Clinicians › Hip

Periprosthetic joint infection (hip)

98 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Periprosthetic joint infection (PJI) of the hip remains a significant clinical challenge, with management complexities that persist despite increasing research interest [3]. The International Consensus on Periprosthetic Joint Infections has successfully aligned the community on 203 of 207 questions regarding prevention, diagnosis, and treatment, aiming to minimize care variations and reduce the burden of infection [1, 2]. While this consensus should lead to improved outcomes, numerous problems remain unresolved, and the BOOM meeting highlighted the low quality of underlying evidence in orthopaedic oncology contexts [3, 8]. The prevalence of PJI as a cause of metal-on-metal hip arthroplasty failure is relatively high compared to other bearing combinations, though responsible organisms are similar across implant types [5].

Diagnosis relies on the Musculoskeletal Infection Society (MSIS) definition, with a need for further study on emerging technologies and prevention protocols [17]. Routine use of synovial alpha-defensin is not recommended; it should be reserved for cases where PJI cannot be diagnosed or ruled out with standard testing [16]. Preoperative antimicrobial prophylaxis can be administered safely in patients undergoing revision arthroplasty with planned microbiologic sampling without compromising the diagnostic sensitivity of tissue sample cultures [32]. Epidemiological data indicate that the risk of subsequent PJI in patients with multiple arthroplasties is one half of previous estimates [6]. Infection rates following internal fixation range from 0% to 10%, compared with arthroplasty rates of 0% to 18% [56]. A series of over 3,000 intracapsular hip fractures recorded deep infection rates of 1.26% for hemiarthroplasty and 0.18% after fixation, while other large modern series have reported infection rates of 5% to 6% after fixation [56]. Reliable evidence linking poor oral health to PJI remains unclear [60].

Treatment strategies vary by patient fitness and organism sensitivity. In North America, two-stage revision arthroplasty is the treatment of choice for chronic periprosthetic infection of the hip and knee [7]. One-stage revision may be considered for fitter patients who tolerate major surgery when the infection involves a sensitive organism [56]. However, infection is generally associated with poor outcomes in the hip fracture population, with 1-year mortality rates of 40% to 50% reported in patients with PJI following hemiarthroplasty [56]. Patients presenting with PJI from an outside institution are more likely to undergo implant resection compared to those with an index arthroplasty at the investigating institution [73].

Anatomy & Pathophysiology

Bony Anatomy

The hip is a multiaxial ball-and-socket diarthrodial joint connecting the axial skeleton to the lower extremity, with stability based primarily on bony architecture [79, 76]. The hemipelvis comprises the ilium, ischium, and pubis, which unite at the triradiate cartilage within the concave acetabulum [79]. The ilium is a large flat bone forming the majority of the coxal bone, while the ischium is a small L-shaped bone forming the posteroinferior margin of the pelvis [79]. The pubis consists of a body and two rami connecting superiorly to the ilium and inferiorly to the ischium to form the obturator foramen [79]. The hemipelvises unite anteriorly at the pubic symphyses and articulate posteriorly with the sacral ala to form the sacroiliac joint [79].

The acetabulum comprises an articular crescent-moon–shaped lunate surface and a nonarticular central fossa serving as the attachment point for the ligamentum teres [79]. It is incomplete inferiorly, forming a notch through which vital blood vessels and nerves pass to supply the joint [79]. The femoral head forms two-thirds of a sphere, with a small central depression from which the ligamentum teres extends to connect to the acetabular notch [79]. The neck-shaft angle of the femur averages 125° [79], with the mean adult femoral neck-shaft angle reported as 130° ± 7° [85]. Normal version, defined as the head-neck angle in the frontal plane, averages 15 to 20° [79], while the mean anteversion of the femoral neck is 10° ± 7° [85].

The proximal femur contains two prime trabecular groups: the principal tensile group and the principal compressive group [85]. The weakest area in the femoral neck is located in the Ward triangle [85]. The calcar femorale is a medial area of dense trabecular bone that transfers stress from the femoral shaft to the inferior portion of the femoral neck [85].

Ligaments and Capsule

The hip is surrounded by a dense fibrous capsule extending from the periphery of the acetabulum to the intertrochanteric line of the femoral neck [79]. The capsule enhances joint stability by preventing translation of the femoral head in the acetabulum [79]. It attaches anteriorly and posteriorly along the periphery of the acetabulum outside the labrum, and inferiorly to the acetabular labrum [80]. On the femur, the capsule attaches anteriorly along the intertrochanteric crest; posteriorly, it attaches only partially, leaving the basicervical region of the femoral neck and the intertrochanteric region extracapsular [80, 76]. The capsule is tight in extension and internal rotation, and relaxed in flexion and external rotation [76].

Three main ligaments support the hip: Iliofemoral ligament: Y-shaped and the thickest and strongest of the three main ligaments, also known as the Y ligament of Bigelow [79, 76]. The medial portion connects the anterior inferior iliac spine to the anterior intertrochanteric line, while the lateral portion originates slightly superior to the medial arm and attaches to the anterior greater trochanter [79]. It functions to limit external rotation, with the lateral arm limiting extension in isolation [79]. It becomes taut in full extension, preventing anterior dislocation and hyperextension [80]. In severe hip arthritis, it may become very contracted and require release at surgery to relieve internal and flexion contracture [80]. Ischiofemoral ligament: Extends from the ischial margin of the acetabulum to the greater trochanter, providing posterior support and restricting internal rotation [79, 80]. It reinforces the posterior capsule and provides a check to internal rotation [80]. Pubofemoral ligament: Extends from the obturator crest of the pubic bone to the femoral neck, acting to limit abduction [79]. It attaches to the inferior and medial part of the capsule and may cause a hip adduction contracture [80].

Deep fibers from all three ligaments merge to form the zona orbicularis, which circumvents the femoral neck [79]. The twisted orientation of these ligaments provides a screw mechanism for the hip in full extension [80]. The ischiofemoral and pubofemoral ligaments are weaker but provide additional stability [76].

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

The ligamentum teres originates in the cotyloid fossa and attaches on the fovea of the femoral head [80]. It transmits an arterial branch of the posterior division of the obturator artery to the femoral head, which is less significant in adults [76].

Muscles

Primary hip flexors include the iliopsoas, rectus femoris, and sartorius muscles [83]. The iliopsoas has a large origin along the iliac crest, iliac fossa, sacra ala, iliolumbar ligaments, and sacroiliac ligaments, as well as origins along the bodies of T12 through L4 vertebrae, transverse processes of L1–L5, and intervertebral disks [83]. The rectus femoris crosses the hip and knee joints; its straight head originates from the AIIS, while its reflected head originates from the supra-acetabular tubercle [83]. It flexes the hip and extends the knee [83]. The sartorius originates on the ASIS, crosses the hip and knee joints, and inserts on the medial aspect of the tibia and pes anserine complex [83]. The tensor fasciae latae originates laterally on the anterolateral edge of the iliac crest and acts to flex, abduct, and rotate the hip [83]. Other flexors include the pectineus, adductor longus, adductor brevis, adductor magnus, and gracilis [83].

The gluteus maximus and hamstring muscles are the most important hip extensors [83]. The gluteus maximus originates from the sacrum, coccyx, and sacrotuberous ligaments, while the hamstrings originate on the ischial tuberosity [83]. The primary abductors are the gluteus medius and minimus muscles [83]. The gluteus medius has anterior, middle, and posterior components [83]. These muscles function together to maintain and abduct the femur during the stance phase of gait [83]. A Trendelenburg lurch compensates for abductor weakness by bringing the center of gravity closer to the hip center, forcing the patient to lean toward the affected side [83]. Damage or weakness to abductor muscles can occur during surgical approaches, affecting stability and potentially necessitating constrained hip implants [83].

