Articles | Volume 10, issue 4
https://doi.org/10.5194/jbji-10-217-2025
© Author(s) 2025. This work is distributed under
the Creative Commons Attribution 4.0 License.
the Creative Commons Attribution 4.0 License.
https://doi.org/10.5194/jbji-10-217-2025
© Author(s) 2025. This work is distributed under
the Creative Commons Attribution 4.0 License.
the Creative Commons Attribution 4.0 License.
Original full-length article
| 
14 Jul 2025
Original full-length article |
| 14 Jul 2025
| 14 Jul 2025
Risk factors for treatment failure in late acute periprosthetic joint infection in patients with rheumatoid arthritis treated with surgical debridement – a case-control study
Hendrika M. Schenk
Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
Marine Sebillotte
Department of Infectious Diseases and Intensive Care Medicine, Rennes University Hospital, Rennes, France
Jose Lomas
Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
Adrian Taylor
Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
Eva Benavent
Infectious Disease Service, Bellvitge University Hospital, IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
Oscar Murillo
Infectious Disease Service, Bellvitge University Hospital, IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
Marta Fernandez-Sampedro
Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
Infectious Diseases Service, Department of Medicine, Hospital Universitario Marqués de Valdecilla–IDIVAL, Cantabria, Spain
Kaisa Huotari
Inflammation Center, Infectious Diseases, Peijas Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
Craig Aboltins
The Department of Infectious Diseases, Northern Health, Melbourne, Australia
Department of Medicine, Northern Clinical School, The University of Melbourne, Melbourne, Australia
Rihard Trebse
Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
Alex Soriano
Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, Barcelona, Spain
Marjan Wouthuyzen-Bakker
CORRESPONDING AUTHOR
Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
A full list of authors appears at the end of the paper.
Related authors
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Irene K. Sigmund, Marjan Wouthuyzen-Bakker, Tristan Ferry, Ricardo Sousa, Daniel Pérez-Prieto, Alex Soriano, Volker Alt, Willem J. Metsemakers, Martin Clauss, and Rihard Trebse
J. Bone Joint Infect., 11, 651–654, https://doi.org/10.5194/jbji-11-651-2026, https://doi.org/10.5194/jbji-11-651-2026, 2026
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Sinus tracts are currently classified as present or absent in PJI definitions. Although appropriate for diagnosis, this binary approach does not reflect the considerable heterogeneity encountered in clinical practice. This Viewpoint highlights characteristics that may determine sinus tract complexity and proposes a framework for future standardized characterization to better inform surgical decision-making and treatment outcomes.
Urban Vadnjal, Samo Roškar, René Mihalič, Mitja Rak, and Rihard Trebše
J. Bone Joint Infect., 11, 565–568, https://doi.org/10.5194/jbji-11-565-2026, https://doi.org/10.5194/jbji-11-565-2026, 2026
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The case demonstrates the importance of having well-established hospital algorithms for fracture related infection (FRI)/periprosthetic
joint infection (PJI) treatment and strictly following them at each step. In most severe cases related to multidrug-resistant (MDR) bacteria, a multiple-stage protocol is indicated, and intra-articular infusions of antibiotics should be considered in addition to standard intravenous regimens.
joint infection (PJI) treatment and strictly following them at each step. In most severe cases related to multidrug-resistant (MDR) bacteria, a multiple-stage protocol is indicated, and intra-articular infusions of antibiotics should be considered in addition to standard intravenous regimens.
Laura Bessems, Jolien Onsea, Marjan Wouthuyzen-Bakker, Irene K. Sigmund, Tristan Ferry, Richard Kuehl, Martin Clauss, Alex Soriano, Ricardo Sousa, Annette Schuermans, and Willem-Jan Metsemakers
J. Bone Joint Infect., 11, 489–492, https://doi.org/10.5194/jbji-11-489-2026, https://doi.org/10.5194/jbji-11-489-2026, 2026
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We examined whether patients with musculoskeletal infections need to be separated in hospital. A review of published studies found no support for routine isolation or dedicated wards for infections without multidrug-resistant organisms when standard precautions are applied. An international survey showed wide variation in clinician attitudes. These findings highlight a gap between evidence and perception and support a more risk-based approach.
Sander Bruyninckx, Stijn Ghijselings, Melissa Depypere, Alex Soriano, Willem-Jan Metsemakers, and Georges Vles
J. Bone Joint Infect., 11, 207–217, https://doi.org/10.5194/jbji-11-207-2026, https://doi.org/10.5194/jbji-11-207-2026, 2026
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When infection around an artificial hip or knee is suspected, joint fluid sampling is essential but often unsuccessful. We performed a systematic review to evaluate whether rinsing the joint with sterile salt water after an unsuccessful attempt improves diagnosis. Our findings show that this approach is safe, yields testable fluid in nearly all cases, and identifies infection in about one in five patients that would otherwise be missed.
Ernesto Muñoz-Mahamud, Melissa Rivera, Ana Belén Larque, Laura Morata, Andrés Combalia, Alfonso Alías, Jenaro Ángel Fernández-Valencia, and Álex Soriano
J. Bone Joint Infect., 11, 43–52, https://doi.org/10.5194/jbji-11-43-2026, https://doi.org/10.5194/jbji-11-43-2026, 2026
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Several factors have been linked to failure in chronic prosthetic joint infection revisions. We hypothesize that osteomyelitis in septic hip revisions is underestimated and may significantly impact outcomes. In this series, 30.8 % of septic revisions exhibited bone samples consistent with osteitis, mainly associated with prolonged unsuccessful surgical and antibiotic treatments, the presence of a sinus tract, and subsequent failure after implant removal.
Graham S. Goh, Elise R. Naufal, Michelle M. Dowsey, Sina Babazadeh, Jesse E. Otero, Carlos A. Higuera-Rueda, Marjan Wouthuyzen-Bakker, and Orthopaedic Device Infection Network (ODIN)
J. Bone Joint Infect., 10, 553–559, https://doi.org/10.5194/jbji-10-553-2025, https://doi.org/10.5194/jbji-10-553-2025, 2025
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A multi-center study of 563 periprosthetic joint infections (PJIs) found that 16.5 % were culture negative. These patients more often had prior revision or PJI, longer symptom duration and fewer systemic signs. On multivariable analysis, symptom duration >12 weeks was the only independent risk factor (odds ratio 2.24). The findings support the fact that culture-negative infections present insidiously, informing diagnostic strategies.
Benjamin R. Paul, David G. Deckey, Alex Soriano, Andy Miller, and Thorsten M. Seyler
J. Bone Joint Infect., 10, 525–541, https://doi.org/10.5194/jbji-10-525-2025, https://doi.org/10.5194/jbji-10-525-2025, 2025
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A total of 51 studies were reviewed to compare the alpha-defensin enzyme-linked immunosorbent assay (ELISA) and the lateral flow test for diagnosing joint replacement infections. Both tests are highly specific and accurately confirm infection, but ELISA showed greater sensitivity (87.8 % vs. 81.8 %), making it better for detection. These findings support the continued use of ELISA as the preferred diagnostic method.
Laura Bessems, Jolien Onsea, Baixing Chen, Marjan Wouthuyzen-Bakker, Irene K. Sigmund, Tristan Ferry, Richard Kuehl, Martin Clauss, Alex Soriano, Ricardo Sousa, Annette Schuermans, and Willem-Jan Metsemakers
J. Bone Joint Infect., 10, 489–500, https://doi.org/10.5194/jbji-10-489-2025, https://doi.org/10.5194/jbji-10-489-2025, 2025
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Isolation of patients with musculoskeletal infections in orthopedic care is controversial. Evidence supports selective isolation for certain resistant pathogens but not for non-resistant pathogens, nor does it support the routine use of septic wards. Effective infection control depends on hospital-wide strategies and adherence to standard precautions, with specialized centres offering better care than dedicated isolation units.
Marta Sabater-Martos, Laura Morata, Josep Maria Segur, Alex Soriano, and Juan Carlos Martínez-Pastor
J. Bone Joint Infect., 10, 237–241, https://doi.org/10.5194/jbji-10-237-2025, https://doi.org/10.5194/jbji-10-237-2025, 2025
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This study's aim was to analyse the healing and failure rates of one-stage knee replacement in patients with positive and negative preoperative cultures and sinus presence. We concluded that culture-negative infections or the presence of a sinus tract showed similar results compared to patients that had undergone the same procedure with positive cultures or spared soft tissue.
Irene K. Sigmund, Tristan Ferry, Ricardo Sousa, Alex Soriano, Willem-Jan Metsemakers, Martin Clauss, Rihard Trebse, and Marjan Wouthuyzen-Bakker
J. Bone Joint Infect., 10, 101–138, https://doi.org/10.5194/jbji-10-101-2025, https://doi.org/10.5194/jbji-10-101-2025, 2025
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In this paper, we discuss the most relevant factors influencing the outcome and define indications, contraindications, and risk factors of a DAIR procedure based on the currently available literature. Furthermore, we discuss the surgical technique in combination with systemic antimicrobial therapy in patients undergoing a DAIR procedure.
