2-stage revision are associated with the higher success rates and remain the mainstay of treatment [41]. Novel antibiotic implant and wound care materials, improved methods for organism identification, and well-defined organism-specific treatment algorithms are needed to optimize outcomes of PJI [41].

I&D may be performed for early post-operative infections that occur within 3 months of index primary arthroplasty and within 3 weeks after symptom onset [132]. No hip had recurrence of the infection with the same pathogen more than two years after the follow-up period in a study of 106 infections [67]. Many areas regarding periprosthetic joint infection still require further research [1]. The management of periprosthetic joint infections remains challenging with numerous problems to resolve and scope for research [3].

Clinical Presentation

History and Physical Examination

A careful history and physical examination are crucial in diagnosing total hip infection [109]. Early or late acute infections may present with pain, fever, or erythema [109]. In chronic cases, pain unrelieved by a seemingly well-functioning arthroplasty may indicate infection [109]. Historical factors that raise suspicion include excessive wound drainage after the initial arthroplasty, multiple episodes of wound erythema, and prolonged antibiotic treatment by the operating surgeon [109]. Physical examination focuses on painful hip range of motion, swelling, erythema, sinus formation, or fluctuance [109]. A sinus tract serves as a major criterion for the diagnosis of periprosthetic bone and joint infections [36]. While typical signs include erythema, swelling, fever, and increased blood infection markers [52], these are not always present [52]. The diagnosis relies on converging information from clinical, laboratory, and imaging assessments [36], as no single test is totally reliable [52].

Radiographic Findings

Radiographs of the affected hip are often normal or indistinguishable from aseptic loosening of the prosthesis [109]. However, progressive radiolucencies or periosteal reaction may be seen on radiographs, indicating possible infection [109].

Laboratory Markers

The pre-operative work-up for a painful joint with suspected late periprosthetic joint infection includes a systematic approach with laboratory tests and joint aspiration [10]. Initial blood tests should include erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) [107]. ESR greater than 30 mm/h and CRP greater than 10 mg/L are reasonably sensitive and specific for chronic infection [109]. The threshold for a positive D-dimer test has been reported to be 850 ng/mL [109]. Peripheral white blood cell (WBC) count is rarely elevated in late chronic infection and is not a sensitive screening tool [109]. Modern inflammatory serum markers, such as interleukin (IL)-6, tumour necrosis factor (TNF)-α, and procalcitonin, have not shown distinct advantages over conventional markers like CRP and ESR and have not found their way into routine clinical practice [52]. D-dimer shows high sensitivity for PJI diagnosis in cases of low-virulence organisms which might be missed by most diagnostic tests [57]. In patients with periprosthetic fracture, increased inflammatory laboratory values are not good indicators for deep periprosthetic infection and do not necessarily warrant additional evaluations before definitive surgical treatment [53]. The diagnostic utility of serum and synovial markers is lower in the setting of concomitant periprosthetic fracture compared to PJI alone [54].

Synovial Fluid Analysis

Hip aspiration is warranted if ESR, CRP, or D-dimer are elevated, or if the index of suspicion for infection is high despite normal values [109]. Aspiration should not be undertaken until at least 2 weeks after discontinuation of antibiotic therapy [109]. The procedure is performed in an outpatient setting under local anesthesia with the same attention to sterile technique as a surgical procedure, including full surgical scrub and preparation [109]. Fluoroscopy or ultrasonography are useful for accurate needle insertion [109]. An 18-gauge spinal needle is inserted from anterior at a point just lateral to the femoral artery along a line from the symphysis pubis to the ASIS, or alternatively laterally just superior to the greater trochanter [109]. The tip must enter the joint and be seen and felt to come in contact with the metal of the neck of the femoral component [109]. Gentle rotation of the extremity helps bring fluid toward the needle if none is easily withdrawn [109]. Aerobic and anaerobic cultures, and cell count with differential, are obtained from the aspirant [109]. Approximately one third of patients have dry hip aspiration, in which cases cultures are less predictive of intraoperative findings [65].

Additional synovial fluid markers include leukocyte esterase (LE) and alpha-defensin, which have shown high sensitivity and specificity [109]. LE is an accurate and effective marker and should be used in conjunction with the current battery of available diagnostic tests [63]. The authors recommend the use of the synovial fluid biomarker IL-6 for the diagnosis of PJI following total hip and knee arthroplasty [26]. Alpha-defensin testing using a lateral flow device shows promising results and should be considered as part of the diagnostic toolbox for PJIs [40]. In patients with unclear diagnosis due to recent antibiotic use, equivocal laboratory findings, or suspected false-negative or false-positive cultures, synovial fluid alpha-defensin can provide an additional data point [112]. However, alpha-defensin is prone to false-positive results in this specific population [112]. Understanding how the accuracy of diagnostic tests varies with respect to demographic factors can help physicians avoid unnecessary additional testing and reach more accurate diagnoses [39]. Further investigation of diagnostic tests following staged treatment of PJI is needed [59].

