header advert
Bone & Joint Research Logo

Receive monthly Table of Contents alerts from Bone & Joint Research

Comprehensive article alerts can be set up and managed through your account settings

View my account settings

Visit Bone & Joint Research at:



Open Access


Prosthetic joint infection

Download PDF

Prosthetic joint infection (PJI) is still a relatively rare but devastating complication following total hip (THA) and knee (TKA) arthroplasty. The incidence of PJI ranges from 1% to 2% in primary procedures. The overall weighted mean of PJI from multiple national registry data is 0.97% for THA and 1.03% for TKA.1 The risk of revision due to PJI has risen by twofold for primary THA and by threefold for revision THA.2 Moreover, the demand for arthroplasty is expected to increase by 400% from the early 2000s to 2030, which is likely to further increase the prevalence of PJI. When this is allied to a reduction in other causes of revision, such as polyethylene-related loosening and osteolysis,3 a lower threshold for diagnosis of infection, including so-called culture-negative infections, and better capture in joint registries – the genesis of the epidemic becomes clearer.

Despite our best efforts to reduce the incidence of PJI, international registry data show the rate to be on the increase.4 One must also consider that joint registry data only capture infection as an indication for a revision procedure (e.g. one-stage, two-stage). Cases managed with long-term antibiotic suppression are not included, nor are those managed with washout debridement and implant retention. The validity of the UK National Joint Registry (NJR) was compared with records from the London Implant Retrieval Centre, with 39.1% of retrieved implants being incorrectly registered over a ten-year period.5 A study analyzing the data in the Danish joint registry found that only two-thirds of revisions for infection were captured, and only 77% of them were accurately reported.6 Studies analyzing data from other registries have also reported similar findings.5,7-9 Therefore, one must appreciate that registry data have not fully captured the prevalence of infection, but may be now be starting to do so, either directly or through linkages to other datasets.

Highly crosslinked polyethylene has shown wear rates 40 times lower than conventional polyethylene. Improvement in implant technology and surgical technique will result in a decline of revisions for aseptic loosening, wear, dislocation, and instability.10-17 This will potentially see PJIs becoming the leading cause of revision procedures.

PJIs are notoriously difficult to manage, resulting in the need for multiple interventions and prolonged courses of systemic antibiotics. The impact on a patient’s life is dramatic, involving long periods of immobility, recurrent hospital encounters and potential psychological distress. There is also a significant economic burden to costing at a mean of £50,000 for a revision procedure for an infected THA in the UK. Efforts therefore continue to improve the recognition and management in order to preserve function and reduce morbidity.4,18,19

There has been much interest in the diagnostic criteria for PJI. The Philadelphia consensus meeting in 2018 suggested a score-based system to replace the Musculoskeletal Infection Society (MSIS) criteria.20 However, too much emphasis is applied to white cell count, D-dimer, and relatively new biomarkers such as alpha defensin. This has to an extent been driven by new tests available in the market for these biomarkers. D-dimer is a non-specific haematological marker and its validity in detecting PJI is questionable.21 There are several studies that have investigated the sensitivity and specificity of alpha defensin, using the ‘lateral flow test’ to detect PJI. Analyzing these studies reveals a potential bias, with great variation in sensitivity and specificity between studies.22-29 We need to be mindful of changing diagnostic criteria too frequently as this would complicate the interpretation of the literature on the subject.

PJI diagnosis must continue to be based on a combination of clinical and laboratory findings that include blood tests, synovial fluid analysis, microbiological and histopathological evaluation of periprosthetic tissue, and intraoperative inspection to reach a definitive diagnosis. The new tests and criteria discussed above will lead to an increase in numbers of ‘culture-negative’ infections. This is clearly adding volume to the ‘infection’ burden.

There is now a shift towards using genomics and proteomics, which identify proteins transcribed via messenger RNA (mRNA) in response to infection.30,31 Currently, the results have to be carefully interpreted with due consideration for the possibility of false positives, as we are yet to validate the clinical relevance of the results of these tests. The converse problem is that we must also be cautious in diagnosing PJI in the absence of organisms in periprosthetic tissue and fluid culture. While culture-negative infection undoubtedly contributes to the increasing burden,32 we must be careful not to overcall this devastating complication. This is particularly important as the management of choice in most countries remains very aggressive/ablative.

The UK NJR reports that the number of revision procedures performed for PJI has increased from 140 in 2003, to over 1,000 per year.33 Despite our collective efforts in tackling infection,34 the epidemic of PJI is a reality. Careful evaluation over the next decade will confirm whether this has been inflated by our having a higher index of suspicion, by the reduction in other failure modes, by modifying our diagnostic protocols, and by better capture in studies and registries. Regardless, we must refocus our prevention and management strategies to control the infection burden.

S. S. Ahmed; email:

Open access

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/.

Funding statement

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

Conflict of interest statement

Fares S. Haddad reports consultancies and royalties from Smith & Nephew, Corin, MatOrtho, and Stryker, and payments for lectures (including service on speakers bureaus) from Smith & Nephew and Stryker, none of which are related to this editorial.

