Periprosthetic Joint Infection (PJI)

PJI happens because germs infect the total joint during or following surgery. While these types of infections can happen to anyone who has had a joint replacement, certain groups of people are more at risk for developing an infection. Risk factors for PJI include:

• Anemia
• Immune deficiencies, such as HIV/AIDS
• Injected drug use
• Uncontrolled diabetes
• Malnutrition
• Tobacco use
• Obesity
• Peripheral vascular disease
• Other conditions that may compromise your immune system, such as cancer or being an organ transplant recipient

Just because you have one or more of these risk factors doesn’t mean you’ll develop a prosthetic joint infection; however, it’s important to pay close attention to any risk factors so you can look for early signs of an infection following your surgery.

How to prevent PJI?

While PJI isn’t entirely preventable, managing some of these risk factors ahead of your arthroplasty can help reduce your risk of a postoperative infection. Some ways to prevent prosthetic joint infection include:

• Stop smoking or using tobacco products
• Maintain a healthy weight
• Control diabetes
• Manage any nutrient deficiencies through supplements or diet changes
• Take antibiotics before dental procedures or other surgeries, as directed
• Talk to your joint surgeon about any risk factors

Also, it’s important to have your joint replacement surgery at a hospital that’s highly skilled in preventing periprosthetic joint infections and following strict protocols. The Joint Replacement Institute at the Ohio State Wexner Medical Center goes to great lengths to ensure the sterileness of our operating rooms and the safety of our patients during surgery. We’re using leading technology and the latest treatments to prevent infections, including the injection of antibiotics into the bone and bone marrow and the use of antimicrobial irrigants during surgery. We also screen people for resistant bacteria and treat infections prior to surgery, optimizing the health of our patients before we operate.

Symptoms of a periprosthetic joint infection

Knowing and recognizing the early symptoms of PJI can produce better outcomes, and in some cases, help prevent life-threatening issues. The biggest sign of a possible infection following joint replacement surgery is that you aren’t healing as quickly as anticipated. While everyone’s recovery from arthroplasty looks different, a slower recovery could indicate that something is wrong. Other PJI symptoms you should discuss with your surgeon include:

• Excessive swelling after the first few days following surgery
• Pinkish skin near incision site or redness near joint
• An incision site that isn’t healing, including pus or cloudy drainage
• Excessive drainage
• Foul odor
• Fever above 101 degrees
• Body shakes or chills

Infections that develop later than six months or even years after surgery can have different symptoms. Sudden onset of pain or an inability to bear weight on the joint can mean there is an infection. Other symptoms of PJI that develop years after surgery include redness, swelling, warmth around the joint or fever.

These symptoms can be easy to ignore, but it’s important to talk immediately to your surgeon and surgical team about any of the above symptoms or sudden changes in your condition. Catching prosthetic joint infections early can mean treatment is easier and less invasive, as well as more effective.

How is periprosthetic joint infection diagnosed?

Diagnosing a periprosthetic joint infection can be challenging unless you have expertise and experience in the condition, like our musculoskeletal infection physicians do. To start, our PJI specialists will perform a comprehensive physical examination and talk with you about your condition, symptoms, medical history and any prior treatments. Then, we’ll use a combination of the following diagnostic tests to help us rule out other conditions or determine the cause of the infection:

• Imaging: Tests like X-rays, magnetic resonance imaging and computed tomography scans help to see possible abnormalities in bones, joints and soft tissues.
• Blood tests: These may include a complete blood count to measure red and white blood cells and hemoglobin, and an erythrocyte sedimentation rate test and a C-reactive protein test to check for inflammation in the body.
• Joint fluid analysis: This is a test that uses a needle to withdraw a sample of your joint fluid for examination. The fluid in your joints can tell us the exact problem causing your pain and inflammation.

How is periprosthetic joint infection treated?

Once a diagnosis of PJI is confirmed, your doctor will talk to you about what type of surgery would best treat your infection. The recommended treatment plan will depend on a variety of factors, including what caused the infection, how long you’ve had it and your current health. Surgery is usually performed alongside aggressive antibiotic treatment. For more serious infections, multiple surgeries or a staged approach may be necessary. Surgeries for PJI include:

• Operative irrigation and debridement. For infections that are caught early or for ones that occur just a few weeks after joint replacement, we can sometimes cure the infection with one surgery. During this procedure, the physician removes the infected bone area and cleans it out. As part of the infection management strategy, we may pack the area with calcium sulfate beads that have the appearance of plaster and have been mixed with antibiotics. We’ll continually monitor your progress over time.
• Explant of hardware. This is the removal of an implanted device. This could include pins, plates or screws from a previous fracture or the joint implant itself. When an implant is removed entirely, your doctor’s first concern is treating or eliminating the infection before determining if you’re a candidate for another replacement surgery.
• Mobile spacers. To treat the infection, we might surgically insert an antibiotic-filled cement spacer. The spacer is a medical-grade material that’s mixed with antibiotics and then molded to the joint. It likely will stay in place for two to six months, during which time we’ll closely monitor you. Once the infection is gone, a surgeon will remove the spacer. If reimplantation is an option, joint replacement surgery will happen next.
• Static spacers. If your infection is very serious, it may take longer to treat. Some infections may never completely clear up. Such serious infections may require surgically implanting a static spacer, which is a rod with cement and antibiotic packed around the space where the joint implant was previously located. This spacer can remain in place for two or even three years until the infection is gone. At that time, another joint replacement could be an option.

Why choose Ohio State for periprosthetic joint infection treatment?

The Ohio State Wexner Medical Center is one of the only hospital systems in the nation with a dedicated musculoskeletal infection program. We’ve made it a priority to innovate new and improved ways of treating these conditions when other hospitals and facilities can’t care for such complex cases. Other highlights of our periprosthetic infection care include:

• Our program is truly collaborative. More than 30 specialists, ranging from orthopedic surgeons, plastic surgeons, infectious disease experts, radiologists and wound care specialists, participate in our MSK Infection Group.
• Our experts are available any time – day or night. Ohio State is one of the only hospitals in the country that always staffs a joint infection specialist on its surgery call list. Plus, many of our Emergency Department providers are trained in identifying and managing possible PJI cases.
• We’re the preferred provider across the region. We treat more than 400 cases of bone and joint infections annually, with many of these coming from referrals across Ohio and the region.
• We rely on research and innovation to guide our PJI care. Currently, we’re participating in several studies that are being conducted at only the largest research hospitals. We can give you access to alternative treatments available at only a few hospitals nationwide. We continue to look for new ways to treat infections, including antibiotic coatings, peptides and bacteriophages. We’re part of an ongoing trial (Apex) looking at a one-week treatment of PJI versus the current treatment protocol, which is a minimum of three months.