https://doi.org/10.4081/ejtm.2026.15177
Infection prevention in total knee arthroplasty: current concepts, controversies, and a clinical algorithm
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Published: 25 May 2026
Periprosthetic Joint Infection (PJI) remains one of the most serious and challenging complications following Total Knee Arthroplasty (TKA), with a substantial impact on patient outcomes and healthcare systems. Despite advances in surgical techniques and perioperative management, the incidence of PJI has not significantly declined, highlighting the need for more effective preventive strategies. This review aims to provide a comprehensive and clinically oriented overview of current infection prevention strategies in TKA, with a particular focus on risk stratification, perioperative optimization, and the development of a practical clinical algorithm to guide decision-making. A narrative review of the literature was conducted using major medical databases to identify relevant studies on PJI prevention in TKA. Priority was given to recent systematic reviews, meta-analyses, and high-quality clinical studies addressing patient-related risk factors, intraoperative measures, and postoperative management. PJI is a multifactorial complication influenced by the interaction between patient-related, surgical, and postoperative factors. Modifiable risk factors such as obesity, diabetes, malnutrition, and smoking play a pivotal role and should be optimized preoperatively. Intraoperative strategies, including strict aseptic technique, appropriate antibiotic prophylaxis, and minimization of operative time, are essential to reduce contamination risk. Postoperative measures focusing on wound management, hematoma prevention, and early detection of complications further contribute to infection prevention. Several aspects remain controversial, including the role of laminar airflow systems, antibiotic-loaded bone cement in primary TKA, and optimal decolonization strategies for Staphylococcus aureus. Effective prevention of PJI requires a structured, multimodal approach integrating all phases of care. Risk stratification enables personalized preventive strategies and improved perioperative planning. The clinical algorithm proposed in this review provides a practical framework to support decision-making and may help standardize infection prevention pathways. Future research should focus on validating risk-based approaches and emerging technologies to further reduce the burden of PJI in TKA.
Downloads
1. Guo J, Jin Z, Xia M. Evaluating surgical outcomes: robotic-assisted vs. conventional total knee arthroplasty. J Orthop Surg Res 2025;20:166.
2. Kayani B, Konan S, Tahmassebi J, et al. Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty: a prospective cohort study. Bone Joint J 2018;100-B:930–7.
3. Li J, Liu Z, Wang Z, et al. Risk factors for periprosthetic joint infection following primary total knee arthroplasty: a systematic review and meta-analysis. Front Surg 2026;12:1715571.
4. McElroy MJ, Pivec R, Issa K, et al. The effects of obesity and morbid obesity on outcomes in TKA. J Knee Surg 2013;26:83–8.
5. Marchant MH Jr, Viens NA, Cook C, et al. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am 2009;91:1621–9.
6. Berkovich Y, Nissan EC, Maman D, et al. Diabetes and total knee arthroplasty: a nationwide analysis of complications, hospitalization outcomes and revision burden. Knee Surg Sports Traumatol Arthrosc 2025;33:3250–60.
7. Sowden J. The influence of diabetes on wound healing. Diabet Foot J 2010;13:22–6.
8. Patel AV, Stevens AJ, White R, et al. Hip, knee, and shoulder arthroplasty in patients with a history of solid organ transplant: A review. J Orthop 2024;51:116–21.
9. Akkaya M, Buday Z, Akcaalan S, et al. In-hospital complications following total knee and hip arthroplasty in patients with HIV. Jt Dis Relat Surg 2022;33:3–8.
10. Gu A, Malahias MA, Strigelli V, et al. Preoperative malnutrition negatively correlates with postoperative wound complications and infection after total joint arthroplasty: a systematic review and meta-analysis. J Arthroplasty 2019;34:1013–24.
11. Shin KH, Kim JH, Han SB. Greater risk of periprosthetic joint infection associated with prolonged operative time in primary total knee arthroplasty: meta-analysis of 427,361 patients. J Clin Med 2024;13:3046.
