The diagnostic protocol for evaluation of periprosthetic joint infection

  • Alen Mlekuž Ortopedska bolnišnica Valdoltra Jadranska cesta 31 6280 Ankaran
  • Rihard Trebše Ortopedska bolnišnica Valdoltra Jadranska cesta 31 6280 Ankaran
  • Rene Mihalič Ortopedska bolnišnica Valdoltra Jadranska cesta 31 6280 Ankaran
  • Vesna Levašič Ortopedska bolnišnica Valdoltra Jadranska cesta 31 6280 Ankaran
Keywords: Total joint arthroplasty infection, algorithm, diagnostic procedures,


Infection is becoming the most important as well as the most devastating mechanism of prosthetic joint failure. The incidence is increasing due to increased sensitivity of orthopedic surgeons for this diagnosis, better diagnostics, and  because the absolute number of operated patients is increasing and because more often very sick, debilitated, and immunocompromised patients are operated on. The trend shows the incidence to further increase in the years to come. The diagnosis may be very easy in case of high grade processes, but also extremely difficult in low grade infections. Misdiagnosing infection leads to repeat early failures and revisions that are distressing for patients as well as for surgeons. To avoid failures related to misdiagnosed prosthetic joint infections a step-wise algorithm of action is proposed and the diagnostic strength of the steps discussed. The key point is to select the potential candidates to define the possibility of an ongoing infection and then to select the tools to strengthen the suspicion. The further procedures base on the analysis of the pseudo-synovial fluid obtained by aspiration. The diagnostic conclusions form the basis for considered treatment decisions.


Download data is not yet available.

Author Biographies

Alen Mlekuž, Ortopedska bolnišnica Valdoltra Jadranska cesta 31 6280 Ankaran
Rihard Trebše, Ortopedska bolnišnica Valdoltra Jadranska cesta 31 6280 Ankaran



Rene Mihalič, Ortopedska bolnišnica Valdoltra Jadranska cesta 31 6280 Ankaran
Vesna Levašič, Ortopedska bolnišnica Valdoltra Jadranska cesta 31 6280 Ankaran


Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978; 49: 399-406.

Pierce EC. The 34th Rovenstine Lecture: 40 years behind the mask – safety revisited. Anestesiology. 1996; 84: 965-75.

Kurtz SM, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780-5.

Kurtz SM, Ong KL, Lau E, Manley MT. Current and projected utilization of total joint replacement. In: Ducheyne P, Healy K, Hutmacher DW, Grainger DW, Kirkpatrick CJ, eds. Comprehensive Biomaterials. Philadelphia: Elsevier Science. 2011; 1-9.

Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Rel Resea. 2008; 466: 1710-15.

Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty. 2009; 24: 84-8.

Jaekel DJ, Ong KL, Lau EC, Kurtz SM. The Epidemiology of total joint arthroplasty infections. In: Trebše R, ed. Total joint arthroplasty infections. The algorithmic approach. London: Springer 2012, In press.

Jamsen E, Huhtala H, Puolakka T, Moilanen T. Risk factors for infection after knee arthroplasty. A register- based analysis of 43,149 cases. J Bone Joint Surg Am. 2009; 91:38-47.

Dale H, Skramm I, Lower HL, et al.. Infection after primary hip arthroplasty. Acta orthopaedica. 2011;82:646- 54.

Kurtz SM, Ong KL, Schmier J, et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89 (Suppl 3):144-51.

Azzam K, McHale K, Austin M, Purtill JJ, Parvizi J. Outcome of a second two-stage reimplantation for periprosthetic knee infection. Clinical orthopaedics and related research. 2009;467:1706-14.

Hanssen AD, Osmon DR. Evaluation of a staging system for infected hip arthroplasty. Clin. Orthop Rel Res. 2002; 403:16-22.

Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Should Elb Surg. 2011; 20: 146-157.

Gerometta A, Rodriguez Olaverri JC, Bittan F. Infection and revision strategies in total disc arthroplasty. International orthopaedics. 2012; 36: 471-4.

Beadel G, King G. Revision elbow arthroplasty. In: Williams GR, Yamaguchi K, Ramsey ML, Galatz LM, eds. Shoulder and Elbow Arthroplasty. Philadelphia: Lippincott Williams and Wilkins; 2005:428.

Kim JM, Mudgal CS, Konopka JF, Jupiter JB. Complications of total elbow arthroplasty. J Am Acad Orthop Surg. 2011; 19: 328-39.

