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Periprosthetic joint infection (knee)

117 citationsUpdated Sep 2026

Overview

Periprosthetic joint infection (PJI) is a severe complication of total knee arthroplasty that generates high costs for public health systems [23]. Patient factors remain the most important predictors of early prosthetic joint infection [3], with a history of treated septic arthritis conferring high risk, particularly in knee arthroplasty compared to hip arthroplasty [1]. Wound complications after total knee arthroplasty increase the risk of deep infection, as well as cost, length of hospitalization, and readmission rates [70]. Polymicrobial infections represent a substantial proportion of all PJI occurrences [27].

Diagnosis and treatment approaches vary globally due to logistical constraints and resource availability [11]. The International Consensus on Periprosthetic Joint Infections has focused the community and should lead to better research and outcomes [2], successfully reaching agreement on all but four of 207 questions regarding prevention, diagnosis, and treatment [10]. All patients undergoing revision arthroplasty should be investigated for PJI [9]. Early-postoperative and late-chronic PJI might require different thresholds for serological markers [71].

In North America, two-stage revision arthroplasty is the treatment of choice for chronic PJI of the hip and knee [6]. Operative débridement remains the single most important treatment for infection at the site of a knee prosthesis [8]. Debridement, antibiotics, and implant retention (DAIR) is a viable and safe option when performed early after primary surgery with a relevant postrevision antibiotic regime [66]. The success of prosthesis salvage for infections occurring within 28 days after arthroplasty depends on the location, extent, and microbiology of the infection [25]. No substantial improvement in treatment success rates was detected over the 17 years examined [7]. Salvage of an infection-free prosthetic knee was achieved in only about two thirds of cases following prior staged reimplantation for septic total knee arthroplasty [5]. Polymicrobial PJI was associated with a poor outcome and a higher likelihood of requiring salvage operation when compared with monomicrobial and culture-negative infections [13], although polymicrobial prosthetic joint infections have a relatively favorable outcome, especially when treated with two-stage exchange [27]. A review failed to identify a significant difference in the ability of static or articulating spacers to eradicate PJI following total knee arthroplasty [15]. For high-risk candidates, articulating spacers can preserve knee function, reduce morbidity from second-stage surgery, and lower the costs with similar rates of infection clearance as 2-stage exchange [38]. Survivorship free from persistent PJI at 1 year is 76% in unicompartmental knee arthroplasty [19]. Patients who have been successfully managed for PJI show improvement in generic and joint-specific patient-reported outcome measures compared to their preprimary total joint arthroplasty scores [68]. 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 [72]. The management of PJI in the future may still be challenging, with numerous problems to resolve and scope for plenty of research [4].

Anatomy & Pathophysiology

Osseous Anatomy

The knee joint comprises the distal femur, proximal tibia, and patella [40]. The medial femoral condyle is larger and projects farther posteriorly and distally than the lateral condyle [80]. Conversely, the lateral femoral condyle projects farther anteriorly and is wider in the medial-lateral direction than the medial condyle [80]. The tibial articular surface slopes 7° to 10° in the sagittal plane [80], with the posterior slope of the medial tibial plateau averaging 10.7° and the lateral plateau averaging 7.2° [85]. The patella is the largest sesamoid bone in the body, with a mean thickness of 2.5 cm [80, 85]. Its articular surface features a vertical central ridge separating the broader lateral facet from the medial facet, along with a smaller medial facet known as the odd facet [80]. The fibular head is located a mean of 1.5 cm distal to the joint line [85].

Ligamentous Anatomy

The anterior cruciate ligament (ACL) prevents anterior translation and rotation of the tibia on the femur [40], while the posterior cruciate ligament (PCL) prevents posterior subluxation of the tibia on the femur [40]. The medial collateral ligament stabilizes the knee against valgus stresses [40], and the lateral collateral ligament serves as the main stabilizer against varus stress [40]. The ACL is composed of 90% type I collagen and 10% type III collagen [80, 85]. It has a mean length of 33 mm and a mean midsubstance width of 11 mm [80, 85]. The PCL has a mean length of 38 mm and a mean width of 13 mm [85, 93]. As the largest intra-articular ligament, the PCL has a cross-sectional area approximately 120% to 150% greater than that of the ACL [93]. The PCL consists of two distinct bundles defined by their femoral insertion: an anterolateral (AL) bundle and a posteromedial (PM) bundle [93]. The AL bundle is larger, comprising 85% of the PCL's cross-sectional area [93].

The ACL femoral attachment is a semicircular area on the posteromedial aspect of the lateral femoral condyle [80, 85]. The ACL tibial attachment is a broad, irregular, oval-shaped area between the medial and lateral tibial spinous processes [80, 85]. The PCL inserts onto a midline depression on the tibia 10 to 15 mm below the level of the medial and lateral tibial plateaus [85, 93]. The middle geniculate artery provides the primary blood supply to both the ACL and PCL [80, 85], while the posterior articular branch of the posterior tibial nerve innervates both ligaments [85]. Biomechanically, the anteromedial bundle of the ACL is tight in knee flexion, and the posterolateral bundle is tight in knee extension [85]. Similarly, the AL bundle of the PCL is tight in knee flexion, and the PM bundle is tight in knee extension [85]. Meniscofemoral ligaments are present in 93% of knees, with both ligaments present in 70% [85, 93]. These ligaments connect the posterior horn of the lateral meniscus to the intercondylar notch [93].

Meniscal Anatomy

The menisci are C-shaped fibrocartilaginous disks that provide shock absorption, increase congruency between joint surfaces, enhance joint stability, and aid in the distribution of synovial fluid [40]. The medial meniscus is firmly attached to the joint capsule along its entire peripheral edge [40]. In contrast, the lateral meniscus is attached to the anterior and posterior capsule but has a region posterolaterally where it is not firmly attached [40]. Consequently, the medial meniscus has less mobility than the lateral meniscus and is more susceptible to tearing when trapped between the femoral condyle and tibial plateau [40]. The lateral meniscus is larger than the medial meniscus and carries a greater share of the lateral compartment pressure [40]. Structurally, the menisci consist of type I collagen fibers arranged obliquely, radially, and vertically [85]. Vascular supply is derived from the geniculate arteries, which penetrate into 20% to 30% of the peripheral medial meniscus and 10% to 25% of the peripheral lateral meniscus [85]. Morphologically, the medial meniscus is crescent-shaped and attaches more anterior and posterior [85]. The lateral meniscus is circular in shape and covers a larger proportion of the tibial plateau [85].

