Synopsis
Recognise acute and indolent prosthetic-joint infection, protect microbiological yield, obtain multiple deep samples and coordinate biofilm-active therapy with an appropriate implant surgical strategy.
- Prosthetic-joint infection is a biofilm infection involving an arthroplasty surface and surrounding tissue; it cannot be managed as simple cellulitis or native-joint sepsis.
- Classify timing and symptom duration: early postoperative, acute haematogenous and chronic indolent presentations have different surgical opportunities.
- In a stable patient, protect culture yield by withholding empirical antibiotics until aspiration or operative deep samples have been obtained.
- Do not swab a sinus or superficial wound as the definitive culture; obtain multiple separately labelled deep tissue samples with clean instruments.
- Plain radiographs assess loosening and fracture but cannot exclude infection; CRP and ESR support probability but may be normal in indolent disease.
- Definitive management combines surgery with prolonged organism-directed therapy: DAIR, one- or two-stage exchange, resection or selected suppression.
- DAIR is most successful with a stable implant, intact soft tissues, a susceptible organism and short symptom duration before mature biofilm establishes.
- Rifampicin is used only in combination for selected susceptible staphylococcal retained-implant infections after adequate debridement; never prescribe it alone.
Key red flags
Hypotension, confusion, tachypnoea or rising lactate indicates prosthetic-joint infection with sepsis.
A draining sinus communicating with the prosthesis is definitive evidence of implant-associated infection.
Acute pain and effusion during Staphylococcus aureus bacteraemia suggests haematogenous prosthetic seeding.
Wound dehiscence, persistent drainage or exposed implant soon after surgery requires immediate arthroplasty-team review.
Progressive loosening, night pain or loss of function can represent indolent infection even without fever.
Neurovascular deficit, dislocation or periprosthetic fracture adds an orthopaedic emergency to the infection.
Persistent drainage, wound breakdown, new erythema, effusion, escalating pain or fever soon after arthroplasty suggests early implant infection.
Sudden severe pain and loss of function in a previously well prosthesis during or after bacteraemia supports bloodstream implantation.
A sinus tracking to the prosthesis is diagnostic of infection regardless of a superficial swab result.
Dislocation, fracture, implant migration, gross loosening or neurovascular compromise requires urgent orthopaedic management alongside infection planning.
Investigation priorities
Assess implant position, migration, radiolucency, osteolysis, fracture and baseline mechanical failure.
Management branches
Prosthetic-joint infection is suspected but the patient has no sepsis, wound catastrophe or neurovascular emergency.
- Contact the arthroplasty or implant surgeon early and document implant type, operation date, revisions, symptom duration, wound history and previous antibiotics.
- Obtain radiographs, CRP and ESR and arrange image-guided aspiration under the local prosthetic-joint protocol.
- Withhold empirical antibiotics until aspiration or operative tissue has been collected when this is clinically safe.
- Agree the likely surgical strategy and required number and handling of deep samples before the patient enters theatre.
Infection is acute, the implant is stable, soft tissues are salvageable and symptom duration and organism make retention plausible.
- Perform urgent open debridement, extensive synovectomy and exchange modular components where technically possible while retaining fixed stable components.
- Take multiple deep tissue samples before irrigation and antibiotics, using separate instruments and clear anatomical labels.
- Begin directed or empirical systemic therapy after sampling and add rifampicin combination therapy only when specialist criteria for susceptible staphylococcal retained-implant disease are met.