Diagnosing and Managing Infection in THA

Archival Presentation Notice: This article modernizes the multimedia presentation “Diagnosing and Managing Infection in THA” originally presented by Dr. David Backstein, MD, MEd, FRCSC (Associate Professor, Department of Surgery, Mount Sinai Hospital, University of Toronto). The historical Flash lecture has been reconstructed into the synchronized video slide presentation above, with the original file preserved in the digital archives (Diagnosing_and_Managing_Infection_Backstein.swf).

1. High-Yield Summary

Periprosthetic joint infection (PJI) following total hip arthroplasty (THA) is one of the most challenging and devastating complications in reconstructive orthopaedic surgery, requiring rapid diagnostic discrimination and decisive surgical intervention.

• Diagnostic Cardinal Rule: Withhold all antimicrobial therapy prior to joint aspiration unless the patient exhibits hemodynamic instability or frank sepsis, avoiding false-negative synovial fluid cultures.
• Serologic Screening Triad: Serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) serve as the primary screening threshold; elevated markers mandate fluoroscopic or ultrasound-guided hip arthrocentesis.
• Synovial Fluid Diagnostic Cutoffs: In chronic PJI (>6 weeks from index surgery), synovial leukocyte count >3,000 cells/µL and polymorphonuclear percentage (% PMN) >70% indicate infection, supported by synovial alpha-defensin or leukocyte esterase strip positivity.
• Surgical Timing and Algorithm: Acute postoperative infections (<3–4 weeks) and acute hematogenous infections (<3 weeks of symptoms) with well-fixed components and a healthy soft tissue envelope are candidates for Debridement, Antibiotics, and Implant Retention (DAIR) with mandatory modular component exchange.
• Chronic Infection Protocol: Two-stage exchange arthroplasty with an antibiotic-loaded polymethylmethacrylate (PMMA) spacer remains the established standard in North America, while single-stage exchange is reserved for strictly selected hosts with identified, susceptible pathogens and robust soft tissue envelopes.

2. Anatomy

Surgical exposure during revision THA for periprosthetic infection requires precise anatomical navigation through altered, scarred tissue planes with constant vigilance regarding neurovascular danger zones and bone preservation.

Surgical Approaches & Internervous Planes

• Posterolateral Approach (Moore / Southern): Does not utilize a true internervous plane; splits the gluteus maximus (inferior gluteal nerve) and detaches the short external rotators (piriformis, obturator internus, and gemelli). Provides excellent posterior acetabular and proximal femoral exposure for component extraction.
• Direct Anterior Approach (Smith-Petersen): Internervous plane lies superficially between the sartorius (femoral nerve) and tensor fasciae latae (TFL, superior gluteal nerve), and deeply between the rectus femoris (femoral nerve) and gluteus medius (superior gluteal nerve). Extended exposure requires detachment of the rectus femoris indirect head and anterior capsule.
• Direct Lateral Approach (Hardinge): Splits the gluteus medius and vastus lateralis in continuity. The superior gluteal nerve crosses 3 to 5 cm proximal to the tip of the greater trochanter; splitting the gluteus medius beyond this safe zone causes denervation and permanent abductor lurch.

Neurovascular Danger Zones

• Sciatic Nerve: Exits the greater sciatic foramen inferior to the piriformis and traverses over the short external rotators. At extreme risk during revision posterior exposures, extensive debridement of inflammatory pseudotumors, posterior acetabular wall reaming, or aggressive retractor placement across the posterior column.
• Femoral Neurovascular Bundle: Traverses anterior to the psoas tendon and anterior capsule. Anterior acetabular retractors misplaced directly against the anterior pelvis can compress or lacerate the external iliac or femoral vessels.
• Wasielewski Acetabular Quadrants: A line from the anterior superior iliac spine through the fovea to the posterior ischium, bisected perpendicular, creates four quadrants. Screws placed in the posterosuperior quadrant are safe; screws in the anterosuperior (external iliac vessels), anteroinferior (obturator vessels and nerve), and posteroinferior (sciatic nerve and inferior gluteal vessels) quadrants risk severe hemorrhage or nerve palsy.
• Medial Acetabular Wall (Cotyloid Notch): Aggressive medial wall debridement or reaming through the quadrilateral plate risks penetrating intrapelvic structures, including the obturator neurovascular bundle and bladder.

3. Pathogenesis

The pathophysiology of periprosthetic joint infection is governed by microbial surface adhesion, biofilm formation, and phenotypic bacterial alterations that protect organisms from host immune clearance and systemic antimicrobials.

• Inoculation Mechanisms: Bacteria colonize the prosthetic environment through direct intraoperative contamination (operating theatre airborne particulate, gloves, exposed skin margins), contiguous extension from surgical site hematomas or wound necrosis, or late hematogenous seeding from remote infectious foci (dental procedures, urinary tract instrumentation, vascular access lines, gastrointestinal disease).
• The Race for the Surface: Immediately upon implantation, biomaterials (titanium, cobalt-chromium, polyethylene, PMMA) are coated by host extracellular matrix proteins (fibronectin, fibrinogen, vitronectin, collagen). Bacteria utilize microbial surface components recognizing adhesive matrix molecules (MSCRAMMs) to dock onto the implant surface before host cell integration occurs.
• Biofilm Architecture & Matrix Synthesis: Following reversible attachment, sessile bacteria undergo irreversible binding and synthesize an extracellular polymeric substance (EPS) matrix consisting of polysaccharides, extracellular DNA (eDNA), lipids, and proteins. Biofilm maturation leads to microcolonies with fluid transport channels.
• Phenotypic Tolerance & Persister Cells: Within the mature biofilm, bacterial metabolic rates decrease dramatically. Deep layers experience hypoxia, nutrient deprivation, and acid accumulation, yielding metabolically dormant “persister cells.” These phenotypic shifts increase antibiotic resistance by 100 to 1,000 times compared to planktonic counterparts, rendering minimum inhibitory concentrations (MIC) clinically ineffective and mandating mechanical debridement.

Microbiological Spectrum

• Coagulase-Negative Staphylococci (Staphylococcus epidermidis, S. lugdunensis): 30% to 40% of cases, typified by insidious, low-virulence biofilm formation and indolent presentation.
• Staphylococcus aureus (MSSA and MRSA): 20% to 30% of cases, marked by destructive tissue necrosis, acute systemic illness, and toxin release.
• Streptococcus and Enterococcus spp.: 10% to 15% of cases, frequently hematogenous or associated with gastrointestinal and genitourinary portals.
• Gram-Negative Bacilli (Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis): 5% to 10% of cases, associated with compromised hosts, acute early surgical breakdown, or urosepsis.
• Anaerobic Pathogens (Cutibacterium acnes, Finegoldia magna): 2% to 5% of cases, requiring prolonged culture incubation up to 14 days.
• Culture-Negative PJI: 10% to 20% of cases, often secondary to prior empirical antibiotic administration or atypical fastidious microorganisms.

4. Natural History

The cumulative incidence of periprosthetic infection following primary total hip arthroplasty ranges between 0.5% and 1.5%, rising to 2.0% to 5.0% following revision procedures.