Adductor muscles include the adductor brevis, adductor longus, adductor magnus, pectineus, and gracilis [83]. External rotators include the obturator internus and externus, superior and inferior gemelli, quadratus femoris, and piriformis muscles [83]. The obturator internus originates from the inner component of the obturator foramen and emerges through the lesser sciatic foramen [83]. The piriformis originates from the greater sciatic foramen and inserts onto the greater trochanter [83]. It serves as the reference structure for the posterior hip, with structures identified by whether they originate above or below it [83]. The superior gluteal nerve and artery exit the pelvis above the piriformis [83]. The pudendal nerve, internal pudendal artery, nerve to the obturator internus, posterior femoral cutaneous nerve, sciatic nerve, inferior gluteal nerve, inferior gluteal artery, and nerve to the quadratus femoris all exit below the piriformis [83]. In 10% of cases, the common peroneal component of the sciatic nerve passes through the division in the piriformis [83]. Most often, the sciatic nerve passes below the piriformis and is situated on top of the short external rotators [83]. The most consistent internal rotators are the gluteus medius and tensor fascia latae muscles [83].

The average range of motion of a normal hip is approximately 120° of flexion, 30° of extension, 45° of abduction, 20° to 30° of adduction, 35° of internal rotation, and 45° of external rotation [83]. Normal gait function requires hip flexion of 30°, hyperextension of 10°, abduction and adduction of 5°, and internal and external rotation of 5° [83].

Neurovascular Anatomy

Blood supply to the femoral head evolves with age. From birth to approximately 4 years, the major supply comes from the medial and lateral femoral circumflex arteries, with major contributions from the artery of the ligamentum teres [88]. From age 4 to adulthood, the posterosuperior and posteroinferior retinacular arteries (from the medial circumflex artery) are the major supply [88]. In adulthood, the major supply is from the medial femoral circumflex and lateral epiphyseal arteries [88].

The common femoral artery arises from the external iliac artery as it passes underneath the inguinal ligament and passes anterior and medial to the hip capsule [88]. It is the most commonly reported extrapelvic vascular structure injured during THA, typically due to errant retractor placement anterior to the acetabulum [88]. The profundus or deep femoral artery arises from the lateral aspect of the common femoral artery approximately 3.5 cm below the inguinal ligament [88]. The lateral circumflex artery arises from the lateral side of the proximal profundus femoris artery [88]. The medial circumflex artery most commonly comes from the posteromedial profundus femoris artery but may also arise directly from the femoral artery [88].

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

The medial femoral circumflex artery is the main blood supply to the femoral head and terminates in the posterior aspect of the extracapsular arterial ring [85]. The lateral femoral circumflex artery gives rise to the anterior aspect of this ring [85]. The superior and inferior gluteal arteries also contribute branches to the extracapsular arterial ring [85]. Ascending cervical arteries originate from this ring and are divided into lateral, medial, posterior, and anterior groups based on their relationship to the femoral neck [85]. The lateral group is the main blood supply to the femoral head [85]. These branches give off perforator vessels to the femoral neck and terminate in the subsynovial arterial ring at the margin of the articular surface [85]. The lateral epiphyseal artery penetrates the femoral head and is believed to be the dominant blood supply from this system [85]. Fractures disrupting ascending blood flow to the lateral epiphyseal vessel increase the risk of osteonecrosis [85]. The artery of the ligamentum teres arises from either the obturator or medial femoral circumflex artery and does not provide sufficient blood supply to maintain femoral head viability [85].

Pathophysiology of Infection

Biofilms are defined as microbially derived sessile communities characterized by cells irreversibly attached to a substratum or interface, embedded in a matrix of extracellular polymeric substances, and exhibiting an altered phenotype regarding growth rate and gene transcription [33]. Biofilm bacteria display characteristics that affect the identification of causative organisms and antimicrobial therapy compared to free-floating bacteria [33]. Treatment is much more challenging than for planktonic bacteria, requiring 100-1000 times the standard concentration of cell wall active antibiotics [33].

Staphylococcal species are a leading cause of community- and nosocomiacquired infections, where foreign material placement increases infection risk [143]. Indwelling medical devices and prosthetic implants are targets for staphylococcal cell adherence and biofilm formation [143]. Staphylococcal invasion at the surgical site followed by adherence to the prosthesis frequently results in biofilm formation [143]. The biofilm matrix supports three-dimensional bacterial organization while acting as a barrier to host defenses [143]. Biofilm products actively suppress proinflammatory microbicidal responses, evidenced by macrophage polarization toward an anti-inflammatory phenotype and recruitment of myeloid-derived suppressor cells [143]. Prosthetic joint infections likely originate from colonization with small numbers of bacteria, providing a survival window if the pathogen does not elicit an initial vigorous immune response [143].

The pathogen spectra of periprosthetic and native joint infections differ considerably [19]. The prevalence of PJI as a cause of MoM hip arthroplasty failure was relatively high compared to other hip bearing combinations, though the responsible organisms were similar [5]. The overall risk for implant-associated infection in orthopedic surgery is below 1%-2% [33]. In total hip arthroplasty, septic revision accounts for 7.5% of all revision surgeries [33]. The annual cost of infected revision total joint arthroplasty to US hospitals was projected to exceed $1.62 billion by 2020 [30]. Costs of PJI exceeded $900 million in 2012 and are projected to exceed $1.6 billion by 2020 [41]. The management of PJI remains difficult primarily due to the evolution of

Classification

The diagnosis of peri-prosthetic bone and joint infections relies on converging information from clinical, laboratory, and imaging assessments [36]. Clinical findings such as a sinus tract serve as major criteria for the diagnosis of peri-prosthetic bone and joint infections [36]. The definition of peri-prosthetic joint infection includes infections that occur within 3 months of index primary arthroplasty and within 3 weeks after symptom onset [132].

Diagnostic Paradigm: The orthopedic community should consider a probability and likelihood paradigm to create a PJI diagnostic definition, as probably not a single definition might be suited for all situations [35]. Biomarkers perform differently according to the selected PJI definitions [38]. The cutoff level for the 2018 International Consensus Meeting Minor Criteria seems to be different between the hip and knee [37].

Laboratory and Imaging Workup: The workup of patients with painful joint and suspected late periprosthetic joint infection should follow a systematic approach including laboratory tests and aspiration of the joint [10]. Synovial fluid analysis is adequate in differentiating patients with periprosthetic hip and knee infections [31]. FISH represents a fast and reliable tool for detecting PJI in periprosthetic membranes, especially in combination with clinical and histopathological classification [137]. The change in serum interleukin-6 between stages does not appear to identify subsequent PJI in patients who have two-stage revision for periprosthetic joint infection [23].

Other Considerations: The consensus process provided a comprehensive approach to minimize variations in care and reduce the burden of infection [2]. The prevalence of multiple periprosthetic joint infections has decreased compared with historical reports, likely due to higher rates of 2-stage revisions and fewer patients treated with I&D [27]. The management of periprosthetic joint infections in the future may still be challenging, with numerous problems to resolve and scope for plenty of research [3].

Clinical Presentation

Clinical Signs and Symptoms

Typical signs of periprosthetic joint infection include erythema, swelling, fever, and increased blood infection markers [52]; however, these signs are not always present [52]. Early or late acute infections may present with pain, fever, or erythema [109]. In chronic cases, pain unrelieved by a seemingly well-functioning arthroplasty serves as a clue towards infection [109]. A history of excessive wound drainage, multiple episodes of wound erythema, or prolonged antibiotic treatment by the operating surgeon is worrisome for infection [109].

Diagnostic Challenges and Variability

Diagnosis is challenging because clinical presentations vary and no single test is totally reliable [52]. The diagnosis is usually made on the basis of a combination of different parameters, including clinical, serum, and synovial fluid findings [52]. In the early postoperative period after total hip arthroplasty, diagnosis is difficult because normal cues from the physical examination are often unreliable and serological markers commonly used for diagnosis are elevated from recent surgery [105]. Late chronic infections can be challenging to distinguish from other causes of pain in a patient with a previous total hip arthroplasty [109].

The prevalence of periprosthetic joint infection as a cause of metal-on-metal hip arthroplasty failure was relatively high compared to other hip bearing combinations, though the responsible organisms were similar to those in other combinations [5]. Concomitant multiple periprosthetic joint infections are rare events that occur most often as a result of secondary hematogenous spread from a distant infectious focus [64]. Cutibacterium is an increasingly recognized pathogen in total hip arthroplasty that can present with normal serology, leading to misdiagnosis as aseptic failure [113].

Imaging Findings

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

Laboratory and Biomarker Considerations

The workup of patients with a painful joint and suspected late periprosthetic joint infection should follow a systematic approach including laboratory tests and aspiration of the joint [10]. Modern inflammatory serum markers such as interleukin (IL)-6, tumour necrosis factor (TNF)-α, and procalcitonin have not shown distinct advantages over conventional inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), and have not found their way into routine clinical practice [52].

