Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Prosthetic joint infection: Epidemiology, clinical manifestations, and diagnosis

Elie Berbari, MD, FIDSA
Larry M Baddour, MD, FIDSA, FAHA
Section Editor
Daniel J Sexton, MD
Deputy Editor
Elinor L Baron, MD, DTMH


The epidemiology, clinical manifestations, microbiology, and diagnosis of prosthetic joint infections (PJIs) will be reviewed here. Infections associated with other implanted orthopedic devices, such as pins and rods, will not be specifically discussed, but similar principles may apply [1].

Treatment and prevention of PJIs are discussed separately. (See "Prosthetic joint infection: Treatment" and "Prevention of prosthetic joint and other types of orthopedic hardware infection".)


Nearly one million total hip arthroplasties (THAs) or total knee arthroplasties (TKAs) are performed in the United States each year. It is estimated that, by 2030, more than four million THAs or TKAs will be performed in the United States annually [2].

The rate of prosthetic joint infection (PJI) in most centers ranges between 0.5 to 1.0 percent for hip replacements, 0.5 to 2 percent for knee replacements, and less than 1 percent for shoulder replacements [1,3-7]. The risk of prosthetic joint infection is greater for knee arthroplasty than hip arthroplasty.

In a study involving over 69,000 patients undergoing elective total knee arthroplasty followed longitudinally from 1997 to 2006, the rate of infection was highest during the first two years following surgery (incidence 1.5 percent). The rate of infection 2 to 10 years after joint replacement was 0.5 percent [8]. Depending on the type of surgical procedure, causative pathogen, and comorbid conditions, upwards of 10 to 20 percent of patients experience recurrent PJI [9,10].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Jul 06, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Widmer AF. New developments in diagnosis and treatment of infection in orthopedic implants. Clin Infect Dis 2001; 33 Suppl 2:S94.
  2. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89:780.
  3. NIH consensus conference: Total hip replacement. NIH Consensus Development Panel on Total Hip Replacement. JAMA 1995; 273:1950.
  4. Berbari EF, Hanssen AD, Duffy MC, et al. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis 1998; 27:1247.
  5. Sperling JW, Kozak TK, Hanssen AD, Cofield RH. Infection after shoulder arthroplasty. Clin Orthop Relat Res 2001; :206.
  6. Namba RS, Inacio MC, Paxton EW. Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am 2013; 95:775.
  7. Edwards JR, Peterson KD, Mu Y, et al. National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009. Am J Infect Control 2009; 37:783.
  8. Kurtz SM, Ong KL, Lau E, et al. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res 2010; 468:52.
  9. Went P, Krismer M, Frischhut B. Recurrence of infection after revision of infected hip arthroplasties. J Bone Joint Surg Br 1995; 77:307.
  10. Hanssen AD, Trousdale RT, Osmon DR. Patient outcome with reinfection following reimplantation for the infected total knee arthroplasty. Clin Orthop Relat Res 1995; :55.
  11. Kunutsor SK, Whitehouse MR, Blom AW, et al. Patient-Related Risk Factors for Periprosthetic Joint Infection after Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0150866.
  12. Poss R, Thornhill TS, Ewald FC, et al. Factors influencing the incidence and outcome of infection following total joint arthroplasty. Clin Orthop Relat Res 1984; :117.
  13. Jämsen E, Nevalainen P, Eskelinen A, et al. Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone Joint Surg Am 2012; 94:e101.
  14. Aslam S, Reitman C, Darouiche RO. Risk factors for subsequent diagnosis of prosthetic joint infection. Infect Control Hosp Epidemiol 2010; 31:298.
  15. Rao N, Cannella BA, Crossett LS, et al. Preoperative screening/decolonization for Staphylococcus aureus to prevent orthopedic surgical site infection: prospective cohort study with 2-year follow-up. J Arthroplasty 2011; 26:1501.
  16. Matthews PC, Berendt AR, McNally MA, Byren I. Diagnosis and management of prosthetic joint infection. BMJ 2009; 338:b1773.
  17. Momohara S, Kawakami K, Iwamoto T, et al. Prosthetic joint infection after total hip or knee arthroplasty in rheumatoid arthritis patients treated with nonbiologic and biologic disease-modifying antirheumatic drugs. Mod Rheumatol 2011; 21:469.
  18. Berbari EF, Osmon DR, Lahr B, et al. The Mayo prosthetic joint infection risk score: implication for surgical site infection reporting and risk stratification. Infect Control Hosp Epidemiol 2012; 33:774.