• Host Risk Factors: Systemic comorbidities severely compromise host local defense mechanisms. Critical predisposing factors include poorly controlled diabetes mellitus (HbA1c >8.0%), morbid obesity (BMI >40 kg/m²), active tobacco abuse, systemic inflammatory arthropathies, chronic immunosuppressive medication (biologics, corticosteroids), end-stage renal disease on hemodialysis, liver cirrhosis, severe malnutrition (serum albumin <3.5 g/dL, total lymphocyte count <1,500/mm³), and active distant bacterial colonization.
• Untreated Disease Trajectory: If unrecognized or inappropriately managed with suppressive antibiotics alone, persistent biofilm infection induces progressive osteoclastic bone resorption at the bone-implant interface. This leads to catastrophic aseptic/septic implant loosening, progressive peri-acetabular and femoral osteolysis, periprosthetic fracture, cutaneous sinus tract formation with draining purulence, and chronic debilitating pain.
• Systemic Morbidity and Mortality: Chronic uncontrolled PJI can trigger recurrent bacteremia, sepsis, multiple organ dysfunction, and prolonged immobilization. The 5-year mortality rate following surgical treatment for periprosthetic joint infection is estimated at 15% to 25%, exceeding the mortality rates of several common malignancies.

5. Clinical Presentation

Clinical evaluation requires detailed chronological stratification between acute postoperative infection, acute hematogenous seeding, and insidious, indolent chronic infection.

History

• Pain Characteristics: Pain is the primary clinical manifestation. Unlike mechanical loosening, which typically elicits start-up thigh or groin pain during weight-bearing, infection commonly produces constant, throbbing, unremitting rest pain and nocturnal pain.
• Timing of Symptoms: Note the exact postoperative timeframe when pain began. Identify whether the patient experienced an initial pain-free interval followed by acute deterioration (suggestive of hematogenous seeding) or never achieved pain relief after surgery (suggestive of perioperative inoculation).
• Systemic Features: Inquire about low-grade fevers, chills, diaphoresis, recent invasive dental procedures, urinary tract symptoms, or non-healing cutaneous ulcers.
• Wound Healing History: Document delayed wound closure, prolonged postoperative drainage (>72 hours), superficial wound breakdown, or prior antibiotic prescriptions.

Physical Exam

• Incision and Soft Tissue Inspection: Examine for erythema, localized warmth, induration, fluctuating subcutaneous fluid collections, or wound dehiscence.
• Sinus Tract Evaluation: A cutaneous sinus tract communicating with the prosthesis or draining visible purulence is a pathognomonic major criterion for PJI.
• Log-Roll Test: Gentle internal and external rotation of the extended lower limb reproducing deep groin pain indicates active joint capsule inflammation [Sensitivity 60%, Specificity 75%].
• Stinchfield Test: Resisted active straight leg raise at 30° of hip flexion eliciting sharp deep groin pain signifies intra-articular pathology [Sensitivity 70%, Specificity 80%].
• Abductor Strength and Trendelenburg Gait: Pain-mediated abductor inhibition or anatomical disruption of the gluteus medius insertion produces a positive Trendelenburg sign.

6. Imaging and Diagnostic Studies

Diagnosis demands a multi-tiered, systematic algorithm integrating serologic screening, image-guided arthrocentesis, radiographic assessment, and advanced imaging.

Serologic Screening Biomarkers

• C-Reactive Protein (CRP): Normal baseline <10 mg/L (or <1.0 mg/dL). CRP rises rapidly within 6 hours of surgery, peaks at 48 to 72 hours, and normalizes by 2 to 3 weeks. A secondary rise or failure to normalize beyond 3 weeks is highly sensitive for infection.
• Erythrocyte Sedimentation Rate (ESR): Normal baseline 30 mm/h alongside elevated CRP warrants definitive workup.
• Serum D-dimer: An adjunctive systemic biomarker reflecting fibrinolytic activity with elevated levels (>860 ng/mL) correlating with PJI in the absence of venous thromboembolism or systemic inflammatory states.

Synovial Fluid Analysis (Arthrocentesis)

Joint aspiration is mandatory in any patient with elevated serologic markers or clinical suspicion of PJI prior to revision surgery. Must be performed under sterile conditions with fluoroscopic or ultrasound confirmation. Antibiotics must be discontinued for a minimum of 2 weeks beforehand.

• Chronic PJI Cutoffs (>6 weeks from surgery): Synovial leukocyte count >3,000 cells/µL or >70% to 80% polymorphonuclear cells (% PMN).
• Acute Postoperative PJI Cutoffs (<6 weeks from surgery): Thresholds are higher due to normal surgical hemarthrosis: synovial leukocyte count >10,000 cells/µL or >90% PMN.
• Synovial Alpha-Defensin: An antimicrobial peptide released by neutrophils in response to pathogens. Qualitative immunoassay or quantitative ELISA demonstrates >95% sensitivity and >97% specificity, remaining accurate even in the presence of prior antibiotic exposure.
• Leukocyte Esterase (LE) Strip: Inexpensive, rapid enzymatic test (+ or ++ reading correlates with elevated synovial neutrophil activity). If heavily blood-stained, centrifuge fluid prior to application.
• Microbiological Culture Protocol: Inoculate fluid into pediatric blood culture bottles alongside aerobic, anaerobic, and fungal media. Hold cultures for 14 days to capture fastidious organisms like Cutibacterium acnes.

Radiographic & Advanced Imaging

• Plain Radiographs: Complete AP pelvis, dedicated AP and cross-table lateral views. Halmarks include progressive widening radiolucent lines (>2 mm), focal endosteal scalloping, periosteal reaction, component migration, vertical subsidence (>3 mm), or cement mantle fracture.
• Computed Tomography (CT): Crucial for pre-revision surgical planning to quantify acetabular and femoral osteolytic defect volume, identify pelvic discontinuity, and evaluate anterior/posterior column stability.
• MARS-MRI (Metal Artifact Reduction Sequence): Visualizes soft tissue collections, extracapsular fluid extensions, periprosthetic abscess formation, and abductor tendon complex continuity.
• Nuclear Medicine Imaging: Combined 99mTc-sulfur colloid and 111In-labeled white blood cell (WBC) scintigraphy is utilized in complex, equivocal presentations. Concordant uptake indicates physiologic marrow; discordant focal WBC uptake without sulfur colloid activity confirms infection.

7. Classification

Classifying periprosthetic joint infection establishes the chronologic timeframe, defines biofilm maturity, and determines whether implant retention or component explantation is required.

Tsukayama Classification of Periprosthetic Joint Infection

International Consensus Meeting (ICM) 2018 Diagnostic Criteria

The 2018 validated ICM criteria stratifies diagnosis into major criteria (definitive infection) and minor criteria (scored algorithm requiring an aggregate score >=6 for infection):

• Major Criterion 1: Sinus tract communicating directly with the prosthesis (Definitive PJI).
• Major Criterion 2: Isolation of the identical pathogen in >=2 separate periprosthetic tissue or fluid cultures (Definitive PJI).
• Preoperative Minor Criteria: Elevated serum CRP (>10 mg/L) or D-dimer (>860 ng/mL) [2 points]; elevated serum ESR (>30 mm/h) [1 point]; elevated synovial leukocyte count (>3,000 cells/µL) [3 points]; positive synovial alpha-defensin [3 points]; positive synovial leukocyte esterase strip [3 points]; elevated synovial polymorphonuclear % (>70%) [2 points].
• Intraoperative Minor Criteria: Positive histology (>5 neutrophils per high-power field in >=5 HPFs) [3 points]; positive intraoperative purulence [3 points]; single positive periprosthetic culture [2 points].

8. Treatment

Management requires multidisciplinary coordination between orthopaedic reconstructive surgeons, infectious disease specialists, and musculoskeletal microbiologists to execute targeted surgical eradication and rational antimicrobial delivery.

Medical / Nonoperative Management

• Chronic Suppressive Antibiotic Therapy: Non-curative strategy indicated solely in patients with prohibitive surgical mortality risk (terminal illness, extreme frailty, decompensated cardiopulmonary failure) or patients who refuse surgery.
• Prerequisites for Suppression: Implants must be clinically and radiographically well fixed, the soft tissue envelope must be intact without sinus tracts, and the infecting organism must be isolated with documented susceptibility to well-tolerated, low-toxicity oral antimicrobials (e.g., oral cephalexin, amoxicillin, doxycycline, or trimethoprim-sulfamethoxazole).
• Failure Thresholds: Breakthrough bacteremia, severe progressive periprosthetic osteolysis, impending pathological fracture, or intolerable medication toxicity constitute failure and dictate surgical consideration or palliative hospice care.

Operative Strategy: DAIR (Debridement, Antibiotics, and Implant Retention)

• Indications: Acute postoperative PJI (<3–4 weeks from index surgery) or acute hematogenous seeding (<3 weeks of symptoms); well-fixed femoral and acetabular components; stable soft tissue envelope; pathogen sensitive to biofilmicidal antimicrobials (e.g., rifampin for staphylococci).
• Surgical Technique: Complete synovectomy and radical excision of non-viable tissue. Mandatory modular exchange: disengage and remove the modular femoral head and polyethylene/ceramic acetabular liner to debride the sub-liner space and inspect taper trunnions and shell fixation. Copious low-pressure pulsed lavage (minimum 6–9 L of normal saline or dilute chlorhexidine/povidone-iodine). Re-implant new modular components.

Operative Strategy: Two-Stage Exchange Arthroplasty (Gold Standard)

• Indications: Chronic PJI (>4 weeks duration), presence of a cutaneous sinus tract, component loosening, compromised soft tissue envelope, highly resistant organisms (MRSA, vancomycin-resistant enterococci, multidrug-resistant gram-negative bacilli, fungal species), or culture-negative infection.
• Stage 1 (Explantation and Spacer Placement): Complete explantation of all prosthetic components, hardware, and cement mantles. Radical debridement of infected acetabular and femoral bed down to bleeding, healthy bone. Placement of an antibiotic-loaded PMMA spacer. Articulating spacers preserve limb length, reduce joint scarring, and improve post-reimplantation hip function compared to static block spacers. Cement typically incorporates 3 to 4 g of vancomycin plus 3 to 4 g of tobramycin per 40 g batch of PMMA.
• Interim Therapy: 6 weeks of pathogen-directed systemic intravenous or high-bioavailability oral antimicrobial therapy. Followed by an antibiotic-free holiday (2–4 weeks) with monitoring of wound healing, serum CRP/ESR, and repeat hip aspiration to confirm infection eradication before reimplantation.
• Stage 2 (Reimplantation): Re-exposure through the same surgical plane, excision of spacer and interim fibrous capsule, frozen section confirmation (<5 neutrophils per HPF), and reconstruction using revision arthroplasty techniques (porous trabecular metal cups, acetabular augments, cages, and modular tapered fluted revision stems).

Operative Strategy: Single-Stage Exchange Arthroplasty

• Strict Inclusion Criteria: Preoperatively identified organism with confirmed susceptibility to oral antimicrobials with excellent bioavailability; robust soft tissue envelope without sinus tracts; healthy host (Cierny-Mader Host A); absence of severe bone loss requiring structural allograft.
• Surgical Execution: Radical explantation and debridement, followed by complete change of gown, gloves, drapes, and surgical instruments. Immediate reimplantation using antibiotic-loaded cement or porous uncemented implants accompanied by local antimicrobial delivery systems.

Operative Strategy: Salvage Procedures

• Girdlestone Resection Arthroplasty: Complete removal of all implants without reconstruction. Reserved for intractable, multiply recurrent infections, non-reconstructible acetabular or femoral bone stock, severe host debility, or bedbound non-ambulatory patients. Results in substantial limb shortening and abductor deficiency, typically requiring assistive walking devices.
• Hip Disarticulation: Rarely indicated; limited to life-threatening, necrotizing soft tissue infections with uncontrolled sepsis or extensive vascular compromise.

Surgical Indications & Contraindications Matrix

9. Outcome

Clinical success following surgical intervention for periprosthetic hip infection is defined by infection-free implant survivorship, restoration of functional mobility, and preservation of patient-reported quality of life.

Infection Eradication Rates

• Two-Stage Exchange Arthroplasty: Achieves infection eradication rates between 85% and 95% at 5-year follow-up in North American and international registry cohorts. Success depends heavily on thorough mechanical debridement during Stage 1 and appropriate targeted antimicrobial dosing.
• Single-Stage Exchange Arthroplasty: In appropriately selected patient cohorts adhering to strict European inclusion criteria, single-stage exchange yields infection control rates comparable to two-stage protocols (85% to 92%), avoiding the morbidity and functional decline associated with an interim cement spacer.
• DAIR: Demonstrates successful infection control in 65% to 85% of carefully selected acute cases. Success drops below 40% to 50% if symptoms exceed 4 weeks, modular components are not exchanged, or MRSA/multidrug-resistant pathogens are present.

Functional Outcomes & Long-Term Survivorship

• Patient-Reported Outcome Measures (PROMs): Following successful two-stage revision THA, patients achieve mean Harris Hip Scores (HHS) between 75 and 85 points, representing substantial functional recovery compared to Girdlestone resection (mean HHS 50–60 points). However, functional outcomes and patient satisfaction remain lower than those following uncomplicated primary or aseptic revision THA.
• Re-revision and Survivorship: Mechanical failure rates (aseptic loosening, dislocation, recurrent periprosthetic fracture) following revision for PJI are approximately 10% to 15% at 10 years, emphasizing the importance of robust initial mechanical fixation with revision porous metals and augments.

10. Complications

Complications associated with surgical management of THA infection span intraoperative technical hazards, interim spacer complications, and long-term mechanical or recurrent septic failure.

11. Pearls and Pitfalls

Mastery of THA infection management requires disciplined avoidance of common diagnostic and technical judgment traps while implementing validated operative pearls.

• Pearl: Zero Empiric Antibiotics Before Arthrocentesis: Never administer antibiotics to a patient with a painful THA until diagnostic joint aspiration is completed. Even a single dose of oral antibiotics significantly suppresses culture yield and precipitates culture-negative PJI.
• Pearl: Mandatory Modular Component Exchange in DAIR: During any DAIR procedure, always disengage and discard the modular femoral head and acetabular liner. Retention of modular components prevents visual inspection of the Morse taper and shell interface, leaving behind mature biofilm that guarantees recurrence.
• Pearl: Systematic Multi-Site Tissue Biopsy: Obtain a minimum of 5 to 6 separate periprosthetic tissue specimens from distinct anatomical regions (anterior capsule, posterior capsule, acetabular membrane, femoral pseudocapsule, intramedullary canal) using a separate clean scalpel and forceps for each biopsy to eliminate cross-contamination.
• Pitfall: Treating Postoperative ESR as an Infection Marker: Relying on an elevated ESR during the first 6 to 12 weeks post-surgery to diagnose infection is a major pitfall. ESR remains elevated for months following normal uneventful arthroplasty; CRP is far more clinically reliable, returning to baseline within 2 to 3 weeks.
• Pitfall: Attempting DAIR in Chronic Infection or Loose Implants: Performing DAIR for symptoms lasting >4 weeks or when radiolucent lines indicate mechanical component loosening results in failure rates exceeding 70%. These patients must undergo complete component explantation.
• Pitfall: Discarding Microbiological Cultures Prematurely: Terminating culture incubation at 5 to 7 days misses slow-growing anaerobes and indolent pathogens such as Cutibacterium acnes. Microbiology laboratories must be instructed to maintain anaerobic cultures for 14 full days.

12. Controversy

Modern orthopaedic reconstructive surgery faces dynamic debates regarding surgical paradigms, antimicrobial delivery vehicles, and antiseptic irrigation protocols.

• One-Stage vs. Two-Stage Exchange Arthroplasty: The debate between European centers (pioneered by the ENDO-Klinik advocating single-stage exchange with targeted antibiotic cement) and North American surgeons (who traditionally favor two-stage exchange as the safer paradigm) remains intense. Recent prospective randomized trials demonstrate comparable infection control rates in carefully selected patients, prompting wider adoption of single-stage protocols when host and organism criteria are strictly fulfilled.
• Oral vs. Intravenous Antimicrobial Regimens (The OVIVA Paradigm): The landmark Oral Versus IntraVenous Antibiotics (OVIVA) trial challenged the historical dogma requiring 6 weeks of continuous outpatient parenteral antibiotic therapy (OPAT) for bone and joint infections. High-bioavailability oral regimens (fluoroquinolones, rifampin, linezolid, cotrimoxazole) have demonstrated non-inferiority to intravenous therapy after an initial stabilization period, reducing vascular catheter complications, hospitalization days, and healthcare costs.
• Antiseptic Irrigation Solutions: Orthopaedic consensus is actively debating the optimal chemical composition and contact time for intraoperative wound irrigation. While dilute povidone-iodine (0.35%) and chlorhexidine gluconate (0.05%) show superior bactericidal efficacy against biofilm compared to normal saline, concerns regarding local synovial tissue cytotoxicity and wound healing impairment remain a subject of active research.

13. Evidence-Based Synthesis

Modern clinical decision-making is grounded in high-quality randomized controlled trials and prospective registry analyses, corroborated by seminal biomechanical and anatomical descriptions.

14. References

• Longo UG, De Salvatore S, Bandini B et al. Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review. J ISAKOS. 2024. doi:10.1016/j.jisako.2023.09.003 [Level I: Systematic Review / Meta-Analysis]
• Fehring TK, Otero JE, Fehring KA et al. One-Stage Versus Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection: A Prospective Randomized Trial. J Bone Joint Surg Am. 2026. doi:10.2106/JBJS.25.00713 [Level I: Randomized Controlled Trial]
• Machinski E, da Cruz VF, Conde RAS et al. Chlorhexidine or Povidone-Iodine Solution Irrigation Versus Saline Irrigation for the Prevention of Postoperative Infections in Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty. 2025. doi:10.1016/j.arth.2025.02.037 [Level I: Systematic Review / Meta-Analysis]
• Douglas R. Osmon, Elie F. Berbari, Anthony Robert Berendt et al. Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines by the Infectious Diseases Society of Americaa. Clinical Infectious Diseases. 2012. doi:10.1093/cid/cis803 [Level V (Expert Conceptual Review): Seminal Conceptual / Observational Study]
• Javad Parvizi, Timothy L. Tan, Karan Goswami et al. The 2018 Definition of Periprosthetic Hip and Knee Infection: An Evidence-Based and Validated Criteria. The Journal of Arthroplasty. 2018. doi:10.1016/j.arth.2018.02.078 [Level V (Expert Conceptual Review): Seminal Conceptual / Observational Study]

15. Master Class Pro-Tip

When encountering a patient with persistent, unexplained hip pain or early stiffness following total hip arthroplasty, never dismiss the presentation as “soft tissue inflammation” or “bursitis” without an exhaustive infection workup. Serum CRP and ESR must be obtained immediately. If markers are elevated, or if a high clinical index of suspicion exists despite equivocal serologies, image-guided hip aspiration is non-negotiable. Withhold all empiric antibiotics until cultures are secured, insist that the laboratory hold anaerobic cultures for 14 days, and remember that during DAIR, modular head and liner exchange is mandatory—leaving an old liner in place guarantees biofilm recurrence.

Master Class Surgical Pearl: Periprosthetic Joint Infection in Total Hip Arthroplasty