Irene K. Sigmund, Marjan Wouthuyzen-Bakker, Tristan Ferry, Willem-Jan Metsemakers, Martin Clauss, Alex Soriano, Rihard Trebse, and Ricardo Sousa
J. Bone Joint Infect., 10, 139–142, https://doi.org/10.5194/jbji-10-139-2025, https://doi.org/10.5194/jbji-10-139-2025, 2025
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This is a summary of our position paper on debridement, antimicrobial therapy, and implant retention (DAIR) procedures as a curative treatment strategy for acute periprosthetic hip and knee infections. It includes the defined indications as well as the contraindications of DAIR procedures when eradication/cure is intended, based on the currently available literature.
Sebastian Simon, Marjan Wouthuyzen-Bakker, Susana Gardete Hartmann, Jennyfer A. Mitterer, Sujeesh Sebastian, Stephanie Huber, Bernhard J. H. Frank, and Jochen G. Hofstaetter
J. Bone Joint Infect., 10, 51–59, https://doi.org/10.5194/jbji-10-51-2025, https://doi.org/10.5194/jbji-10-51-2025, 2025
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We compared the re-revision rates in rTHA and rTKA (revison total hip and knee arthroplasty) with and without AB (antibiotic) treatment in patients with UPICs (unexpected positive intraoperative cultures). The re-revision rate between the AB group and the non-AB group was similar. Postoperative AB treatment did not result in a decreased re-revision rate in patients with UPICs in presumed aseptic rTHA and rTKA. Patients with pathogens classified as a likely contaminant can be safely ignored.
Marta Sabater-Martos, Oscar Garcia, Laia Boadas, Laura Morata, Alex Soriano, and Juan Carlos Martínez-Pastor
J. Bone Joint Infect., 10, 41–49, https://doi.org/10.5194/jbji-10-41-2025, https://doi.org/10.5194/jbji-10-41-2025, 2025
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This is a retrospective diagnostic study in acute postoperative prosthetic joint infection in total knee arthroplasty that wants to determine diagnostic accuracy of synovial glucose and serum-to-synovial glucose ratio in acute postoperative infection. Both tests demonstrated good diagnostic potential. Notably, these biomarkers exhibited superior accuracy compared to the combination of C-reactive protein, synovial white blood cell count and polymorphonuclear percentage.
Laia Boadas-Gironès, Marta Sabater-Martos, Marc Ferrer-Banus, Àlex Soriano-Viladomiu, and Juan Carlos Martínez-Pastor
J. Bone Joint Infect., 9, 241–248, https://doi.org/10.5194/jbji-9-241-2024, https://doi.org/10.5194/jbji-9-241-2024, 2024
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When acute soft tissue defects are present after knee arthroplasty, the infection risk is high. A gastrocnemius flap is used for anterior defects, and it is not usually combined with debridement surgery unless infection is clear. We examined the benefit of combining coverage treatment with debridement surgery, DAIR, comparing the isolated traditional coverage treatment. The results suggested a higher healing rate in the combined treatment, so we recommended it.
Seung-Jae Yoon, Paul C. Jutte, Alex Soriano, Ricardo Sousa, Wierd P. Zijlstra, and Marjan Wouthuyzen-Bakker
J. Bone Joint Infect., 9, 231–239, https://doi.org/10.5194/jbji-9-231-2024, https://doi.org/10.5194/jbji-9-231-2024, 2024
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This study validated three models for predicting infection after hip and knee replacement surgery. By analyzing data from 2684 patients in the Netherlands, Portugal, and Spain, we found that the models developed by Tan, Del Toro, and Bülow effectively identified high-risk patients. These models can be used to enhance preoperative counseling and to tailor infection prevention measures individually, potentially improving outcomes and reducing healthcare costs.
