Periprosthetic joint infection continues to frustrate the medical community. Although the demand for total joint arthroplasty is increasing, the burden of such infections is increasing even more rapidly, and they pose a unique challenge because their accurate diagnosis and eradication can prove elusive. This review describes the current knowledge regarding diagnosis and treatment of periprosthetic joint infection. A number of tools are available to aid in establishing a diagnosis of periprosthetic joint infection. These include the erythrocyte sedimentation rate, serum C-reactive protein concentration, synovial white blood-cell count and differential, imaging studies, tissue specimen culturing, and histological analysis. Multiple definitions of periprosthetic joint infection have been proposed but there is no consensus. Tools under investigation to diagnose such infections include the C-reactive protein concentration in the joint fluid, point-of-care strip tests for the leukocyte esterase concentration in the joint fluid, and other molecular markers of periprosthetic joint infection. Treatment options include irrigation and debridement with prosthesis retention, one-stage prosthesis exchange, two-stage prosthesis exchange with intervening placement of an antibiotic-loaded spacer, and salvage treatments such as joint arthrodesis and amputation. Treatment selection is dependent on multiple factors including the timing of the symptom onset, patient health, the infecting organism, and a history of infection in the joint. Although prosthesis retention has the theoretical advantages of decreased morbidity and improved return to function, two-stage exchange provides a lower rate of recurrent infection. As the burden of periprosthetic joint infection increases, the orthopaedic and medical community should become more familiar with the disease. It is hoped that the tools currently under investigation will aid clinicians in diagnosing periprosthetic joint infection in an accurate and timely fashion to allow appropriate treatment. Given the current knowledge and planned future research, the medical community should be prepared to effectively manage this increasingly prevalent disease.

Javad, "Successful identification of pathogens by polymerase chain reaction (PCR)-based electron spray ionization time-of-flight mass spectrometry (ESI-TOF-MS) in culture-negative periprosthetic joint infection." (2012). Rothman Institute. Paper 22.

Periprosthetic joint infection has become the most common cause of failure following total knee arthroplasty. Over the past 4 decades, treatment of this disease has evolved with technological innovations and pathogen profiling. The appropriate treatment selection is dependent on patient immune system quality, timing of symptom onset, and pathogen type. Antibiotic suppression alone is reserved for those cases without drainage, low-virulent antimicrobial-susceptible pathogens, and patients whose level of health increases the risk of surgery past any risk associated with chronic infection. In patients with an acute onset of symptoms and antimicrobial-susceptible pathogens, irrigation and debridement with exchange of modular components is moderately successful and offers the advantage of component retention and maximum knee function. In failed irrigation or chronic periprosthetic joint infection, resection of all components is necessitated. Resection and reimplantation can either be performed in one or two stages. A single-stage exchange has the potential to decrease the number of surgeries and therefore cost. However, the success rate of direct exchange is lower than that of two-stage revision. This has led to two-stage revision, with the placement of an intra-stage antibiotic-loaded spacer, to become the "gold" standard for periprosthetic joint infection eradication. In an immunocompromised patient with an uncontrollable periprosthetic joint infection, salvage procedures are necessitated. Complete eradication of periprosthetic joint infection is achieved by resection of all components without reimplantation through arthrodesis or above-the-knee-amputation. While amputation may be unpopular with patients it provides a greater ability to reconstruct, with an external prosthesis, a functioning joint.

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Background Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty. Lack of confirmation of an infecting organism poses a challenge with regard to the selection of an appropriate antibiotic agent and surgical treatment. It is unclear whether patients with negative cultures presumed to have infections achieve similar rates of infection-free survival as those with positive cultures. Questions/purposes The purposes of this study were (1) to report the infection control rates using irrigation and débridement and two-stage exchange for treatment of culture-negative PJIs; and (2) to compare infection control rates in culture-negative cases with those in culturepositive cases. Methods We retrospectively reviewed 55 patients with culture-negative PJI treated between 2000 and 2007. We compared the infection-free survival rate in the culturenegative patients with that of 295 culture-positive cases of PJI. Results Overall infection control rate in culture-negative cases was 73% at minimum 1-year followup (mean, 47 months; range, 12-119 months). We found similar infection control rates in culture-negative and culturepositive PJI. Infection-free survival rates in both groups were highest after two-stage exchange arthroplasty and postoperative vancomycin therapy. Conclusion Our observations suggest aggressive twostage exchange arthroplasty and postoperative parenteral vancomycin therapy in patients with culture-negative PJI achieves similar rates of infection-free survival as with patients having culture-positive PJI. Level of Evidence Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

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Background C-reactive protein (CRP) serum assays are a standard element of the diagnostic workup for periprosthetic joint infection (PJI). However, because CRP is a marker for systemic inflammation, this test is not specific to PJI. Questions/purposes Our purpose was to assess whether synovial fluid and serum assays alone could differentiate between infected and uninfected revision knee arthroplasties and to determine which of these methods had the greatest diagnostic accuracy. Methods We collected synovial fluid specimens from 66 patients undergoing revision total knee arthroplasty. Patients were judged uninfected or infected by standardized criteria. Synovial CRP levels were measured using an individual CRP assay (15 samples; 10 infected, five uninfected) and a multiplex immunoassay platform (59 samples; 25 infected, 34 uninfected). Results from preoperative standard serum CRP assays conducted were also collected (55 samples; 25 infected, 30 uninfected). Sensitivity, specificity, and receiver operating characteristic curve analyses were performed for each assay with a diagnosis of infection based on previously established criteria.Results Synovial CRP concentrations differed between infected and uninfected joints in the multiplex and serum analyses. The area under the curve was 0.84 for the individual assay, 0.91 for the multiplex assay, and 0.88 for the serum CRP assay. Sensitivity and specificity were 70.0% and 100.0% for the individual enzyme-linked immunosorbent assay, 84.0% and 97.1% for the multiplex assay, and 76.0% and 93.3% for the serum CRP assay. Conclusions An assay measuring CRP in synovial fluid may be more accurate in diagnosing PJI than the standard serum CRP assay. We believe such an assay holds promise as a new diagnostic marker for PJI.

Our findings complement the theory from in vitro studies suggesting that neck impingement on the elevated titanium rim is the probable cause of the increased frequency of squeaking with this design.