Arthroplasty-Associated Infections Clinical Presentation

Updated: Aug 10, 2023
  • Author: Rajesh Malhotra, MBBS, MS; Chief Editor: William L Jaffe, MD  more...
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History and Physical Examination

In the presence of wound drainage, erythema, and swelling about the hip associated with systemic symptoms (fever, chills, and generalized malaise), the diagnosis of an infected total hip arthroplasty (THA) can be relatively straightforward. Unfortunately, many periprosthetic infections do not exhibit obvious signs and symptoms of infection. [41, 42]

In the absence of obvious indicators, a thorough history and a detailed examination of the patient should suggest the possibility of infection. A high index of suspicion is necessary. Often, the only symptom is the acute onset of pain in a previously well-functioning joint.

The American Academy of Orthopaedic Surgeons (AAOS) clinical guidelines are helpful for guiding the management of prosthetic joint infection. [43]  These guidelines have also been endorsed by the Infectious Diseases Society of America (IDSA).



Criteria for periprosthetic joint infection

The Musculoskeletal Infection Society proposed the following criteria for periprosthetic joint infections (PJIs) [44] :

  • A sinus tract is communicating with the prosthesis
  • Two separate tissue or fluid samples yield a positive culture from the joint
  • Four of the following six criteria exist: (1) elevated erythocyte sedimentation rate (ESR) and C-reactive protein (CRP); (2) elevated synovial leukocyte count; (3) elevated synovial neutrophil percentage; (4) frank purulence in the joint; (5) one culture positive; (6) more than five neutrophils per high-power field (HPF) in five HPFs observed in periprosthetic tissue magnification at ×400

Types of arthroplasty-associated infection

Tsukayama et al classified arthroplasty-associated infections into four types according to the most common presenting patterns; they also recommended treatments for each type, as follows [45] :

  • Type I - Positive intra operative cultures in a hip undergoing revision for aseptic loosening, without previous indications of infection; two positive cultures out of a minimum of five are necessary to make the diagnosis; revision surgery in these patients is already performed for a presumed aseptic failure when the culture results become available
  • Type II - Early postoperative infection occurring within 1 month of the index procedure; classic symptoms and signs of infection may be present; the infection may be either superficial (because of fat necrosis) or deep-seated, and the two must be distinguished
  • Type III - Acute infection in a well-functioning joint; often, there is a recent history of an infection elsewhere in the body or an invasive procedure (eg, tooth extraction); immunocompromised patients are susceptible to these infections, which may be preventable if antibiotic prophylaxis is routinely provided when these patient undergo total joint arthroplasty
  • Type IV - Deep infection that presents insidiously at least 1 month and as much as 2 years after the index procedure; often, there are no systemic symptoms, and persistent pain may be the only local problem