Increased inflammatory laboratory values in patients with periprosthetic fracture are not good indicators for deep periprosthetic infection and do not necessarily warrant additional evaluations before definitive surgical treatment [53]. The diagnostic utility of serum and synovial markers for diagnosing periprosthetic joint infection was lower in the setting of concomitant periprosthetic fracture compared to periprosthetic joint infection alone [54]. Biomarkers perform differently according to the selected periprosthetic joint infection definitions [38]. 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 [39].

Regarding specific synovial fluid markers, the authors recommend against the routine use of synovial alpha-defensin and suggest it be reserved for cases where periprosthetic joint infection cannot be diagnosed or ruled out with standard testing [16]. Conversely, the authors recommend the use of the synovial fluid biomarker IL-6 for the diagnosis of periprosthetic joint infection following total hip and knee arthroplasty [26]. 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 [63]. D-dimer shows high sensitivity for periprosthetic joint infection diagnosis in cases of low-virulence organisms which might be missed by most diagnostic tests [57]. Further studies are needed to explore diagnostic tests that will better detect periprosthetic joint infection in patients with inflammatory arthritis [62]. Although other causes exist, it is essential to perform a work-up for prosthetic joint infections when C-reactive protein levels are elevated in the early postoperative period [117].

Aspiration and Sampling

Hip aspiration is warranted if one of the three previously mentioned lab values (ESR, CRP, D-dimer) are elevated, or if the index of suspicion for infection is high despite normal values [109]. Aspiration should not be undertaken until at least 2 weeks after discontinuation of antibiotic therapy [109]. Patients with suspected late periprosthetic joint infection should not receive antibiotics until the diagnosis is reached or refuted [29].

Aspiration is done in an outpatient setting with the patient under local anesthesia [109]. Fluoroscopy or ultrasonography are useful for accurate insertion of the needle during aspiration [109]. The aspiration is done with the same attention to sterile technique as a surgical procedure, with a full surgical scrub and preparation, as skin flora may be introduced into the cultures and confuse the results, or introduced into the joint [109]. An 18-gauge spinal needle is inserted from anterior at a point just lateral to the femoral artery along a line from the symphysis pubis to the ASIS [109]. As an alternative, the needle is inserted laterally, just superior to the greater trochanter [109]. The tip of the needle must enter the joint and must be seen and felt to come in contact with the metal of the neck of the femoral component [109]. Gentle rotation of the extremity helps bring fluid toward the needle if none is easily withdrawn after entering the joint [109].

Aerobic and anaerobic cultures, and cell count with differential, are obtained from the aspirant [109]. Leukocyte esterase test strip and alpha-defensin testing are additional synovial fluid markers for infection that have shown high sensitivity and specificity and should be obtained if sufficient fluid is available [109]. Approximately one third of patients have dry hip aspiration, in which case cultures are less predictive of intraoperative findings [65]. Results from a small, prospective series suggest that preoperative antimicrobial prophylaxis may be administered safely even in patients undergoing revision hip or knee arthroplasty in which microbiologic sampling is planned without compromising the diagnostic sensitivity of tissue sample cultures [32]. Sonication of retrieved implants improves sensitivity in the diagnosis of periprosthetic joint infection [15].

Diagnostic Criteria and Definitions

The consensus process provides a comprehensive approach to minimize variations in care and reduce the burden of infection [2]. The Musculoskeletal Infection Society definition for diagnosing periprosthetic joint infection is detailed in orthopaedic literature [17]. The orthopedic community should consider a probability and likelihood paradigm to create a periprosthetic joint infection diagnostic definition, as probably not a single definition might be suited for all situations [35]. The 2018 definition of periprosthetic hip and knee infection is an evidence-based and validated criteria [15].

Two positive periprosthetic cultures with phenotypically identical organisms is a major criterion for the diagnosis of periprosthetic joint infection [107]. A sinus tract communicating with the joint is a major criterion for the diagnosis of periprosthetic joint infection [107]. Clinical findings like a sinus tract serve as major criteria in the diagnosis of peri-prosthetic bone and joint infections [36]. Three of the following minor criteria are required for diagnosis if major criteria are absent: elevated serum CRP and ESR, either an elevated synovial fluid WBC count OR ++ reaction on leukocyte esterase test strip, elevated synovial fluid PMN percentage, a single positive culture, or positive histological analysis of periprosthetic tissue [107].

Investigations

Diagnostic Criteria and Consensus: The diagnosis of periprosthetic bone and joint infections relies on converging information from clinical, laboratory, and imaging assessments [36]. Clinical findings such as a sinus tract serve as major criteria for the diagnosis of periprosthetic joint infection [36]. The Musculoskeletal Infection Society (MSIS) definition is used for diagnosing periprosthetic joint infection [17]. The 2018 definition for diagnosing hip and knee periprosthetic joint infection is an evidence-based criterion that has demonstrated excellent performance on formal external validation [75]. The International Consensus on Periprosthetic Joint Infections reached agreement on all but four of 207 questions regarding the prevention, diagnosis, and treatment of periprosthetic joint infection [2].

Laboratory: Synovial fluid interleukin-6 (IL-6) is recommended as a biomarker for the diagnosis of periprosthetic joint infection following total hip and knee arthroplasty [26]. Synovial C-reactive protein (CRP) is a marker for chronic periprosthetic infection in total hip arthroplasty [52]. Modern inflammatory serum markers, including interleukin-6, tumour necrosis factor-alpha, and procalcitonin, have not shown distinct advantages over conventional inflammatory markers such as CRP and erythrocyte sedimentation rate (ESR) [52]. The change in serum interleukin-6 between stages of two-stage revision does not appear to identify subsequent periprosthetic joint infection [23]. D-dimer shows high sensitivity for the diagnosis of periprosthetic joint infection in cases of low-virulence organisms [57]. Leukocyte esterase (LE) is an accurate and effective synovial fluid marker for diagnosing periprosthetic joint infection [63]. The diagnostic utility of serum and synovial markers for diagnosing periprosthetic joint infection is lower in the setting of concomitant periprosthetic fracture compared to periprosthetic joint infection alone [54]. The accuracy of diagnostic tests for periprosthetic joint infection varies with respect to demographic factors [39].

Aspiration: Synovial fluid aspiration, diagnostic imaging, traditional culture, peripheral serum inflammatory markers, and intraoperative frozen sections each have limitations but continue to be the mainstay for the diagnosis of periprosthetic joint infection [142]. Microcalorimetry of synovial fluid allows thermogenic diagnosis of periprosthetic joint infection [150].

Emerging and Specific Diagnostic Tools: The routine use of synovial alpha-defensin is not recommended, and it should be reserved for cases where periprosthetic joint infection cannot be diagnosed or ruled out with standard testing [16]. The alpha-defensin lateral flow test is considered part of the diagnostic toolbox for periprosthetic joint infections [40]. However, the alpha-defensin lateral flow test has a sensitivity limited to 54% to 84% and should be used as a confirmatory test rather than for screening [149]. Transcriptome-wide high-density microarray analysis reveals differential gene transcription in periprosthetic tissue from hips with chronic periprosthetic joint infection versus aseptic loosening [28]. Further investigation of diagnostic tests following staged treatment of periprosthetic joint infection is needed [59].

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

MRI: Magnetic resonance imaging (MRI) is the modality of choice for patients suspected of soft tissue or intra-articular pathology due to its superior sensitivity and specificity [93].

CT: Computed tomography (CT) scans are effective for examining cortical and cancellous bone and can create three-dimensional reconstructions of the hip for surgical planning [93].

Ultrasonography: Ultrasonography is a valuable tool to examine pediatric hip conditions, but its utility in evaluating the adult hip is limited [93].

Other Considerations: A thorough clinical examination is required to determine a differential diagnosis for hip pain because many conditions present with similar symptoms [49]. Imaging findings should complement clinical examination findings to provide the most accurate diagnosis of hip pathology [49].

