Cover Page

Cite item


Prosthetic joint infection (PJI) is the second common reason for revision surgery of the hip joint prosthesis. The rate of hip PJI is about 1% after primary surgery and it goes up to 4% or higher after revision surgery. In most cases, the main cause of this complication is an intraoperative bacterial contamination, rarer is a haematogenic one. An up-to-date diagnostic approach and clearly defined treatment strategy are required for the successful therapy of PJI. Based on the analysis of the scientific literature and own experience, an algorithm for diagnosis and treatment of this complication is proposed. A thoroughly obtained case history plays a predominant role in the diagnosis of PJI. Lack of the increased serum C-reactive protein cannot be considered as an exclusion criterion because in some cases, especially chronic infection, it can be within the normal range. Bacteriology lab tests of periprosthetic tissue biopsies and synovial fluid is the gold standard for the diagnosis. Novel methods such as ultrasound debridement of the removed prosthetic components have allowed to substantially increase the diagnostic sensitivity of bacteriology tests. This led to the discovery of PJI in some cases which before that were regarded as aseptic loosening. Visualization methods including MRI and scintigraphy play only a secondary role. The authors propose the classification of PJI for further determination of the treatment strategy which takes into account parameters such as biofilm maturity, prosthesis stability, the type of pathogen and soft tissue state for the decision on the treatment strategy. While desire to retain the implant is only justified in case of the immature biofilm, in most cases the infection can be cured only after the replacement of endoprosthesis. According to the proposed algorithm, patients undergo one- or two-stage procedure with a short or long interval. Antibiotics that are active against biofilm pathogens play an important role in the efficacy of the therapy. Selection of these antibiotics should be based on the results of bacteriology tests, preferably in collaboration with specialists in infectious diseases and microbiology.

About the authors

T. Winkler

Center for Musculoskeletal Surgery, Charité – Universitätsmedizin Berlin

Author for correspondence.
research group leader Germany

A. Trampuz

Center for Musculoskeletal Surgery, Charité – Universitätsmedizin Berlin

head of the center for septic surgery Germany

N. Renz

Center for Musculoskeletal Surgery, Charité – Universitätsmedizin Berlin

head of the infectious diseases consultation service Germany

C. Perka

Center for Musculoskeletal Surgery, Charité – Universitätsmedizin Berlin

рrofessor, medical director Germany

S. A. Bozhkova

Vreden Russian Research Institute of Traumatology and Orthopedics

the head of the research department of prevention and treatment of wound infection and department of clinical pharmacology Russian Federation


