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Infection & Failure

Periprosthetic joint infection (PJI) of the hip: diagnostic criteria, management of acute vs chronic presentations, and DAIR versus two-stage revision.

Overview

Periprosthetic joint infection management presents significant challenges regarding infection control and implant survival. One-stage revision for polymicrobial infection carries a high risk of septic failure, with nearly one in three patients experiencing recurrence at a mean of 5-year follow-up [1]. Two-stage revision remains the standard for chronic infection, yet overall infection control after treatment of a failed two-stage revision is achieved in only 31.1% of patients [4]. In morbidly obese patients, two-stage revision should remain standard, though increased failure rates and poorer outcomes must be anticipated [15]. Total femoral replacement exhibits a high failure rate and propensity for deep infection, particularly in revision settings or with prior infection [5].

Irrigation and debridement with component retention demonstrates limited efficacy. Success rates are approximately 50%, with failure typically driven by organism persistence rather than new infection [7]. This approach is unsuccessful when performed more than two weeks after symptom onset, and retention should not be attempted for chronic infections as failure is universal [18]. In the context of chronic periprosthetic joint infection managed with chronic antibiotic suppression, staphylococcal species infection is the greatest risk factor for failure, followed by age less than 60 years [2]. Furthermore, many patients fail during the antibiotic-free period in the management of periprosthetic joint infection [3].

In specific scenarios, withholding antibiotics may influence outcomes. In patients with positive cultures during the second stage of a two-stage exchange, withholding antibiotic treatment was associated with a lower failure rate [8]. For total knee arthroplasty, intraosseous regional prophylactic antibiotics decrease infection risk compared with intravenous antibiotics, although large randomized clinical studies are required to confirm these findings regarding infection rates and complications [25]. Additionally, the early aseptic failure rate of an uncemented thumb carpometacarpal joint ceramic prosthesis was unacceptably high [9].

Anatomy & Pathophysiology

Diagnostic Imaging and Classification

Diagnostic Modalities: Dynamic 18F-NaF PET is used in diagnosing and distinguishing between septic and aseptic loosening in hip prosthesis [22]. A deep learning-based clinical classification system (Hip-Net) can accurately classify and characterize multiple etiologies of hip prosthesis failure using radiographs [23].

Bearing Surface and Implant Failure Mechanisms

The squeaking hip is a peculiar phenomenon unique to hard-on-hard bearing surfaces [38]. Systemic cobalt toxicity can occur from total hip arthroplasties [79]. Patients with new or evolving hip symptoms and a prior history of total hip arthroplasty warrant orthopaedic surgical evaluation [79]. Current worldwide guidance for metal-on-metal hip patients is neither evidence-based nor financially sustainable [83]. Most protocols for metal-on-metal hip patients lack the sensitivity to detect asymptomatic adverse reaction to metal debris lesions [83]. Other surgical, implant, and patient factors should be considered when determining the mechanisms of failure of large diameter metal-on-metal hip arthroplasties [64]. Using components from different manufacturers affects the rate of wear and corrosion of the head–stem taper junction in metal-on-metal hip arthroplasties [64]. SEM analysis of a modular neck total hip system revealed corrosion at the additional junction of modularity [88]. Impaction deformation with consequent friction, wear, and micromotion likely contributed to the early failure of the Durom acetabular component [71].

Aseptic Loosening and Osteolysis

Polyethylene debris has been observed in lymph nodes after total hip arthroplasty [56]. The observed rates of volumetric wear in total hip arthroplasty suggest that hips may require revision in the future [56]. Male gender, Charnley class C, and severity of bone defects predict the risk for aseptic loosening in the cup of ABG I hip arthroplasty [47]. Factors potentially associated with the quality of bone bed and biomechanics of the hip influence the risk of aseptic loosening in ABG I hip arthroplasty [47]. Biomechanical changes occurring after total knee replacement are related to the occurrence of osteolysis around the components [66].

Periprosthetic Joint Infection (PJI)

The cutoff level for minor criteria for chronic hip and knee periprosthetic joint infection seems to be different between the hip and knee [78]. The direct anterior approach to the hip does not increase the risk for subsequent periprosthetic joint infection [80].

Fracture Risk and Bone Morphology

The identification of preoperative risk factors, in particular femur shape, is crucial for intraoperative periprosthetic fractures in bipolar hemiarthroplasties [81].

Soft Tissue and Functional Outcomes

Clinical outcomes did not differ significantly between cases with gluteal repair and those without tears in degenerative gluteal tears associated with hip arthroplasty [82]. Abductor tears may be repaired at time of hip arthroplasty without forgoing desirable functional outcomes [82]. Increasing symptoms and decreased function related to degenerative hip disease may occur fifteen to twenty years after Colonna Arthroplasty with concomitant femoral shortening and rotational osteotomy [70]. Electrical resistance and reactance of the limbs did not change significantly after total hip arthroplasty [86]. There was no significant benefit for gait kinematics in the early postoperative period (three months) for patients who underwent total hip arthroplasty through a minimally invasive Watson-Jones approach compared with a standard transgluteal approach [87].

