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Infection after joint replacement is the complication my patients worry about most. It is also the one my team prepares for hardest.
After more than twenty years and over 700 joint replacements a year, I can tell you this: the patients who do best are the ones who know exactly what to watch for. Most people never face this problem. About one in a hundred will.
If you are recovering from a total knee replacement or a total hip replacement right now, read the warning signs section first.
What is an infection after joint replacement?
An infection after joint replacement is a bacterial infection that grows on or around your artificial hip or knee. Surgeons call it a periprosthetic joint infection, or PJI: “peri” means around, and the prosthesis is the implant.
Here is the part that surprises most patients. Your immune system is very good at killing bacteria in your own tissue. It is far less effective against bacteria stuck to metal and plastic.
An implant has no blood supply. Bacteria that land on it build a slimy coating called a biofilm, which shields them from antibiotics and immune cells alike.
That biofilm is why a joint replacement infection almost never clears with antibiotic pills alone.
How common is joint replacement infection?
Joint replacement infection is uncommon. Roughly 1 in 100 patients who have a hip or knee replaced will develop one: under 1 percent for hips and under 2 percent for knees after a first-time replacement.
Revision surgery, meaning a redo of a previous replacement, carries a higher rate, closer to 5 percent.
Timing matters as much as the number. About half of these infections appear in the first six months. The rest can show up years later, when bacteria travel through the bloodstream from somewhere else in the body.
Where does a joint replacement infection come from?
Most infections come from the patient’s own skin, not from the operating room. One large study compared bacteria living on patients’ skin before surgery with the bacteria that later caused infection. Close to 90 percent were the same organism.
Sterile technique has made operating room contamination rare, so attention has shifted to the skin a patient brings with them.
Later infections usually arrive by bloodstream. An abscessed tooth, a urinary tract infection, pneumonia, or an untreated skin wound can send bacteria into circulation, and the implant is a place they can settle.
What are the warning signs of infection after joint replacement?
The clearest warning sign of infection after joint replacement is a recovery that stalls or reverses: pain that grows instead of fading, or a wound that will not close. Call your surgeon the same day if you notice any of these.
- Drainage from the incision past ten days, or drainage that turns cloudy, thick, or foul smelling
- Redness that spreads outward from the incision instead of shrinking
- New or worsening pain in a joint that had been feeling better
- Swelling and warmth that increase after the first week rather than settling down
- Wound edges that separate or refuse to seal
- Sudden trouble bearing weight on the leg, even years after surgery
- Chills, night sweats, or feeling unwell alongside joint symptoms
One note about fever: it is no longer a dependable sign, because plenty of confirmed infections never produce one. Do not wait for a temperature before you call.
Is redness and swelling after surgery normal?
Some redness, warmth, and swelling during the first week are normal. Healing tissue is inflamed tissue.
The pattern that concerns me is the one heading the wrong direction. Normal healing improves week over week; infection worsens week over week.
Here is what I tell my patients in Franklin: if you are two weeks out and your knee looks worse than it did at one week, call the office. I would rather look at ninety-nine normal incisions than miss one infection.
Who is at higher risk for joint replacement infection?
The strongest risk factors for joint replacement infection are conditions we can usually improve before surgery ever happens. Published estimates give a sense of how much each one matters.
- Body mass index of 40 or higher: roughly 3.7 times the risk
- Smoking or nicotine use: roughly 1.8 times
- Diabetes, especially with poor blood sugar control: roughly 1.7 times
- Operating time beyond two hours: roughly 1.6 times
- Immune suppression from chemotherapy, long-term steroids, transplant medication, or HIV
- Poor nutrition and low protein stores going into surgery
- Peripheral vascular disease and poor circulation in the legs
- Any active infection in the body on the day of surgery
Having one of these does not mean you will get an infection. It means preparation matters more, and we may take a few extra weeks before scheduling.
How do you prevent infection after joint replacement?
Preventing infection after joint replacement is a shared job. Part belongs to the surgical team, and a meaningful part belongs to you in the weeks before your date.
On our side, the measures with the best evidence are simple: antibiotics within an hour of the incision and continued for 24 hours, strict sterile technique, limited operating room traffic, and an efficient operation. Many centers also screen for staph carriage in the nose beforehand and treat carriers with an antibacterial ointment.
What can I do before surgery to lower my risk?
Patients have more control here than they expect.
- Stop all nicotine. Cigarettes, vapes, patches, and pouches all count.
- Get blood sugar under control with your primary care doctor, well ahead of surgery.
- Handle dental problems first. Cleanings and dental work belong before surgery, not after.
