1. How can prosthetic joint infection (PJI) be distinguished from aseptic failure of the joint arthroplasty due to mechanical loosening or dislocation?

2. Which pathogens are usually responsible for PJIs?

3. What are the management strategies and treatment options for infected prosthetic joints?

4. Can an infected prosthetic joint be effectively treated with retention of the prosthesis?

5. What is the optimal antimicrobial regimen for a PJI?

6. How should patients with PJI s on long-term parenteral or oral antibiotics be monitored and followed up?

Joint replacement surgery (arthroplasty) is one of the major accomplishments of modern medicine over the past four decades. It has provided excellent and cost-effective results in alleviating pain and improving mobility and quality of life in patients with debilitating joint disease. Most arthroplasties are performed on hips and knees, but shoulder, elbow, and other small joint replacements are not uncommon. It is estimated that over 750,000 prosthetic joints are implanted each year in the United States, with projections of over 4 million primary arthroplasties per year by 2030. Less than 10% of prosthesis recipients develop complications that require revision surgery. Fortunately, prosthetic joint infection (PJI) is less common than other forms of joint failure, such as aseptic loosening or dislocation. Nevertheless, given the exponential increase in total joint replacement surgeries, the cumulative numbers of PJI is increasing. Moreover, PJI represents the most dreaded and devastating complication of arthroplasty. Overall, about 1 to 2% of prosthetic joints become infected, with higher rates for total knee arthroplasties (TKA) compared with total hip arthroplasties (THA) (2.5% vs 1.5%). PJIs may occur at any time after arthroplasty. The risk of infection is higher after revision arthroplasty, with rates of 3.2% and 5.6% reported for revision THA and TKA, respectively. Consequences of PJI may include reoperation, potential for permanent removal of the prosthesis, large skeletal defects after surgery, prolonged courses of antimicrobial therapy, severe functional impairment, and persistent joint pain. Rarely, PJIs result in loss of limb or life. The cost of treatment of PJIs is in excess of $50,000 per episode, with an estimated total expenditure of over$250 million per year in the United States.

Conditions and events that predispose a prosthetic joint recipient to infection include host characteristics, index arthroplasty factors, and perioperative and postoperative factors. Host characteristics include advanced age, morbid obesity, diabetes mellitus, malignancy, HIV seropositivity, and systemic steroid use. Arthroplasties performed due to underlying rheumatoid arthritis are four times more likely to be infected compared to those for degenerative osteoarthritis. Other joint factors, such as primary arthroplasty undertaken due to trauma or fracture, revision arthroplasty, regardless of indication, and prior PJI, are independent risk factors for infection. Perioperative factors such as a National Nosocomial Infections Surveillance System surgical risk score greater than 2, American Society of Anesthesiologists greater than 2, duration of surgery greater than 75th percentile for the procedure or longer than three hours, postoperative superficial surgical site infection, wound drainage or wound hematoma, and distant nonarticular infections such ...

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