Classification

Musculoskeletal Infection Society (MIS): The MIS workgroup proposes a universal definition for periprosthetic joint infection to standardize diagnosis and facilitate comparison of published evidence [55]. This new definition serves as a 'gold standard' for clinicians, surveillance authorities, and researchers [57].

Hip-Net: This system provides a clinically applicable strategy for accurately classifying and characterizing multiple etiologies of hip prosthesis failure [23].

Other Considerations: Infection is the major cause of failure after revision total hip arthroplasty, accounting for one-third of failures [24]. Nearly one in three patients experienced septic failure after one-stage revision total hip arthroplasty for polymicrobial periprosthetic joint infection at a mean of 5-year follow-up [1]. Overall, 31.1% of patients obtained infection control after treatment of a failed 2-stage revision due to periprosthetic joint infection [4]. All failures in the treatment of periprosthetic hip infection using a 2-stage reimplantation protocol occurred only in the resistant microorganism group (33% vs 0% in nonresistant group) [54].

For revision knee arthroplasties, mechanisms of failure differ from primary knee arthroplasties [60]. Revisions for infection are four times more likely to fail than revisions for aseptic loosening in revision knee arthroplasties [60]. Infection with a staphylococcal species is the greatest risk factor for failure in irrigation and debridement with chronic antibiotic suppression for infected total knee arthroplasty [2]. Age less than 60 years is the second greatest risk factor for failure in irrigation and debridement with chronic antibiotic suppression for infected total knee arthroplasty [2]. Many patients fail during the antibiotic-free period in the management of periprosthetic joint infection [3].

For Class-C periprosthetic joint infections following primary total knee arthroplasty, Cephazolin or Flucloxacillin is likely sufficient [58]. The presence of low-grade infection did not increase the risk of re-revision in a cohort of revision hip arthroplasty for aseptic loosening [59].

Recurrent infection after treatment of a periprosthetic shoulder infection is associated with increasing severity scores as defined in the 2018 consensus statement [53]. Recurrent infection after treatment of a periprosthetic shoulder infection is associated with more aggressive microorganisms [53]. Patient outcomes following revision reverse shoulder arthroplasty for infection do not differ from cases attributed to noninfectious causes [16]. Total femoral replacement has a high failure rate and a propensity for deep infection, especially in the setting of revision indications and prior infection [5].

Clinical Presentation

History: The clinical timeline significantly influences outcomes and risk stratification. Patients with acute postoperative infection after rotator cuff repair present with good functional results at final follow-up despite the infection [6]. Conversely, many patients fail during the antibiotic-free period in the management of periprosthetic joint infection [3]. In elbow periprosthetic joint infection managed with débridement, antibiotics, and implant retention, longer duration of symptoms is a possible risk factor for failure [10]. Late polymicrobial infection in hip arthroplasty is associated with the worst outcomes [11]. Delayed manifestation of infection raises the risk of negative pressure wound therapy failure in patients with postoperative infections after osteosynthetic fracture fixation [13].

Inspection: Physical examination must account for specific localizing signs. The presence of a sinus tract is a possible risk factor for failure after débridement, antibiotics, and implant retention for elbow periprosthetic joint infection [10]. Synchronous periprosthetic joint infections are associated with a high incidence of bacteremia [35]. In total hip arthroplasty, Cutibacterium infection can present with normal serology and lead to misdiagnosis as aseptic failure [33].

Palpation & Range-of-Motion: Clinical evaluation supplemented by laboratory data is required for the diagnosis of septic arthritis and differentiation of surgical site infections from periprosthetic joint infections [21]. No single objective test or imaging approach is established for this differentiation [21]. Challenges remain in the management of bone and joint infection for complex cases, uncertain diagnoses, and prevention [17].

Stability & Special Tests: Diagnostic accuracy is critical to prevent loss of function and other devastating sequelae after anterior cruciate ligament reconstruction [20]. Culture-negative periprosthetic joint infection is a common diagnostic conundrum with significant clinical implications [29]. It is associated with higher failure rates [29] and increased reoperation rates [29]. Most unexpected failures by infection (66.7%) could be attributed to an organism previously detected by next-generation sequencing and not identified by culture [31]. A negative test result does not rule out infection [32]. A comprehensive workup using a combination of tests is recommended in the presence of high clinical suspicion for infection [32].