- Wash with chlorhexidine soap the nights before surgery, exactly as instructed.
- Do not shave the surgical leg. Hair removal, if needed, is done in the hospital.
- Check your skin daily and report any cut, scrape, rash, blister, or bug bite on that leg.
- Eat protein. Poor nutrition is one of the most fixable risk factors, and the most ignored.
Our free joint replacement guide walks through the full preoperative checklist we use with patients.
How is a joint replacement infection treated?
Treatment pairs surgery with a long, targeted course of antibiotics. Antibiotics alone can suppress an infection, but they rarely cure one, because biofilm keeps the drug from reaching the bacteria.
Which operation you need depends on three things: how long the infection has been present, whether the implant is still solidly fixed to bone, and which organism is growing.
- Washout with implant retention (DAIR): the surgeon removes infected tissue, exchanges the removable plastic parts, and leaves the fixed components in place. Antibiotics follow.
- One-stage exchange: the infected implant comes out and a new one goes in during the same operation, when the organism is known and the soft tissue is healthy.
- Two-stage exchange: the implant is removed and replaced with an antibiotic-loaded cement spacer. Once the infection clears, a new implant is placed in a second operation.
How long does joint replacement infection treatment take?
Antibiotic treatment usually runs six weeks to three months. Full recovery from a two-stage exchange often takes nine to twelve months from start to finish.
Outcomes depend heavily on timing. When symptoms have been present less than about three weeks and the implant is still solidly fixed, published series report the implant can be saved in 35 to 90 percent of cases. Two-stage exchange for long-standing infection reports success in the range of 80 to 90 percent.
That spread is exactly why I push so hard on early calls. Days matter here in a way they do not for most orthopedic problems.
Do I need antibiotics before dental work?
Some patients should take an antibiotic before dental procedures, but this is no longer a blanket rule for everyone. I generally recommend coverage in the first two years after replacement, and for patients with a suppressed immune system, hard-to-control diabetes, or a prior joint infection.
Ask your surgeon and your dentist together rather than guessing. Steady dental hygiene protects your implant more than any single premedication dose does.
When should you call your surgeon?
Call the same day you notice drainage, spreading redness, worsening pain, or sudden difficulty bearing weight. Do not wait for the next scheduled visit, and do not start leftover antibiotics from an old prescription.
Antibiotics taken before we culture the joint can hide the organism and delay diagnosis by weeks.
Patients in Franklin, Nashville, Columbia, and the surrounding Middle Tennessee communities can reach the Bone and Joint Institute of Tennessee at (615) 791-2630. We are located at 3000 Edward Curd Lane, Franklin, TN 37067. If you want a second opinion on a painful or suspicious replacement, you can request an appointment with Dr. Calendine directly.
Infection after joint replacement is rare, serious, and time sensitive. Knowing the signs is the most useful thing a patient can carry home. You can read more about Dr. Calendine or learn how robotic-assisted joint replacement fits into the way we operate.
Medical disclaimer: This article is for educational purposes only and does not replace personal medical advice. Every patient’s situation is different, and individual results vary. If you think your joint replacement may be infected, contact your orthopaedic surgeon or seek emergency care immediately rather than waiting.
References
- Otto-Lambertz C, Yagdiran A, Wallscheid F, Eysel P, Jung N. Periprosthetic infection in joint replacement: diagnosis and treatment. Dtsch Arztebl Int. 2017;114(20):347-353. doi:10.3238/arztebl.2017.0347
- Kunutsor SK, Whitehouse MR, Blom AW, Beswick AD; INFORM Team. Patient-related risk factors for periprosthetic joint infection after total joint arthroplasty: a systematic review and meta-analysis. PLoS One. 2016;11(3):e0150866. doi:10.1371/journal.pone.0150866
- Osmon DR, Berbari EF, Berendt AR, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56(1):e1-e25. doi:10.1093/cid/cis803
- Triantafyllopoulos GK, Soranoglou V, Memtsoudis SG, Poultsides LA. Implant retention after acute and hematogenous periprosthetic hip and knee infections: whom, when and how? World J Orthop. 2016;7(9):546-552. doi:10.5312/wjo.v7.i9.546
- Kunutsor SK, Whitehouse MR, Blom AW, Beswick AD; INFORM Team. Re-infection outcomes following one- and two-stage surgical revision of infected hip prosthesis: a systematic review and meta-analysis. PLoS One. 2015;10(9):e0139166. doi:10.1371/journal.pone.0139166
- Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351(16):1645-1654. doi:10.1056/NEJMra040181
- American Academy of Orthopaedic Surgeons. Infection After Joint Replacement. OrthoInfo.