Voloshin I, Schippert DW, Kakar S, Kaye EK, Morrey BF. Complications of total elbow replacement: a systematic review. J Should Elb Surg. 2011; 20: 158-168.

Fevang BT, Lie SA, Havelin LI, Skredderstuen A, Furnes O. Results after 562 total elbow replacements: a report from Norwegian arthroplasty register. J Shoulder Elbow Surg. 2009; 18: 449-56.

Trebše R (ed). Total joint arthroplsty infections. The algorithmic approach. London: Springer 2012. In press.

Zimmerli W, Trampuž A, Ochsner P. Prosthetic joint infections. N Engl J Med. 2004; 351: 1645–54.

Milosev I, Trebše R, Kovač S. Materials development and latest results of various bearings. In: Aoi T, Toshida A eds Hip replacements, approaches, complications and effectiveness. New York: Nova Science Publishers Inc. 2009.

Milošev I, Kovač S, Trebše R, Levašič V, Pišot V. Comparison of 10-year survivorship of a hip prosthesis using conventional polyethylene, metal-on-metal or ceramic-on-ceramic bearings. JBJS Am in press.

Kovač S, Trebše R, Milošev I, Pavlovčič V, Pišot V. Long-term survival of the straight titanium stem. J Bone Joint Surg Br 2006; 88-B: 1567-73.

Hallab N, Merritt K, Jacobs JJ. Metal sensitivity in patients with orthopedic implants. J Bone Joint Surg Am. 2001; 83-a: 428-36.

AAOS (American academy of orthopedic surgeons) The diagnosis of periprosthetic joint infections in the hip or knee. Guideline and evidence report, 1sted, Rosmont: AAOS 2010. (

Trampuž A, Piper KE, Jacobson MJ et al. Sonication of the removed hip and knee prostheses for diagnosis of infection. N Engl J Med. 2007; 357:654–63.

Del Pozzo JL, Patel R. Infections associated with prosthetic joints. N Eng J Med. 2009; 361:787-94.

Canadian Hip Resurfacing Study Group. A survey on the prevalence of pseudotumors with metal-on-metal hip resurfacing in Canadian academic centers. J Bone Joint Surg Am. 2011; 93-a; Suppl 2:118-21.

Steckelberg JM, Osmon DR. Prosthetic Joint Infection. In: Bisno AL, Waldvogel FA, eds. Infections associated with indwelling medical devices. 3rd ed. Washington, DC: American Society for Microbiology. 2000; 173-209.

Fink B, Makowiak C, Fuerst M, Berger I, Schafer P, Frommelt L. The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late periprosthetic infection of total knee replacements. J Bone joint Surg Br. 2008; 90:874-8.

Greidanus NV, Masri BA, Garbut DS, et al. Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before revision total knee arthroplasty: a prospective evaluation. J Bone joint Surg Am. 2007; 89:1409-16.

Muller M, Moravietz L, Hassart O, Strube P Perka C, Tothz S (2008) Diagnosis of periprosthetic infection following total hip arthroplasty – evaluation of the diagnostic values of pre- and intraoperative parameters and the associated strategy to preoperatively select patients with high probability of joint infection. J Orthop Surg Res. 2008; 3:31-9

Love C, Marwin SE, Palestro CJ. Nuclear medicine and the infected joint replacement. Semin Nucl Med. 2008; 39:66-78.

Tigges S, Stiles RG, Robertson JR. Appearance of septic hip protheses on plain radiographs. Am J Roentgenol. 1994; 163: 377–80.

Schafroth M, Zimmerli W, Brunazzi M, Ochsner PE. Infections. In: Ochsner PE, ed. Total hip replacement. Berlin: Springer-Verlag. 2003;65-90.

Hain SF, O'Doherty MJ, Smith MA. Functional imaging and the orthopaedic surgeon. J Bone Joint Surg Br. 2002; 84-br: 315–21.

White LM, Kim JK, Mehta M Complications of total hip arthroplasty: MR imaging-initial experience. Radiology. 2000; 215:254-62.

Potter HG, Nestor BJ, Sofka CM. Magnetic resonance imaging after total hip arthroplasty: evaluation of periprosthetic soft tissue. J Bone Joint Surg Am. 2004; 86:1947-54.

Mackowiak PA, Jones SR, and Smith JW. Diagnostic value of sinus-tract cultures in chronic osteomyelitis. JAMA. 1978; 239: 2772-5.

Bauer TW, Parvizi J, Kobayashi N, Krebs V. Diagnosis of Periprosthetic Infection. J Bone Joint Surg Am. 2006; 88-a: 869-882.