Treatment

Non-Operative

Non-operative management is an option for frail patients with organisms sensitive to common antibiotics, utilizing low-dose antibiotic therapy to suppress infection [56]. This approach is particularly relevant given the high carriage of methicillin-resistant Staphylococcus aureus in the frail population, a common cause of deep infection in these cases [56]. Excision arthroplasty to control infection is generally associated with very poor postoperative mobility, with older patients usually becoming wheelchair-bound [56].

Operative

Indications: Two-stage exchange arthroplasty is indicated for septic or medically compromised patients, unidentified organisms, virulent or drug-resistant bacteria, sinus tracts, and compromised surrounding soft tissues [110]. One-stage exchange is reasonable when effective antibiotics are available and systemic symptoms of sepsis are absent [110]. Relative contraindications to single-stage treatment include lack of preoperative identification of the infecting organism, patients with multiple medical comorbidities, presence of sinus track(s), and soft-tissue compromise possibly requiring flap coverage [110]. Debridement and retention is worth considering particularly if the infection is caused by a single antibiotic-sensitive organism [56].

Surgical Approach / Technique: The consensus process aims to minimize variations in care and reduce the burden of infection [2]. Management remains challenging with numerous problems to resolve and scope for further research [3]. Biofilm bacteria require 100-1000 times the standard concentration of cell wall active antibiotics compared to planktonic bacteria for treatment [33]. The evidence for treating periprosthetic joint infections due to resistant staphylococci is variable and often suffers from small numbers of heterogeneous patients [4]. The annual cost of infected revision total joint arthroplasty to US hospitals was projected to exceed $1.62 billion by 2020 [30].

Implant Selection: Two-stage reimplantation is associated with a high rate of early success in the treatment of deep infection after total hip arthroplasty but is associated with a modest rate of recurrent infection or mechanical failure [72]. Treatment of infection at the site of a hip arthroplasty with 2-stage revision using cementless components and an articulated spacer yields recurrence rates similar to revisions where at least one of the components at the second stage is fixed with antibiotic-loaded cement [70]. A 2-stage reimplantation protocol with a standardized 1:8 minimal antibiotic serum bactericidal titer is effective for the treatment of periprosthetic infections of the hip, including those caused by drug-resistant organisms [20]. 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 [44]. Partial component-retained two-stage reconstruction could be an alternative treatment option for chronic infection after an uncemented total hip arthroplasty with a radiographically and clinically well-fixed component in selected patients who are not immunocompromised and are infected by a low-virulence organism [22]. Two-stage revision total hip arthroplasty without spacer placement is a viable option to manage infection in patients with severe bone loss or abductor deficiency, though dislocation continues to be a major concern [45].

Spacers and Reconstruction: Growing data and International Consensus Meeting recommendations support using articulating antibiotic spacers whenever possible, reserving static spacers only for cases with major femoral/acetabular bone loss or abductor mechanism loss [68]. A specific articulating antibiotic spacer design allows for reliable periprosthetic joint infection eradication, low spacer-related complications, and reliable improvement in functional outcomes [12]. There was a high rate of mechanical complications with stage-one antibiotic coated molded hip spacers, especially in those patients who required an extended trochanteric osteotomy [34]. The PROSTALAC technique involves implanting a prosthesis of antibiotic-loaded acrylic cement at the time of the initial debridement [110]. At 10- to 15-year follow-up, Biring et al. reported an overall 89% success rate with the PROSTALAC technique [110]. Others have described similar interval spacers of various types, with 77% to 100% eradication of the infection reported [110]. Complications other than recurrent or persistent infection with interval spacers include dislocation or fracture of the interval prosthesis [110]. A PJI eradication rate of 72% with acceptable functional outcome was described for massive endoprostheses used for managing periprosthetic joint infections of the hip and knee [13].

Antibiotic Therapy and Prophylaxis: Most hips and Gram-positive infections treated with chronic antibiotic suppression successfully avoided reoperation in a specific cohort [14]. Local antibiotic prophylaxis in patients with non-modifiable risk factors undergoing hip or knee replacement reduces the incidence of acute periprosthetic joint infection compared to IV antibiotics [114]. The use of vancomycin as the perioperative prophylactic antibiotic for primary total joint arthroplasties appeared to be effective in decreasing the rate of periprosthetic joint infection and may result in infections with less virulent organisms when they occur [125]. Preoperative antimicrobial prophylaxis may be administered safely even in patients undergoing revision hip or knee arthroplasty in which microbiologic sampling is planned without compromising the diagnostic sensitivity of tissue sample cultures [32]. Rifampin combination therapy was evaluated in a randomized controlled trial for staphylococcal prosthetic joint infections [111].

Debridement and Implant Retention: Several authors have reported on debridement and implant retention for management of infection with success rates of between 65% and 75% after total hip arthroplasty [56]. The results of debridement and retention for management of infection after hemiarthroplasty for intracapsular hip fracture have been less favorable in terms of infection eradication compared to total hip arthroplasty [56]. del Toro reported a 44% success rate for debridement and retention after hemiarthroplasty [56]. Guren et al. reported a success rate of eradication of infection in 15/35 (43%) cases for debridement and retention after hemiarthroplasty [56].

Other Considerations: In a review of 168 patients treated with two-stage exchange, infection-free survival was 87.5% at 7 years average follow-up [110]. An administrative database study of over 10,000 patients treated with prosthesis removal and spacer placement found a 90-day mortality rate of 2.6% [110]. The optimal timing for reimplantation of another prosthesis has not been determined [110]. Reimplantation of a total hip can be difficult because of extensive scarring of the soft tissues and disuse osteoporosis [110]. Dislocation after surgery is not uncommon following reimplantation of a total hip [110]. The sciatic nerve may be encased in scar tissue near the posterior margin of the acetabulum and should be protected during reimplantation [110]. Complete capsulectomy, along with release of the iliopsoas and gluteus maximus tendons, may be necessary during reimplantation [110]. The most recent systematic review and meta-analysis comparing one-stage and two-stage revision for periprosthetic joint infection have shown no difference in reinfection rates in both knees and hips [129]. One-stage exchange of the hip for periprosthetic joint infection is a reliable treatment option with a high rate of infection control and long-lasting favorable outcomes [43]. The committee recognized the importance of antibiotic-containing cement or bone graft in the reconstruction to achieve success in one-stage exchange [110].

The results of immediate exchange arthroplasty are not likely to be as good in the hip fracture population, with a much frailer population [56]. Management of septic arthritis by arthroplasty using a specific protocol gave very good functional results in both knee and hip, with 87% of eradication of infection in evolutive septic arthritis and 95% in quiescent septic arthritis [48]. The results of modified Girdlestone resection arthroplasty after a total hip replacement in general are not as satisfactory as the results after hip joint infections that have required less bone and soft-tissue resection [110]. Almost all patients require some sort of assistive device to walk after modified Girdlestone resection arthroplasty [110]. Functional outcomes are poor in elderly patients, females, and patients with more extensive resection of bone from the proximal femur after modified Girdlestone resection arthroplasty [110]. Most patients are unwilling to live with the constraints of a resection arthroplasty and will elect to undergo reimplantation of their prosthesis [110].

The routine use of synovial alpha-defensin is not necessary and should be reserved for cases where periprosthetic joint infection cannot be diagnosed or ruled out with standard testing [16]. The routine use of alpha-defensin in the work-up prior to a second-stage arthroplasty procedure for periprosthetic joint infection may not be warranted [130]. The prevalence of periprosthetic joint infection as a cause of metal-on-metal hip arthroplasty failure was relatively high compared to other hip bearing combinations, however, the organisms responsible were similar [5]. Chronic institutionalized patients have a higher risk of acute periprosthetic joint infection after hip hemiarthroplasty, commonly caused by gram-negative microorganisms not covered by current prophylaxis strategies [140].

Complications

Infection (PJI): The prevalence of periprosthetic joint infection as a cause of metal-on-metal hip arthroplasty failure is relatively high compared to other hip bearing combinations, though the responsible organisms are similar [5]. Patients diagnosed with a urinary tract infection within 1 week of total knee arthroplasty or within 2 weeks of total hip arthroplasty face an increased risk of developing subsequent periprosthetic joint infection within 2 years of surgery [74]. Periprosthetic joint infections caused by enterococci have poor outcomes [124]. The prevalence of multiple periprosthetic joint infections has decreased compared with historical reports, likely due to higher rates of 2-stage revisions and fewer patients treated with irrigation and debridement [27].