Red-Flag Patterns: Specific microbiological and patient factors predict treatment failure. Nearly one in three patients experienced septic failure at midterm follow-up after one-stage revision total hip arthroplasty for polymicrobial periprosthetic joint infection [1]. In infected total knee arthroplasty managed with irrigation and debridement with chronic antibiotic suppression, the greatest risk factor for failure is infection with a staphylococcal species [2]. Age less than 60 years is also a risk factor for failure in this context [2]. Irrigation and debridement with component retention for recurrent periprosthetic joint infection had a success rate of approximately 50% [7]. Recurrent periprosthetic joint infection after irrigation and debridement with component retention is most often due to organism persistence rather than a new infection [7]. Culture-negative infection is a possible risk factor for failure after débridement, antibiotics, and implant retention for elbow periprosthetic joint infection [10]. Treatment failure rate was higher in the presence of infection by multidrug-resistant bacteria [36]. This risk is further elevated in the presence of multidrug-resistant bacteria associated with rheumatic diseases [36]. Patient outcomes following revision reverse shoulder arthroplasty for infection do not differ from cases attributed to noninfectious causes [16].

High-Risk Subgroups: Certain patient populations require heightened vigilance. The patient population with synchronous periprosthetic joint infections typically presents with significant comorbidities [35]. High CRP blood levels at discharge raise the risk of negative pressure wound therapy failure in patients with postoperative infections after osteosynthetic fracture fixation [13]. Alterations in the infecting bacterial species under therapy raise the risk of negative pressure wound therapy failure in patients with postoperative infections after osteosynthetic fracture fixation [13]. In presumed aseptic revision hip arthroplasty, a single unexpected positive culture without other signs of infection does not warrant antibiotic treatment [34].

Investigations

Plain radiography: Radiolucencies are common in patients with interpositional bioprosthesis (iBP) elbow prostheses, yet the discrepancy between clinical signs and radiological results warrants structural follow-up [61]. Close radiological follow-up is also recommended for soft-tissue lesions around metal-on-metal total hip arthroplasties, particularly in high-risk groups [68].

MRI: Magnetic resonance imaging (MRI) serves as a crucial early evaluation tool when infection rates unexpectedly rise after anterior cruciate ligament reconstruction [41]. Metal artifact reduction sequence (MARS)-MRI is as suitable as standard diagnostic tools to distinguish between aseptic failure and periprosthetic joint infection in patients with total hip arthroplasty [65]. Furthermore, a negative 18F-FDG PET/CT and MRI scan can provide an important reference point, strongly suggesting infection eradication and supporting a decision to proceed with the second stage of reimplantation surgery in two-stage revision arthroplasty [52].

CT: Wider studies are required to identify normal and pathological patterns in both hip and knee prostheses using dynamic 18F-NaF PET [22].

Bone scan: Nuclear medicine techniques for diagnosing periprosthetic joint infection have added value when correct acquisition and interpretation protocols are used, offering convenience and potential cost-effectiveness [73]. Prospective randomized trials are needed to generate evidence-based data for the role of nuclear medicine in diagnosing periprosthetic joint infection [73].

Aspiration: Sonication of retrieved implants improves sensitivity in the diagnosis of periprosthetic joint infection [69]. Implant sonication increases the diagnostic accuracy of infection in patients with delayed, but not early, orthopaedic implant failure [76]. Implant sonication was mainly useful in patients with unsuspected septic failure [76]. The relevance of unexpected positive cultures in revision arthroplasty without signs of infection remains unknown [77].

Laboratory: Diagnosis of septic arthritis and differentiation of surgical site infections from periprosthetic joint infections rely on clinical evaluation supplemented by laboratory data [21]. No single objective test or imaging approach is established for the diagnosis of septic arthritis and differentiation of surgical site infections from periprosthetic joint infections [21]. Traditional laboratory markers hold low diagnostic utility for immunosuppressed patients with periprosthetic joint infections [75]. Further investigation is necessary to identify the best means of diagnosing periprosthetic joint infection in immunosuppressed patients [75]. Intraoperative frozen sections are recommended to differentiate aseptic from septic loosening in revision total joint arthroplasty [74].

Other Considerations: The diagnosis of periprosthetic joint infection remains a difficult challenge requiring different diagnostic tools to optimize the outcome [69]. Management of bone and joint infection has greatly progressed, yet challenges remain for complex cases, uncertain diagnoses, and prevention [17]. Recommendations for the management of infections after anterior cruciate ligament reconstruction guide clinicians in achieving timely and accurate diagnosis as well as providing optimal management to prevent loss of function and other devastating sequelae [20]. Targeted intervention of acute postoperative infection after rotator cuff repair results in good functional outcomes at final follow-up [6]. Nearly one in three patients experienced septic failure at midterm follow-up after one-stage revision total hip arthroplasty for polymicrobial periprosthetic joint infection [1]. Infection is the major cause of failure after revision total hip arthroplasty, accounting for one-third of failures [24]. The greatest risk factor for failure in irrigation and debridement with chronic antibiotic suppression for infected total knee arthroplasty was infection with a staphylococcal species [2]. Age less than 60 years is a risk factor for failure in irrigation and debridement with chronic antibiotic suppression for infected total knee arthroplasty [2].