Trampuz A, Widmer AF. Infections associated with orthopedic implants. Current Opinion in Infectious Diseases. 2006; 19: 349-56.

Terčič D, Božič B. The basis of the synovial fluid analysis. Clin Chem Lab Med. 2001; 39: 1221–6.

Trampuz A, Hanssen AD, Osmon DR, Mandrekar J, Steckelberg JM, Patel R Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med. 2004; 117:556-62.

Bernard L, Lubbeke A, Stern R. Value of preoperative investigations in diagnosing prosthetic joint infection: retrospective cohort study and literature review. Scand J Infecti Dis. 2004; 36:410-16.

Ali F, Wilkinson JM, Kerry RM, Hamer AJ, Norman P, Stockley I. Accuracy of joint aspiration for preoperative diagnosis of infection in total hip arthroplasty. J Arthroplasty. 2006; 21: 221-6.

Meermans G, Haddad FS. Is there a role for tissue biopsy in the diagnosis of periprosthetic infection? Clin Ortop. 2010; 468:1410-7.

Costerton JW. Biofilm theory can guide the treatment of device- related orthopaedic infections. Clin Orthop Relat Res. 2005; 437: 7–11.

Fenollar F, Roux V, Stein A, Drancourt M, Raoult D. Analysis of 525 samples to determine the usefulness of PCR amplification and sequencing of the 16S rRNA gene for diagnosis of bone and joint infections. J Clin Microbiol. 2006; 44:1018-28.

Fishman V, Hannouche D, Bousson V. Improved diagnosis specificity in bone and joint infections using molecular techniques. J Infect. 2007; 55: 510-517.

Panousis K, Grigoris P, Butcher I, Rana B, Reilly JH, Hamblen DL. Poor predictive value of broad-range PCR for the detection of arthroplasty infection in 92 cases. Acta Orthop. 2005; 76 :341-6

Worthington T, Dunlop D, Casey A, Lambert R, Luscombe J, Elliott T. Serum procalcitonin, interleukin-6, soluble intercellular adhesin molecule-1 and IgG to short-chain exocellular lipoteichoic acid as predictors of infection in total joint prosthesis revision. Br J Biomed Sci. 2010; 67: 71-6.

Di Cesare PE, Chang E, Preston CF, Liu CJ. Serum interleukin-6 as a marker of periprosthetic infection following total hip and knee arthroplasty. J Bone Joint Surg Am. 2005; 87: 1921-7.

Bottner F, Wegner A, Winkelmann W, Becker K, Erren M, Gotze C. Interleukin-6, procalcitonin and TNF- alpha: markers of peri-prosthetic infection following total joint replacement J Bone Joint Surg Br. 2007;89:94-9.

Deirmengian C, Hallab N, Tarabishy A, et al. Synovial fluid biomarkers for periprosthetic infection. Clin Orthop Relat Res. 2010; 468:2017-23.

Jacovides CL, Parvizi J, Adeli B, Jung KA. Molecular markers for diagnosis of periprosthetic joint infection. J Arthroplasty. 2011; 26 (6 Suppl);99-103.e1.

Lerchner J, Wolf A, Buchholz F et al. Miniaturized calorimetry - a new method for real-time biofilm activity analysis. J Microbiol Methods. 2008; 74-2-3:74-81.

Buchholz F, Harms H, Maskow T. Biofilm research using calorimetry - a marriage made in heaven? Biotechnology Journal. 2010; 5-12:1339-50.

Clauss M, Trampuz A, Borens O, Bohner M, Ilchmann T. Biofilm formation on bone grafts and bone graft substitutes: comparison of different materials by a standard in vitro test and microcalorimetry. Acta Biomater. 2010; 6: 3791-7.

Furustrand Tafin U, Majic I, Zalila Belkhodja C. Gentamicin improves the activities of daptomycin and vancomycin against enterococcus faecalis in vitro and in an experimental foreign body infection. Antimicrob Agents Chemother. 2011; 55: 4821-7.

Corstens FH, van der Meer JW. Nuclear medicine's role in infection and inflammation. Lancet. 1999; 354:765-70.

Smith SL, Wastie ML, Forster I. Radionuclide bone scintigraphy in the detection of significant complications after total knee joint replacement. Clin Radiol. 2001; 56:221-4.

Reing CM, Richin PF, Kemnore PI. Differential bone scanning in the evaluation in the painful total joint replacement. J Bone Joint Surg Am. 2004; 86:1947-54.

