Total hip arthroplasty (THA) is a successful and durable operation for end-stage arthritis of the hip [1]. The number of THAs performed annually in the United States continues to rise and is expected to hit four million by the year 2030 [2]. Chronic, deep periprosthetic joint infection (PJI) is a rare, but devastating, complication of THA that is associated with increased perioperative costs, extended duration of hospital stays, and compromised patient outcomes [3]. Though the incidence of PJI after THA is variable throughout the literature, most arthroplasty centers report an incidence somewhere between 0.2 and 2% for primary THAs and 2 and 4% for revision THAs [4–6]. Currently, infection is the third most common reason for THA revision [7].

Risk factors for the development of infection can be categorized into:

The single most important factor in the prevention of PJI is the use of perioperative prophylactic antibiotics [20]. Though the proper dose, duration, and type of antibiotic have not been definitively established [11], it is common practice to administer an antibiotic that targets the common offending microorganisms within 1 h prior to making skin incision, repeated every 3 h intraoperatively, and continued for 24 h postoperatively. Recently, there has been increasing interest in the routine screening of arthroplasty patients for the presence of common offending organisms in PJI such as methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA) [13]. There is some evidence that decolonizing these patients is associated with a lower risk of PJI [13], but further study is needed before this becomes standard of practice.

Prior to undergoing elective THA, all patients should undergo a thorough medical evaluation. Any modifiable risk factors that are identified should be optimized prior to surgery. A thorough patient history and physical examination in the immediate preoperative period are critical to ensure that there are no signs of active infection in the body. Specifically, the skin around the operative extremity should be assessed for any signs of open wounds or superficial infections. Similarly, the oral cavity should be inspected for signs of tooth decay or gingival infection or abscess. Any active infection that is identified should be treated and resolved well prior to undergoing elective THA.

Patients should be instructed to thoroughly cleanse their skin with a chlorhexidine-based solution the night prior to the operation [14]. Though reports on hair removal preoperatively have been inconclusive [15], the authors still routinely remove the hair surrounding the surgical field. The use of hair clipper is superior to the use of a razor for hair removal [16]. The surgical site should be prepped thoroughly and in its entirety with either an alcohol-based or chlorhexidine-based preparation as iodine-based preparations have proven inferior [17].

Strict adherence to sterile technique during surgery is the cornerstone to preventing infection. The use of sterile drapes, a surgical gown, a face mask , and two sets of surgical gloves should be routine for all arthroplasty surgeons. Face masks prevent contamination from the respiratory system and surgical gloves have reported perforation rates of 3–18% during primary and revision hip and knee arthroplasty [18–22], which has been shown to increase the risk of infection [23]. Changing the outer gloves periodically throughout a THA appears to reduce surgical glove contamination [19], but its direct effect on infection prevention has not been established. Limiting traffic in and out of the operating room appears to lower the risk of PJI and should be encouraged for all arthroplasty surgery [24, 25]. Safe, but efficient, surgical technique can minimize the time the wound is open and has been demonstrated in numerous studies to decrease the risk of infection [4, 26]. In addition, numerous topical treatments have been studied. Vancomycin powder applied topically to the wound has had demonstrated effectiveness in spine surgery [27], and appears to achieve effective local concentrations [28] while not interfering with wear patterns of THA [29]. Additionally, lavage of the wound in a dilute Betadine solution prior to wound closure has been associated with lower rates of surgical site infection [30] and has been implemented in many practices across North America.

All patients being evaluated for infection should be assessed with plain radiographs of the hip (an anteroposterior [AP] of the pelvis and an AP and lateral view of the hip), as well as an erythrocyte sedimentation rate (ESR) and a C-reactive protein (CRP) . Radiographs may show lucency around the prostheses or scalloping of the surrounding bone [31]. An elevated ESR and a CRP, particularly when used in combination, can be highly sensitive markers for infection [32]. Additionally, all patients with suspected infection should undergo arthrocentesis of the hip to assess the quantitative leukocyte count in the synovial fluid and to attempt to culture an offending microorganism [33]. Though varying cutoff levels to diagnose PJI based on synovial fluid analysis have been reported [34, 35], in the authors’ experience, a synovial fluid leukocyte count of 1700 cells (and/or a leukocyte differential of >65% polymorphonuclear cells) is both a sensitive and specific marker for late, chronic PJI in patients without inflammatory arthropathy .

Though the precise definition of deep PJI remains elusive and controversial, the Musculoskeletal Infection Society (MSIS) has adopted the following definition [36]:

The onset of patient symptoms is paramount to determining the correct treatment strategy for THA PJI. Periprosthetic joint infection can be classified into four categories based upon the timing of the diagnosis [37].

In early postoperative and acute hematogenous infections an attempt at prosthesis salvage is an option in certain patients. This is traditionally accomplished through an open irrigation and debridement, and polyethylene (PE) liner and femoral head exchange of the THA [38], followed by a course of intravenous (IV) antibiotics targeting the offending microorganism. Positive cultures obtained at the time of THA implantation or reimplantation should be treated with antibiotic suppression targeting the identified microorganism(s).

Patients with late, chronic PJI or patients with a failed irrigation and debridement and PE liner and femoral head exchange require removal of their implants. Although some authors advocate for the use of a single-stage exchange in the setting of chronic, deep PJI of the hip [39], the North American gold standard is a two-stage exchange of the implants [40–42]. Contraindications to performing a two-stage exchange are rare and include medical comorbidities that preclude the patient from safely undergoing surgery or femoral/acetabular bone stock that is inadequate to allow joint reconstruction.