Twenty common errors in the diagnosis and treatment of periprosthetic joint infection

Abstract

Background: Misconceptions and errors in the management of periprosthetic joint infection (PJI) can compromise the treatment success. The goal of this paper is to systematically describe twenty common mistakes in the diagnosis and management of PJI, to help surgeons avoid these pitfalls.

Materials and methods: Common diagnostic and treatment errors are described, analyzed and interpreted.

Results: Diagnostic errors include the use of serum inflammatory biomarkers (such as C-reactive protein) to rule out PJI, incomplete evaluation of joint aspirate, and suboptimal microbiological procedures (such as using swabs or collection of insufficient number of periprosthetic samples). Further errors are missing possible sources of distant infection in hematogenous PJI or overreliance on suboptimal diagnostic criteria which can hinder or delay the diagnosis of PJI or mislabel infections as aseptic failure. Insufficient surgical treatment or inadequate antibiotic treatment are further reasons for treatment failure and emergence of antimicrobial resistance. Finally, wrong surgical indication, both underdebridement and overdebridement or failure to individualize treatment can jeopardize surgical results.

Conclusion: Multidisciplinary teamwork with infectious disease specialists and microbiologists in collaboration with orthopedic surgeons have a synergistic effect on the management of PJI. An awareness of the possible pitfalls can improve diagnosis and treatment results.

Keywords: Hip arthroplasty; Joint replacement surgery; Knee arthroplasty; Periprosthetic joint infection; Synovial fluid analysis.

Fig. 1

Origin of haematogenous infection (adapted from Rakow et al. [29])

Fig. 2

Sensitivity, specificity, and accuracy of diagnosis of PJI with two or more samples using conventional culture methods (using Bayesian latent class modeling) (extracted from the data in Peel et al. [43])

Fig. 3

Percentage of patients diagnosed with periprosthetic joint infection using the diagnostic criteria proposed by different scientific societies (Musculoskeletal Infection Society (MSIS) criteria, IDSA criteria, and the proposed European Bone and Joint Infection Society (EBJIS, working draft) criteria. Data extracted from references [35, 49]

Fig. 4

Algorithms of the different treatment modalities of PJI. Adapted from Li et al. [6]