Treatment

Non-Operative

Chronic antibiotic suppression serves as a management option for periprosthetic joint infection, particularly when combined with irrigation and debridement with component retention in appropriate candidates without major comorbidities [2, 72]. For infected total knee arthroplasty, the risk of failure with this approach is highest with staphylococcal species, followed by patient age less than 60 years [2]. Many patients fail during the antibiotic-free period in the management of periprosthetic joint infection [3]. Treatment of Cutibacterium acnes periprosthetic joint infections with chronic antibiotic suppression alone had few treatment failures at mid-term follow-up [14]. While there is no evidence that prophylactic antibiotics are beneficial, they should be administered pending definitive evidence of ineffectiveness, particularly for patients at particular risk for infection [26].

Operative

Indications: Débridement and retention of components following hip arthroplasty has not been successful when performed more than two weeks after onset, and retention should not be attempted for chronic infections as failure is universal [18]. Débridement and retention of the implant should be performed urgently after medical optimization, as chronic infections are an absolute contraindication due to mature biofilm formation [27]. Possible risk factors for failure after débridement, antibiotics, and implant retention for elbow periprosthetic joint infection include the presence of a sinus tract, longer duration of symptoms, and culture-negative infection [10]. Treatment failure was significantly higher in haematogenous compared to non-haematogenous periprosthetic joint infection [63].

Surgical Approach / Technique: One-stage revision total hip arthroplasty for polymicrobial periprosthetic joint infection leads to high reinfection rates, with nearly one in three patients experiencing septic failure at a mean of 5-year follow-up [1]. A favourable short-term control of infection can be achieved in patients with periprosthetic joint infection by a single-stage revision using non-contact low frequency ultrasonic debridement, without associated complications [12]. Irrigation and debridement with component retention for periprosthetic joint infection had a success rate of approximately 50% and typically failed due to organism persistence rather than a new infection [7]. Debridement is the less aggressive option for infected reversed shoulder arthroplasty but exposes patients to healing failure and should be proposed as a first treatment attempt [62].

Revision: Overall, 31.1% of patients obtained infection control after treatment of a failed 2-stage revision due to periprosthetic joint infection [4]. In patients with positive cultures during the second stage of a two-stage exchange, withholding antibiotic treatment was associated with a lower failure rate [8]. A nonspacer two-stage exchange is a viable option for managing chronically infected total hip arthroplasty with severe bone loss or abductor deficiency, showing comparable rates of interim revision and recurrence of infection [67]. A three-stage revision protocol effectively eradicated persistent shoulder periprosthetic joint infection while producing excellent functional and subjective outcomes [19]. Although single-stage revision for shoulder periprosthetic joint infection appears more effective than two-stage revision, this is likely confounded by treatment bias given the higher propensity of virulent and drug-resistant bacteria treated with two-stage revision in the published literature [30].

Implant Selection: Total femoral replacement has a high failure rate and a propensity for deep infection, especially in the setting of revision indications and prior infection [5]. The rate of early aseptic failure of an uncemented thumb carpometacarpal joint ceramic prosthesis was unacceptably high [9].

Complications

Infection (PJI): Infection remains a significant driver of failure across multiple joint arthroplasties. In contemporary total knee arthroplasty, infection is the primary cause of early revision [42]. For infected total knee arthroplasty managed with irrigation and debridement and chronic antibiotic suppression, the greatest risk factor for failure is infection with a staphylococcal species, and age less than 60 years is also a risk factor [2]. Many patients fail during the antibiotic-free period in this management strategy [3]. In hip arthroplasty, nearly one in three patients experienced septic failure at midterm follow-up after one-stage revision for polymicrobial periprosthetic joint infection [1]. Late polymicrobial infections in hip arthroplasty are associated with lower treatment success rates, increased surgery, and longer hospitalization, yielding the worst outcomes [11]. In elbow periprosthetic joint infection treated with débridement, antibiotics, and implant retention, possible risk factors for failure include the presence of a sinus tract, longer duration of symptoms, and culture-negative infection [10]. For infected shoulder arthroplasty, two-stage revision carries a risk of recurrent infection and postoperative complications [48, 49]. In primary total elbow arthroplasty, failure due to infection leads to a greater likelihood of revision failure and requires a greater number of subsequent operations compared to other etiologies [50]. Nearly half of patients failed to eradicate infection after two-stage revision for infected total elbow arthroplasty [51]. Postoperative surgical site infection after primary hip hemiarthroplasty is responsible for prolonged hospital stays, increased mortality, and greater healthcare costs [40].

