Systematic Reviews
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. May 18, 2017; 8(5): 400-411
Published online May 18, 2017. doi: 10.5312/wjo.v8.i5.400
Predicting lower limb periprosthetic joint infections: A review of risk factors and their classification
David A George, Lorenzo Drago, Sara Scarponi, Enrico Gallazzi, Fares S Haddad, Carlo L Romano
David A George, Fares S Haddad, Department of Trauma and Orthopaedics, University College London Hospitals, London NW1 2BU, United Kingdom
Lorenzo Drago, Microbiological Laboratory, Orthopaedic Research Institute Galeazzi, 20161 Milan, Italy
Sara Scarponi, Enrico Gallazzi, Carlo L Romano, Centre for Reconstructive Surgery and Osteoarticular Infections, Orthopaedic Research Institute Galeazzi, 20161 Milan, Italy
Author contributions: George DA and Romano CL designed the research; George DA, Scarponi S, Gallazzi E and Romano CL performed the research; Drago L and Haddad FS contributed to the results analysis and discussion; George DA, Scarponi S and Gallazzi E analyzed the data; George DA wrote the paper; Drago L, Haddad FS and Romano CL edited the paper.
Conflict-of-interest statement: The authors declare that they have no competing interests.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Dr. David A George, Specialist Registrar, Department of Trauma and Orthopaedic, University College London Hospital, 235 Euston Road, London NW1 2BU, United Kingdom.
Telephone: +44-20-3456789
Received: October 25, 2016
Peer-review started: October 28, 2016
First decision: December 1, 2016
Revised: January 5, 2017
Accepted: March 12, 2017
Article in press: March 13, 2017
Published online: May 18, 2017

To undertook a systematic review to determine factors that increase a patient’s risk of developing lower limb periprosthetic joint infections (PJI).


This systematic review included full-text studies that reviewed risk factors of developing either a hip or knee PJI following a primary arthroplasty published from January 1998 to November 2016. A variety of keywords were used to identify studies through international databases referencing hip arthroplasty, knee arthroplasty, infection, and risk factors. Studies were only included if they included greater than 20 patients in their study cohort, and there was clear documentation of the statistical parameter used; specifically P-value, hazard ratio, relative risk, or/and odds ratio (OR). Furthermore a quality assessment criteria for the individual studies was undertaken to evaluate the presence of record and reporting bias.


Twenty-seven original studies reviewing risk factors relating to primary total hip and knee arthroplasty infections were included. Four studies (14.8%) reviewed PJI of the hip, 3 (11.21%) of the knee, and 20 (74.1%) reviewed both joints. Nineteen studies (70.4%) were retrospective and 8 (29.6%) prospective. Record bias was identified in the majority of studies (66.7%). The definition of PJI varied amongst the studies but there was a general consensus to define infection by previously validated methods. The most significant risks were the use of preoperative high dose steroids (OR = 21.0, 95%CI: 3.5-127.2, P < 0.001), a BMI above 50 (OR = 18.3, P < 0.001), tobacco use (OR = 12.76, 95%CI: 2.47-66.16, P = 0.017), body mass index below 20 (OR = 6.00, 95%CI: 1.2-30.9, P = 0.033), diabetes (OR = 5.47, 95%CI: 1.77-16.97, P = 0.003), and coronary artery disease (OR = 5.10, 95%CI: 1.3-19.8, P = 0.017).


We have highlighted the need for the provider to optimise modifiable risk factors, and develop strategies to limit the impact of non-modifiable factors.

Keywords: Periprosthetic joint infection, Risk factor, Predictive, Hip arthroplasty, Knee arthroplasty

Core tip: This systematic review determines the most statistically significant factors that increase a patient’s risk of developing lower limb periprosthetic joint infections. Reviewing all relevant papers until November 2016 through international databases, we have included 27 original studies. The results include multiple factors relating to the patient and the Institute, as well as post-operative predictors and causes of infection. This ultimately reiterates the importance of optimising the patients pre-operatively by addressing modifiable risk factors (such as their immunosuppression, nutrition, diabetes, and smoking), and develops strategies to limit the impact of non-modifiable factors.