Microbiological Considerations

Cutibacterium is an increasingly recognized pathogen in total hip arthroplasty that can present with normal serology, leading to misdiagnosis as aseptic failure [113]. Concomitant multiple PJIs are rare events that occur most often as a result of secondary hematogenous spread from a distant infectious focus [64]. The prevalence of multiple periprosthetic joint infections has decreased compared with historical reports, likely due to higher rates of 2-stage revisions and fewer patients treated with I&D [27]. One study identified the risk of developing a subsequent periprosthetic joint infection to be one half of previous studies [6].

Diagnostic Challenges and Definitions

Diagnosis of periprosthetic joint infection can be difficult in the early postoperative period after total hip arthroplasty because normal cues from the physical examination are often unreliable [105]. Serological markers commonly used for diagnosis are elevated from the recent surgery in the early postoperative period [105]. Although other causes exist, it is essential to perform a work-up for prosthetic joint infections when C-reactive protein levels are elevated in the early postoperative period [117]. Patients with suspected late-PJI should not receive antibiotics until the diagnosis is reached or refuted [29]. Results from a small, prospective series suggest that preoperative antimicrobial prophylaxis may be administered safely even in patients undergoing revision hip or knee arthroplasty in which microbiologic sampling is planned without compromising the diagnostic sensitivity of tissue sample cultures [32]. Further studies are needed to explore diagnostic tests that will better detect PJI in patients with inflammatory arthritis [62].

Investigations

Diagnostic Criteria and Consensus: The Musculoskeletal Infection Society (MSIS) definition is used for diagnosing periprosthetic joint infection [17]. The 2018 definition for diagnosing hip and knee periprosthetic joint infection is an evidence-based and validated criteria that has shown excellent performance on formal external validation [75]. Clinical findings such as a sinus tract serve as major criteria for the diagnosis of periprosthetic joint infection [36]. Synovial fluid aspiration, diagnostic imaging, traditional culture, peripheral serum inflammatory markers, and intraoperative frozen sections each have limitations but continue to be the mainstay for diagnosis of periprosthetic joint infection [142].

Laboratory: Synovial fluid interleukin-6 (IL-6) is recommended for the diagnosis of periprosthetic joint infection following total hip and knee arthroplasty [26]. The change in serum interleukin-6 between stages of two-stage revision does not appear to identify subsequent periprosthetic joint infection [23]. Synovial C-reactive protein (CRP) is a marker for chronic periprosthetic infection in total hip arthroplasty [52]. Modern inflammatory serum markers such as interleukin-6, tumour necrosis factor-alpha, and procalcitonin have not shown distinct advantages over conventional inflammatory markers such as CRP and erythrocyte sedimentation rate (ESR) [52]. Leucocyte esterase (LE) is an accurate and effective synovial fluid marker for diagnosing periprosthetic joint infection and should be used in conjunction with the current battery of available diagnostic tests [63]. D-dimer shows high sensitivity for periprosthetic joint infection diagnosis in cases of low-virulence organisms which might be missed by most diagnostic tests [57].

Microbiology and Tissue Sampling: Patients with suspected late periprosthetic joint infection should not receive antibiotics until the diagnosis is reached or refuted [29].

Synovial Fluid Biomarkers and Emerging Tests: The routine use of synovial alpha-defensin is not necessary, and it should be reserved for cases where periprosthetic joint infection cannot be diagnosed or ruled out with standard testing [16]. The alpha-defensin lateral flow test has a sensitivity limited to 54% to 84% and should not be used for screening, but rather as a confirmatory test for periprosthetic joint infection [149]. The alpha-defensin lateral flow device is considered part of the diagnostic toolbox for periprosthetic joint infections [40]. Microcalorimetry of synovial fluid allows thermogenic diagnosis of periprosthetic joint infection [150]. Further investigation of diagnostic tests following staged treatment of periprosthetic joint infection is needed [59].

Other Considerations: Increased inflammatory laboratory values in patients with periprosthetic fracture are not good indicators for deep periprosthetic infection and do not necessarily warrant additional evaluations before definitive surgical treatment [53]. The diagnostic utility of serum and synovial markers for diagnosing periprosthetic joint infection was lower in the setting of concomitant periprosthetic fracture compared to periprosthetic joint infection alone [54]. The accuracy of diagnostic tests for periprosthetic joint infection varies with respect to demographic factors [39]. Further studies are needed to explore diagnostic tests that will better detect periprosthetic joint infection in patients with inflammatory arthritis [62].