Aseptic loosening: In contemporary total knee arthroplasty, aseptic loosening is the primary cause of late revision [42].

Other Considerations: Several specific scenarios demonstrate high failure rates or unique complications. Overall, only 31.1% of patients obtained infection control after treatment of a failed two-stage revision due to periprosthetic joint infection [4]. Total femoral replacement has a high failure rate and a propensity for deep infection, especially in the setting of revision indications and prior infection [5]. The rate of early aseptic failure of an uncemented thumb carpometacarpal joint ceramic prosthesis was unacceptably high [9]. Patients in whom primary total elbow arthroplasty fails because of infection are more likely to experience revision failure than patients with other etiologies of primary total elbow arthroplasty failure [50]. Patients with late polymicrobial infection had the worst outcomes in hip arthroplasty [11]. A young age is a primary risk factor associated with mechanical complications of articulating polymethylmethacrylate spacers in two-stage revision hip arthroplasty [37]. Chronic infection is a primary risk factor associated with mechanical complications of articulating polymethylmethacrylate spacers in two-stage revision hip arthroplasty [37]. Prolonged infection duration and increased comorbidities complicated the surgical management of fracture-related infection in the proximal femur [46]. Patients who develop septic arthritis as a complication of anterior cruciate ligament reconstruction surgery have diminished long-term subjective, functional, and radiographic outcomes compared with historical reports of uncomplicated cases [44].

Recovery

Light activity (weeks): Evidence does not provide specific week ranges for light activity or desk work return.

Full activity (months): Evidence does not provide specific month ranges for full activity, manual work, or strength return.

Complete recovery / outcome plateau (months): Evidence does not provide specific month ranges for outcome plateau.

Rehabilitation protocol: Evidence does not specify PT phasing, immobilisation duration, or weight-bearing progression.

Functional milestones: Targeted intervention of acute postoperative infection after rotator cuff repair results in good functional outcomes, with patients presenting good functional results at final follow-up despite the infection [6]. Reasonable long-term functional outcome scores can be achieved after infected mini-open rotator cuff repair in a 10-year review [45]. The three-stage revision protocol for shoulder periprosthetic joint infection effectively eradicated persistent infection while producing excellent functional and subjective outcomes [19].

Other Considerations: One-stage revision total hip arthroplasty for polymicrobial periprosthetic joint infection leads to high reinfection rates, with nearly one in three patients experiencing septic failure at a mean of 5-year follow-up [1]. Irrigation and debridement with chronic antibiotic suppression for infected total knee arthroplasty carries the greatest risk of failure from infection with a staphylococcal species, followed by age less than 60 years [2]. Many patients fail during the antibiotic-free period in the management of periprosthetic joint infection [3]. Overall, 31.1% of patients obtained infection control after treatment of a failed two-stage revision due to periprosthetic joint infection [4]. Patients with late polymicrobial infection in hip arthroplasty had the worst outcomes, characterized by lower treatment success rates, increased surgery, and longer hospitalization [11]. A favourable short-term control of infection can be achieved in periprosthetic joint infection patients by a single-stage revision using non-contact low frequency ultrasonic debridement without associated complications [12]. Delayed manifestation of infection, high CRP blood levels at discharge, and alterations in the infecting bacterial species under therapy raise the risk of negative pressure wound therapy failure in patients with postoperative infections after osteosynthetic fracture fixation [13]. Treatment of Cutibacterium acnes periprosthetic joint infections with two-stage exchange or chronic antibiotic suppression alone both had few treatment failures at mid-term follow-up [14]. Although two-stage revision should remain a standard treatment for chronic periprosthetic joint infection in morbidly obese patients, increased failure rates and poorer outcomes should be anticipated [15]. Poor host status predicted reinfection in debridement, antibiotics, and implant retention for acute periprosthetic joint infection, but success was markedly improved at extended follow-up of seven years with a rigorous definition of acute PJI [43]. Debridement, antibiotics, and implant retention failure is associated with earlier time to mortality [85]. Patient variables associated with infection differ among total knee arthroplasty infections that occur before and after one year [89]. Recurrently infected patients following two-stage exchange arthroplasty for prosthetic joint infection utilizing a premade antibiotic loaded cement hemiarthroplasty were younger and had longer follow-up [90]. Old age, high preoperative CRP, and resistant organism profile are potential risk factors that may predict treatment failure following a two-stage procedure for evolutive septic arthritis [91].

