Periprosthetic Joint Infection (PJI)
Periprosthetic joint infection — infection of an artificial hip or knee joint — is the most feared complication of joint replacement surgery. PJI causes profound pain, implant failure, and significant morbidity, and its treatment is far more complex and demanding than the original joint replacement. Accurate, timely diagnosis and selection of the appropriate treatment strategy — from antibiotics and irrigation, to full implant exchange — are critical to achieving the best possible outcome. At Maryland Orthopedic Specialists, our Adult Reconstruction team follows evidence-based diagnostic and treatment protocols drawn from leading international consensus guidelines to manage both acute and chronic periprosthetic joint infections.
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What is periprosthetic joint infection (pji)?
A periprosthetic joint infection occurs when bacteria or other microorganisms colonize the surface of a joint replacement implant. Biofilm formation — a protective matrix the organisms construct on the implant — makes these infections notoriously resistant to antibiotics alone and immune system clearance.
A periprosthetic joint infection occurs when bacteria or other microorganisms colonize the surface of a joint replacement implant. Biofilm formation — a protective matrix the organisms construct on the implant — makes these infections notoriously resistant to antibiotics alone and immune system clearance. The most common organisms are coagulase-negative Staphylococcus (including S. epidermidis) and Staphylococcus aureus, accounting for approximately 50–60% of cases. Gram-negative organisms and polymicrobial infections are less common but more challenging.
PJI is classified by timing and mechanism:
- Acute post-operative (Type I): Within the first 3–4 weeks after surgery; often from direct contamination at the time of surgery.
- Acute hematogenous (Type II): Sudden seeding of an otherwise well-functioning implant from a distant bacteremic source (dental procedure, urinary tract infection, skin infection); can occur years after implantation.
- Chronic / Late (Type III): Presents > 3–4 weeks post-operatively with gradual, indolent infection; often low-virulence organisms forming an established biofilm.
The overall incidence of PJI after primary total knee replacement is approximately 1–2% and 1% after primary total hip replacement.
Treatment options
Treatment of PJI depends on the timing and chronicity of infection, organism characteristics, implant fixation, and the patient's overall medical condition.
DAIR (Debridement, Antibiotics, and Implant Retention)
DAIR is appropriate for acute PJI — both early post-operative and acute hematogenous — when symptoms have been present for fewer than 3 to 4 weeks (before mature biofilm forms), the implant is well-fixed, the infecting organism is known and susceptible, and soft tissues are adequate. The procedure involves surgical debridement of all infected and necrotic tissue, exchange of all modular components (polyethylene tibial insert, femoral head), thorough joint irrigation, and a course of pathogen-directed IV followed by oral antibiotics — typically 6 to 12 weeks, sometimes followed by prolonged suppression. Success rates for well-selected acute PJI cases are 70 to 80%.
Suppressive Antibiotics
Chronic oral antibiotic suppression — indefinite low-dose antibiotics to control rather than eradicate infection — is reserved for patients who cannot tolerate revision surgery due to medical comorbidities, or as an adjunct after failed two-stage exchange. This is not a curative approach.
Revision Hip Arthroplasty
Surgical revision of a failed hip replacement, addressing worn components, loosening, instability, or periprosthetic infection. Requires specialized revision implant systems and reconstruction techniques beyond primary replacement.
Click for more Surgical ProcedureRevision Total Knee Replacement
Complex re-operation to address worn, loose, unstable, or infected knee replacement components. Requires modular augments, intramedullary stems, and increased constraint levels matched to the degree of bone and ligament deficiency.
Click for moreFrequently Asked Questions
Can PJI be prevented?
Is PJI always apparent immediately after surgery?
What if the infection can't be eradicated?
Do I need to tell my dentist I have a joint replacement?
How is periprosthetic joint infection treated, and will I need my implant removed?
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References
- Parvizi J, Gehrke T, Chen AF. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone Joint J. 2013;95-B(11):1450–1452. https://doi.org/10.1302/0301-620X.95B11.33135
- Zmistowski B, Karam JA, Durinka JB, Casper DS, Parvizi J. Periprosthetic joint infection increases the risk of one-year mortality. J Bone Joint Surg Am. 2013;95(24):2177–2184. https://doi.org/10.2106/JBJS.L.00789
- Osmon DR, Berbari EF, Berendt AR, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56(1):e1–e25. https://doi.org/10.1093/cid/cis803
- 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. https://doi.org/10.1007/s11999-014-3543-8
- Gehrke T, Alijanipour P, Parvizi J. The management of an infected total knee arthroplasty. Bone Joint J. 2015;97-B(10 Suppl A):20–29. https://doi.org/10.1302/0301-620X.97B10.36475
- American Academy of Orthopaedic Surgeons. Periprosthetic Joint Infection. OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/periprosthetic-joint-infection/