Plain radiography: Conventional radiographs remain critical in the initial imaging evaluation of the hip [50]. A complete hip series usually consists of an anterior-posterior (AP) pelvis, a centered AP hip, a lateral view, and a false-profile (Lequesne) view [50].

MRI: MRI is the modality of choice for patients suspected of soft tissue or intra-articular pathology due to its superior sensitivity and specificity [93]. Magnetic resonance arthrography (MRA) is more appropriate than conventional MRI to determine injuries to labrochondral structures and the ligamentum teres [93]. MRI is helpful in assessing complications of conventional and resurfacing hip arthroplasties, particularly those with metal-on-metal bearing systems [98]. Major MRI findings that help predict histologic ALVAL scores include synovial thickening, synovitis, synovial volume, abductor disruption, and soft-tissue edema [98].

CT: CT scans are effective for examining cortical and cancellous bone and can be used to create three-dimensional reconstructions of the hip for surgical planning [93].

Ultrasonography: Ultrasonography can be an effective modality to identify musculotendinous disruptions, effusions associated with intra-articular pathology, or inflammatory conditions such as bursitis [93].

Treatment

Non-Operative

Chronic antibiotic suppression successfully avoided reoperation in most hips and Gram-positive infections within a specific cohort [14]. While local antibiotic prophylaxis reduces the incidence of acute periprosthetic joint infection compared to intravenous antibiotics in patients with non-modifiable risk factors [114], this strategy is distinct from the management of established deep infection, which typically requires surgical intervention.

Operative

Indications: The International Consensus on Musculoskeletal Infection indicates two-stage exchange arthroplasty for septic or medically compromised patients, unidentified organisms, virulent or drug-resistant bacteria, sinus tracts, and compromised surrounding soft tissues [110]. One-stage exchange is considered reasonable when effective antibiotics are available and systemic symptoms of sepsis are absent [110]. Relative contraindications to single-stage treatment include the lack of preoperative identification of the infecting organism, multiple medical comorbidities, the presence of sinus tracks, and soft-tissue compromise possibly requiring flap coverage [110].

Surgical Approach / Technique: Two-stage reimplantation is associated with a high rate of early success in treating deep infection after total hip arthroplasty, though it carries a modest rate of recurrent infection or mechanical failure [72]. Favorable outcomes in two-stage procedures are associated with infections sustained by Gram-positive bacteria, the absence of known comorbidities, and the administration of oral therapy [44]. Two-stage revision total hip arthroplasty without spacer placement is a viable option for patients with severe bone loss or abductor deficiency, although dislocation remains a major concern [45]. The optimal timing for reimplantation has not been determined; however, reconstruction is performed at approximately 3 months if the ESR and CRP are improving and repeat aspiration of the hip, if performed due to concern of persistent infection, is negative [110]. Debridement and implant retention for managing infection after total hip arthroplasty reports success rates between 65% and 75% [56]. Results for debridement and retention after hemiarthroplasty for intracapsular hip fracture are less favorable regarding infection eradication compared to total hip arthroplasty [56]. Management of septic arthritis by arthroplasty using a specific protocol yielded very good functional results in both knee and hip, with infection eradication rates of 87% in evolutive septic arthritis and 95% in quiescent septic arthritis [48].

Implant Selection: Growing data and International Consensus Meeting recommendations support using articulating antibiotic spacers whenever possible, reserving static spacers only for cases with major femoral or acetabular bone loss or abductor mechanism loss [68]. Stage-one antibiotic-coated molded hip spacers are associated with a high rate of mechanical complications, especially in patients requiring an extended trochanteric osteotomy [34]. The decision regarding cemented or cementless reimplantation should be guided by available femoral bone stock, the physiologic age and expected longevity of the patient, and reported infection cure rates with each technique [110]. In a review of two-stage exchange patients, the femoral component fixation method, with or without cement, had no effect on reinfection or mechanical complication rates [110]. The committee recognized the importance of antibiotic-containing cement or bone graft in the reconstruction to achieve success in one-stage exchange [110]. Clinical outcomes of massive endoprostheses used for managing periprosthetic joint infections of the hip and knee describe a periprosthetic joint infection eradication rate of 72% with acceptable functional outcome [13].