Other Considerations: Diagnostic Challenges: The change in serum interleukin-6 between stages does not appear to identify subsequent periprosthetic joint infection in patients who have two-stage revision [23].

Prophylaxis and Prevention: Single-dose prophylactic antibiotics did not lead to an increased risk of acute periprosthetic joint infection or short-term complications after total joint arthroplasty [136]. Extending perioperative prophylactic antibiotics until intraoperative culture results become available in patients undergoing revision total hip arthroplasty for aseptic failures does not provide any additional benefit in terms of reducing the risk of subsequent periprosthetic joint infection [139]. Extended oral antibiotic prophylaxis after aseptic revision total hip arthroplasty was not associated with a statistically significant decreased risk of any infection, periprosthetic joint infection, or re-revision or reoperation for infection at all time points [141].

Treatment Efficacy: Antibiotics combined with 1 or 2-stage revision are associated with the higher success rates and remain the mainstay of treatment for periprosthetic joint infection [41]. The use of massive endoprostheses for managing periprosthetic joint infections of the hip and knee resulted in a periprosthetic joint infection eradication rate of 72% with acceptable functional outcome [13]. Partial component-retained two-stage reconstruction could be an alternative treatment option for chronic infection after an uncemented total hip arthroplasty in selected patients who are not immunocompromised and are infected by a low-virulence organism [22]. Most hips and Gram-positive infections treated with chronic antibiotic suppression successfully avoided reoperation [14]. Management of septic arthritis by arthroplasty using a specific protocol gave very good functional results in both knee and hip, with 87% eradication of infection in evolutive septic arthritis and 95% in quiescent septic arthritis [48].

Mechanical and Systemic Complications: There was a high rate of mechanical complications after stage-one antibiotic coated molded hip spacer use, especially in those patients who required an extended trochanteric osteotomy [34]. Spacer design, acetabular and femoral bone loss, and offset restoration were significantly associated with perioperative complications in two-stage revision hip arthroplasty [71]. Acute renal failure can occur after the first stage of a 2-stage exchange for periprosthetic joint infection [122].

Recovery

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

Treatment Outcomes and Complications: A favorable outcome in patients with periprosthetic joint infection undergoing a two-stage procedure was associated with an infection sustained by Gram-positive bacteria, absence of known comorbidities, and administration of oral therapy [44]. The PJI eradication rate for massive endoprostheses used for managing periprosthetic joint infections of the hip and knee is 72% with acceptable functional outcome [13]. Using one-stage revision for chronic infected hip replacements without applying any exclusion criteria can result in a greater success rate from a clinical point of view with an important reduction in the morbidity-mortality rate of the patients [42]. Debridement, antibiotics, and implant retention is a valuable option in the treatment of hip periprosthetic joint infection, especially in the early postoperative period (≤6 weeks), with good outcomes [158]. Two-stage revision total hip arthroplasty without spacer placement is a viable option to manage infection in patients with severe bone loss or abductor deficiency, but dislocation continues to be a major concern [45]. There was a high rate of mechanical complications after stage-one antibiotic coated molded hip spacer, especially in those patients who required an extended trochanteric osteotomy [34]. At a minimum 2-year followup, infection control was attained in 29 of 30 patients without evidence of graft resorption when using vancomycin-supplemented cancellous bone allografts in hip revision surgery [157]. Patients diagnosed with urinary tract infection within 1 week of total knee arthroplasty or within 2 weeks of total hip arthroplasty are at an increased risk of developing subsequent periprosthetic joint infection within 2 years of surgery [74].