Vascular and Neural Anatomy

The blood supply to the knee forms an anastomosis around the joint derived from the descending geniculate artery, medial and lateral superior geniculate arteries, medial and lateral inferior geniculate arteries, middle geniculate artery, and anterior tibial recurrent arteries [80]. The knee is innervated by branches of the femoral nerve (L2, L3, L4), obturator nerve (L2, L3, L4), and sciatic nerve (L4, L5, S1, S2) [80]. The posterior articular branch of the tibial nerve is the largest nerve providing innervation to the intra-articular knee [80]. The popliteus artery travels through the adductor hiatus, where it is relatively immobile, and distally through the fibrous arch deep to the soleus muscle [90]. The common peroneal nerve travels along the posterior edge of the biceps femoris and continues distally around the fibular neck [90].

Kinematics and Biomechanics

The knee is a hinge joint that incorporates both gliding and rolling, which are essential to its kinematics [81, 82]. The "screw-home" mechanism involves the tibia externally rotating 5 degrees in the final 15 degrees of extension [81, 82]. The greatest range of motion occurs in the sagittal plane at approximately 160° [97]. Knee rotation ranges from 45° in external rotation to 30° in internal rotation [97]. The normal instant center of the knee joint follows a semicircular path related to the tibiofemoral surface and ligaments crossing the joint [97]. Rupture of the cruciate ligaments or disruption of the tibiofemoral surface causes a major change in the path of the instant center, leading to articular dysfunction [97]. In full extension, the knee slightly hyperextends with slight tibial external rotation while collateral and cruciate ligaments are tightened to lock the knee in extension [98]. The popliteus muscle initiates flexion by pulling the lateral femoral condyle backward while the medial femoral condyle slides forward, resulting in tibial internal rotation [98].

Pathophysiology of Infection

Patients with a history of treated septic arthritis are at high risk of developing periprosthetic joint infection after total joint arthroplasty, with the risk appearing greater in knee arthroplasty compared to hip arthroplasty [1]. Patient factors remain the most important in predicting early prosthetic joint infection following total knee arthroplasty [3, 172]. Greater knee soft tissue thickness predisposes patients to subsequent periprosthetic joint infection after total knee arthroplasty [39]. Therefore, soft tissue depth around the knee should be considered in all patients undergoing primary total knee arthroplasty, even in those with lower body mass index [39]. Periprosthetic joint infections occur in 1%-2% of primary total hip and knee arthroplasty cases, with an increased prevalence in revision arthroplasty cases [73]. The management of periprosthetic joint infection remains difficult primarily due to the evolution of resistance by the infecting organisms [73].

The nature of biofilm varies depending on the type of device and anatomic location, and its dynamic life cycle necessitates complex interdisciplinary studies [21]. The biofilm paradigm is different from the planktonic paradigm in all of the five H’s (Who, What, When, Where and How) [21]. The exact mechanism by which joint contamination becomes an infection is still poorly understood [159]. However, Neutrophil Extracellular Trap-related biomarkers are increased in the synovial fluid of patients with periprosthetic joint infections [159]. Synovial fluid analysis is adequate in differentiating patients with periprosthetic hip and knee infections [24]. There are differences in cell count cutoff levels between knees and hips, suggesting international guidelines and diagnostic criteria need revisions [161]. In the absence of definitive X-ray findings, synovial fluid analysis offers a promising diagnostic modality for aseptic loosening following cemented total knee arthroplasty [190]. The cellular pathophysiology of aseptic TKA complications can be used to aid in clarifying the diagnosis of aseptic loosening versus instability [75].

Classification

Periprosthetic joint infections are classified into four types based on duration and the interval from the index procedure [48]. A classification system popularised by Tsukayama in the 1990s divides periprosthetic joint infections into four categories based on the time elapsed since the operation and the preoperative status [113].

Early Postoperative: These infections present within 4 weeks of the index procedure and are usually seeded intraoperatively, though they can also be caused by hematogenous spread [48].

Acute Hematogenous: This type is characterized by an acute presentation in a previously well-functioning joint arthroplasty and may be associated with a documented or suspected bacteremia [48].

Late Chronic: These infections present indolently 1 month or more after the index arthroplasty and are usually low-grade infections thought to originate perioperatively [48]. This category includes missed acute infections (early postoperative or hematogenous) that are now greater than 4 weeks in duration [48].

Intraoperative Cultures: A final classification group includes patients with positive intraoperative cultures found at the time of revision for presumed aseptic failure [48].

Other Considerations: Infections associated with prosthetic joints can be categorized into three groups: early infections (occurring within three months after surgery), delayed infections (appearing between three and 24 months after surgery), and late infections (emerging more than 24 months after surgery) [113]. A staging system for periprosthetic infections incorporates the infection classification system with the status of the host, including both systemic and local compromising factors [48]. The Musculoskeletal Infection Society criteria are used for the diagnosis of periprosthetic joint infection, with major criteria including a communicating sinus tract and two positive cultures with the same organism [140]. The Musculoskeletal Infection Society criteria include minor criteria, where meeting at least four of six minor criteria contributes to the diagnosis [140]. The JS-BACH classification predicts outcome in periprosthetic joint infections based on joint-specific bone involvement, antimicrobial options, coverage of the soft tissues, and host status [142]. The KLIC score is a predictor of treatment response in acute prosthetic joint infection and is a useful tool in multidisciplinary treatment in hospitals that are not prosthetic joint infection reference centres [62]. The AAOS work group proposed an algorithm for diagnosing periprosthetic joint infection based on available evidence for diagnostic modalities [18]. The International Consensus on Periprosthetic Joint Infection reached agreement on all but four of 207 questions regarding the prevention, diagnosis, and treatment of periprosthetic joint infection [10].

Clinical Presentation

Brucella periprosthetic joint infections in total knee arthroplasty typically present late with nonspecific symptoms, often mimicking aseptic loosening or culture-negative periprosthetic joint infections [20]. A sinus tract serves as a major criterion for the diagnosis of periprosthetic joint infection [31]. The diagnosis relies on converging information from clinical, laboratory, and imaging assessments [31]. No single test has demonstrated absolute accuracy for the diagnosis of periprosthetic joint infection [53]. Consequently, physicians rely on a combination of serological tests, synovial markers, and clinical findings plus clinical judgment to help guide preoperative decision-making [53]. 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 [59].

Laboratory Markers: Approximately 4% of patients with periprosthetic joint infection present with normal ESR and CRP [45]. Traditional laboratory markers hold low diagnostic utility for immunosuppressed patients with periprosthetic joint infections [16]. Atypical prosthetic joint infection should be considered in painful total knee arthroplasty with negative cultures and equivocal laboratory results [17]. 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 [55].

Synovial Fluid Analysis: Leukocyte esterase 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 [60]. The specificity of the leukocyte esterase test was found to be 99.3% in a study of 149 patients with total knee arthroplasty [43]. Synovial fluid alpha-defensin can provide an additional data point to assist the clinician in determining whether periprosthetic joint infection is present in patients with equivocal diagnosis due to recent antibiotic use, equivocal laboratory findings, or suspected false-negative or false-positive cultures [117]. However, synovial fluid alpha-defensin is prone to false-positive results in the challenging population of patients with equivocal diagnosis of periprosthetic joint infection [117]. The synovial fluid biomarker IL-6 is recommended for the diagnosis of periprosthetic joint infection following total hip and knee arthroplasty [56]. MicroRNA biomarkers offer sensitive and specific pathogen-independent biomarkers with potential clinical applications in the diagnosis of hip and knee periprosthetic joint infection [52]. D-dimer shows high sensitivity for periprosthetic joint infection diagnosis in cases of low-virulence organisms which might be missed by most diagnostic tests [121].

Microbiological Considerations: Pathogens causing periprosthetic infection in both culture-positive and culture-negative samples of synovial fluid could be identified by next-generation sequencing [124]. The pathogen spectra of periprosthetic and native joint infections differ considerably [63]. Polymicrobial periprosthetic joint infection was associated with a poor outcome when compared with monomicrobial and culture-negative infections, with patients being more likely to require a salvage operation [13].

Management Implications: Patients with suspected late periprosthetic joint infection should not receive antibiotics until the diagnosis is reached or refuted [122]. The AAOS work group recommends against initiating antibiotics before cultures are obtained and against using intraoperative Gram stain to rule out periprosthetic joint infection [18]. Diagnostic criteria and treatment approaches for periprosthetic joint infection vary globally due to logistical constraints and resource availability, hindering comparative research [11].

Investigations

Diagnostic Criteria and Algorithms: The diagnosis of peri-prosthetic bone and joint infections relies on converging information from clinical, laboratory, and imaging assessments, with clinical findings such as a sinus tract serving as major criteria [31]. No single test has demonstrated absolute accuracy for the diagnosis of periprosthetic joint infection (PJI); physicians rely on a combination of serological tests, synovial markers, and clinical findings plus clinical judgment to help guide preoperative decision-making [53]. A validated, evidence-based algorithm for diagnosing PJI should guide clinicians in the workup of patients undergoing revision arthroplasty [157].

Aspiration: Leukocyte 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 [60]. In a study of 200 patients undergoing total knee arthroplasty, the specificity of the leukocyte esterase test was found to be 99.3% [43]. The use of the synovial fluid biomarker IL-6 is recommended for the diagnosis of periprosthetic joint infection following total hip and knee arthroplasty [56]. 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 [57]. Synovial fluid microRNA biomarkers offer sensitive and specific pathogen-independent biomarkers with potential clinical applications in the diagnosis of hip and knee periprosthetic joint infection [52]. The study provides insight into the cellular pathophysiology of aseptic TKA complications and can be used to aid in clarifying the diagnosis of aseptic loosening versus instability [75]. Sonication is an evolving modality in the context of periprosthetic joint infections [174].

Laboratory: Interleukin-6 (IL-6) in serum and in synovial fluid enhances the differentiation between periprosthetic joint infection and aseptic loosening [56]. Variation in inflammatory biomarkers among demographic groups significantly affects their accuracy in diagnosing periprosthetic joint infection [55]. 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 [79]. The study identified two intra-articular CRP cut-offs of potential usefulness for diagnosing knee prosthesis infection [173]. More accurate diagnostic tools are needed to support clinical judgment in monitoring infection progress and thus deciding whether or not to proceed with TKA reimplantation [171]. Further investigation of diagnostic tests following staged treatment of PJI is needed [165]. Further studies are needed to explore diagnostic tests that will better detect PJI in patients with inflammatory arthritis [167].

CT: CT imaging in the axial, sagittal, and coronal planes may help visualize osteolytic lesions around joint arthroplasty and cortical disruption in cases of infection or neoplasia [42].

Bone scan: Gallium-67 (Ga-67) is a radionuclide that may help differentiate between aseptic and septic prosthetic loosening; 24 to 72 hours are needed for a complete study [42].

Plain radiography: A high index of suspicion may result from careful examination of plain radiographs, and further imaging studies, including CT or MRI, are essential for diagnosis of septic knee arthritis with adjacent chronic osteomyelitis [147].

Other Considerations: We recommend that all patients undergoing revision arthroplasty be investigated for periprosthetic joint infection [9]. Brucella PJIs in a TKA typically present late with nonspecific symptoms, often mimicking aseptic loosening or culture-negative PJIs [20]. This case report demonstrates the importance of considering atypical prosthetic joint infection in painful total knee arthroplasty with negative cultures and equivocal laboratory results [17].

Treatment

General Principles

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 [2]. Despite increasing clinical focus and research advances, no substantial improvement in treatment success rates for periprosthetic joint infection was detected over the 17 years examined [7]. The BOOM meeting achieved consensus for important topics on periprosthetic infection in orthopaedic oncology, but highlighted the low quality of the underlying evidence [37].

Debridement, Antibiotics, and Implant Retention (DAIR)

Indications: DAIR is recommended as a choice for patients with current infection within 12 weeks after primary TKA [146]. It is a viable and safe treatment option for PJI following primary TKA surgery when performed early after primary surgery and with the addition of a relevant postrevision antibiotic regime [66]. Success of prosthesis salvage for periprosthetic infections occurring within 28 days after arthroplasty depends on the location, extent, and microbiology of the infection [25]. In a prospective multicenter study of 189 cases, time since primary total knee arthroplasty was a key predictor of DAIR success, with success highest in infections occurring within 1 month and progressively decreasing as time increased [28]. Late infections had a high failure rate of DAIR irrespective of their classification as hematogenous or chronic [28].

Outcomes and Limitations: In a retrospective review of 104 patients, irrigation and debridement was successful in 46 patients (44%), with staphylococcal infection, elevated American Society of Anesthesiologists score, and purulence around the prosthesis being more likely to fail [114]. The high failure rate of irrigation and debridement implies that it should be preferably limited to select healthy patients with low virulence organisms and equivocal intraoperative findings [114]. Surgeons should be cautious using irrigation and debridement as a routine means to address periprosthetic joint infection [145]. The treatment failed to eradicate the infection in 16 cases (84% failure rate), with a total success rate of open debridement and component retention in acute periprosthetic MRSA knee infection of 18% when combined with literature review [35]. Given that persistent infection was most common in knees and Staphylococcus aureus, irrigation and debridement should have a limited role in treating periprosthetic joint infection, especially in these cases [61]. Survivorship free from persistent PJI at 1 year is low at 76% for unicompartmental knee arthroplasty treated with DAIR, which is consistent with similar reports for total knee arthroplasties [19].

Surgical Strategy: The probability of treatment failure (removal of implants) was not significantly different between patients treated with single versus multiple irrigation and debridements [54]. The interval between serial irrigation and debridements was a significant factor determining outcomes in patients treated with multiple procedures [54]. Patients treated with multiple irrigation and debridements had a significantly higher prevalence of peripheral vascular disease [54].

Two-Stage Revision

Outcomes: Salvage of an infection-free prosthetic knee was achieved in only about two thirds of the cases following prior staged reimplantation [5]. A favorable outcome in patients with PJI undergoing a 2-stage procedure was associated with an infection sustained by Gram-positive bacteria, absence of known comorbidities, and administration of oral therapy [36]. The results support the effectiveness of a 2-stage reimplantation protocol with a standard 1:8 minimal bactericidal titer for treating infections after TKA, including multidrug-resistant organisms [143]. Consistent infection eradication was found at a 1-year follow-up with a short-interval two-stage approach to primary total knee arthroplasty for acutely septic osteoarthritic knees, with postoperative range of motion and knee scores comparing favourably with other case series [22].

Technique and Spacers: Two-stage revision of septic knee prosthesis with articulating knee spacers yields better infection eradication rate than one-stage or two-stage revision with static spacers [51]. Prerevision cultures, grown after discontinuation of antibiotic treatment and before reimplantation of the components, helped to identify patients with infection at the site of a total knee arthroplasty in whom the infection might recur [78]. Outcomes after prosthesis removal and antibiotic spacer placement are variable, and there are several independent risk factors for such outcomes that may be used to develop and improve existing treatment strategies for patients presenting with chronic PJI after TKA [148]. This study highlights the challenge of treating infected knee arthroplasties in physiologically compromised patients with 9/13 (69%) having satisfactory clinical outcomes [12].

One-Stage Revision

Data provide preliminary support to the use of a single-stage approach in highly selected patients with chronically infected TKAs as an alternative to a two-stage procedure [166]. With an overall revision rate of about 25% at 6 years and limited functional results based on poor Oxford Knee Scores, patients should be counseled to have modest expectations concerning postoperative pain and function for infected rotating-hinge implants treated with one-stage-exchange [29].

Spacer Management

Treatment of patients with an infected total knee arthroplasty with high-dose vancomycin and gentamicin antibiotic spacers seems to be clinically safe [127]. Use of an articulating spacer achieved soft tissue compliance, allowed for ease of operation, reduced postoperative pain, improved function, and eradicated infection equal to standards reported in the literature [116]. The practice patterns of American Association of Hip and Knee Surgeons members show a preference toward performing a two-stage exchange arthroplasty with an articulating spacer using a metal femoral component and an all-polyethylene liner [120].

Antibiotic Therapy

Rifampin combination therapy in staphylococcal prosthetic joint infections was evaluated in a randomized controlled trial [112]. The role of long-term antibiotic suppression in the management of peri-prosthetic joint infections treated with debridement, antibiotics, and implant retention was evaluated in a systematic review [119].

Prevention and Prophylaxis

Routine prophylactic use of antibiotic-laden bone cement in primary total knee arthroplasty has not led to changes in infecting pathogen profile, nor has it led to the emergence of antimicrobial resistance at this institution [26]. 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 [128]. Administration of intrawound vancomycin powder has no efficacy in preventing periprosthetic joint infection in primary total knee arthroplasty [138]. The intrawound application of vancomycin powder was demonstrated to be inferior to standard postoperative IV antibiotics in reducing the incidence of periprosthetic joint infections after total knee arthroplasty [139].

Specific Pathogens and Patient Factors

Soft tissue depth around the knee should be considered in all patients undergoing primary total knee arthroplasty, even in those with lower body mass index, as greater soft tissue thickness predisposes patients to subsequent periprosthetic joint infection [39]. Orthopaedic surgeons should strongly consider patient comorbidities when selecting treatment pathways for PJIs [149].

Complications

Infection (PJI): Periprosthetic joint infection risk is elevated in patients with a history of treated septic arthritis, particularly in knee arthroplasty compared to hip arthroplasty [1]. Prior cellulitis, especially within one year of surgery, also predisposes to infection [162]. Polymicrobial infections carry a poorer prognosis than monomicrobial or culture-negative cases [13]. Methicillin-resistant organisms are associated with a 3.37-fold increased likelihood of failed two-stage exchange arthroplasty [77]. Favorable outcomes in two-stage procedures correlate with Gram-positive pathogens, the absence of known comorbidities, and the administration of oral therapy [36]. Atypical pathogens, such as Mycobacterium kansasii, must be considered in painful knees with negative cultures and equivocal laboratory results [17].

Treatment Outcomes and Failure Rates: Failure rates remain high after revision for PJI, with significant risk of failure at one-year follow-up [50]. High pathogen persistence and low survival time to recurrence necessitate close monitoring within two years [74]. In significantly compromised (host-C) patients, 9/13 (69%) achieved satisfactory clinical outcomes following two-stage revision [12]. Open debridement and component retention for acute methicillin-resistant Staphylococcus aureus infections resulted in an 84% failure rate (16 cases) [35], with a total success rate of 18% when combined with literature review data [35]. For unicompartmental knee arthroplasty treated with debridement, antibiotics, and implant retention, survivorship free from persistent infection at one year is 76% [19]. The probability of treatment failure via implant removal was not significantly different between single irrigation and debridement and additional procedures, though the interval between serial debridements significantly determined outcomes [54]. A short-interval two-stage approach for acutely septic osteoarthritic knees yielded consistent infection eradication at one year and favorable postoperative range of motion and knee scores compared to other case series [22]. Hematogenous infection after successful two-stage exchange is a rare but critical cause of reinfection [169].

Salvage and Alternative Procedures: Arthrodesis using a silver-coated intramedullary device successfully eradicates infection and allows limb conservation in unsalvageable infected total knee arthroplasties [130]. In a retrospective analysis of eight patients, there were no amputations, deaths, or implant revisions at follow-up [130]. One case of recurrent infection was successfully managed with washout and debridement [130]. The mean difference in Oxford Knee Score between pre- and post-arthrodesis was 8.9 points (P .086) [130]. Pain, night pain, and ease of standing showed significant improvement following silver-coated arthrodesis (P .019, P .021, and P .003, respectively) [130].

Wound Complications: Wound complications after total knee arthroplasty increase cost, length of hospitalization, readmission rates, and the risk of deep infection [70]. Intrawound vancomycin administration does not decrease PJI occurrence but significantly causes aseptic wound complications in primary total knee arthroplasty [152]. Routine prophylactic use of antibiotic-laden bone cement has not altered the infecting pathogen profile or led to the emergence of antimicrobial resistance at the reporting institution [26].

Other Considerations: The prevalence of multiple periprosthetic joint infections has decreased compared to historical reports, likely due to higher rates of two-stage revisions and fewer patients treated with irrigation and debridement [34]. Concomitant multiple periprosthetic joint infections are rare events that most often result from secondary hematogenous spread from a distant infectious focus [133].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a month range for manual work, sport, or full range-of-motion and strength return.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The provided evidence does not detail specific physical therapy phasing, immobilisation duration, weight-bearing progression, or brace removal timing.

Functional milestones: Postoperative range of motion and knee scores for the short-interval two-stage approach to primary total knee arthroplasty for acutely septic osteoarthritic knees compare favourably with those of other case series [22]. Two-stage re-implantation with an articulating spacer for infected total knee arthroplasty effectively treats infection and provides excellent knee motion between stages, as well as at mid- to long-term follow-up [155]. Rotating hinge total knee arthroplasty using a single modular implant demonstrates acceptable survival rates and function compared to previous studies [76].

Other Considerations: Prognosis is influenced by specific patient factors and pathogen types. The risk of periprosthetic joint infection after total joint arthroplasty appears greater in knee arthroplasty compared to hip arthroplasty for patients with a history of treated septic arthritis [1]. In patients with neuropathic (Charcot) arthropathy, periprosthetic joint infection led to a 10-year survivorship free of any revision of 70% [58]. At a mean follow-up of 6.4 years, overall survival was 96.7%, with only 2.2% of patients revised due to a periprosthetic joint infection in patients with asymptomatic elevated inflammatory markers [65].

Treatment efficacy varies by procedure and organism. A favorable outcome in patients with periprosthetic joint infection undergoing a 2-stage procedure was associated with an infection sustained by Gram-positive bacteria, absence of known comorbidities, and administration of oral therapy [36]. The treatment failed to eradicate the infection in 16 cases (84% failure rate) for acute periprosthetic methicillin-resistant Staphylococcus aureus knee infection treated by open debridement and retention of components [35]. A periprosthetic joint infection eradication rate of 72% with acceptable functional outcome was described for massive endoprostheses used for managing periprosthetic joint infections of the hip and knee [69]. 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 [34]. The risk of developing a subsequent periprosthetic joint infection in patients with multiple arthroplasties was identified to be one half of previous studies [14].

Diagnostic monitoring presents specific challenges. Prerevision cultures, grown after discontinuation of antibiotic treatment and before reimplantation of the components, helped to identify the patients with infection at the site of a total knee arthroplasty in whom the infection might recur [78]. The change in serum interleukin-6 between stages does not appear to identify subsequent periprosthetic joint infection in patients who have two-stage revision [79]. Brucella periprosthetic joint infections in a total knee arthroplasty typically present late with nonspecific symptoms, often mimicking aseptic loosening or culture-negative periprosthetic joint infections [20].