Stéphanie Pascual, Brooklyn Noble, Nusreen Ahmad-Saeed, Catherine Aldridge, Simone Ambretti, Sharon Amit, Rachel Annett, Shaan Ashk O'Shea, Anna Maria Barbui, Gavin Barlow, Lucinda Barrett, Mario Berth, Alessandro Bondi, Nicola Boran, Sara E. Boyd, Catarina Chaves, Martin Clauss, Peter Davies, Ileana T. Dianzo-Delgado, Jaime Esteban, Stefan Fuchs, Lennart Friis-Hansen, Daniel Goldenberger, Andrej Kraševac Glaser, Juha O. Groonroos, Ines Hoffmann, Tomer Hoffmann, Harriet Hughes, Marina Ivanova, Peter Jezek, Gwennan Jones, Zeynep Ceren Karahan, Cornelia Lass-Flörl, Frédéric Laurent, Laura Leach, Matilde Lee Horsbøll Pedersen, Caroline Loiez, Maureen Lynch, Robert J. Maloney, Martin Marsh, Olivia Milburn, Shanine Mitchell, Luke S. P. Moore, Lynn Moffat, Marianna Murdjeva, Michael E. Murphy, Deepa Nayar, Giacomo Nigrisoli, Fionnuala O'Sullivan, Büşra Öz, Teresa Peach, Christina Petridou, Mojgan Prinz, Mitja Rak, Niamh Reidy, Gian Maria Rossolini, Anne-Laure Roux, Patricia Ruiz-Garbajosa, Kordo Saeed, Llanos Salar-Vidal, Carlos Salas Venero, Mathyruban Selvaratnam, Eric Senneville, Peter Starzengruber, Ben Talbot, Vanessa Taylor, Rihard Trebše, Deborah Wearmouth, Birgit Willinger, Marjan Wouthuyzen-Bakker, Brianne Couturier, and Florence Allantaz
J. Bone Joint Infect., 9, 87–97, https://doi.org/10.5194/jbji-9-87-2024, https://doi.org/10.5194/jbji-9-87-2024, 2024
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This study conducted in multiple sites across Europe aimed to evaluate the BIOFIRE Joint Infection (JI) Panel, a new technology that uses multiplex PCR to detect microorganisms in synovial fluid of patients with suspicion of joint infections in 1 h, in comparison with synovial fluid culture. Results showed an overall agreement of 85 % to 88.4 % between the two methods. The JI Panel detected additional organisms, and the positive user experience highlights its clinical significance.
Marta Sabater-Martos, Marc Ferrer, Laura Morata, Alex Soriano, and Juan Carlos Martínez-Pastor
J. Bone Joint Infect., 9, 17–26, https://doi.org/10.5194/jbji-9-17-2024, https://doi.org/10.5194/jbji-9-17-2024, 2024
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This is a meta-analysis of six studies describing the cutoff values of white blood cell count and polymorphonuclear percentage in synovial fluid for the diagnosis of acute postoperative peri-prosthetic joint infection (PJI).
We found that both the WBC count and PMN percentage are good markers for diagnosis of acute postoperative PJI. However, the synovial WBC count is more powerful in diagnosing acute postoperative PJI.
We found that both the WBC count and PMN percentage are good markers for diagnosis of acute postoperative PJI. However, the synovial WBC count is more powerful in diagnosing acute postoperative PJI.
Jorrit Willem Adriaan Schoenmakers, Rosanne de Boer, Lilli Gard, Greetje Anna Kampinga, Marleen van Oosten, Jan Maarten van Dijl, Paulus Christiaan Jutte, and Marjan Wouthuyzen-Bakker
J. Bone Joint Infect., 8, 45–50, https://doi.org/10.5194/jbji-8-45-2023, https://doi.org/10.5194/jbji-8-45-2023, 2023
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In a first evaluation, the accuracy of a novel multiplex PCR (polymerase chain reaction) panel for rapid detection of pathogens in patients with a clinical suspicion of acute septic arthritis of native and prosthetic joints is assessed. Clear benefit is seen in patients with a suspected native septic arthritis and late acute prosthetic joint infection. This indicates that the panel allows for fast tailoring of antibiotics and may prompt the surgeon for surgical lavage in doubtful clinical cases.