Key Evidence

• [L5] The International Consensus on Periprosthetic Joint Infections has focused the community and should lead to better research and outcomes, though many areas still require further research. [1] (10.1302/0301-620x.95b11.33224)
• [L5] The consensus process successfully reached agreement on all but four of 207 questions regarding the prevention, diagnosis, and treatment of periprosthetic joint infection, providing a comprehensive approach to minimize variations in care and reduce the burden of infection. [2] (10.1302/0301-620x.95b11.33135)
• [L5] Despite increasing recent interest, the management of periprosthetic joint infections in the future may still be challenging, with numerous problems to resolve and scope for plenty of research. [3] (10.1302/0301-620x.104b11.bjj-2022-0944)
• [L4] The evidence for treating periprosthetic joint infections due to resistant staphylococci is variable and often suffers from small numbers of heterogenous patients. [4] (10.1302/0301-620x.96b11.34333)
• [L3] The prevalence of PJI as a cause of MoM hip arthroplasty failure was relatively high compared to other hip bearing combinations; however, the organisms responsible were similar. [5] (10.1016/j.arth.2016.03.064)
• [L3] The study identified the risk of developing a subsequent periprosthetic joint infection to be one half of previous studies. [6] (10.1016/j.arth.2017.10.024)
• [L5] In North America, two-stage revision arthroplasty is the treatment of choice for chronic periprosthetic infection of the hip and knee. [7] (10.5435/jaaos-22-03-153)
• [L5] The BOOM meeting achieved consensus for important topics on periprosthetic infection in orthopaedic oncology, but highlighted the low quality of the underlying evidence. [8] (10.1302/0301-620x.107b12.bjj-2024-1039.r4)
• [L4] Using cementless prostheses in two-stage revisions of periprosthetic infections of the hip in combination with a specific local and systemic antibiotic therapy seems to eradicate infection and provide implant stability. [9] (10.1007/s11999-008-0611-y)
• [L4] The workup of patients with painful joint and suspected late periprosthetic joint infection should follow a systematic approach including laboratory tests and aspiration of the joint. [10] (10.1002/jor.22561)
• [L4] Eradication of periprosthetic joint infections, while minimizing patient morbidity, continues to be a challenge. [11] (10.1016/j.arth.2019.07.001)
• [L3] This design allows for reliable PJI eradication, low spacer-related complications, and reliable improvement in functional outcomes. [12] (10.1016/j.arth.2018.08.016)
• [L4] We describe PJI eradication rate of 72% with acceptable functional outcome. [13] (10.1016/j.arth.2017.09.046)
• [L3] Most hips and Gram-positive infections treated with CAS successfully avoided reoperation in this cohort. [14] (10.1016/j.arth.2022.02.003)
• [L3] [15] (10.1186/s12891-019-3006-1)
• [L2] The authors recommend against its routine use and suggest it be reserved for cases where PJI cannot be diagnosed or ruled out with standard testing. [16] (10.1302/0301-620X.102B5.BJJ-2019-0473.R3)
• [L5] It also details the MSIS definition for diagnosing periprosthetic joint infection and highlights the need for further study on emerging diagnostic technologies and prevention protocols. [17] (10.5435/jaaos-d-16-00634)
• [L3] The pathogen spectra of periprosthetic and native joint infections differ considerably. [19] (10.1186/s13018-021-02850-3)
• [L4] This study supports the efficacy of a 2-stage reimplantation protocol with a standardized 1:8 minimal antibiotic serum bactericidal titer for the treatment of periprosthetic infections of the hip, including those caused by drug-resistant organisms. [20] (10.1016/j.arth.2008.07.004)
• [L4] The authors consider that no patient with an infected hip joint should be offered Girdlestone resection arthroplasty as the only alternative. [21] (10.1016/j.arth.2007.06.007)
• [L4] Partial component-retained two-stage reconstruction could be an alternative treatment option for chronic infection after an uncemented total hip arthroplasty with a radiographically and clinically well-fixed component in selected patients, who are not immunocompromised and are infected by a low-virulence organism. [22] (10.1007/s00264-017-3505-3)
• [L3] Furthermore, the change in between stages does not appear to identify subsequent PJI. [23] (10.1016/j.arth.2023.06.008)
• [L4] Surgeons should be cautious using this procedure as a routine means to address periprosthetic joint infection. [25] (10.1007/s11999-011-1910-2)
• [L2] On the basis of the results we recommend the use of the synovial fluid biomarker IL-6 for the diagnosis of periprosthetic joint infection following total hip and knee arthroplasty. [26] (10.1371/journal.pone.0089045)
• [L4] The prevalence of multiple periprosthetic joint infections has decreased compared with historical reports, likely due to higher rates of 2-stage revisions and fewer patients treated with I&D. [27] (10.1016/j.arth.2016.05.013)
• [L4] [28] (10.1016/j.arth.2016.06.036)
• [L3] Patients with suspected late-PJI should not receive antibiotics until the diagnosis is reached or refuted. [29] (10.1007/s11999-015-4142-z)
• [L5] [30] (10.5435/jaaos-d-14-00455)
• [L1] Synovial fluid analysis is adequate in differentiating patients with periprosthetic hip and knee infections. [31] (10.1007/s00264-018-3865-3)
• [L2] Results from this small, prospective series suggest that preoperative antimicrobial prophylaxis may be administered safely even in patients undergoing revision hip or knee arthroplasty in which microbiologic sampling is planned without compromising the diagnostic sensitivity of tissue sample cultures. [32] (10.1007/s11999-015-4486-4)
• [L1] [33] (10.1016/j.arth.2018.02.077)
• [L4] There was a high rate of mechanical complications, especially in those patients who required an extended trochanteric osteotomy. [34] (10.1016/j.arth.2022.02.116)
• [L4] The orthopedic community should consider a probability and likelihood paradigm to create a PJI diagnostic definition, as probably not a single definition might be suited for all situations. [35] (10.1016/j.arth.2019.10.032)
• [L4] The diagnosis of peri-prosthetic bone and joint infections relies on converging information from clinical, laboratory, and imaging assessments, with clinical findings like a sinus tract serving as major criteria. [36] (10.1016/j.otsr.2018.04.029)
• [L3] The cutoff level seems to be different between the hip and knee. [37] (10.1016/j.arth.2020.03.014)
• [L1] Biomarkers perform differently according to the selected PJI definitions. [38] (10.1016/j.arth.2023.06.017)
• [L3] Understanding how the accuracy of diagnostic tests varies with respect to demographic factors can help physicians avoid subjecting patients to unnecessary additional testing and reach more accurate diagnoses of PJI. [39] (10.1016/j.arth.2020.10.036)
• [L2] The results are promising for the care of the painful or problematic knee and hip joint arthroplasty and the test should be considered as part of the diagnostic toolbox for PJIs. [40] (10.1302/0301-620x.99b9.bjj-2016-1345.r2)
• [L4] [41] (10.1016/j.arth.2017.07.045)
• [L3] Using 1-stage revision for chronic infected hip replacements without applying any exclusion criteria can result in a greater success rate from a clinical point of view with an important reduction in the morbidity-mortality rate of the patients. [42] (10.1016/j.arth.2017.08.033)
• [L3] One-stage exchange of the hip for PJI is a reliable treatment option with high rate of infection control and long-lasting favorable outcomes. [43] (10.1016/j.arth.2019.02.021)
• [L3] A favorable outcome in patients with PJI undergoing 2-stage procedure was associated with an infection sustained by Gram-positive bacteria, absence of known comorbidities, and administration of oral therapy. [44] (10.1016/j.arth.2017.02.057)
• [L3] However, dislocation continues to be a major concern. [45] (10.1016/j.arth.2021.02.040)
• [L4] One-stage revision hip arthroplasty using cementless implants appears to have a role in the treatment of carefully selected patients with an infected hip replacement if meticulous débridement is performed and appropriate antibiotics are properly used. [47] (10.1007/s00264-008-0640-x)
• [L4] Management of septic arthritis by arthroplasty using the present protocol gave very good functional results in both knee and hip, with 87% of eradication of infection in evolutive septic arthritis and 95% in quiescent septic arthritis. [48] (10.1016/j.otsr.2010.06.009)
• [L2] [52] (10.1302/0301-620x.97b2.34550)
• [L3] Increased inflammatory laboratory values in patients with periprosthetic fracture are not good indicators for deep periprosthetic infection and do not necessarily warrant additional evaluations before definitive surgical treatment. [53] (10.1016/j.arth.2008.05.026)
• [L3] The diagnostic utility of serum and synovial markers for diagnosing periprosthetic joint infection was lower in the setting of concomitant periprosthetic fracture compared to PJI alone. [54] (10.1016/j.arth.2020.08.029)
• [L3] However, it shows high sensitivity for PJI diagnosis in cases of low-virulence organisms which might be missed by most diagnostic tests. [57] (10.1016/j.arth.2023.05.022)
• [L3] Further investigation of this and other diagnostic tests following staged treatment of PJI is needed. [59] (10.1016/j.arth.2019.03.019)
• [L5] While guidelines exist for antibiotic prophylaxis in arthroplasty patients undergoing dental procedures, reliable evidence linking poor oral health to periprosthetic joint infection remains unclear, necessitating continued refinement of recommendations. [60] (10.5435/jaaos-d-14-00419)
• [L2] Further studies are needed to explore diagnostic tests that will better detect PJI in patients with inflammatory arthritis. [62] (10.1016/j.arth.2019.01.051)
• [L3] LE is an accurate and effective synovial fluid marker for diagnosing periprosthetic joint infection and should be used in conjunction with the current battery of available diagnostic tests. [63] (10.1016/j.arth.2017.06.005)
• [L4] Concomitant multiple PJIs are rare events that occur most often as a result of secondary hematogenous spread from a distant infectious focus. [64] (10.1016/j.arth.2016.02.012)
• [L3] Approximately one third of patients have dry hip aspiration, and in these patients cultures are less predictive of intraoperative findings. [65] (10.1016/j.arth.2022.01.066)
• [L5] Growing data and International Consensus Meeting recommendations support using articulating antibiotic spacers whenever possible, reserving static spacers only for cases with major femoral/acetabular bone loss or abductor mechanism loss. [68] (10.1016/j.arth.2019.11.007)
• [L1] Intrawound vancomycin may reduce the risk of periprosthetic joint infection in primary and revision total knee and hip arthroplasty; however, only low-quality evidence exists, highlighting the need for randomized controlled trials before broad adoption. [69] (10.1016/j.arth.2019.03.071)
• [L4] Treatment of infection at the site of a hip arthroplasty with 2-stage revision using cementless components and an articulated spacer yields recurrence rates similar to revisions where at least one of the components at the second stage is fixed with antibiotic-loaded cement. [70] (10.1016/j.arth.2006.02.156)
• [L3] Spacer design, acetabular and femoral bone loss, and offset restoration were significantly associated with perioperative complications. [71] (10.1016/j.arth.2019.02.012)
• [L4] Two-stage reimplantation is associated with a high rate of early success in the treatment of deep infection after THA but is associated with a modest rate of recurrent infection or mechanical failure. [72] (10.1007/s11999-008-0480-4)
• [L3] Patients presenting with prosthetic joint infection from an outside institution were more likely to undergo implant resection compared to those with an index arthroplasty at the investigating institution. [73] (10.1016/j.arth.2018.09.091)
• [L3] Patients diagnosed with UTI within 1 week of TKA or within 2 weeks of THA are at an increased risk of developing subsequent PJI within 2 years of surgery. [74] (10.1016/j.arth.2022.05.034)
• [L2] This study offers an evidence-based definition for diagnosing hip and knee PJI, which has shown excellent performance on formal external validation. [75] (10.1016/j.arth.2018.02.078)
• [L3] [105] (10.1007/s11999-013-3089-1)
• [L3] [107] (10.1302/0301-620x.99b3.bjj-2016-0684.r1)
• [L1] [111] (10.1186/s13018-020-01877-2)
• [L4] Cutibacterium is an increasingly recognized pathogen in THA that can present with normal serology, leading to misdiagnosis as aseptic failure. [113] (10.1016/j.arth.2022.01.015)
• [L2] Local antibiotic prophylaxis in patients with non-modifiable risk factors undergoing hip or knee replacement reduces the incidence of acute PJI compared to IV antibiotics. [114] (10.1016/j.jisako.2022.08.002)
• [L3] Although other causes exist, it is essential to perform a work-up for prosthetic joint infections. [117] (10.1016/j.arth.2016.02.037)
• [L3] [122] (10.1016/j.arth.2020.08.028)
• [L3] [124] (10.1016/j.arth.2016.09.017)
• [L3] The use of vancomycin as the perioperative prophylactic antibiotic for primary total joint arthroplasties appeared to be effective in decreasing the rate of PJI and may result, when they occur, in infections with less virulent organisms. [125] (10.1016/j.arth.2012.03.040)
• [L4] The most recent systematic review and meta-analysis comparing the 2 treatment options have shown no difference in reinfection rates in both knees and hips. [129] (10.1016/j.arth.2019.10.051)
• [L3] The routine use of AD in the work-up prior to a second-stage arthroplasty procedure for PJI may not be warranted. [130] (10.1016/j.arth.2022.06.024)
• [L5] [132] (10.1016/j.otsr.2014.04.001)
• [L3] Single-dose prophylactic antibiotics did not lead to an increased risk of acute PJI or short-term complications after TJA. [136] (10.1016/j.arth.2021.02.037)
• [L3] FISH represents a fast and reliable tool for detecting PJI in periprosthetic membranes, especially in combination with clinical and histopathological classification. [137] (10.2106/jbjs.18.00243)
• [L3] Extending perioperative prophylactic antibiotics until intraoperative culture results become available in patients undergoing revision THA for aseptic failures does not provide any additional benefit in terms of reducing the risk of subsequent PJI. [139] (10.1016/j.arth.2019.06.012)
• [L3] Chronic institutionalized patients have a higher risk of acute periprosthetic joint infection after hip hemiarthroplasty, commonly caused by gram-negative microorganisms not covered by current prophylaxis strategies. [140] (10.1016/j.injury.2015.12.032)
• [L3] Extended oral antibiotic prophylaxis after aseptic revision total hip arthroplasty was not associated with a statistically significant decreased risk of any infection, periprosthetic joint infection, or re-revision or reoperation for infection at all time points. [141] (10.1016/j.arth.2022.06.023)
• [L5] Synovial fluid aspiration, diagnostic imaging, traditional culture, peripheral serum inflammatory markers, and intraoperative frozen sections each have their limitations but continue to be the mainstay for diagnosis of periprosthetic joint infection. [142] (10.5435/jaaos-d-14-00385)
• [L4] [143] (10.5435/jaaos-d-16-00636)
• [L1] However, its sensitivity was limited (54% to 84%) and it should therefore not be used for screening, but rather as a confirmatory test for PJI. [149] (10.2106/jbjs.17.01005)
• [L2] Microcalorimetry of synovial fluid allows thermogenic diagnosis of periprosthetic joint infection in synovial fluid. [150] (10.1186/s12891-020-03366-3)
• [L4] At a minimum 2-year followup, infection control was attained in 29 of 30 patients without evidence of graft resorption. [157] (10.1097/blo.0b013e318073c290)
• [L4] DAIR is a valuable option in the treatment of hip PJI, especially in the early postoperative period (≤6 weeks), with good outcomes. [158] (10.1016/j.arth.2017.02.066)

See Also

• Total hip replacement

References

[1] Is this the era of consensus?. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b11.33224

[2] Proceedings of the International Consensus on Periprosthetic Joint Infection. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b11.33135

[3] Periprosthetic joint infection: what next?. The Bone & Joint Journal. 2022. DOI: 10.1302/0301-620x.104b11.bjj-2022-0944

[4] The challenge of methicillin resistant staphylococcal infection after total hip replacement. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b11.34333

[5] The Diagnosis of Infection in Metal-on-Metal Hip Arthroplasties. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.03.064

[6] Risk of Periprosthetic Joint Infection in Patients With Multiple Arthroplasties. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2017.10.024

[7] Two-stage Revision Arthroplasty for Management of Chronic Periprosthetic Hip and Knee Infection. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-03-153

[8] A modified Delphi consensus on periprosthetic infection in orthopaedic oncology. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b12.bjj-2024-1039.r4

[9] Two-stage Cementless Revision of Infected Hip Endoprostheses. Clinical Orthopaedics & Related Research. 2009. DOI: 10.1007/s11999-008-0611-y

[10] Prevention of Late PJI. Journal of Orthopaedic Research. 2014. DOI: 10.1002/jor.22561

[11] Partial 2-Stage Exchange for Infected Total Hip Arthroplasty: An Updated Report. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.07.001

[12] Two-Stage Revision Total Hip Arthroplasty With a Specific Articulating Antibiotic Spacer Design: Reliable Periprosthetic Joint Infection Eradication and Functional Improvement. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.08.016

[13] Clinical Outcome of Massive Endoprostheses Used for Managing Periprosthetic Joint Infections of the Hip and Knee. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2017.09.046

[14] Predictors of Success With Chronic Antibiotic Suppression for Prosthetic Joint Infections. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.02.003

[15] Sonication of retrieved implants improves sensitivity in the diagnosis of periprosthetic joint infection. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-3006-1

[16] The routine use of synovial alpha-defensin is not necessary.. The bone & joint journal. 2020. DOI: 10.1302/0301-620X.102B5.BJJ-2019-0473.R3

[17] Orthopaedic Infection: Prevention and Diagnosis. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00634

[19] Microbiological pathogen analysis in native versus periprosthetic joint infections: a retrospective study. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-021-02850-3

[20] Treatment of Infected Total Hip Arthroplasty With a 2-Stage Reimplantation Protocol. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.07.004

[21] Two-Stage Reconstruction of Infected Hip Joints. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2007.06.007

[22] Partial component-retained two-stage reconstruction for chronic infection after uncemented total hip arthroplasty: results of sixteen cases after five years of follow-up. International Orthopaedics. 2017. DOI: 10.1007/s00264-017-3505-3

[23] The Change of Serum Interleukin-6 Fails to Identify Subsequent Periprosthetic Joint Infection in Patients Who Have Two-Stage Revision for Periprosthetic Joint Infection. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2023.06.008

[25] Infection Control Rate of Irrigation and Débridement for Periprosthetic Joint Infection. Clinical Orthopaedics & Related Research. 2011. DOI: 10.1007/s11999-011-1910-2

[26] Interleukin-6 in Serum and in Synovial Fluid Enhances the Differentiation between Periprosthetic Joint Infection and Aseptic Loosening. PLoS ONE. 2014. DOI: 10.1371/journal.pone.0089045

[27] Multiple Periprosthetic Joint Infections: Evidence for Decreasing Prevalence. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.05.013

[28] Transcriptome-Wide High-Density Microarray Analysis Reveals Differential Gene Transcription in Periprosthetic Tissue From Hips With Chronic Periprosthetic Joint Infection vs Aseptic Loosening. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2016.06.036

[29] Premature Therapeutic Antimicrobial Treatments Can Compromise the Diagnosis of Late Periprosthetic Joint Infection. Clinical Orthopaedics & Related Research. 2015. DOI: 10.1007/s11999-015-4142-z

[30] Novel Developments in the Prevention, Diagnosis, and Treatment of Periprosthetic Joint Infections. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00455

[31] The role of synovial fluid analysis in the detection of periprosthetic hip and knee infections: a systematic review and meta-analysis. International Orthopaedics. 2018. DOI: 10.1007/s00264-018-3865-3

[32] Does Preoperative Antimicrobial Prophylaxis Influence the Diagnostic Potential of Periprosthetic Tissues in Hip or Knee Infections?. Clinical Orthopaedics & Related Research. 2016. DOI: 10.1007/s11999-015-4486-4

[33] 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

[34] Clinical Outcomes After Stage-One Antibiotic Coated Molded Hip Spacer. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.02.116

[35] Evolution of Diagnostic Definitions for Periprosthetic Joint Infection in Total Hip and Knee Arthroplasty. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2019.10.032

[36] New diagnostic tools for prosthetic joint infection. Orthopaedics & Traumatology: Surgery & Research. 2019. DOI: 10.1016/j.otsr.2018.04.029

[37] The 2018 International Consensus Meeting Minor Criteria for Chronic Hip and Knee Periprosthetic Joint Infection: Validation From a Single Center. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2020.03.014

[38] Synovial Fluid Biomarkers for the Diagnosis of Periprosthetic Joint Infection—A Systematic Review and Meta-Analysis of Their Diagnostic Accuracy According to Different Definitions. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2023.06.017

[39] Variation in Inflammatory Biomarkers Among Demographic Groups Significantly Affects Their Accuracy in Diagnosing Periprosthetic Joint Infection. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2020.10.036

[40] Diagnosis of prosthetic joint infection with alpha-defensin using a lateral flow device. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b9.bjj-2016-1345.r2

[41] Multidrug-Resistant Organisms in the Setting of Periprosthetic Joint Infection—Diagnosis, Prevention, and Treatment. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2017.07.045

[42] Preliminary Results After Changing From Two-Stage to One-Stage Revision Arthroplasty Protocol Using Cementless Arthroplasty for Chronic Infected Hip Replacements. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2017.08.033

[43] Ten-Year Results Following One-Stage Septic Hip Exchange in the Management of Periprosthetic Joint Infection. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.02.021

[44] Oral Therapy, Microbiological Findings, and Comorbidity Influence the Outcome of Prosthetic Joint Infections Undergoing 2-Stage Exchange. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.02.057

[45] Two-Stage Revision Total Hip Arthroplasty Without Spacer Placement: A Viable Option to Manage Infection in Patients With Severe Bone Loss or Abductor Deficiency. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2021.02.040

[47] One-stage cementless revision arthroplasty for infected hip replacements. International Orthopaedics. 2008. DOI: 10.1007/s00264-008-0640-x

[48] Arthroplasty following a septic arthritis history: A 53 cases series. Orthopaedics & Traumatology: Surgery & Research. 2010. DOI: 10.1016/j.otsr.2010.06.009

[49] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Summary.