Reinfection remains a critical failure mode. (Re-)infection is the most relevant mode of failure for rotating hinge total knee arthroplasty using a single modular implant [76]. Many areas regarding periprosthetic joint infection still require further research [2]. Continued investigation is required to determine the fate of infected joints that undergo debridement, antibiotics, and implant retention with regard to ultimate patient outcome [176].

Key Evidence

• [L3] Patients with a history of treated septic arthritis are at high risk of developing periprosthetic joint infection after total joint arthroplasty, with the risk appearing greater in knee arthroplasty compared to hip arthroplasty. [1] (10.1097/corr.0000000000000734)
• [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. [2] (10.1302/0301-620x.95b11.33224)
• [L2] Patient factors remain the most important in terms of predicting early prosthetic joint infection following total knee arthroplasty. [3] (10.1302/0301-620x.98b3.36775)
• [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. [4] (10.1302/0301-620x.104b11.bjj-2022-0944)
• [L3] Salvage of an infection-free prosthetic knee was achieved in only about two thirds of the cases. [5] (10.1016/j.arth.2010.04.017)
• [L5] In North America, two-stage revision arthroplasty is the treatment of choice for chronic periprosthetic infection of the hip and knee. [6] (10.5435/jaaos-22-03-153)
• [L3] Despite increasing clinical focus and research advances, no substantial improvement in treatment success rates for periprosthetic joint infection was detected over the 17 years examined. [7] (10.1016/j.arth.2020.01.080)
• [L5] Operative débridement remains the single most important treatment for an infection at the site of a knee prosthesis. [8] (10.2106/00004623-199302000-00018)
• [L2] We recommend that all patients undergoing revision arthroplasty be investigated for periprosthetic joint infection. [9] (10.1016/j.arth.2011.01.019)
• [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. [10] (10.1302/0301-620x.95b11.33135)
• [L5] Diagnostic criteria and treatment approaches for periprosthetic joint infection vary globally due to logistical constraints and resource availability, hindering comparative research. [11] (10.2106/jbjs.25.00775)
• [L4] This study highlights the challenge of treating infected knee arthroplasties in physiologically compromised patients with 9/13 (69%) having satisfactory clinical outcomes. [12] (10.1007/s00167-018-5051-y)
• [L3] Polymicrobial periprosthetic joint infection was associated with a poor outcome when compared with monomicrobial and culture-negative infections, with patients being more likely to require a salvage operation. [13] (10.2106/jbjs.15.01450)
• [L3] The study identified the risk of developing a subsequent periprosthetic joint infection to be one half of previous studies. [14] (10.1016/j.arth.2017.10.024)
• [L2] Our review failed to identify a significant difference in the ability of static or articulating spacers to eradicate periprosthetic infection following total knee arthroplasty. [15] (10.2106/jbjs.l.01461)
• [L3] Further investigation is necessary to identify the best means of diagnosing periprosthetic joint infection in this patient population. [16] (10.1016/j.arth.2019.03.013)
• [L5] This case report demonstrates the importance of considering atypical prosthetic joint infection in painful total knee arthroplasty with negative cultures and equivocal laboratory results. [17] (10.5435/jaaosglobal-d-21-00183)
• [L5] The AAOS work group convened to evaluate available evidence for diagnostic modalities and propose an algorithm for diagnosing periprosthetic joint infection (PJI), recommending against initiating antibiotics before cultures are obtained and against using intraoperative Gram stain to rule out PJI. [18] (10.5435/00124635-201012000-00007)
• [L3] Survivorship free from persistent PJI at 1 year is low at 76% but is consistent with similar reports of DAIRs for total knee arthroplasties. [19] (10.1016/j.arth.2020.02.036)
• [L3] Brucella PJIs in a TKA typically present late with nonspecific symptoms, often mimicking aseptic loosening or culture-negative PJIs. [20] (10.2106/jbjs.rvw.25.00079)
• [L5] [21] (10.5435/jaaos-d-14-00455)
• [L5] Consistent infection eradication was found at a 1-year follow-up with postoperative range of motion and knee scores comparing favourably with those of other case series. [22] (10.1007/s00167-016-3982-8)
• [L4] PJIs are a severe complication of total knee arthroplasty that generates a high cost for the public health system. [23] (10.1016/j.arth.2013.02.012)
• [L1] Synovial fluid analysis is adequate in differentiating patients with periprosthetic hip and knee infections. [24] (10.1007/s00264-018-3865-3)
• [L4] Success of prosthesis salvage for periprosthetic infections occurring within 28 days after arthroplasty depends on the location, extent, and microbiology of the infection. [25] (10.1007/s11999-010-1291-y)
• [L3] Routine prophylactic use of antibiotic-laden bone cement in primary total knee arthroplasty has not led to changes in infecting pathogen profile, nor has it led to the emergence of antimicrobial resistance at this institution. [26] (10.1016/j.arth.2013.12.004)
• [L3] Polymicrobial prosthetic joint infections represent a substantial proportion of all PJI occurrences and have a relatively favorable outcome, especially when treated with two-stage exchange. [27] (10.1007/s11999-008-0230-7)
• [L2] [28] (10.1016/j.arth.2023.04.024)
• [L4] With an overall revision rate of about 25% at 6 years and limited functional results based on poor Oxford Knee Scores, patients should be counseled to have modest expectations concerning postoperative pain and function. [29] (10.1097/corr.0000000000001868)
• [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. [31] (10.1016/j.otsr.2018.04.029)
• [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. [34] (10.1016/j.arth.2016.05.013)
• [L3] The treatment failed to eradicate the infection in 16 cases (84% failure rate), with a total success rate of ODCR in acute periprosthetic MRSA knee infection of 18% when combined with literature review. [35] (10.1016/j.arth.2009.04.028)
• [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. [36] (10.1016/j.arth.2017.02.057)