Adjuncts: The use of a closed-suction drain does not reduce the effectiveness of an antibiotic-loaded spacer in two-stage exchange arthroplasty for periprosthetic hip infection [121]. A two-stage reimplantation protocol with a standardized 1:8 minimal antibiotic serum bactericidal titer is effective for treating periprosthetic infections of the hip, including those caused by drug-resistant organisms [20]. Intrawound vancomycin may reduce the risk of periprosthetic joint infection in primary and revision total knee and hip arthroplasty; however, only low-quality evidence exists, highlighting the need for randomized controlled trials before broad adoption [69]. The use of vancomycin as the perioperative prophylactic antibiotic for primary total joint arthroplasties appeared to be effective in decreasing the rate of periprosthetic joint infection and may result, when they occur, in infections with less virulent organisms [125]. Preoperative antimicrobial prophylaxis may be administered safely even in patients undergoing revision hip or knee arthroplasty in which microbiologic sampling is planned without compromising the diagnostic sensitivity of tissue sample cultures [32]. Rifampin combination therapy was evaluated in a randomized controlled trial for staphylococcal prosthetic joint infections [111].

Other Considerations: The most recent systematic review and meta-analysis comparing one-stage and two-stage treatment options have shown no difference in reinfection rates in both knees and hips [129]. An administrative database study of over 10,000 patients treated with prosthesis removal and spacer placement found a 90-day mortality rate of 2.6% [110]. In a review of 168 patients treated with two-stage exchange, infection-free survival was 87.5% at 7 years average follow-up [110]. One-stage exchange of the hip for periprosthetic joint infection is a reliable treatment option with a high rate of infection control and long-lasting favorable outcomes [43]. The authors consider that no patient with an infected hip joint should be offered Girdlestone resection arthroplasty as the only alternative [21]. Excision arthroplasty to control infection is generally associated with very poor postoperative mobility, and older patients are usually wheelchair-bound after this procedure [56]. The results of modified Girdlestone resection arthroplasty after a total hip replacement in general are not as satisfactory as the results after hip joint infections that have required less bone and soft-tissue resection [110]. Almost all patients require some sort of assistive device to walk following modified Girdlestone resection arthroplasty [110]. Functional outcomes are poor in elderly patients, females, and patients with more extensive resection of bone from the proximal femur following modified Girdlestone resection arthroplasty [110]. The results are not likely to be as good for immediate exchange arthroplasty in the hip fracture population, with a much frailer population [56]. Some of the identified factors for surgical treatment of periprosthetic joint infection are indeed modifiable and should be addressed before treating a patient [46]. Chronic institutionalized patients have a higher risk of acute periprosthetic joint infection after hip hemiarthroplasty, commonly caused by gram-negative microorganisms not covered by current prophylaxis strategies [140]. The prevalence of periprosthetic joint infection as a cause of metal-on-metal hip arthroplasty failure was relatively high compared to other hip bearing combinations; however, the organisms responsible were similar [5]. Despite increasing recent interest, the management of periprosthetic joint infections in the future may still be challenging, with numerous problems to resolve and scope for plenty of research [3].

Complications

Infection (PJI): Periprosthetic joint infection represents a significant cause of metal-on-metal hip arthroplasty failure, with a prevalence relatively high compared to other hip bearing combinations [5]. Diagnostic accuracy is compromised by premature therapeutic antimicrobial treatments [29], while the change in serum interleukin-6 between stages does not identify subsequent PJI in patients undergoing two-stage revision [23]. Risk factors include urinary tract infection within 1 week of total knee arthroplasty or within 2 weeks of total hip arthroplasty, which increases the risk of developing PJI within 2 years [74]. Concomitant multiple PJIs are rare, typically resulting from secondary hematogenous spread from a distant infectious focus [64]; their prevalence has decreased compared with historical reports, likely due to higher rates of two-stage revisions and fewer patients treated with irrigation and debridement [27]. In a series of 106 infections, one hip became reinfected with a different pathogen (coagulase-negative staphylococci) after successful treatment for coagulase-positive staphylococci, though no hip had recurrence with the same pathogen more than two years after the follow-up period [67]. Infections caused by enterococci have poor outcomes [124].

Treatment Outcomes and Efficacy: Antibiotics combined with one or two-stage revision remain the mainstay of treatment for PJI, associated with higher success rates [41]. A two-stage reimplantation protocol using a standardized 1:8 minimal antibiotic serum bactericidal titer supports efficacy for hip PJI, including drug-resistant organisms [20]. Favorable outcomes in two-stage procedures are associated with Gram-positive bacteria, absence of known comorbidities, and administration of oral therapy [44]. Massive endoprostheses for hip and knee PJI achieved a 72% eradication rate with acceptable functional outcomes [13]. Partial component-retained two-stage reconstruction is an alternative for chronic infection after uncemented total hip arthroplasty in selected non-immunocompromised patients infected by low-virulence organisms [22]. One-stage revision for chronic infected hip replacements without exclusion criteria can yield greater clinical success and reduced morbidity-mortality [42]. Most hips and Gram-positive infections treated with chronic antibiotic suppression successfully avoided reoperation [14]. Management of septic arthritis by arthroplasty using a specific protocol yielded very good functional results, with 87% eradication in evolutive septic arthritis and 95% in quiescent septic arthritis [48].

