This JBJS review takes the long view on periprosthetic joint infection, tracing how management moved from empirical, procedure-centred practice to something structured around host, organism and disease.
Three shifts are identified. Diagnosis moved from clinical suspicion plus culture to a multimodal framework: validated diagnostic criteria, serological and synovial fluid biomarkers, and molecular techniques for the cases where culture stays negative. Surgical strategy moved from a default operation to a decision - debridement with implant retention, one-stage revision, two-stage revision, or salvage - chosen by the characteristics of the patient and the pathogen rather than by unit habit. And the microbiology moved, with the recognition of biofilm explaining why a course of antibiotics against a sensitive organism reliably fails around retained hardware, and the microbiome now entering the picture.
The honest framing is that this is a narrative review with no new data, and reviews of progress tend to flatter the field. But it is a useful audit against your own practice, and the questions it prompts are concrete. Are you applying validated diagnostic criteria or an impression? Is a negative culture being treated as an absence of infection? Is the choice between debridement with retention and two-stage revision made on the organism and the host, or on what your unit does? In Indian practice, where synovial biomarker assays and molecular diagnostics are unevenly available and culture-negative infection is common, the diagnostic half of this is the part with the most room in it.
- Apply a validated diagnostic criteria set rather than an overall impression - write down which criteria you used
- Do not read a negative culture as absence of infection; send multiple samples and hold them long enough for indolent organisms
- Choose between debridement with implant retention and staged revision on symptom duration, organism and host, not on unit convention
- Where synovial biomarkers are available, use them for the equivocal case rather than as routine
- Remember biofilm is why antibiotics alone fail around retained hardware, whatever the sensitivities say
Why it matters
It gives a reference standard for a pathway most units assembled piecemeal over years.
Don't overread it
A narrative review of progress in a field, not new evidence or a guideline - it summarises direction rather than establishing practice.
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