• [L5] The BOOM meeting achieved consensus for important topics on periprosthetic infection in orthopaedic oncology, but highlighted the low quality of the underlying evidence. [37] (10.1302/0301-620x.107b12.bjj-2024-1039.r4)
• [L3] For high-risk candidates, articulating spacers can preserve knee function, reduce morbidity from second-stage surgery, and lower the costs with similar rates of infection clearance as 2-stage exchange. [38] (10.1016/j.arth.2023.01.036)
• [L3] Soft tissue depth around the knee should be considered in all patients undergoing primary total knee arthroplasty, even in those with lower body mass index. [39] (10.1016/j.arth.2020.02.049)
• [L3] [43] (10.1016/j.arth.2016.05.065)
• [L3] Approximately 4% of patients with periprosthetic joint infection present with normal ESR and CRP. [45] (10.1302/0301-620x.97b7.35500)
• [L4] [48] (10.1007/s11999-010-1293-9)
• [L3] The risk of failure after one-year follow-up is high after revision for periprosthetic joint infection. [50] (10.1002/ksa.12762)
• [L4] [51] (10.1007/s00167-012-1885-x)
• [L2] These miRNAs offer sensitive and specific pathogen-independent biomarkers with potential clinical applications in the diagnosis of hip and knee periprosthetic joint infection. [52] (10.2106/jbjs.24.01559)
• [L4] No single test has demonstrated absolute accuracy for the diagnosis of periprosthetic joint infection (PJI); physicians rely on a combination of serological tests, synovial markers, and clinical findings plus clinical judgment to help guide preoperative decision-making. [53] (10.2106/jbjs.23.00669)
• [L3] [54] (10.1016/j.arth.2015.06.051)
• [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. [55] (10.1016/j.arth.2020.10.036)
• [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. [56] (10.1371/journal.pone.0089045)
• [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. [57] (10.1302/0301-620X.102B5.BJJ-2019-0473.R3)
• [L4] While 10-year survivorship free of aseptic revision was 88%, periprosthetic joint infection led to the poorer survivorship free of any revision of 70% at 10 years. [58] (10.1016/j.arth.2018.04.003)
• [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. [59] (10.5435/jaaos-d-14-00385)
• [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. [60] (10.1016/j.arth.2017.06.005)
• [L3] Given that persistent infection was most common in knees and Staphylococcus aureus, irrigation and debridement should have a limited role in treating periprosthetic joint infection, especially in these cases. [61] (10.1016/j.arth.2016.05.040)
• [L3] The KLIC score is a useful tool in the multidisciplinary treatment of acute prosthetic joint infections in hospitals that are not prosthetic joint infection reference centres. [62] (10.1007/s00264-017-3670-4)
• [L3] The pathogen spectra of periprosthetic and native joint infections differ considerably. [63] (10.1186/s13018-021-02850-3)
• [L3] At a mean follow-up of 6.4 years, overall survival was 96.7%, with only 2.2% of patients revised due to a PJI. [65] (10.1016/j.arth.2024.10.063)
• [L3] We find DAIR to be a viable and safe treatment option for PJI following primary TKA surgery, when performed early after primary surgery and with the addition of a relevant postrevision antibiotic regime. [66] (10.1016/j.arth.2018.09.088)
• [L4] Patients who have been successfully managed for PJI show improvement in generic and joint-specific PROMs compared to their preprimary TJA PROMs. [68] (10.1016/j.arth.2025.02.011)
• [L4] We describe PJI eradication rate of 72% with acceptable functional outcome. [69] (10.1016/j.arth.2017.09.046)
• [L5] Wound complications after total knee arthroplasty increase cost, length of hospitalization, readmission rates, and the risk of deep infection; prevention is ideal through optimal patient health, careful planning, and detailed postoperative care. [70] (10.1016/j.arth.2007.03.014)
• [L3] Early-postoperative and late-chronic PJI might require different thresholds. [71] (10.1007/s11999-013-3070-z)
• [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. [72] (10.1016/j.arth.2018.09.091)
• [L4] [73] (10.1016/j.arth.2017.07.045)
• [L3] The high rate of pathogen persistence and the relatively low survival time to recurrence suggests a need to more closely monitor PJIs cases within 2 years. [74] (10.1016/j.arth.2023.04.063)
• [L3] This study provides insight into the cellular pathophysiology of aseptic TKA complications and can be used to aid in clarifying the diagnosis of aseptic loosening versus instability. [75] (10.1016/j.arth.2024.12.017)
• [L3] Rotating hinge total knee arthroplasty using a single modular implant shows acceptable survival rates and function compared to previous studies with (re-)infection being the most relevant mode of failure. [76] (10.1007/s00167-019-05593-1)
• [L4] Patients who failed two-stage exchange arthroplasty were 3.37 times more likely to have been originally infected with a methicillin-resistant organism. [77] (10.1007/s11999-010-1296-6)
• [L3] Prerevision cultures, grown after discontinuation of antibiotic treatment and before reimplantation of the components, helped to identify the patients with infection at the site of a total knee arthroplasty in whom the infection might recur. [78] (10.2106/00004623-200011000-00006)
• [L3] Furthermore, the change in between stages does not appear to identify subsequent PJI. [79] (10.1016/j.arth.2023.06.008)
• [L1] [112] (10.1186/s13018-020-01877-2)
• [L1] [113] (10.1016/j.jisako.2023.09.003)
• [L3] [114] (10.1016/j.arth.2010.01.104)
• [L4] [116] (10.1097/01.blo.0000149241.77924.01)
• [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. [117] (10.1016/j.arth.2018.06.026)
• [L4] [119] (10.1016/j.arth.2019.11.026)
• [L4] [120] (10.1016/j.arth.2023.04.059)
• [L3] However, it shows high sensitivity for PJI diagnosis in cases of low-virulence organisms which might be missed by most diagnostic tests. [121] (10.1016/j.arth.2023.05.022)
• [L3] Patients with suspected late-PJI should not receive antibiotics until the diagnosis is reached or refuted. [122] (10.1007/s11999-015-4142-z)
• [L2] Pathogens causing periprosthetic infection in both culture-positive and culture-negative samples of synovial fluid could be identified by next-generation sequencing. [124] (10.1302/0301-620x.100b2.bjj-2017-0531.r2)
• [L4] Treatment of patients with an infected total knee arthroplasty with high-dose vancomycin and gentamicin antibiotic spacers seems to be clinically safe. [127] (10.1097/01.blo.0000144476.43661.10)
• [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. [128] (10.1016/j.arth.2012.03.040)
• [L4] [130] (10.1016/j.arth.2016.04.009)
• [L4] Concomitant multiple PJIs are rare events that occur most often as a result of secondary hematogenous spread from a distant infectious focus. [133] (10.1016/j.arth.2016.02.012)
• [L3] Administration of intrawound vancomycin powder has no efficacy in preventing periprosthetic joint infection in primary total knee arthroplasty. [138] (10.1007/s00167-019-05778-8)
• [L1] The trial demonstrated the intrawound application of vancomycin powder to be inferior to standard postoperative IV antibiotics in reducing the incidence of periprosthetic joint infections after total knee arthroplasty. [139] (10.1016/j.arth.2023.01.040)
• [L4] [140] (10.1016/j.arth.2025.03.005)
• [L2] [142] (10.1016/j.arth.2024.03.070)
• [L3] The results support previous studies that demonstrated the effectiveness of a 2-stage reimplantation protocol with a standard 1:8 minimal bactericidal titer for treating infections after TKA, including multidrug-resistant organisms. [143] (10.1016/j.arth.2009.07.017)
• [L4] Surgeons should be cautious using this procedure as a routine means to address periprosthetic joint infection. [145] (10.1007/s11999-011-1910-2)
• [L3] We recommended DAIR as a choice for patients with current infection within 12 weeks after primary TKA. [146] (10.1186/s13018-022-03218-x)
• [L4] A high index of suspicion may result from careful examination of plain radiographs, and further imaging studies, including CT or MRI, are essential for diagnosis of septic knee arthritis with adjacent chronic osteomyelitis. [147] (10.1007/s00167-009-0976-9)
• [L3] Outcomes after prosthesis removal and antibiotic spacer placement are variable, and there are several independent risk factors for such outcomes that may be used to develop and improve existing treatment strategies for patients presenting with chronic PJI after TKA. [148] (10.1016/j.arth.2017.08.037)
• [L3] Orthopaedic surgeons should strongly consider patient comorbidities when selecting treatment pathways for PJIs. [149] (10.1016/j.arth.2025.05.127)
• [L2] Intrawound vancomycin administration does not decrease periprosthetic joint infection occurrence in primary total knee arthroplasty and significantly causes aseptic wound complications. [152] (10.1007/s00167-019-05498-z)
• [L4] Two-stage re-implantation with an articulating spacer for infected TKA effectively treats infection and gives excellent knee motion between stages, and at mid- to long-term follow-up. [155] (10.1016/j.arth.2008.04.003)
• [L3] This validated, evidence-based algorithm for diagnosing PJI should guide clinicians in the workup of patients undergoing revision arthroplasty and improve clinical practice. [157] (10.1016/j.arth.2019.06.016)
• [Paper] [159] (10.1097/corr.0000000000002971)
• [L3] However, there are differences in cutoff levels between knees and hips, suggesting international guidelines and diagnostic criteria need revisions. [161] (10.1016/j.arth.2018.05.018)
• [L3] Prior cellulitis is a risk factor for periprosthetic joint infection after total knee arthroplasty, especially when it occurs within a year of surgery. [162] (10.1016/j.arth.2025.07.007)
• [L3] Further investigation of this and other diagnostic tests following staged treatment of PJI is needed. [165] (10.1016/j.arth.2019.03.019)
• [L3] Our data provide preliminary support to the use of a single-stage approach in highly selected patients with chronically infected TKAs as an alternative to a two-stage procedure. [166] (10.1007/s11999-014-3721-8)
• [L2] Further studies are needed to explore diagnostic tests that will better detect PJI in patients with inflammatory arthritis. [167] (10.1016/j.arth.2019.01.051)
• [L4] Hematogenous infection after a successful two-stage exchange arthroplasty is a rare but very important cause of a reinfection. [169] (10.1007/s00402-018-2972-3)
• [L3] More accurate diagnostic tools are needed to support clinical judgment in monitoring infection progress and thus deciding whether or not to proceed with TKA reimplantation. [171] (10.1016/j.arth.2008.11.041)
• [L3] Patient factors remain the most important in terms of predicting early PJI following TKA. [172] (10.1177/2325967116s00087)
• [L3] The study identified two intra-articular CRP cut-offs of potential usefulness for diagnosing knee prosthesis infection. [173] (10.1016/j.otsr.2013.10.017)
• [L1] Sonication is an evolving modality in the context of periprosthetic joint infections. [174] (10.1016/j.arth.2018.02.077)
• [L3] Continued investigation is required to determine the fate of infected joints that undergo DAIR with regard to ultimate patient outcome. [176] (10.1097/corr.0000000000003138)
• [L4] In the absence of definitive X-ray findings, synovial fluid analysis offers a promising diagnostic modality. [190] (10.1016/j.arth.2025.04.067)

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[148] Risk Factors for Repeat Debridement, Spacer Retention, Amputation, Arthrodesis, and Mortality After Removal of an Infected Total Knee Arthroplasty With Spacer Placement. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2017.08.037

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[157] Development and Validation of an Evidence-Based Algorithm for Diagnosing Periprosthetic Joint Infection. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.06.016

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[161] How Reliable Is the Cell Count Analysis in the Diagnosis of Prosthetic Joint Infection?. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.05.018

[162] Prior Cellulitis as a Risk Factor for Periprosthetic Joint Infection in Total Knee Arthroplasty: Influence of Timing and Antibiotic Prophylaxis. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.07.007

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[174] What Is the Role of Diagnostic and Therapeutic Sonication in Periprosthetic Joint Infections?. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.02.077

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