Christen Ravn, Jeroen Neyt, Natividad Benito, Miguel Araújo Abreu, Yvonne Achermann, Svetlana Bozhkova, Liselotte Coorevits, Matteo Carlo Ferrari, Karianne Wiger Gammelsrud, Ulf-Joachim Gerlach, Efthymia Giannitsioti, Martin Gottliebsen, Nis Pedersen Jørgensen, Tomislav Madjarevic, Leonard Marais, Aditya Menon, Dirk Jan Moojen, Markus Pääkkönen, Marko Pokorn, Daniel Pérez-Prieto, Nora Renz, Jesús Saavedra-Lozano, Marta Sabater-Martos, Parham Sendi, Staffan Tevell, Charles Vogely, Alex Soriano, and the SANJO guideline group
J. Bone Joint Infect., 8, 29–37, https://doi.org/10.5194/jbji-8-29-2023, https://doi.org/10.5194/jbji-8-29-2023, 2023
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Management of septic arthritis in native joints (SANJO) is often conducted by clinicians of different specialties, experience levels, and at all hours of the day. The SANJO guideline group makes evidence-based recommendations for diagnosis, microbiological investigation, initial surgery, empirical antibiotic treatment, early mobilization, evaluation of outcomes, and treatment failure. Special considerations were made for children, tuberculosis, and SANJO after cruciate ligament reconstruction.
Efthymia Giannitsioti, Mauro José Salles, Andreas Mavrogenis, Dolors Rodriguez-Pardo, Ibai Los-Arcos, Alba Ribera, Javier Ariza, María Dolores del Toro, Sophie Nguyen, Eric Senneville, Eric Bonnet, Monica Chan, Maria Bruna Pasticci, Sabine Petersdorf, Natividad Benito, Nuala O' Connell, Antonio Blanco García, Gábor Skaliczki, Pierre Tattevin, Zeliha Kocak Tufan, Nikolaos Pantazis, Panayiotis D. Megaloikonomos, Panayiotis Papagelopoulos, Alejandro Soriano, Antonios Papadopoulos, and the ESGIAI collaborators study group
J. Bone Joint Infect., 7, 279–288, https://doi.org/10.5194/jbji-7-279-2022, https://doi.org/10.5194/jbji-7-279-2022, 2022
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Our multicentre study on a lower-limb osteosynthesis-associated infection (OAI) cohort by multidrug (MDR) and extensively drug (XDR) resistant Gram-negative bacteria found the following: implant retention with debridement was mostly performed in early OAI; 50.9 % of patients achieved remission of infection; remission reached 50 % (MDR) vs. 25 % (XDR) in early OAI and 60 % (MDR) vs. 44.4 % (XDR) in late OAI; age (> 60) and multiple surgeries were independent factors influencing lack of remission.
Ernesto Muñoz-Mahamud, Eduard Tornero, José A. Estrada, Jenaro A. Fernández-Valencia, Juan C. Martínez-Pastor, and Álex Soriano
J. Bone Joint Infect., 7, 109–115, https://doi.org/10.5194/jbji-7-109-2022, https://doi.org/10.5194/jbji-7-109-2022, 2022
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A patient with normal D-dimer value has a low risk of prosthetic joint infection, so serum D-dimer assessment should always be considered as a useful test to rule out chronic prosthetic joint infection (especially in those cases caused by low-virulence microorganisms in which conventional tests may lead to misdiagnosis). Conversely, the platelet count to mean platelet volume ratio may be of limited value for accurately diagnosing prosthetic joint infection.
Marjan Wouthuyzen-Bakker and Alexander L. Boerboom
J. Bone Joint Infect., 7, 33–34, https://doi.org/10.5194/jbji-7-33-2022, https://doi.org/10.5194/jbji-7-33-2022, 2022
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This case illustrates the clinical picture of a worn-out elbow prosthesis resulting in severe metallosis and a subsequent periprosthetic joint infection.
Karsten D. Ottink, Stefan J. Gelderman, Marjan Wouthuyzen-Bakker, Joris J. W. Ploegmakers, Andor W. J. M. Glaudemans, and Paul C. Jutte
J. Bone Joint Infect., 7, 1–9, https://doi.org/10.5194/jbji-7-1-2022, https://doi.org/10.5194/jbji-7-1-2022, 2022
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A low-grade periprosthetic joint infection (PJI) may be difficult to diagnose, and nuclear imaging could help in the diagnosis. However, its diagnostic value is unclear. We retrospectively evaluated this diagnostic value. We conclude that in patients presenting with nonspecific symptoms and a low a priori chance of PJI based on clinical evaluation, nuclear imaging is of no clear added value in diagnosing a PJI.
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Short summary
Patients with rheumatoid arthritis have a high treatment failure rate when faced with a late acute periprosthetic joint infection. Because of the rarity of the condition, we performed a multicenter case-control study. We identified predictors of treatment failure to ultimately improve the treatment outcome. Exchange of modular components seems important in this patient group, likely due to a higher rate of positive blood cultures compared to control patients.
Patients with rheumatoid arthritis have a high treatment failure rate when faced with a late...
