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Evaluation and Management of Periprosthetic Joint Infection–an International, Multicenter Study

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Controversies still exist regarding the optimal diagnostic and therapeutic strategies in patients with prosthetic joint infections (PJI).


How effective are preoperative and intraoperative cultures in isolating organisms and how do these culture results compare to one another? What are the results of surgical treatment of PJI in the hip and knee in an international, tertiary referral center cohort?

Patients and Methods

One hundred sixteen patients (N = 59 hip PJI, N = 57 knee PJI) were recruited prospectively to registries at three international, tertiary referral centers between December 2008 to November 2011. Retrospective review of prospective registry data including demographics, microbiology results, and operative reports was performed.


Preoperative synovial fluid aspiration yielded an organism in only 45.2% and 44.4% of cases, respectively, for knee and hip PJI. False-negative rates of preoperative aspiration relative to intraoperative culture were 56% and 46% in hip and knee PJI, respectively, with discordance rates of 25% and 21.4%, respectively. Rates of negative intraoperative cultures were 15% in hip PJI and 20.7% in knee PJI. Open debridement with prosthetic retention was the most common initial revision procedure performed (48.3% of hip PJI and 63.8% of knee PJI). This method of revision was successful in 41.3% of hip PJI and 59.4% of knee PJI. Initial failure rates for prosthetic revision was lower than debridement with prosthetic retention but remained substantial in both hip PJI (initial success of one-stage exchange 60% and two-stage exchange 70%) and knee PJI (initial success of one-stage exchange 80% and two-stage exchange 75%).


Diagnosis and treatment of PJI remains challenging with difficulty in isolating the offending organism and with high rates of prosthetic revision and initial treatment failures. Future advances in organism isolation and international standardization of treatment protocols may improve patient outcomes.

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The authors wish to thank the International Society of Orthopedic Centers (ISOC) for providing funding through the Traveling Fellowship for Dr. Shanmugasundaram.


Conflict of Interest: Saseendar Shanmugasundaram, MD, Benjamin F. Ricciardi, MD and Timothy WR. Briggs, MD have declared that they no conflict of interest. Patrick S. Sussmann, MD, receives speaker fees from Depuy and Johnson and Johnson, outside the work. Mathias P. Bostrom, MD, is a paid consultant to Smith and Nephew and serves as a board member of the Orthopedic Research Society and HSS Journal, outside the work.

Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

Informed Consent: Informed consent was obtained from all patients for being included in the study.

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Correspondence to Benjamin F. Ricciardi MD.

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Level of Evidence: Level IV (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

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Shanmugasundaram, S., Ricciardi, B.F., Briggs, T.W.R. et al. Evaluation and Management of Periprosthetic Joint Infection–an International, Multicenter Study. HSS Jrnl 10, 36–44 (2014).

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