Hip iSAWE 5

Question

A 68 year old man has increasing pain and a discharging sinus 18 months after a total hip arthroplasty.

Hip iSAWE 5, radiograph of the hip
Radiograph of the hip. Image by Zhenxin Shen, Tania N Crotti, Kevin P McHugh, Kenichiro Matsuzaki, Ellen M Gravallese, Benjamin E Bierbaum and Steven R Goldring, Wikimedia Commons, CC BY 2.0.
  1. How is periprosthetic joint infection defined and classified?
  2. How would you investigate him?
  3. Outline your management.

Answer

Definition and classification

  • A sinus tract communicating with the joint confirms infection (major criterion)
  • 2018 ICM and EBJIS criteria combine serum markers, synovial fluid tests and histology
  • Tsukayama classification of early postoperative, acute haematogenous, chronic late and positive intraoperative cultures
  • This is a chronic infection

Investigations

  • CRP and ESR
  • Aspiration of the hip for white cell count, neutrophil percentage, alpha defensin and prolonged culture
  • Stop antibiotics for 2 weeks before aspiration if safe
  • Radiographs for loosening and osteolysis

Management

  • Multidisciplinary care with infectious diseases
  • DAIR (debridement, antibiotics and implant retention) with exchange of modular parts only for early or acute haematogenous infection with well fixed implants
  • Two stage revision with an antibiotic loaded spacer is the traditional standard for chronic infection
  • Single stage revision in selected patients with known organisms and good soft tissues
  • Take at least five tissue samples with separate instruments
  • Suppressive antibiotics or excision arthroplasty for patients unfit for revision

Related pages

Author Contributions

Orthofracs team

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.