What is the percentage risk of prosthetic joint infection?

Prosthetic Joint Infection Risk: Incidence and Prevalence

The cumulative incidence of prosthetic joint infection (PJI) is approximately 1-2% over the lifetime of the prosthetic joint, with rates varying depending on the type of prosthesis and whether the surgery is primary or revision. 1

Incidence by Procedure Type

• Primary joint replacements:

  • Hip replacements: 1.63% at 2 years post-surgery 2
  • Knee replacements: 1.55% at 2 years post-surgery 2
  • Long-term rates exceed 2% at 10 years 2

• Revision procedures:

  • Significantly higher risk (HR 2.99) compared to primary procedures 3
  • Revision arthroplasty is an independent predictor of subsequent PJI 3

• Previous PJI history:

  • Prior PJI in the same joint increases risk 5.49-fold 3
  • Prior PJI in another joint increases risk 3.3-fold 4

Temporal Patterns of Infection

PJI can be classified based on timing of presentation:

• Early infections (≤3 months post-operatively): Typically acquired intra- or peri-operatively 5
  • Increasing incidence from 0.11 per 100 primary THAs in 2008 to 1.09 in 2021 6
• Delayed infections (3-24 months post-operatively) 5
• Late infections (>24 months post-operatively): Usually hematogenous in origin 5

Risk Factors for PJI

• Patient-specific factors:

  • Rheumatoid arthritis (HR 4.08 compared to osteoarthritis) 3
  • Higher ASA class (Class 4 patients increased from 10.5% to 20% in recent years) 6
  • Body mass index >25 5
  • Malignancy 5
  • Previous operation on the index joint 5
  • Previous arthroplasty at a different site 5

• Procedure-related factors:

  • Procedure duration <2 or >4 hours 5
  • Intra-articular glucocorticoid injections within 3 months prior to surgery (increases risk from 0.5% to 1.0%) 1

Microbiology of PJI

• Staphylococcus aureus and coagulase-negative staphylococci account for >50% of infections 5
• The proportion of infections caused by S. aureus has increased from 26.3% in 2008-2009 to 40% in 2020-2021 6

Temporal Trends

• The prevalence of revision due to PJI has increased:
  • 2.3-fold increase in the three months following primary hip arthroplasty between 2005 and 2013 7
  • 3.0-fold increase following revision hip arthroplasty in the same period 7
  • Overall 2.6-fold increase in procedures performed for hip PJI between 2005 and 2013 7

Clinical Implications

• PJI is associated with decreased quality of life, increased morbidity, and potential for decreased mobility 2
• The increasing comorbidity burden of patients experiencing PJI presents a growing treatment challenge 6
• The overall burden of PJI is rising, with over 1,000 procedures performed annually as a consequence of hip PJI alone 7

Prevention Strategies

• Appropriate antibiotic prophylaxis
• Thorough skin preparation
• Optimization of modifiable risk factors:
  • Glycemic control
  • Weight management
  • Nutritional status
  • Smoking cessation
  • MRSA decolonization when indicated 2

Important Considerations

• Patients on chronic antibiotic suppression have a 15-fold higher risk of developing PJI in a new joint replacement 4
• Intra-articular glucocorticoid injections should be avoided within 3 months prior to joint replacement surgery 1
• For patients with a history of PJI, careful risk assessment and enhanced preventive measures are warranted before proceeding with additional joint replacements