Periprosthetic Joint Infection

Aka: Periprosthetic Joint Infection, Prosthetic Septic Joint, Prosthetic Joint Infection, Infected Joint Replacement

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II. Risk Factors

  1. Obesity (highest risk)
  2. Cardiac disease
  3. Immunocompromised
  4. Peripheral Vascular Disease
  5. Inflammatory Arthritis
  6. Prior joint infection
  7. Renal disease
  8. Liver disease
  9. Malnutrition
  10. Alcohol Abuse
  11. Tobacco Abuse
  12. Diabetes Mellitus
  13. Anemia
  14. Tubb (2020) J Am Acad Orthop Surg 28(8): e340-8 [PubMed]

III. Epidemiology

  1. Prosthetic Joint Infection carries a 1-2% risk at 2 years and >2% at 10 years
  2. Nearly half of infections occur in the first 3 months after surgery (nearly 80% occur within first 2 years)
  3. Prosthetic Hip Joint and Prosthetic Knee Joint infections are responsible for most Prosthetic Septic Joints

IV. Causes

  1. Early infection
    1. Staphylococcus epidermidis
  2. Late Infection
    1. Gram Positive Cocci (e.g. pneumococcus)
    2. Anaerobic Bacteria
    3. Pseudomonas

V. Findings

  1. See Septic Joint
  2. Findings are more subtle in infected prosthetic joints than in native joint infections

VI. Diagnosis

  1. Major Criteria
    1. Two joint cultures positive for same organism
    2. Sinus tract communicating with joint
  2. Minor Criteria
    1. Score 2: Serum C-RP > 10 mg/L or D-Dimer > 860 ng/ml
    2. Score 1: Serum ESR >30 mm/hour
    3. Score 3: Synovial WBC >3000/uL or Leukocyte esterase (2+)
    4. Score 3: Synovial Alpha-defensin (signal to cutoff ratio >1)
    5. Score 2: Synovial PMNs >80%
    6. Score 1: Synovial C-RP >6.9 mg/L
  3. Intraoperative Criteria (optional)
    1. Score 3: Histology positive
    2. Score 3: Purulence
    3. Score 2: Single Culture Positive
  4. Interpretation
    1. Infection
      1. Either major criteria positive OR
      2. Minor Criteria Score >6 OR
      3. Minor AND Intraoperative Criteria >6 (with Minor Score at least 2)
    2. Inconclusive
      1. Neither major criteria present AND
      2. Minor AND Intraoperative Criteria 2 to 5 (with Minor Score at least 2)
    3. No Infection
      1. Neither major criteria present AND
      2. Minor Criteria 0 to 1 (or combined with intraoperative criteria <3)
  5. References
    1. Parvizi (2018) J Arthroplasty 33(5): 1309-14 [PubMed]

VII. Labs

  1. See Septic Joint
  2. Synovasure Lateral Flow Test
    1. Detects human alpha defensins released by activated Neutrophils
    2. Positive test suggestive of Bacterial periprosthetic infection

VIII. Imaging

  1. Nuclear scan
    1. Negative Nuclear scan excludes septic prosthetic joint
  2. Pet Scan
  3. Avoid CT Scan or MRI in infected prosthetic joint
    1. Does not distinguish infected prosthetic joint from other causes of pain

IX. Management

  1. See Septic Joint
  2. Empiric therapy before culture results
    1. Option 1 (2 drug regimen)
      1. Drug 1: Vancomycin
      2. Drug 2: Ciprofloxacin, Aztreonam, or Gentamycin
    2. Option 2 (2 drug regimen)
      1. Drug 1
        1. Ciprofloxacin 750 PO bid or
        2. Ofloxacin 200 mg PO tid
      2. Drug 2: Rifampin 900 mg PO qd
  3. Ciprofloxacin and Rifampin sensitive by culture
    1. Option 1 (2 drug regimen)
      1. Drug 1: Ciprofloxacin or Ofloxacin
      2. Drug 2: Rifampin 900 mg PO qd
    2. Option 2 (2 drug regimen)
      1. Drug 1: Oxacillin 2 grams IV every 4 hours
      2. Drug 2: Rifampin 900 mg PO qd
  4. Ciprofloxacin or Rifampin resistance by culture
    1. Vancomycin and
    2. Rifampin (if sensitive)

X. References

  1. Buddendorff (2021) Crit Dec Emerg Med 35(12): 18-9
  2. Earwood (2021) Am Fam Physician 104(6): 589-97 [PubMed]

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