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Periprosthetic Joint Infection

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Edited by Laura Lu and Matthew Lindsey - 7/1/2021

Descriptors

Periprosthetic infection is around an implant (e.g. total hip replacement, knee replacement, shoulder replacement, etc).
It is NOT an infection of any orthopaedic hardware (e.g. plates and screws, intramedullary rods are not considered periprosthetic infections)

Exam Pearls

Examine for wound dehiscence, open wounds, skin erythema, or draining sinuses.

May be swollen, warm, and painful, though PJI may not present with the classic short-arc ROM pain associated with native joint septic arthritis. Evaluate for effusion.

Record two time points: 1) time from index surgery and 2) time from symptom onset.

Workup

History: Acute: < 90 days from index surgery; Chronic: > 90 days from index surgery.
Risk factors: intravenous drug use (even remote/prior), diabetes, immunosuppression, dental work, remote site of infection

Surgical history: surgeon, implant information, history of prior periprosthetic infection, history of bacteremia. If proceeding to OR, need operative report from index surgery.

Radiographs:
Knee: XR knee AP and lateral.
Hip: XR pelvis and hip AP and lateral
Shoulder: AP and lateral.

Other imaging: None, consult with senior/fellow/attending before recommending advanced imaging.

Labs: ESR, CRP, WBC important for diagnostics. Full preop workup for triaging.

Aspiration: Should send for gram stain, cell count, crystals, and culture to be held for 14 days (must specify 14 days).

Other: Inform original surgeon if available of potential for PJI and plan for diagnostic aspiration.

MSIS Criteria

There is a sinus tract communicating with the prosthesis; or
A pathogen is isolated by culture from at least two separate tissue or fluid samples obtained from the affected prosthetic joint; or
Four of the following six criteria exist:

Elevated serum erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) concentration,Elevated synovial leukocyte count,Elevated synovial neutrophil percentage (PMN%),Presence of purulence in the affected joint,Isolation of a microorganism in one culture of periprosthetic tissue or fluid, orGreater than five neutrophils per high-power field in five high-power fields observed from histologic analysis of periprosthetic tissue at ×400 magnification.

Note: Several definitions for PJI exist, including later international consensus meeting definitions, however for the purposes here are using the original MSIS criteria as outlined in Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469(11):2992-2994. doi:10.1007/s11999-011-2102-9

Management

Need for acute intervention: Yes if patient septic/unstable. If patient stable, discuss timing with attending.

Weight-bearing and range of motion: WBAT, ROMAT

Type of immobilization: None

Admission or discharge status: Discuss with fellow/attending

Anticoagulation: Hold anticoagulation until possible operative plan decided.

Antibiotics: No antibiotics prior to joint aspiration.

Surgical Indications

Absolute: Unstable septic patient

Relative: Chronic PJI with marginal/nonspecific labs on an outpatient basis

Not an indication: None