Frontiers in the Management of Orthopaedic Periprosthetic Joint Infection.

Abstract

Periprosthetic joint infection (PJI) is a devastating complication of total joint arthroplasty (TJA), one of the most frequently performed surgical procedures worldwide. Management of acute PJI commonly involves debridement, antibiotics, and implant retention (DAIR), though failure rates remain high due to antibiotic-tolerant biofilms. Chronic PJI is typically treated with two-stage revision using antibiotic-loaded spacers, but this approach carries substantial morbidity, especially during the interstage period. Preventative strategies include preoperative patient optimization, antibiotic prophylaxis, tranexamic acid, antiseptic skin preparation, and local antibiotic powders and rinses. To improve outcomes, emerging innovations include biofilm-active antimicrobial agents, targeted postoperative antibiotic delivery, intraarticular irrigation protocols, and one-stage revision strategies. While biofilm is a significant contributor to persistent infection, technologies to combat this problem include antibacterial implant surfaces, mechanically disruptive shockwave and magnetic fields, bioactive glass, and induction heating. In cases of treatment failure, salvage options remain limited, but novel approaches such as pathogen-specific bacteriophage therapy offer promising new directions.