Key Evidence

  • [L3] Nearly one in three patients experienced septic failure at midterm follow-up. (10.1016/j.arth.2025.06.048)
  • [L3] The greatest risk factor for failure was infection with a staphylococcal species, followed by age less than 60 years. (10.1302/0301-620x.100b11.bjj-2018-0515.r1)
  • [L3] However, many patients fail during the antibiotic-free period. (10.1016/j.arth.2018.04.019)
  • [L3] Overall, 31.1% of the patients obtained infection control after treatment of a failed 2-stage revision due to PJI. (10.1016/j.arth.2023.04.063)
  • [L4] TFR has a high failure rate and a propensity for deep infection, especially in the setting of revision indications and prior infection. (10.2106/jbjs.19.01022)
  • [L3] Despite the infection, patients presented good functional results at final follow-up. (10.1007/s00167-017-4743-z)
  • [L3] Irrigation and debridement had a success rate of approximately 50% and typically failed due to organism persistence rather than a new infection. (10.1016/j.arth.2016.05.040)
  • [L1] In patients with positive cultures, withholding antibiotic treatment was associated with lower failure rate. (10.1016/j.arth.2023.09.022)
  • [L4] The rate of early aseptic failure was unacceptably high. (10.1177/1753193416688427)
  • [L4] Possible risk factors for failure include the presence of a sinus tract, longer duration of symptoms, and culture-negative infection. (10.1016/j.jse.2022.11.009)
  • [L3] Patients with late polymicrobial infection had the worst outcomes. (10.1016/j.arth.2018.09.090)
  • [L4] A favourable short-term control of infection can be achieved in these patients by a single-stage revision using NLFUD, without associated complications. (10.1302/0301-620x.107b6.bjj-2024-0848.r2)
  • [L4] Delayed manifestation of infection, high CRP blood levels at discharge, and alterations in the infecting bacterial species under therapy raise the risk of NPWT failure. (10.1186/s12891-017-1607-0)
  • [L3] Treatment with two-stage exchange or chronic antibiotic suppression alone both had few treatment failures at mid-term follow-up. (10.1302/0301-620x.106b12.bjj-2024-0437.r1)
  • [L3] Although two-stage revision should remain a standard treatment for chronic periprosthetic joint infection in morbidly obese patients, increased failure rates and poorer outcomes should be anticipated. (10.2106/jbjs.m.01289)
  • [L3] Despite the unique challenges associated with rRSA for infection, patient outcomes do not differ from cases attributed to noninfectious causes. (10.1016/j.jse.2024.02.031)
  • [L5] Management of bone and joint infection has greatly progressed, yet challenges remain for complex cases, uncertain diagnoses, and prevention. (10.1016/j.otsr.2021.102928)
  • [L4] This procedure has not been successful when performed more than two weeks after onset, and retention should not be attempted for chronic infections as failure is universal. (10.2106/00004623-199809000-00009)
  • [L3] The three-stage revision protocol effectively eradicated persistent infection while producing excellent functional and subjective outcomes. (10.1016/j.jse.2018.07.014)
  • [L5] These recommendations guide clinicians in achieving timely and accurate diagnosis as well as providing optimal management, both of which are paramount to prevent loss of function and other devastating sequelae of infection in the knee joint. (10.1007/s00167-023-07463-3)
  • [L5] Diagnosis of septic arthritis and differentiation of surgical site infections from periprosthetic joint infections rely on clinical evaluation supplemented by laboratory data, as no single objective test or imaging approach is established. (10.1016/j.arth.2018.09.044)
  • [L2] Wider studies are required to identify normal and pathological patterns in both hip and knee prostheses. (10.1186/s13018-014-0147-7)
  • [L3] Hip-Net provided a clinically applicable strategy for accurately classifying and characterizing multiple etiologies of hip prosthesis failure. (10.2106/jbjs.24.01601)
  • [L1] Large randomized clinical studies comparing infection rates and related complications with IO and IV antibiotics are required. (10.1530/eor-22-0130)
  • [Case_report] The authors conclude that while there is no evidence that prophylactic antibiotics are beneficial, they should be administered pending definitive evidence of ineffectiveness, particularly for patients at particular risk for infection. (10.2106/00004623-199507000-00023)
  • [L4] While not an absolute emergency, the procedure should be performed urgently after medical optimization, as chronic infections are an absolute contraindication due to mature biofilm formation. (10.1016/j.arth.2018.09.025)
  • [L3] The treatment failure rate of streptococcal PJIs was similar to that for PJIs caused by other pathogens. (10.1186/s42836-025-00341-y)
  • [L5] Culture-negative periprosthetic joint infection is a common diagnostic conundrum with significant clinical implications, including higher failure rates and increased reoperation rates. (10.1016/j.arth.2022.01.061)
