AAOS Guideline on The Diagnosis of Periprosthetic Joint Infections of the Hip and Knee
Summary of Recommendations
The following is a summary of the recommendations in the AAOS’ clinical practice guideline, The Diagnosis of Periprosthetic Joint Infections of the Hip and Knee. This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly encouraged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will note that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility.
This summary of recommendations is not intended to stand alone. Clinical decisions should be made in light of all circumstances presented by the patient. Procedures applicable to the individual patient rely on mutual communication between patient, physician, and other healthcare practitioners.
- In the absence of reliable evidence about risk stratification of patients with a potential periprosthetic joint infection, it is the opinion of the work group that testing strategies be planned according to whether there is a higher or lower probability that a patient has a hip or knee periprosthetic infection.
- Strength of Recommendation: Consensus Note: Please see page 17 of this document for a definition of "higher and lower probability".
- We recommend erythrocyte sedimentation rate and C-reactive protein testing for patients assessed for periprosthetic joint infection.
- Strength of Recommendation: Strong
- We recommend joint aspiration of patients being assessed for periprosthetic knee infections who have abnormal erythrocyte sedimentation rate AND/OR C-reactive protein results. We recommend that the aspirated fluid be sent for microbiologic culture, synovial fluid white blood cell count and differential.
- Strength of Recommendation: Strong
- We recommend a selective approach to aspiration of the hip based on the patient's probability of periprosthetic joint infection and the results of the erythrocyte sedimentation rate (ESR) AND C-reactive protein (CRP). We recommend that the aspirated fluid be sent for microbiologic culture, synovial fluid white blood cell count and differential.
- Strength of Recommendation: Strong
- We suggest a repeat hip aspiration when there is a discrepancy between the probability of periprosthetic joint infection and the initial aspiration culture result.
- Strength of Recommendation: Moderate
- In the absence of reliable evidence, it is the opinion of the work group that patients judged to be at lower probability for periprosthetic hip infection and without planned reoperation who have abnormal erythrocyte sedimentation rates OR abnormal C-reactive protein levels be re-evaluated within three months. We are unable to recommend specific diagnostic tests at the time of this follow-up.
- Strength of Recommendation: Consensus
- In the absence of reliable evidence, it is the opinion of the work group that a repeat knee aspiration be performed when there is a discrepancy between the probability of periprosthetic joint infection and the initial aspiration culture result.
- Strength of Recommendation: Consensus
- We suggest patients be off of antibiotics for a minimum of 2 weeks prior to obtaining intra-articular culture.
- Strength of Recommendation: Moderate
- Nuclear imaging (Labeled leukocyte imaging combined with bone or bone marrow imaging, FDG-PET imaging, Gallium imaging, or labeled leukocyte imaging) is an option in patients in whom diagnosis of periprosthetic joint infection has not been established and are not scheduled for reoperation.
- Strength of Recommendation: Weak
- We are unable to recommend for or against computed tomography (CT) or magnetic resonance imaging (MRI) as a diagnostic test for periprosthetic joint infection.
- Strength of Recommendation: Inconclusive
- We recommend against the use of intraoperative Gram stain to rule out periprosthetic joint infection.
- Strength of Recommendation: Strong
- We recommend the use of frozen sections of peri-implant tissues in patients who are undergoing reoperation for whom the diagnosis of periprosthetic joint infection has not been established or excluded.
- Strength of Recommendation: Strong
- We recommend that multiple cultures be obtained at the time of reoperation in patients being assessed for periprosthetic joint infection.
- Strength of Recommendation: Strong
- We recommend against initiating antibiotic treatment in patients with suspected periprosthetic joint infection until after cultures from the joint have been obtained.
- Strength of Recommendation: Strong
- We suggest that prophylactic preoperative antibiotics not be withheld in patients at lower probability for periprosthetic joint infection and those with an established diagnosis of periprosthetic joint infection who are undergoing reoperation.
- Strength of Recommendation: Moderate