  19. Tande AJ, Palraj BR, Osmon DR, et al. Clinical Presentation, Risk Factors, and Outcomes of Hematogenous Prosthetic Joint Infection in Patients with Staphylococcus aureus Bacteremia. Am J Med 2016; 129:221.e11.
  20. Parvizi J, Saleh KJ, Ragland PS, et al. Efficacy of antibiotic-impregnated cement in total hip replacement. Acta Orthop 2008; 79:335.
  21. Giulieri SG, Graber P, Ochsner PE, Zimmerli W. Management of infection associated with total hip arthroplasty according to a treatment algorithm. Infection 2004; 32:222.
  22. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004; 351:1645.
  23. Coventry MB. Treatment of infections occurring in total hip surgery. Orthop Clin North Am 1975; 6:991.
  24. Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am 1996; 78:512.
  25. Fitzgerald RH Jr. Infections of hip prostheses and artificial joints. Infect Dis Clin North Am 1989; 3:329.
  26. Cuckler JM, Star AM, Alavi A, Noto RB. Diagnosis and management of the infected total joint arthroplasty. Orthop Clin North Am 1991; 22:523.
  27. Saravolatz LK. Infections in implantable prosthetic devices. In: Prevention and Control of Nosocomial Infections, Wenzel RP (Ed), Williams & Wilkins, Baltimore 1987. p.385.
  28. Lewis SS, Dicks KV, Chen LF, et al. Delay in diagnosis of invasive surgical site infections following knee arthroplasty versus hip arthroplasty. Clin Infect Dis 2015; 60:990.
  29. Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med 2009; 361:787.
  30. Blackburn WD Jr, Alarcón GS. Prosthetic joint infections. A role for prophylaxis. Arthritis Rheum 1991; 34:110.
  31. Trampuz A, Hanssen AD, Osmon DR, et al. Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med 2004; 117:556.
  32. Maderazo EG, Judson S, Pasternak H. Late infections of total joint prostheses. A review and recommendations for prevention. Clin Orthop Relat Res 1988; :131.
  33. Rodríguez D, Pigrau C, Euba G, et al. Acute haematogenous prosthetic joint infection: prospective evaluation of medical and surgical management. Clin Microbiol Infect 2010; 16:1789.
  34. Murdoch DR, Roberts SA, Fowler Jr VG Jr, et al. Infection of orthopedic prostheses after Staphylococcus aureus bacteremia. Clin Infect Dis 2001; 32:647.
  35. Kanafani ZA, Sexton DJ, Pien BC, et al. Postoperative joint infections due to Propionibacterium species: a case-control study. Clin Infect Dis 2009; 49:1083.
  36. Mook WR, Klement MR, Green CL, et al. The Incidence of Propionibacterium acnes in Open Shoulder Surgery: A Controlled Diagnostic Study. J Bone Joint Surg Am 2015; 97:957.
  37. Tande AJ, Patel R. Prosthetic joint infection. Clin Microbiol Rev 2014; 27:302.
  38. Sendi P, Rohrbach M, Graber P, et al. Staphylococcus aureus small colony variants in prosthetic joint infection. Clin Infect Dis 2006; 43:961.
  39. von Eiff C. Staphylococcus aureus small colony variants: a challenge to microbiologists and clinicians. Int J Antimicrob Agents 2008; 31:507.
  40. Vaudaux P, Kelley WL, Lew DP. Staphylococcus aureus small colony variants: difficult to diagnose and difficult to treat. Clin Infect Dis 2006; 43:968.
  41. Tande AJ, Osmon DR, Greenwood-Quaintance KE, et al. Clinical characteristics and outcomes of prosthetic joint infection caused by small colony variant staphylococci. MBio 2014; 5:e01910.
  42. Shah NB, Osmon DR, Fadel H, et al. Laboratory and clinical characteristics of Staphylococcus lugdunensis prosthetic joint infections. J Clin Microbiol 2010; 48:1600.
  43. Lutz MF, Berthelot P, Fresard A, et al. Arthroplastic and osteosynthetic infections due to Propionibacterium acnes: a retrospective study of 52 cases, 1995-2002. Eur J Clin Microbiol Infect Dis 2005; 24:739.
  44. Million M, Bellevegue L, Labussiere AS, et al. Culture-negative prosthetic joint arthritis related to Coxiella burnetii. Am J Med 2014; 127:786.e7.
  45. Malekzadeh D, Osmon DR, Lahr BD, et al. Prior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infection. Clin Orthop Relat Res 2010; 468:2039.
  46. Zimmerli W, Waldvogel FA, Vaudaux P, Nydegger UE. Pathogenesis of foreign body infection: description and characteristics of an animal model. J Infect Dis 1982; 146:487.
  47. Zimmerli W, Lew PD, Waldvogel FA. Pathogenesis of foreign body infection. Evidence for a local granulocyte defect. J Clin Invest 1984; 73:1191.
  48. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of persistent infections. Science 1999; 284:1318.
  49. Donlan RM. Biofilm formation: a clinically relevant microbiological process. Clin Infect Dis 2001; 33:1387.
  50. Anwar H, Strap JL, Chen K, Costerton JW. Dynamic interactions of biofilms of mucoid Pseudomonas aeruginosa with tobramycin and piperacillin. Antimicrob Agents Chemother 1992; 36:1208.