  • [L4] Although the analysis showed single-stage to be more effective than 2-stage, this is likely confounded by treatment bias given the higher propensity of virulent and drug-resistant bacteria treated with 2-stage in the published literature. (10.1016/j.jse.2020.05.034)
  • [L2] Most unexpected failures by infection (66.7%) could be attributed to an organism previously detected by NGS and not identified by culture. (10.1016/j.jse.2022.09.026)
  • [L5] A negative test result does not rule out infection, and a comprehensive workup using a combination of tests is recommended in the presence of high clinical suspicion. (10.1016/j.arth.2018.09.019)
  • [L4] Cutibacterium is an increasingly recognized pathogen in THA that can present with normal serology, leading to misdiagnosis as aseptic failure. (10.1016/j.arth.2022.01.015)
  • [L4] A single unexpected positive culture without other signs of infection does not warrant antibiotic treatment. (10.2106/jbjs.20.01559)
  • [L3] The patient population typically presents with significant comorbidities and a high incidence of bacteremia. (10.1016/j.arth.2021.05.010)
  • [L3] In the presence of infection by multidrug-resistant bacteria or association with rheumatic diseases the treatment failure rate was higher and other surgical options should be considered in this specific population. (10.1186/s12891-020-03570-1)
  • [L3] A young age and chronic infection were the primary risk factors associated with mechanical complications. (10.1186/s12891-019-2759-x)
  • [L2] The squeaking hip is a peculiar phenomenon unique to hard-on-hard bearing surfaces. (10.1016/j.arth.2006.12.012)
  • [L3] Postoperative SSI is a serious complication that is responsible for prolonged hospital stays, increased mortality, and greater healthcare costs. (10.1186/s42836-022-00155-2)
  • [Case_report] Early MRI evaluation and investigation of instrument-specific infections are crucial when infection rates unexpectedly rise. (10.1016/j.jisako.2025.100893)
  • [L3] Poor host status predicted reinfection, and with a rigorous definition of acute PJI, success was markedly improved at extended follow-up compared to many historical series. (10.1016/j.arth.2025.02.009)
  • [L4] Patients who develop septic arthritis as a complication of ACL reconstruction surgery have diminished long-term subjective, functional, and radiographic outcomes compared with historical reports of uncomplicated cases, likely related to pain from advanced arthritis. (10.1177/0363546512461903)
  • [L4] Reasonable long-term functional outcome scores can be achieved. (10.1016/j.jse.2017.09.003)
  • [L4] Prolonged infection duration and increased comorbidities complicated the treatments. (10.1186/s12891-025-08609-9)
  • [L3] Factors potentially associated with the quality of bone bed and biomechanics of the hip might influence the risk of aseptic loosening in this implant. (10.1186/1471-2474-11-243)
  • [L4] However, it is important to recognize the risk of recurrent infection and postoperative complications in this challenging patient population. (10.1016/j.jse.2016.12.041)
  • [L4] However, it is important to recognize the risk of recurrent infection and postoperative complications in this challenging patient population. (10.1016/j.jse.2016.09.056)
  • [L4] Patients in whom primary TEA fails because of infection are more likely to experience revision failure and require a greater number of subsequent operations than patients with other etiologies of primary TEA failure. (10.1016/j.jse.2019.10.010)
  • [L4] Nearly half of the patients failed to eradicate infection after 2-stage revision. (10.1016/j.jse.2024.01.023)
  • [L3] A negative 18F-FDG PET/CT and MRI scan can provide an important reference point, strongly suggesting infection eradication and supporting a decision to proceed with the second stage of reimplantation surgery. (10.1186/s13018-026-06713-7)
  • [L3] Recurrent infection after treatment of a periprosthetic infection is associated with increasing severity scores, as defined in the 2018 consensus statement, and more aggressive microorganisms. (10.1016/j.jse.2023.11.013)
  • [L3] All failures occurred only in the resistant microorganism group (33% vs 0% in nonresistant group). (10.1016/j.arth.2009.05.012)
  • [L5] The workgroup proposes a universal definition for periprosthetic joint infection (PJI) based on evaluated evidence to standardize diagnosis and facilitate comparison of published evidence. (10.1016/j.arth.2011.09.026)
  • [L4] The observed rates of volumetric wear suggest that the hips may require revision in the future. (10.2106/00004623-199505000-00014)
  • [Paper] The workgroup proposes a new definition for periprosthetic joint infection (PJI) to serve as a 'gold standard' that can be universally adopted by clinicians, surveillance authorities, and researchers to ensure consistency in diagnosis and management. (10.1007/s11999-011-2102-9)
  • [L3] For Class-C infections, Cephazolin or Flucloxacillin is likely sufficient. (10.1016/j.arth.2022.04.014)
  • [L3] In this cohort, the presence of low-grade infection did not increase the risk of re-revision. (10.1302/0301-620x.103b6.bjj-2020-2002.r1)
