Infection Management in Joint Arthroplasty

Periprosthetic joint infection (PJI) remains one of the most serious complications following hip and knee arthroplasty, affecting approximately 1–2 % of primary procedures and up to 4 % of revisions. The pathogenesis centres on microbial adhesion to implant surfaces, followed by biofilm formation that renders organisms tolerant to host defences and systemic antimicrobials. Early diagnosis relies on a combination of clinical assessment, laboratory indicators such as C-reactive protein and erythrocyte sedimentation rate, synovial fluid analysis, imaging and intraoperative cultures. Management requires a tailored surgical strategy, ranging from debridement with implant retention and exchange of modular components (DAIR) for acute presentations, to one-stage or two-stage revision arthroplasty for chronic or virulent infections. Adequate soft tissue coverage, dead-space management and stability of the new construct are critical. Adjunctive antimicrobial therapy should be guided by culture and sensitivity, with prolonged courses to eradicate residual biofilm. Prevention strategies include perioperative antibiotic prophylaxis, rigorous asepsis, and optimisation of patient comorbidities such as diabetes, obesity and malnutrition. A multidisciplinary approach with early involvement of microbiologists, orthopaedic surgeons and rehabilitation specialists underpins optimal outcomes and minimises functional impairment.

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Infection Management in Joint Arthroplasty publication trend

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Technical terms

Periprosthetic joint infection (PJI): Infection of the tissues and prosthetic components surrounding a joint implant, often involving biofilm-producing bacteria.

Biofilm: A structured community of microorganisms encased in a self-produced polymeric matrix adherent to implant surfaces, reducing antibiotic susceptibility.

Debridement, antibiotics and implant retention (DAIR): A limb-saving procedure involving surgical removal of infected tissue and irrigation, followed by targeted antibiotic therapy without removal of the main implant.

One-stage and two-stage revision: Surgical strategies for chronic PJI in which infected components are either exchanged and replaced in a single operation or removed with interim spacers before reimplantation in a subsequent procedure.

References

1. C-Reactive Protein, Erythrocyte Sedimentation Rate and Orthopedic Implant Infection. PLOS ONE (2010).
2. The DAIR (debridement, antibiotics and implant retention) procedure for infected total knee replacement – a literature review. SICOT-J (2017).
3. A systematic review of the evidence for single stage and two stage revision of infected knee replacement. BMC Musculoskeletal Disorders (2013).
4. Risk factors associated with revision for prosthetic joint infection following knee replacement: an observational cohort study from England and Wales. The Lancet Infectious Diseases (2019).
5. Risk factors associated with revision for prosthetic joint infection after hip replacement: a prospective observational cohort study. The Lancet Infectious Diseases (2018).