Follow us @BoneJointRes


1. Springer BD , Cahue S , Etkin CD , Lewallen DG , McGrory BJ . Infection burden in total hip and knee arthroplasties: an international registry-based perspective. Arthroplast Today. 2017;3(2):137-140.CrossrefPubMed Google Scholar

2. Lenguerrand E , Whitehouse MR , Beswick AD , Jones SA , Porter ML. , Blom AW . Revision for prosthetic joint infection following hip arthroplasty: evidence from the National Joint Registry. Bone Joint Res. 2017;6(6):391-398.CrossrefPubMed Google Scholar

3. Nebergall AK , Greene ME , Laursen MB , Nielsen PT , Malchau H , Troelsen A . Vitamin E diffused highly cross-linked polyethylene in total hip arthroplasty at five years: a randomised controlled trial using radiostereometric analysis. Bone Joint J. 2017;99-B(5):577-584.CrossrefPubMed Google Scholar

4. George DA , Gant V , Haddad FS . The management of periprosthetic infections in the future: a review of new forms of treatment. Bone Joint J. 2015;97-B(9):1162-1169.CrossrefPubMed Google Scholar

5. Sabah SA , Henckel J , Cook E et al. . Validation of primary metal-on-metal hip arthroplasties on the National Joint Registry for England, Wales and Northern Ireland using data from the London Implant Retrieval Centre: a study using the NJR dataset. Bone Joint J. 2015;97-B(1):10-18.CrossrefPubMed Google Scholar

6. Gundtoft PH , Pedersen AB , Schønheyder HC , Overgaard S . Validation of the diagnosis ‘prosthetic joint infection’ in the Danish Hip Arthroplasty Register. Bone Joint J. 2016;98-B(3):320-325. Google Scholar

7. Lindgren JV , Gordon M , Wretenberg P , Kärrholm J , Garellick G . Validation of reoperations due to infection in the Swedish Hip Arthroplasty Register. BMC Musculoskelet Disord. 2014;15(1):384.CrossrefPubMed Google Scholar

8. Arthursson AJ , Furnes O , Espehaug B , Havelin LI , Söreide JA . Validation of data in the Norwegian Arthroplasty Register and the Norwegian Patient Register: 5,134 primary total hip arthroplasties and revisions operated at a single hospital between 1987 and 2003. Acta Orthop. 2005;76(6):823-828.CrossrefPubMed Google Scholar

9. Huotari K , Lyytikäinen O , Ollgren J , et al.; Hospital Infection Surveillance Team. Disease burden of prosthetic joint infections after hip and knee joint replacement in Finland during 1999-2004: capture-recapture estimation. J Hosp Infect. 2010;75(3):205-208.CrossrefPubMed Google Scholar

10. Glyn-Jones S , McLardy-Smith P , Gill HS , Murray DW . The creep and wear of highly cross-linked polyethylene: a three-year randomised, controlled trial using radiostereometric analysis. J Bone Joint Surg Br. 2008;90(5):556-561.CrossrefPubMed Google Scholar

11. Hanna SA , Somerville L , McCalden RW , Naudie DD , MacDonald SJ . Highly cross-linked polyethylene decreases the rate of revision of total hip arthroplasty compared with conventional polyethylene at 13 years’ follow-up. Bone Joint J. 2016;98-B(1):28-32. Google Scholar

12. Kuzyk PRT , Saccone M , Sprague S , Simunovic N , Bhandari M , Schemitsch EH . Cross-linked versus conventional polyethylene for total hip replacement: a meta-analysis of randomised controlled trials. J Bone Joint Surg Br. 2011;93(5):593-600.CrossrefPubMed Google Scholar

13. Langlois J , Atlan F , Scemama C , Courpied JP , Hamadouche M . A randomised controlled trial comparing highly cross-linked and contemporary annealed polyethylene after a minimal eight-year follow-up in total hip arthroplasty using cemented acetabular components. Bone Joint J. 2015;97-B(11):1458-1462.CrossrefPubMed Google Scholar

14. Ponzio DY , Weitzler L , deMeireles A , Esposito CI , Wright TM , Padgett DE . Antioxidant-stabilized highly crosslinked polyethylene in total knee arthroplasty: a retrieval analysis. Bone Joint J. 2018;100-B(10):1330-1335.CrossrefPubMed Google Scholar

15. Teeter MG , Lanting BA , Naudie DD , McCalden RW , Howard JL , MacDonald SJ . Highly crosslinked polyethylene wear rates and acetabular component orientation: a minimum ten-year follow-up. Bone Joint J. 2018;100-B(7):891-897.CrossrefPubMed Google Scholar

16. Hexter AT , Hislop SM , Blunn GW , Liddle AD . The effect of bearing surface on risk of periprosthetic joint infection in total hip arthroplasty: a systematic review and meta-analysis. Bone Joint J. 2018;100-B(2):134-142.CrossrefPubMed Google Scholar