Mechanical Complications: A high rate of mechanical complications follows stage-one antibiotic-coated molded hip spacer placement, particularly in patients requiring an extended trochanteric osteotomy [34]. In two-stage revision hip arthroplasty, spacer design, acetabular and femoral bone loss, and offset restoration are significantly associated with perioperative complications [71].

Other Considerations: Acute renal failure is a reported complication after the first stage of a two-stage exchange for PJI [122]. Some identified prognostic factors for the surgical treatment of PJI are modifiable and should be addressed before treating a patient [46]. Single-dose prophylactic antibiotics did not increase the risk of acute PJI or short-term complications after total joint arthroplasty [136]. Extending perioperative prophylactic antibiotics until intraoperative culture results are available in patients undergoing revision total hip arthroplasty for aseptic failures provides no additional benefit in reducing subsequent PJI risk [139]. Extended oral antibiotic prophylaxis after aseptic revision total hip arthroplasty was not associated with a statistically significant decreased risk of any infection, PJI, or re-revision for infection at all time points [141].

Recovery

Diagnostic Workup and Monitoring: The synovial fluid biomarker IL-6 is recommended for the diagnosis of periprosthetic joint infection following total hip and knee arthroplasty [26].

Treatment Outcomes and Complications: Debridement, antibiotics, and implant retention is a valuable option in the treatment of hip periprosthetic joint infection, especially in the early postoperative period (≤6 weeks), with good outcomes [158]. Vancomycin-supplemented cancellous bone allografts in hip revision surgery attained infection control in 29 of 30 patients without evidence of graft resorption at a minimum 2-year followup [157]. Management of septic arthritis by arthroplasty using the present protocol gave very good functional results in both knee and hip, with 87% of eradication of infection in evolutive septic arthritis and 95% in quiescent septic arthritis [48].

Complications and Risks: There was a high rate of mechanical complications after stage-one antibiotic coated molded hip spacer, especially in those patients who required an extended trochanteric osteotomy [34]. Dislocation continues to be a major concern in two-stage revision total hip arthroplasty without spacer placement [45]. Patients diagnosed with urinary tract infection within 1 week of total knee arthroplasty or within 2 weeks of total hip arthroplasty are at an increased risk of developing subsequent periprosthetic joint infection within 2 years of surgery [74].

Consensus and Research Status: The prevalence of multiple periprosthetic joint infections has decreased compared with historical reports, likely due to higher rates of 2-stage revisions and fewer patients treated with irrigation and debridement [27].