[50] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Radiography.

[52] Synovial C-reactive protein as a marker for chronic periprosthetic infection in total hip arthroplasty. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b2.34550

[53] Inflammatory Laboratory Markers in Periprosthetic Hip Fractures. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.05.026

[54] Concomitant Hip and Knee Periprosthetic Joint Infection in Periprosthetic Fracture: Diagnostic Utility of Serum and Synovial Fluid Markers. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2020.08.029

[56] Rockwood And Green S Fractures In Adults. 51: Hip Dislocations and Femoral Head Fractures > Infection.

[57] Does Performance of D-Dimer for Diagnosis of Periprosthetic Joint Infection Change With the Virulence of Infecting Organism?. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2023.05.022

[59] Clinical Evaluation of Alpha Defensin Test Following Staged Treatment of Prosthetic Joint Infections. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.03.019

[60] Capturing Orthopaedic Surgical Site Infection Data and Assessing Dental Recommendations With Respect to Total Joint Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00419

[62] Diagnosing Prosthetic Joint Infections in Patients With Inflammatory Arthritis: A Systematic Literature Review. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.01.051

[63] Diagnosing Periprosthetic Joint Infection: And the Winner Is?. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.06.005

[64] Concomitant Multiple Joint Arthroplasty Infections: Report on 16 Cases. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.02.012

[65] How Does a “Dry Tap” Impact the Accuracy of Preoperative Aspiration Results in Predicting Chronic Periprosthetic Joint Infection?. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.01.066

[68] Spacer Design Options and Consideration for Periprosthetic Joint Infection. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2019.11.007

[69] Systematic Review and Meta-Analysis of Intrawound Vancomycin in Total Hip and Total Knee Arthroplasty: A Call for a Prospective Randomized Trial. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.03.071

[70] Cementless Two-Stage Exchange Arthroplasty for Infection after Total Hip Arthroplasty. The Journal of Arthroplasty. 2007. DOI: 10.1016/j.arth.2006.02.156

[71] The Influence of Spacer Design on the Rate of Complications in Two-Stage Revision Hip Arthroplasty. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.02.012

[72] Midterm to Long-term Followup of Staged Reimplantation for Infected Hip Arthroplasty. Clinical Orthopaedics & Related Research. 2009. DOI: 10.1007/s11999-008-0480-4

[73] Treatment of Prosthetic Joint Infection: Established Patient Relationships May Impact Medical Decision-Making. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2018.09.091

[74] The Timing of Preoperative Urinary Tract Infection Influences the Risk of Prosthetic Joint Infection Following Primary Total Hip and Knee Arthroplasty. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.05.034

[75] The 2018 Definition of Periprosthetic Hip and Knee Infection: An Evidence-Based and Validated Criteria. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.02.078

[76] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > 2. Arthrology > Hip (Fig. 2.49).

[79] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Osseous and Ligamentous Anatomy.

[80] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > IV. Hip Capsule and Ligaments.

[83] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > V. Hip Joint Muscles.

[85] Aaos Comprehensive Orthopaedic Review 3. Fractures of the Hip > I. General Considerations.

[88] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > VI. Neurovascular Structures Surrounding the Hip.

[93] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Imaging.

[105] The 2013 Frank Stinchfield Award: Diagnosis of Infection in the Early Postoperative Period After Total Hip Arthroplasty. Clinical Orthopaedics and Related Research®. 2013. DOI: 10.1007/s11999-013-3089-1

[107] Improving the accuracy of synovial fluid analysis in the diagnosis of prosthetic joint infection with simple and inexpensive biomarkers. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b3.bjj-2016-0684.r1

[109] Campbell S Operative Orthopaedics 4 Volume Set. SURGICAL PROBLEMS RELATIVE TO SPECIFIC HIP DISORDERS > DIAGNOSIS.

[110] Campbell S Operative Orthopaedics 4 Volume Set. SURGICAL PROBLEMS RELATIVE TO SPECIFIC HIP DISORDERS > RECONSTRUCTION AFTER INFECTION.

[111] Rifampin combination therapy in staphylococcal prosthetic joint infections: a randomized controlled trial. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01877-2

[113] Cutibacterium Positive Cultures in Total Hip Arthroplasty: Contaminant or Pathogen?. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.01.015

[114] Decrease in acute periprosthetic joint infections incidence with vancomycin-loaded calcium sulfate beads in patients with non-modifiable risk factors. A randomized clinical trial. Journal of ISAKOS. 2022. DOI: 10.1016/j.jisako.2022.08.002

[117] Analysis of the Causes of Elevated C-Reactive Protein Level in the Early Postoperative Period After Primary Total Knee Arthroplasty. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.02.037

[122] Acute Renal Failure After the First Stage of a 2-Stage Exchange for Periprosthetic Joint Infection. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2020.08.028

[124] Periprosthetic Joint Infections Caused by Enterococci Have Poor Outcomes. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2016.09.017

[125] Is it Time to Include Vancomycin for Routine Perioperative Antibiotic Prophylaxis in Total Joint Arthroplasty Patients?. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2012.03.040

[129] Single vs 2-Stage Revision for the Treatment of Periprosthetic Joint Infection. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2019.10.051

[130] Alpha-Defensin Offers Limited Utility in Work-Up Prior to Reimplantation in Chronic Periprosthetic Joint Infection in Total Joint Arthroplasty Patients. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.06.024

[132] Potential changes to French recommendations about peri-prosthetic infections based on the international consensus meeting (ICMPJI). Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2014.04.001

[136] Perioperative Antibiotic Prophylaxis: Single and 24-Hour Antibiotic Dosages are Equally Effective at Preventing Periprosthetic Joint Infection in Total Joint Arthroplasty. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2021.02.037

[137] Fluorescence in Situ Hybridization (FISH) for the Diagnosis of Periprosthetic Joint Infection in Formalin-Fixed Paraffin-Embedded Surgical Tissues. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.18.00243

[139] Extended Antibiotic Prophylaxis Confers No Benefit Following Aseptic Revision Total Hip Arthroplasty: A Matched Case-Controlled Study. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.06.012

[140] Increased infection risk after hip hemiarthroplasty in institutionalized patients with proximal femur fracture. Injury. 2016. DOI: 10.1016/j.injury.2015.12.032

[141] Extended Oral Antibiotic Prophylaxis After Aseptic Revision Total Hip Arthroplasty: Does It Decrease Infection Risk?. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.06.023

[142] Conventional Diagnostic Challenges in Periprosthetic Joint Infection. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00385

[143] Staphylococcal Biofilms and Immune Polarization During Prosthetic Joint Infection. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00636

[149] Alpha Defensin Lateral Flow Test for Diagnosis of Periprosthetic Joint Infection. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.17.01005

[150] Thermogenic diagnosis of periprosthetic joint infection by microcalorimetry of synovial fluid. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03366-3

[157] Vancomycin-supplemented Cancellous Bone Allografts in Hip Revision Surgery. Clinical Orthopaedics & Related Research. 2007. DOI: 10.1097/blo.0b013e318073c290

[158] Outcome Following Debridement, Antibiotics, and Implant Retention in Hip Periprosthetic Joint Infection—An 18-Year Experience. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.02.066