17. Brown TS , Van Citters DW , Berry DJ , Abdel MP . The use of highly crosslinked polyethylene in total knee arthroplasty. Bone Joint J. 2017;99-B(8):996-1002.CrossrefPubMed Google Scholar

18. Rowan FE , Donaldson MJ , Pietrzak JR , Haddad FS . The role of one-stage exchange for prosthetic joint infection. Curr Rev Musculoskelet Med. 2018;11(3):370-379.CrossrefPubMed Google Scholar

19. George DA , Haddad FS . One-stage exchange arthroplasty: a surgical technique update. J Arthroplasty. 2017;32(9S):S59-S62.CrossrefPubMed Google Scholar

20. Haddad FS , Oussedik S , Meek RMD , Konan S , Stockley I , Gant V . Orthopaedic infection: is consensus the answer. Bone Joint J. 2018;100-B(11):1405-1406.CrossrefPubMed Google Scholar

21. Li R , Shao HY , Hao LB et al. . Plasma fibrinogen exhibits better performance than plasma D-dimer in the diagnosis of periprosthetic joint infection: a multicenter retrospective study. J Bone Joint Surg Am. 2019;101(7):613-619.CrossrefPubMed Google Scholar

22. Suen K , Keeka M , Ailabouni R , Tran P . Synovasure 'quick test' is not as accurate as the laboratory-based α-defensin immunoassay: a systematic review and meta-analysis. Bone Joint J. 2018;100-B(1):66-72. Google Scholar

23. Kendoff DGT , Gehrke T . One stage exchange arthroplasty: the devil is in the detail. https://online.boneandjoint.org.uk/pb-assets/FocusOn/FocusOn-one-stage-1574673621143.pdf (date last accessed 25 November 2019). Google Scholar

24. Gehrke T , Lausmann C , Citak M , Bonanzinga T , Frommelt L , Zahar A . The accuracy of the alpha defensin lateral flow device for diagnosis of periprosthetic joint infection: Comparison with a gold standard. J Bone Joint Surg Am. 2018;100(1):42-48.CrossrefPubMed Google Scholar

25. Bonanzinga T , Zahar A , Dütsch M , Lausmann C , Kendoff D , Gehrke T . How reliable is the alpha-defensin immunoassay test for diagnosing periprosthetic joint infection? A prospective study. Clin Orthop Relat Res. 2017;475(2):408-415.CrossrefPubMed Google Scholar

26. Deirmengian C , Kardos K , Kilmartin P , Cameron A , Schiller K , Parvizi J . Diagnosing periprosthetic joint infection: has the era of the biomarker arrived?Clin Orthop Relat Res. 2014;472(11):3254-3262.CrossrefPubMed Google Scholar

27. Berger P , Van Cauter M , Driesen R , Neyt J , Cornu O , Bellemans J . Diagnosis of prosthetic joint infection with alpha-defensin using a lateral flow device: a multicentre study. Bone Joint J. 2017;99-B(9):1176-1182.CrossrefPubMed Google Scholar

28. Marson BA , Deshmukh SR , Grindlay DJC , Scammell BE . Alpha-defensin and the Synovasure lateral flow device for the diagnosis of prosthetic joint infection: a systematic review and meta-analysis. Bone Joint J. 2018;100-B(6):703-711.CrossrefPubMed Google Scholar

29. Sigmund IK , Holinka J , Gamper J et al. . Qualitative α-defensin test (Synovasure) for the diagnosis of periprosthetic infection in revision total joint arthroplasty. Bone Joint J. 2017;99-B(1):66-72.CrossrefPubMed Google Scholar

30. Kuo FC , Lu YD , Wu CT , You HL , Lee GB , Lee MS . Comparison of molecular diagnosis with serum markers and synovial fluid analysis in patients with prosthetic joint infection. Bone Joint J. 2018;100-B(10):1345-1351.CrossrefPubMed Google Scholar

31. Haddad FS . Next generation sequencing: is this the moment?Bone Joint J. 2018;100-B(2):125-126.CrossrefPubMed Google Scholar

32. Jacobs AME , Bénard M , Meis JF , van Hellemondt G , Goosen JHM . The unsuspected prosthetic joint infection : incidence and consequences of positive intra-operative cultures in presumed aseptic knee and hip revisions. Bone Joint J. 2017;99-B(11):1482-1489.CrossrefPubMed Google Scholar

33. No authors listed. National Joint Registry (NJR) Annual Reports. NJR. http://www.njrcentre.org.uk/njrcentre/Reports-Publications-and-Minutes/Annual-reports (date last accessed 20 November 2019). Google Scholar

34. Karczewski D , Winkler T , Renz N et al. . A standardized interdisciplinary algorithm for the treatment of prosthetic joint infections. Bone Joint J. 2019;101-B(2):132-139.CrossrefPubMed Google Scholar