Key Evidence

• [L5] The International Consensus on Periprosthetic Joint Infections has focused the community and should lead to better research and outcomes, though many areas still require further research. [1] (10.1302/0301-620x.95b11.33224)
• [L5] The consensus process successfully reached agreement on all but four of 207 questions regarding the prevention, diagnosis, and treatment of periprosthetic joint infection, providing a comprehensive approach to minimize variations in care and reduce the burden of infection. [2] (10.1302/0301-620x.95b11.33135)
• [L5] Despite increasing recent interest, the management of periprosthetic joint infections in the future may still be challenging, with numerous problems to resolve and scope for plenty of research. [3] (10.1302/0301-620x.104b11.bjj-2022-0944)
• [L4] The evidence for treating periprosthetic joint infections due to resistant staphylococci is variable and often suffers from small numbers of heterogenous patients. [4] (10.1302/0301-620x.96b11.34333)
• [L3] The prevalence of PJI as a cause of MoM hip arthroplasty failure was relatively high compared to other hip bearing combinations; however, the organisms responsible were similar. [5] (10.1016/j.arth.2016.03.064)
• [L3] The study identified the risk of developing a subsequent periprosthetic joint infection to be one half of previous studies. [6] (10.1016/j.arth.2017.10.024)
• [L5] In North America, two-stage revision arthroplasty is the treatment of choice for chronic periprosthetic infection of the hip and knee. [7] (10.5435/jaaos-22-03-153)
• [L5] The BOOM meeting achieved consensus for important topics on periprosthetic infection in orthopaedic oncology, but highlighted the low quality of the underlying evidence. [8] (10.1302/0301-620x.107b12.bjj-2024-1039.r4)
• [L4] Using cementless prostheses in two-stage revisions of periprosthetic infections of the hip in combination with a specific local and systemic antibiotic therapy seems to eradicate infection and provide implant stability. [9] (10.1007/s11999-008-0611-y)
• [L4] The workup of patients with painful joint and suspected late periprosthetic joint infection should follow a systematic approach including laboratory tests and aspiration of the joint. [10] (10.1002/jor.22561)
• [L4] Eradication of periprosthetic joint infections, while minimizing patient morbidity, continues to be a challenge. [11] (10.1016/j.arth.2019.07.001)
• [L3] This design allows for reliable PJI eradication, low spacer-related complications, and reliable improvement in functional outcomes. [12] (10.1016/j.arth.2018.08.016)
• [L4] We describe PJI eradication rate of 72% with acceptable functional outcome. [13] (10.1016/j.arth.2017.09.046)
• [L3] Most hips and Gram-positive infections treated with CAS successfully avoided reoperation in this cohort. [14] (10.1016/j.arth.2022.02.003)
• [L3] [15] (10.1186/s12891-019-3006-1)
• [L2] The authors recommend against its routine use and suggest it be reserved for cases where PJI cannot be diagnosed or ruled out with standard testing. [16] (10.1302/0301-620X.102B5.BJJ-2019-0473.R3)
• [L5] It also details the MSIS definition for diagnosing periprosthetic joint infection and highlights the need for further study on emerging diagnostic technologies and prevention protocols. [17] (10.5435/jaaos-d-16-00634)
• [L3] The pathogen spectra of periprosthetic and native joint infections differ considerably. [19] (10.1186/s13018-021-02850-3)
• [L4] This study supports the efficacy of a 2-stage reimplantation protocol with a standardized 1:8 minimal antibiotic serum bactericidal titer for the treatment of periprosthetic infections of the hip, including those caused by drug-resistant organisms. [20] (10.1016/j.arth.2008.07.004)
• [L4] The authors consider that no patient with an infected hip joint should be offered Girdlestone resection arthroplasty as the only alternative. [21] (10.1016/j.arth.2007.06.007)
• [L4] Partial component-retained two-stage reconstruction could be an alternative treatment option for chronic infection after an uncemented total hip arthroplasty with a radiographically and clinically well-fixed component in selected patients, who are not immunocompromised and are infected by a low-virulence organism. [22] (10.1007/s00264-017-3505-3)
• [L3] Furthermore, the change in between stages does not appear to identify subsequent PJI. [23] (10.1016/j.arth.2023.06.008)
• [L4] Surgeons should be cautious using this procedure as a routine means to address periprosthetic joint infection. [25] (10.1007/s11999-011-1910-2)
• [L2] On the basis of the results we recommend the use of the synovial fluid biomarker IL-6 for the diagnosis of periprosthetic joint infection following total hip and knee arthroplasty. [26] (10.1371/journal.pone.0089045)
• [L4] The prevalence of multiple periprosthetic joint infections has decreased compared with historical reports, likely due to higher rates of 2-stage revisions and fewer patients treated with I&D. [27] (10.1016/j.arth.2016.05.013)
• [L3] Patients with suspected late-PJI should not receive antibiotics until the diagnosis is reached or refuted. [29] (10.1007/s11999-015-4142-z)
• [L5] [30] (10.5435/jaaos-d-14-00455)
• [L1] Synovial fluid analysis is adequate in differentiating patients with periprosthetic hip and knee infections. [31] (10.1007/s00264-018-3865-3)
• [L2] Results from this small, prospective series suggest that preoperative antimicrobial prophylaxis may be administered safely even in patients undergoing revision hip or knee arthroplasty in which microbiologic sampling is planned without compromising the diagnostic sensitivity of tissue sample cultures. [32] (10.1007/s11999-015-4486-4)