  51. Osmon DR, Berbari EF, Berendt AR, et al. Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013; 56:1.
  52. 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:e1.
  53. Parvizi J, Gehrke T, Chen AF. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone Joint J 2013; 95-B:1450.
  54. Workgroup Convened by the Musculoskeletal Infection Society. New definition for periprosthetic joint infection. J Arthroplasty 2011; 26:1136.
  55. Tigges S, Stiles RG, Roberson JR. Appearance of septic hip prostheses on plain radiographs. AJR Am J Roentgenol 1994; 163:377.
  56. Smith SL, Wastie ML, Forster I. Radionuclide bone scintigraphy in the detection of significant complications after total knee joint replacement. Clin Radiol 2001; 56:221.
  57. Kraemer WJ, Saplys R, Waddell JP, Morton J. Bone scan, gallium scan, and hip aspiration in the diagnosis of infected total hip arthroplasty. J Arthroplasty 1993; 8:611.
  58. Censullo A, Vijayan T. Using Nuclear Medicine Imaging Wisely in Diagnosing Infectious Diseases. Open Forum Infect Dis 2017; 4:ofx011.
  59. Kwee TC, Kwee RM, Alavi A. FDG-PET for diagnosing prosthetic joint infection: systematic review and metaanalysis. Eur J Nucl Med Mol Imaging 2008; 35:2122.
  60. Bernard L, Lübbeke A, Stern R, et al. Value of preoperative investigations in diagnosing prosthetic joint infection: retrospective cohort study and literature review. Scand J Infect Dis 2004; 36:410.
  61. Spangehl MJ, Masri BA, O'Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am 1999; 81:672.
  62. Honsawek S, Deepaisarnsakul B, Tanavalee A, et al. Relationship of serum IL-6, C-reactive protein, erythrocyte sedimentation rate, and knee skin temperature after total knee arthroplasty: a prospective study. Int Orthop 2011; 35:31.
  63. Berbari E, Mabry T, Tsaras G, et al. Inflammatory blood laboratory levels as markers of prosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am 2010; 92:2102.
  64. Spangehl MJ, Younger AS, Masri BA, Duncan CP. Diagnosis of infection following total hip arthroplasty. Instr Course Lect 1998; 47:285.
  65. Lachiewicz PF, Rogers GD, Thomason HC. Aspiration of the hip joint before revision total hip arthroplasty. Clinical and laboratory factors influencing attainment of a positive culture. J Bone Joint Surg Am 1996; 78:749.
  66. 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; 90:1869.
  67. Ghanem E, Parvizi J, Burnett RS, et al. Cell count and differential of aspirated fluid in the diagnosis of infection at the site of total knee arthroplasty. J Bone Joint Surg Am 2008; 90:1637.
  68. Parvizi J, Jacovides C, Antoci V, Ghanem E. Diagnosis of periprosthetic joint infection: the utility of a simple yet unappreciated enzyme. J Bone Joint Surg Am 2011; 93:2242.
  69. Deirmengian C, Kardos K, Kilmartin P, et al. Diagnosing periprosthetic joint infection: has the era of the biomarker arrived? Clin Orthop Relat Res 2014; 472:3254.
  70. The diagnosis of periprosthetic joint infections of the hip and knee. Guideline and evidence report. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, June 18, 2010.
  71. Trampuz A, Piper KE, Jacobson MJ, et al. Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med 2007; 357:654.
  72. Atkins BL, Athanasou N, Deeks JJ, 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; 36:2932.
  73. Wadey VM, Huddleston JI, Goodman SB, et al. Use and cost-effectiveness of intraoperative acid-fast bacilli and fungal cultures in assessing infection of joint arthroplasties. J Arthroplasty 2010; 25:1231.
  74. Pandey R, Berendt AR, Athanasou NA. Histological and microbiological findings in non-infected and infected revision arthroplasty tissues. The OSIRIS Collaborative Study Group. Oxford Skeletal Infection Research and Intervention Service. Arch Orthop Trauma Surg 2000; 120:570.
  75. Schäfer P, Fink B, Sandow D, et al. Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis 2008; 47:1403.
  76. Tsaras G, Maduka-Ezeh A, Inwards CY, et al. Utility of intraoperative frozen section histopathology in the diagnosis of periprosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am 2012; 94:1700.
  77. Donlan RM. New approaches for the characterization of prosthetic joint biofilms. Clin Orthop Relat Res 2005; :12.
  78. Achermann Y, Vogt M, Leunig M, et al. Improved diagnosis of periprosthetic joint infection by multiplex PCR of sonication fluid from removed implants. J Clin Microbiol 2010; 48:1208.
  79. Portillo ME, Salvadó M, Trampuz A, et al. Sonication versus vortexing of implants for diagnosis of prosthetic joint infection. J Clin Microbiol 2013; 51:591.