The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Circumstances that Increase the Risk of Periprosthetic Joint Infection after Total Knee Arthroplasty

Document Type : EDITORIAL

Author
E. Carlos RODRIGUEZ-MERCHAN
Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain
10.22038/abjs.2025.91512.4145
Abstract
According to recent publications there are some circumstances that increase the risk of periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). They are the following: 1) Individuals who experience arthroscopic lysis of adhesions after TKA due to postoperative arthrofibrosis have higher rates of PJI than those who do not. 2) Rheumatoid arthritis individuals have higher risks of PJI than osteoarthritis patients. 3) At 2 years, the rate of PJI is significantly higher in the patients having chronic anticoagulation (CA) than in patients not having CA. 4) Cefazolin prophylaxis significantly diminishes 90-day PJI risk following TKA compared to other antibiotics. 5) The frequency of PJI is significantly inferior in patients receiving intraosseus (IO) vancomycin than in patients receiving intravenous vancomycin at 1-month, 3-month, and 1-year follow-up. 6) Cellulitis is a risk factor for PJI following TKA, particularly when it happens within a year of surgery. 7) Individuals who have preoperative anemia (hemoglobin of 10 g/dL) have a 1.86-fold greater risk of PJI. 8) A clostridium difficile infection within 2 years prior to TKA is associated with greater probability of PJI. 9) Individuals experiencing TKA who have hypoalbuminemia (albumin < 3.1 g/dL) before surgery are at higher risk of PJI. 10) It is still unclear whether intraarticular injections before TKA implantation increase the risk of PJI after surgery, as publications on the subject have reached conflicting conclusions. Given that the level of evidence in the published studies is not very high, all the conclusions mentioned here must be confirmed by studies with higher level of evidence.

Level of evidence: III-IV.
Keywords
Periprosthetic joint infection
Risk factors, Total knee arthroplasty
Subjects
  1. Shahi A, Parvizi J. Prevention of periprosthetic joint infection. Arch Bone Jt Surg. 2015;3(2):72-81.
  2. Rodriguez-Merchan EC. The function of sonication in the diagnosis of periprosthetic joint infection after total knee arthroplasty. Arch Bone Jt Surg. 2022;10(9):735-740. doi: 10.22038/abjs.2020.44329.2212.
  3. Rodriguez-Merchan EC, Encinas-Ullan CA. Intraosseous regional administration of vancomycin prophylaxis for primary and revision total knee arthroplasty. Arch Bone Jt Surg. 2024;12(3):219-222. doi: 10.22038/ABJS.2023.71420.3337.
  4. Rodriguez-Merchan EC. Biofilm related total knee arthroplasty infection: prevention, diagnosis and treatment. Arch Bone Jt Surg. 2024;12(7):531-534. doi: 10.22038/ABJS.2024.77560.3583.
  5. Kalali N, Ebrahimzadeh MH, Moradi A, Jirofti N. Periprosthetic joint infection (PJI). Arch Bone Jt Surg. 2025;13(7):406-413. doi: 10.22038/ABJS.2025.81816.3726.
  6. Niknam K, Lezak BA, Mercer NP, et al. Rates of periprosthetic joint infection and revision increase after arthroscopic lysis of adhesions subsequent to primary TKA. J Bone Joint Surg Am. 2025;107(10):e49. doi: 10.2106/JBJS.24.00929.
  7. Mori Y, Tarasawa K, Tanaka H, et al. Increased periprosthetic joint infection rate following total knee arthroplasty in rheumatoid arthritis patients: insights from a japanese nationwide medical claims database study. Int J Rheum Dis. 2025;28(5):e70249. doi: 10.1111/1756-185X.70249.
  8. Goel RK, Ross BJ, Heo KY, et al. Chronic anticoagulation is associated with significantly increased rates of medical complications, periprosthetic joint infection, and revision after primary total knee arthroplasty. Arthroplast Today. 2025;34:101749. doi: 10.1016/j.artd.2025.101749.
  9. Rumalla KC, Sontag-Milobsky IL, Chen AR, Selph TJ, Compton TM, Edelstein AI. Noncefazolin antibiotic prophylaxis is associated with increased periprosthetic joint infection risk following total knee arthroplasty. J Arthroplasty. 2025:S0883-5403(25)00783-1. doi: 10.1016/j.arth.2025.06.057.
  10. McNamara CA, Wininger AE, Sullivan TC, et al. The AAHKS best podium presentation research award: intraosseous vancomycin reduces the rate of periprosthetic joint infection following aseptic revision total knee arthroplasty. J Arthroplasty. 2025;40(9S1):S28-S32. doi: 10.1016/j.arth.2025.04.060.

 

  1. Erling AM, Zhao AY, Marrache M, Das A, Thakkar SC, Golladay GJ. Prior cellulitis as a risk factor for periprosthetic joint infection in total knee arthroplasty: influence of timing and antibiotic prophylaxis. J Arthroplasty. 2025:S0883-5403(25)00870-8. doi: 10.1016/j.arth.2025.07.007.
  2. Telang SS, Palmer RC, Yoshida B, Ball JR, Lieberman JR, Heckmann ND. Preoperative anemia as a predictor of periprosthetic joint infection following total knee arthroplasty: a continuous variable analysis. J Arthroplasty. 2025;40(7S1):S169-S175.e5. doi: 10.1016/j.arth.2025.02.058.
  3. Verhey JT, Boddu SP, Tarabichi S, et al. Gut-joint axis: history of clostridium difficile infection increases the risk of periprosthetic joint infection after total knee arthroplasty. J Arthroplasty. 2025;40(8):2126-2130. doi: 10.1016/j.arth.2025.02.014.
  4. Telang SS, Palmer RC, Cooperman WS, Dobitsch A, Lieberman JR, Heckmann ND. Albumin as a predictor of periprosthetic joint infection following total joint arthroplasty: identifying a new data-driven threshold utilizing a continuous variable analysis. J Arthroplasty. 2025;40(8):2117-2125.e4. doi: 10.1016/j.arth.2025.02.002.
  5. Nin DZ, Chen YW, Talmo CT, et al. Joint injection or aspiration before total knee arthroplasty: does it increase the risk of periprosthetic joint infection? J Knee Surg. 2025;38(4):195-200. doi: 10.1055/a-2451-8845.

16. Jones CM, Acuña AJ, Forlenza EM, Higgins JDD, Gerlinger T, Della Valle CJ. Hyaluronic acid injections administered within two months prior to total knee arthroplasty increase the risk for periprosthetic joint infection. Knee. 2025;53:103-107. doi: 10.1016/j.knee.2024.12.003.

The Archives of Bone and Joint Surgery
Volume 14, Issue 3
March 2026
Pages 167-169

  • Receive Date 25 September 2025
  • Revise Date 15 October 2025
  • Accept Date 11 October 2025