  1. Atkins BL, Athanasou N, Deeks JJ, Crook DW, Simpson H, Peto TE et al. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. The OSIRIS Collaborative Study Group. J Clin Microbiol. 1998; 36(10):2932-2939.
  2. Berbari E, Mabry T, Tsaras G, Spangehl M, Erwin PJ, Murad MH, et al. Inflammatory blood laboratory levels as markers of prosthetic joint infection: a systematic review and metaanalysis. J Bone Joint Surg. Am. 2010; 92(11):2102-2109.
  3. Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg. Am. 2005; 87(8):1746-1751.
  4. Bozic KJ, Lau E, Kurtz S, Ong K, Rubash H, Vail TP, et al. Patient-related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in Medicare patients. J Bone Joint Surg. Am. 2012; 94(9):794-800.
  5. Corona P, Gil E, Guerra E, Soldado F, Amat C, Flores X, et al. Percutaneous interface biopsy in dry-aspiration cases of chronic periprosthetic joint infections: a technique for preoperative isolation of the infecting organism. Int Orthop. 2012; 36(6):1281-1286.
  6. Corvec S, Portillo ME, Pasticci BM, Borens O, Trampuz A. Epidemiology and new developments in the diagnosis of prosthetic joint infection. Int J Artif Organs. 2012; 35(10):923-934.
  7. Fink B, Gebhard A, Fuerst M, Berger I, Schafer P. High diagnostic value of synovial biopsy in periprosthetic joint infection of the hip. Clin Orthop Relat Res. 2013; 471(3):956-964.
  8. Frommelt L. [Aspiration of joint fluid for detection of the pathogen in periprosthetic infection]. Orthopade. 2008; 37(10):1027-1034; quiz 35-36.
  9. Furustrand Tafin U, Corvec S, Betrisey B, Zimmerli W, Trampuz A. Role of rifampin against Propionibacterium acnes biofilm in vitro and in an experimental foreign-body infection model. Antimicrob Agents Chemother. 2012; 56(4):1885-1891.
  10. Hsieh PH, Shih CH, Chang YH, Lee MS, Shih HN, Yang WE. Two-stage revision hip arthroplasty for infection: comparison between the interim use of antibiotic-loaded cement beads and a spacer prosthesis. J Bone Joint Surg. Am. 2004; 86-A(9):1989-1997.
  11. Hwang JS, Beebe KS, Patterson FR, Benevenia J. Infected total femoral replacements: evaluation of limb loss risk factors. Orthopedics. 2011; 34(11):e736-740.
  12. Ivancevic V, Perka C, Hasart O, Sandrock D, Munz DL. Imaging of low-grade bone infection with a technetium- 99m labelled monoclonal anti-NCA-90 Fab’ fragment in patients with previous joint surgery. Eur J Nuclr Med Molec Imag. 2002; 29(4):547-551.
  13. Janz V, Wassilew GI, Hasart O, Matziolis G, Tohtz S, Perka C. Evaluation of sonicate fluid cultures in comparison to histological analysis of the periprosthetic membrane for the detection of periprosthetic joint infection. Int Orthop. 2013; 37(5):931-936.
  14. Janz V, Bartek B, Wassilew GI, Stuhlert M, Perka CF, Winkler T. Validation of synovial aspiration in girdlestone hips for detection of infection persistence in patients undergoing 2-stage revision total hip arthroplasty. J Arthroplasty. 2016; 31(3):684-687.
  15. Jung J, Schmid NV, Kelm J, Schmitt E, Anagnostakos K. Complications after spacer implantation in the treatment of hip joint infections. Int J Med Sci. 2009; 6(5):265-273.
  16. Krenn V, Morawietz L, Kienapfel H, Ascherl R, Matziolis G, Hassenpflug J, et al. [Revised consensus classification: Histopathological classification of diseases associated with joint endoprostheses]. Z Rheumatol. 2013; 72(4):383-392.
  17. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012; 27(8 Suppl):61-65 e1.
  18. Lange J, Troelsen A, Thomsen RW, Soballe K. Chronic infections in hip arthroplasties: comparing risk of reinfection following one-stage and two-stage revision: a systematic review and meta-analysis. Clin Epidemiol. 2012; 4:57-73.
  19. Langlais F, Kerboull M, Sedel L, Ling RS. The ‘French paradox. J Bone Joint Surg. Br. 2003; 85(1):17-20.
  20. Langlais F. Can we improve the results of revision arthroplasty for infected total hip replacement? J Bone Joint Surg. Br. 2003; 85(5):637-640.
  21. Love C, Marwin SE, Palestro CJ. Nuclear medicine and the infected joint replacement. Sem Nucl Med. 2009; 39(1):66-78.
  22. Maderazo EG, Judson S, Pasternak H. Late infections of total joint prostheses. A review and recommendations for prevention. Clin Orthop Rel Res. 1988; (229):131-42.
  23. Miller TT. Imaging of hip arthroplasty. Eur J Radiol. 2012; 81(12):3802-3812.
  24. Morawietz L, Classen RA, Schroder JH, Dynybil C, Perka C, Skwara A et al. Proposal for a histopathological consensus classification of the periprosthetic interface membrane. J Clin Pathol. 2006; 59(6):591-597.
  25. Mulcahy H, Chew FS. Current concepts of hip arthroplasty for radiologists: part 2, revisions and complications. AJR Am J Roentgenol. 2012; 199(3):570-580.
  26. Muller M, Morawietz L, Hasart O, Strube P, Perka C, Tohtz S. Diagnosis of periprosthetic infection following total hip arthroplasty--evaluation of the diagnostic values of preand intraoperative parameters and the associated strategy to preoperatively select patients with a high probability of joint infection. J Orthop Surg Res. 2008; 3:31.
  27. Murdoch DR, Roberts SA, Fowler Jr VG, Jr., Shah MA, Taylor SL, Morris AJ, et al. Infection of orthopedic prostheses after Staphylococcus aureus bacteremia. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 2001; 32(4):647-649.
  28. Oliva A, Furustrand Tafin U, Maiolo EM, Jeddari S, Betrisey B, Trampuz A. Activities of fosfomycin and rifampin on planktonic and adherent Enterococcus faecalis strains in an experimental foreign-body infection model. Antimicrob Agents Chemother. 2014; 58(3):1284-1293.
  29. Parvizi J, Adeli B, Zmistowski B, Restrepo C, Greenwald AS. Management of periprosthetic joint infection: the current knowledge: AAOS exhibit selection. J Bone Joint Surg. Am. 2012; 94(14):e104.
  30. Perka C, Haas N. [Periprosthetic infection]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen. Medizen. 2011; 82(3):218-226.
  31. Portillo ME, Salvadó M, Alier A, Sorli L, Martínez S, Horcajada JP et al. Prosthesis failure within two years of implantation is highly predictive for infection. Clin Orthop Relat Res. 2013; 471(11):3672-3678.
  32. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg. Am. 2008; 90(9):1869-1875.
  33. Sculco TP. The economic impact of infected total joint arthroplasty. Instr. course Lect. 1993; 42: 349-51.
  34. Senthi S, Munro JT, Pitto RP. Infection in total hip replacement: meta-analysis. Int Orthop. 2011; 35(2):253-260.
  35. Spangehl MJ, Masri BA, O’Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites
  36. of two hundred and two revision total hip arthroplasties. J Bone Joint Surg. Am. 1999; 81(5):672-683.
  37. Strobel K, Stumpe KD. PET/CT in musculoskeletal infection. Semin Musculoskelet Radiol. 2007; 11(4): 353-364.
  38. Tohtz SW, Muller M, Morawietz L, Winkler T, Perka C. Validity of frozen sections for analysis of periprosthetic loosening membranes. Clin Orthop Relat Res. 2010; 468(3):762-768.
  39. Trampuz A, Piper KE, Jacobson MJ, Hanssen AD, Unni KK, Osmon DR, et al. Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med. 2007; 357(7):654-663.
  40. Trampuz A, Zimmerli W. Diagnosis and treatment of implant-associated septic arthritis and osteomyelitis. Curr Infect Dise Rep. 2008; 10(5):394-403.
  41. Trampuz A, Perka C, Borens O. [Prosthetic joint infection: new developments in diagnosis and treatment]. Dtsch Med Wochenschr. 2013; 138(31-32):1571-1573.
  42. Winkler H. Bone grafting and one-stage revision of THR – biological reconstruction and effective antimicrobial treatment using antibiotic impregnated allograft bone. Hip Int. 2012; 22 Suppl 8:S62-68.
  43. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004 ;351(16):1645-1654.

Copyright (c) 2016

СМИ зарегистрировано Федеральной службой по надзору в сфере связи, информационных технологий и массовых коммуникаций (Роскомнадзор).
Регистрационный номер и дата принятия решения о регистрации СМИ: серия ПИ № ФС 77 - 82474 от 10.12.2021.

This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies