Periprosthetic joint infection continues to frustrate the medical community. Although the demand for total joint arthroplasty is increasing, the burden of such infections is increasing even more rapidly, and they pose a unique challenge because their accurate diagnosis and eradication can prove elusive. This review describes the current knowledge regarding diagnosis and treatment of periprosthetic joint infection. A number of tools are available to aid in establishing a diagnosis of periprosthetic joint infection. These include the erythrocyte sedimentation rate, serum C-reactive protein concentration, synovial white blood-cell count and differential, imaging studies, tissue specimen culturing, and histological analysis. Multiple definitions of periprosthetic joint infection have been proposed but there is no consensus. Tools under investigation to diagnose such infections include the C-reactive protein concentration in the joint fluid, point-of-care strip tests for the leukocyte esterase concentration in the joint fluid, and other molecular markers of periprosthetic joint infection. Treatment options include irrigation and debridement with prosthesis retention, one-stage prosthesis exchange, two-stage prosthesis exchange with intervening placement of an antibiotic-loaded spacer, and salvage treatments such as joint arthrodesis and amputation. Treatment selection is dependent on multiple factors including the timing of the symptom onset, patient health, the infecting organism, and a history of infection in the joint. Although prosthesis retention has the theoretical advantages of decreased morbidity and improved return to function, two-stage exchange provides a lower rate of recurrent infection. As the burden of periprosthetic joint infection increases, the orthopaedic and medical community should become more familiar with the disease. It is hoped that the tools currently under investigation will aid clinicians in diagnosing periprosthetic joint infection in an accurate and timely fashion to allow appropriate treatment. Given the current knowledge and planned future research, the medical community should be prepared to effectively manage this increasingly prevalent disease.

Background

Periprosthetic joint infection is a devastating complication of total joint arthroplasty. In the United States, periprosthetic joint infection is currently the most common indication for revision total knee arthroplasty and the third most common indication for revision total hip arthroplasty, with an estimated prevalence of between 1% and 3% 1-3. Because of the ease with which periprosthetic joint infection can develop, it is not an uncommon complication. Pathogen proliferation can easily occur in the joint space, with the implanted prosthesis as the growth surface, following the introduction of a small pathogen population into the systemic circulation or a wound in the joint. Periprosthetic joint infection is typically classified according to the timing of symptom development and the mechanism of infection as acute postoperative, acute delayed (hematogenous), or chronic. Treatment algorithms are typically dependent on such a classification. Presently, the increase in the burden of periprosthetic joint infection is outpacing developments in prevention 4.