Scher DM, Pak K, Lonner JH. The predictive value of indium-111 leucocyte scan in the diagnosis of infected total hip, knee, or resection arthroplasties. J Arthroplasty. 2000; 15:295-300.

Palestro CJ. Radionuclide imaging after skeletal interventional procedures. Semin Nucl Med. 1995; 25:3-14.

van der Bruggen W, Bleeker-Rovers CP, Boerman OC, Gotthardt M, Oyen WJ. PET and SPECT in osteomyelitis and prosthetic bone and joint infections: a systematic review. Semin Nucl Med. 2010; 40: 3-15.

Chacko TK, Zhuang H, Nakhoda KZ, Moussavian B, Alavi A. Applications of fluorodeoxyglucose positron emission tomography in the diagnosis of infection. Nucl Med Commun. 2003; 24:615-24.

Kwee TC, Kwee RM, Alawi A. FDG PET for diagnosing prosthetic joint infection: systematic review and metaanalysis. Eur J Nucl Mol Imaging. 2008; 35:2122-32.

Della Valle C, Parvizi J, Bauer TW, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am. 2011; 93: 1355-57.

Gravius S, Gebhard M, Ackermann D, Bohll U,Hermanns-Sachweh B, Mumme T. Analysis of 18F-FDG uptake pattern in PET for diagnosis of aseptic loosening versus prosthesis infection after total knee arthroplasty. A prospective pilot study. Nuklearmedizin. 2010; 49:115-23.

Moran E, Byren I, Atkins BL The diagnosis and management of prosthetic joint infections. J Antimicrob Chemother. 2010; 65 (Suppl 3): 45-54.

Health Protection Agency (2009). Investigation of prosthetic joint infection samples. National Standard Method BSOP 44 Issue 1.1.

Brook I. Comparison of two transport systems for recovery of aerobic and anaerobic bacteria from abscesses. J Clin Microbiol. 1987; 25 :2020-2

Hughes HC, Newnham R, Athanasou N, Atkins BL, Bejon P, Bowler IC Microbiological diagnosis of prosthetic joint infections: a prospective evaluation of four bacterial culture media in the routine laboratory. Clin Microbiol Infect. 2011; 17:1528-30.

Tunney MM, Patrick S, Gorman SP. Improved detection of infection in hip replacements: a currently underestimated problem. J Bone Joint Surg Br. 1998; 80-br: 568-72.

Mihalič R, Trebše R, Terčič D, Trampuž A. Synovial fluid cell count for rapid and accurate intraoperative diagnosis of prosthetic joint infection. In Proceedings of the 10th EFORT Congress. Vienna, Austria: J Bone Joint Surg Br. 2010; 92-B:. 608-608.

Athanasou NA, Pandey R, de Steiger R, et al. The role of intraoperative frozen sections in revision total joint arthroplasty. J Bone Joint Surg Am. 1997; 79: 1433-4.

Lonner JH, Desai P, Dicesare PE, Steiner G, Zuckerman JD. The reliable of analysis of intraoperative frozen sections for identifying acute infection during revision hip or knee arthroplasty. J Bone Joint Surg Am. 1996; 78: 1553-58.

Feldman DS, Lonner JS, Desal P, Zuckerman JD. The role of intraoperative frozen sections in revision total joint arthroplasty. J Bone Joint Surg Am. 1995; 77: 1807-13.

Nunez LV, Buttaro MA, Morandi A, Pusso R, Piccaluga F. Frozen sections of samples taken intraoperatively for diagnosis of infection in revision hip surgery. Acta Orthop. 2007; 78: 226-30.

Spangehl MJ, Masri BA, O’Connel JX, et al. Prospective analysis of preoperative and intraoperative investigational for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999; 81: 672-683.

Fitzgerald RH, Jr., Nolan DR, Ilstrup DM, Van Scoy RE, Washington JA, Coventry MB. Deep wound sepsis following total hip arthroplasty. J Bone Joint Surg Am. 1977; 59: 847-55.

Toms AD, Davidsom D, Masri BA, Duncan CP. The management of periprosthetic infection in total joint arthroplasty. J Bone Joint Surg Br. 2006; 88:149-55.

Tsukajama DT, Estrada R, Gustilo RB. Infections after total hip arthroplasty: a study of the treatment of one hundred and six infections. J Bone Joint Surg Am. 1996; 78: 512-23.

How to Cite
Mlekuž A, Trebše R, Mihalič R, Levašič V. The diagnostic protocol for evaluation of periprosthetic joint infection. ZdravVestn [Internet]. 29Jun.2015 [cited 30Mar.2020];84(6). Available from: