Intended for healthcare professionals


Approach to patients with a potential prosthetic joint infection

BMJ 2022; 376 doi: (Published 21 March 2022) Cite this as: BMJ 2022;376:e069502
  1. B Atkin, foundation year two doctor1,
  2. L Dupley, specialist registrar, trauma and orthopaedic surgery2,
  3. P Chakravorty, specialist registrar, microbiology2,
  4. K Zafar, general practitioner3,
  5. R Boden, consultant, trauma and orthopaedic surgery2
  1. 1University Hospitals Birmingham NHS Foundation Trust, UK
  2. 2Lancashire Teaching Hospitals NHS Foundation Trust, UK
  3. 3New Collegiate Medical Centre, Cheetham Hill and Crumpsall Primary Care Network, Manchester, UK
  1. Correspondence to B Atkin bmlatkin{at}

What you need to know

  • Prosthetic joint infections (PJIs) can occur at any time following surgery, with variable symptoms and signs

  • A high index of suspicion for PJI is necessary for patients presenting with unexplained pain in their joint

  • Serum biochemistry tests cannot be used in isolation to confirm or exclude a PJI

  • Empirical antibiotics should not be started in the community or emergency department unless red flags for sepsis are evident

Hip and knee arthroplasty are safe, cost effective, and reliable surgical procedures that significantly improve patient quality of life by alleviating pain and restoring mobility.1 Every year, more than 2 million people in countries of the Organisation for Economic Co-operation and Development undergo hip or knee replacement, mostly for osteoarthritis.2 This number will rise with increasing life expectancy, bringing with it more patients at risk of developing a prosthetic joint infection (PJI).34

Hip and knee PJIs occur in approximately 1% of primary total hip replacements (THR) and approximately 2% of primary total knee replacements (TKR).1 PJI is a serious complication, with high morbidity and mortality (>10% mortality for patients aged over 804) and requires prolonged and complex treatment with substantial healthcare costs.5 Recent studies estimate the cost at around £36 000 to treat an infected arthroplasty.6 For revision arthroplasty, the risk of PJI is increased, occurring in approximately 4% of cases.7 Worldwide, the incidence of PJIs is similar,1 but with a considerable economic burden in developing countries, where treatment costs on average 4.5 times that of the original arthroplasty.8

How do patients with a prosthetic joint infection present?

The clinical presentations of PJIs vary considerably, contributing to the diagnostic challenge. Factors affecting the presentation include the joint involved, route and timing of infection, causative organism, and the patient’s systemic response (table 1).1 In native joint infections, the patient usually has …

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