• [L1] [33] (10.1016/j.arth.2018.02.077)
• [L4] There was a high rate of mechanical complications, especially in those patients who required an extended trochanteric osteotomy. [34] (10.1016/j.arth.2022.02.116)
• [L4] The orthopedic community should consider a probability and likelihood paradigm to create a PJI diagnostic definition, as probably not a single definition might be suited for all situations. [35] (10.1016/j.arth.2019.10.032)
• [L4] The diagnosis of peri-prosthetic bone and joint infections relies on converging information from clinical, laboratory, and imaging assessments, with clinical findings like a sinus tract serving as major criteria. [36] (10.1016/j.otsr.2018.04.029)
• [L3] The cutoff level seems to be different between the hip and knee. [37] (10.1016/j.arth.2020.03.014)
• [L1] Biomarkers perform differently according to the selected PJI definitions. [38] (10.1016/j.arth.2023.06.017)
• [L3] Understanding how the accuracy of diagnostic tests varies with respect to demographic factors can help physicians avoid subjecting patients to unnecessary additional testing and reach more accurate diagnoses of PJI. [39] (10.1016/j.arth.2020.10.036)
• [L2] The results are promising for the care of the painful or problematic knee and hip joint arthroplasty and the test should be considered as part of the diagnostic toolbox for PJIs. [40] (10.1302/0301-620x.99b9.bjj-2016-1345.r2)
• [L4] [41] (10.1016/j.arth.2017.07.045)
• [L3] Using 1-stage revision for chronic infected hip replacements without applying any exclusion criteria can result in a greater success rate from a clinical point of view with an important reduction in the morbidity-mortality rate of the patients. [42] (10.1016/j.arth.2017.08.033)
• [L3] One-stage exchange of the hip for PJI is a reliable treatment option with high rate of infection control and long-lasting favorable outcomes. [43] (10.1016/j.arth.2019.02.021)
• [L3] A favorable outcome in patients with PJI undergoing 2-stage procedure was associated with an infection sustained by Gram-positive bacteria, absence of known comorbidities, and administration of oral therapy. [44] (10.1016/j.arth.2017.02.057)
• [L3] However, dislocation continues to be a major concern. [45] (10.1016/j.arth.2021.02.040)
• [L3] Some of the identified factors are indeed modifiable and should be addressed before treating a patient for PJI. [46] (10.1016/j.arth.2018.04.034)
• [L4] One-stage revision hip arthroplasty using cementless implants appears to have a role in the treatment of carefully selected patients with an infected hip replacement if meticulous débridement is performed and appropriate antibiotics are properly used. [47] (10.1007/s00264-008-0640-x)
• [L4] Management of septic arthritis by arthroplasty using the present protocol gave very good functional results in both knee and hip, with 87% of eradication of infection in evolutive septic arthritis and 95% in quiescent septic arthritis. [48] (10.1016/j.otsr.2010.06.009)
• [L2] [52] (10.1302/0301-620x.97b2.34550)
• [L3] Increased inflammatory laboratory values in patients with periprosthetic fracture are not good indicators for deep periprosthetic infection and do not necessarily warrant additional evaluations before definitive surgical treatment. [53] (10.1016/j.arth.2008.05.026)
• [L3] The diagnostic utility of serum and synovial markers for diagnosing periprosthetic joint infection was lower in the setting of concomitant periprosthetic fracture compared to PJI alone. [54] (10.1016/j.arth.2020.08.029)
• [L3] However, it shows high sensitivity for PJI diagnosis in cases of low-virulence organisms which might be missed by most diagnostic tests. [57] (10.1016/j.arth.2023.05.022)
• [L3] Further investigation of this and other diagnostic tests following staged treatment of PJI is needed. [59] (10.1016/j.arth.2019.03.019)
• [L5] While guidelines exist for antibiotic prophylaxis in arthroplasty patients undergoing dental procedures, reliable evidence linking poor oral health to periprosthetic joint infection remains unclear, necessitating continued refinement of recommendations. [60] (10.5435/jaaos-d-14-00419)
• [L2] Further studies are needed to explore diagnostic tests that will better detect PJI in patients with inflammatory arthritis. [62] (10.1016/j.arth.2019.01.051)
• [L3] LE is an accurate and effective synovial fluid marker for diagnosing periprosthetic joint infection and should be used in conjunction with the current battery of available diagnostic tests. [63] (10.1016/j.arth.2017.06.005)
• [L4] Concomitant multiple PJIs are rare events that occur most often as a result of secondary hematogenous spread from a distant infectious focus. [64] (10.1016/j.arth.2016.02.012)
• [L3] Approximately one third of patients have dry hip aspiration, and in these patients cultures are less predictive of intraoperative findings. [65] (10.1016/j.arth.2022.01.066)
• [L3] [67] (10.2106/00004623-199604000-00005)
• [L5] Growing data and International Consensus Meeting recommendations support using articulating antibiotic spacers whenever possible, reserving static spacers only for cases with major femoral/acetabular bone loss or abductor mechanism loss. [68] (10.1016/j.arth.2019.11.007)
• [L1] Intrawound vancomycin may reduce the risk of periprosthetic joint infection in primary and revision total knee and hip arthroplasty; however, only low-quality evidence exists, highlighting the need for randomized controlled trials before broad adoption. [69] (10.1016/j.arth.2019.03.071)