  • [L3] Mechanisms of failure for revision arthroplasties differ from primary knee arthroplasties, with revisions for infection being four times more likely to fail than revisions for aseptic loosening. (10.1016/j.arth.2008.04.020)
  • [L4] However, many patients have radiolucencies, and the discrepancy between clinical signs and radiological results warrants structural follow-up. (10.1186/s12891-019-2781-z)
  • [L4] Debridement is the less aggressive option but exposes patients to healing failure and should be proposed as a first treatment attempt. (10.1016/j.jse.2015.03.007)
  • [L3] Treatment failure was significantly higher in haematogenous compared to non-haematogenous PJI. (10.1302/0301-620x.105b12.bjj-2023-0454.r1)
  • [L3] Other surgical, implant and patient factors should be considered when determining the mechanisms of failure of large diameter metal-on-metal hip arthroplasties. (10.1302/0301-620x.98b7.36554)
  • [L2] MARS-MRI is as suitable as standard diagnostic tools to distinguish between aseptic failure and PJI in patients with THA. (10.1186/s12891-022-05560-x)
  • [L3] Biomechanical changes occurring after TKA are related with the occurrence of osteolysis. (10.1007/s00167-014-3088-0)
  • [L3] A nonspacer two-stage exchange is a viable option for managing chronically infected THA with severe bone loss or abductor deficiency, showing comparable rates of interim revision and recurrence of infection. (10.1016/j.arth.2021.02.040)
  • [L3] Close radiological follow-up is recommended, particularly in high-risk groups. (10.1302/0301-620x.97b10.34131)
  • [L3] Nevertheless, the diagnosis of PJI remains a difficult challenge and different diagnostic tools are necessary to optimize the outcome. (10.1186/s12891-019-3006-1)
  • [L4] However, increasing symptoms and decreased function related to degenerative hip disease may occur fifteen to twenty years after the procedure. (10.2106/00004623-199701000-00009)
  • [L4] There is room for irrigation and debridement with component retention in addition to chronic suppression antibiotics in appropriate cases including patients without major comorbidities. (10.2106/jbjs.17.01097)
  • [L5] The authors argue that nuclear medicine techniques for diagnosing periprosthetic joint infection have added value when correct acquisition and interpretation protocols are used, offering convenience and potential cost-effectiveness, though they acknowledge the need for prospective randomized trials to generate evidence-based data. (10.1016/j.arth.2015.07.002)
  • [L3] The authors recommend its use to differentiate aseptic from septic loosening. (10.2106/00004623-199512000-00003)
  • [L3] Further investigation is necessary to identify the best means of diagnosing periprosthetic joint infection in this patient population. (10.1016/j.arth.2019.03.013)
  • [L2] Implant sonication was mainly useful in patients with unsuspected septic failure. (10.1302/0301-620x.95b2.30486)
  • [L5] The document provides recommendations and rationale based on the clinical context, noting that the relevance of unexpected positive cultures in revision arthroplasty without signs of infection remains unknown. (10.1016/j.jse.2019.04.016)
  • [L3] The cutoff level seems to be different between the hip and knee. (10.1016/j.arth.2020.03.014)
  • [L5] Patients with new or evolving hip symptoms and a prior history of total hip arthroplasty warrant orthopaedic surgical evaluation. (10.1302/0301-620x.98b1.36374)
  • [L3] The DA approach to the hip does not increase the risk for subsequent PJI. (10.1016/j.arth.2021.02.016)
  • [L3] The identification of risk factors preoperatively, in particular femur shape, is crucial and should be incorporated into the decision-making process. (10.1186/s13018-019-1494-1)
  • [L3] Clinical outcomes did not differ significantly between cases with gluteal repair and those without tears, suggesting abductor tears may be repaired at time of hip arthroplasty without forgoing desirable functional outcomes. (10.1186/s12891-025-08298-4)
  • [L3] DAIR failure is associated with earlier time to mortality. (10.1016/j.arth.2021.05.023)
  • [L4] Electrical resistance and reactance of the limbs did not change significantly after THA. (10.1186/s12891-023-06893-x)
  • [L2] With regard to gait kinematics in the early postoperative period (three months), the present study showed no significant benefit for patients who underwent a total hip arthroplasty through a minimally invasive Watson-Jones approach in comparison with those who were managed with a standard transgluteal approach. (10.2106/jbjs.h.01086)
  • [L3] Patient variables associated with infection differ among infections that occur before and after one year. (10.1016/j.arth.2022.02.034)
  • [L3] Patient factors are also important to consider given that recurrently infected patients were younger and had longer follow-up. (10.1016/j.jseint.2025.05.036)
  • [L3] The three potential risk factors (old age, high preoperative CRP, and resistant organism profile) may predict treatment failure following a two-stage procedure for evolutive SA. (10.1186/s12891-019-2652-7)

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a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.