• [L4] Treatment of infection at the site of a hip arthroplasty with 2-stage revision using cementless components and an articulated spacer yields recurrence rates similar to revisions where at least one of the components at the second stage is fixed with antibiotic-loaded cement. [70] (10.1016/j.arth.2006.02.156)
• [L3] Spacer design, acetabular and femoral bone loss, and offset restoration were significantly associated with perioperative complications. [71] (10.1016/j.arth.2019.02.012)
• [L4] Two-stage reimplantation is associated with a high rate of early success in the treatment of deep infection after THA but is associated with a modest rate of recurrent infection or mechanical failure. [72] (10.1007/s11999-008-0480-4)
• [L3] Patients presenting with prosthetic joint infection from an outside institution were more likely to undergo implant resection compared to those with an index arthroplasty at the investigating institution. [73] (10.1016/j.arth.2018.09.091)
• [L3] Patients diagnosed with UTI within 1 week of TKA or within 2 weeks of THA are at an increased risk of developing subsequent PJI within 2 years of surgery. [74] (10.1016/j.arth.2022.05.034)
• [L2] This study offers an evidence-based definition for diagnosing hip and knee PJI, which has shown excellent performance on formal external validation. [75] (10.1016/j.arth.2018.02.078)
• [L3] [105] (10.1007/s11999-013-3089-1)
• [L3] [107] (10.1302/0301-620x.99b3.bjj-2016-0684.r1)
• [L1] [111] (10.1186/s13018-020-01877-2)
• [L4] In patients for whom the diagnosis of PJI is unclear because of recent antibiotic use, equivocal laboratory findings, or suspected false-negative or false-positive cultures, synovial fluid alpha-defensin can provide an additional data point to assist the clinician in determining whether PJI is present but is prone to false-positive results in this challenging population. [112] (10.1016/j.arth.2018.06.026)
• [L4] Cutibacterium is an increasingly recognized pathogen in THA that can present with normal serology, leading to misdiagnosis as aseptic failure. [113] (10.1016/j.arth.2022.01.015)
• [L2] Local antibiotic prophylaxis in patients with non-modifiable risk factors undergoing hip or knee replacement reduces the incidence of acute PJI compared to IV antibiotics. [114] (10.1016/j.jisako.2022.08.002)
• [L3] Although other causes exist, it is essential to perform a work-up for prosthetic joint infections. [117] (10.1016/j.arth.2016.02.037)
• [L1] [121] (10.1186/s12891-019-2974-5)
• [L3] [122] (10.1016/j.arth.2020.08.028)
• [L3] [124] (10.1016/j.arth.2016.09.017)
• [L3] The use of vancomycin as the perioperative prophylactic antibiotic for primary total joint arthroplasties appeared to be effective in decreasing the rate of PJI and may result, when they occur, in infections with less virulent organisms. [125] (10.1016/j.arth.2012.03.040)
• [L4] The most recent systematic review and meta-analysis comparing the 2 treatment options have shown no difference in reinfection rates in both knees and hips. [129] (10.1016/j.arth.2019.10.051)
• [L5] [132] (10.1016/j.otsr.2014.04.001)
• [L3] Single-dose prophylactic antibiotics did not lead to an increased risk of acute PJI or short-term complications after TJA. [136] (10.1016/j.arth.2021.02.037)
• [L3] FISH represents a fast and reliable tool for detecting PJI in periprosthetic membranes, especially in combination with clinical and histopathological classification. [137] (10.2106/jbjs.18.00243)
• [Paper] [138] (10.1097/corr.0000000000002971)
• [L3] Extending perioperative prophylactic antibiotics until intraoperative culture results become available in patients undergoing revision THA for aseptic failures does not provide any additional benefit in terms of reducing the risk of subsequent PJI. [139] (10.1016/j.arth.2019.06.012)
• [L3] Chronic institutionalized patients have a higher risk of acute periprosthetic joint infection after hip hemiarthroplasty, commonly caused by gram-negative microorganisms not covered by current prophylaxis strategies. [140] (10.1016/j.injury.2015.12.032)
• [L3] Extended oral antibiotic prophylaxis after aseptic revision total hip arthroplasty was not associated with a statistically significant decreased risk of any infection, periprosthetic joint infection, or re-revision or reoperation for infection at all time points. [141] (10.1016/j.arth.2022.06.023)
• [L5] Synovial fluid aspiration, diagnostic imaging, traditional culture, peripheral serum inflammatory markers, and intraoperative frozen sections each have their limitations but continue to be the mainstay for diagnosis of periprosthetic joint infection. [142] (10.5435/jaaos-d-14-00385)
• [L4] [143] (10.5435/jaaos-d-16-00636)
• [L5] [146] (10.1302/0301-620x.104b5.bjj-2021-1759.r1)
• [L1] However, its sensitivity was limited (54% to 84%) and it should therefore not be used for screening, but rather as a confirmatory test for PJI. [149] (10.2106/jbjs.17.01005)
• [L2] Microcalorimetry of synovial fluid allows thermogenic diagnosis of periprosthetic joint infection in synovial fluid. [150] (10.1186/s12891-020-03366-3)
• [L4] At a minimum 2-year followup, infection control was attained in 29 of 30 patients without evidence of graft resorption. [157] (10.1097/blo.0b013e318073c290)
• [L4] DAIR is a valuable option in the treatment of hip PJI, especially in the early postoperative period (≤6 weeks), with good outcomes. [158] (10.1016/j.arth.2017.02.066)

See Also

• Total hip replacement

References

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