12. Rodríguez-Merchán EC, Davidson DJ, Liddle AD. Recent strategies to combat infections from biofilm-forming bacteria on orthopaedic implants. Int J Mol Sci 2021;22:10243.
13. Lei YT, Xie JW, Huang Q, et al. Benefits of early ambulation within 24 h after total knee arthroplasty. Mil Med Res 2021;8:17.
14. Aftab S, Ali HN, Saeed B, et al. Early physiotherapy for post-total knee arthroplasty recovery: a systematic review. Musculoskeletal Care 2025;23:e70158.
15. Izakovicova P, Borens O, Trampuz A. Periprosthetic joint infection: current concepts and outlook. EFORT Open Rev 2019;4:482–94.
16. Durst C, Rajaee L, Chang K, et al. Psoriasis is a risk factor for surgical site infection after primary TKA. Clin Orthop Relat Res 2024;482:1196–200.
17. Gordon AM, Ng MK, Erez O, et al. Dental procedures and risk of PJI. J Arthroplasty 2023;38:476–83.
18. Wang C, Huang W, Gu Y, et al. Effect of urinary tract infection on PJI risk: a systematic review. Surgeon 2020;19.
19. Tande AJ, Patel R. Prosthetic joint infection. Clin Microbiol Rev 2014;27:302–45.
20. Sørensen LT. Smoking and wound healing. Arch Surg 2012;147:373–83.
21. Zhu X, Sun X, Zeng Y, et al. Nasal screening and decolonization for S. aureus. J Orthop Surg Res 2020;15:60.
22. Schweizer ML, Chiang H, Septimus E, et al. Bundled intervention and SSI reduction. JAMA 2015;313:2162–71.
23. Ontario Health (Quality). Pre-surgical nasal decolonization of staphylococcus aureus: a health technology assessment. Ont Health Technol Assess Ser 2022;22:1-165.
24. Bode LG, Kluytmans JA, Wertheim HF, et al. Preventing surgical-site infections in nasal carriers. N Engl J Med 2010;362:9–17.
25. Ghanem E, Antoci V Jr, Pulido L, et al. ESR and CRP in diagnosing periprosthetic infection. Int J Infect Dis 2009;13:e444–49.
26. Enz A, Klinder A, Bisping L, et al. Surgical gloves and infection risk. Knee Surg Sports Traumatol Arthrosc 2023;31:1824–32.
27. Mastrocola M, Matziolis G, Böhle S, et al. Chlorhexidine vs povidone iodine. Sci Rep 2021;11:18634.
28. Chen S, Chen JW, Guo B, Xu CC. Antisepsis meta-analysis. World J Surg 2020;44:1412–24.
29. Lepelletier D, Maillard JY, Pozzetto B, Simon A. Povidone iodine role. Antimicrob Agents Chemother 2020;64:e00682-20.
30. Clayman E, Beauchamp Z, Troy J. Hypochlorous acid in infection control. Eplasty 2023;23:e1.
31. Gastmeier P, Breier AC, Brandt C. Laminar airflow and PJI. J Hosp Infect 2012;81:73–8.
32. Kirschbaum S, Hommel H, Strache P, et al. LAF effectiveness. Knee Surg Sports Traumatol Arthrosc 2021;29:3641–7.
33. Spagnolo AM, Ottria G, Amicizia D, et al. Operating theatre quality. J Prev Med Hyg 2013;54:131–7.
34. Voigt J, Mosier M, Darouiche R. Antibiotics in arthroplasty. Antimicrob Agents Chemother 2015;59:6696–707.
35. American Academy of Orthopaedic Surgeons. Perioperative antibiotics guidelines. 2019.
36. Martínez-Moreno J, Merino V, Nácher A, et al. Antibiotic-loaded bone cement. Orthop Surg 2017;9:331–41.
37. Leong JW, Cook MJ, O'Neill TW, Board TN. ALBC and revision risk. Bone Joint J 2020;102-B:997–1002.
38. Cooper HJ, Santos WM, Neuwirth AL, et al. Randomized controlled trial of incisional negative pressure following high-risk direct anterior total hip arthroplasty. J Arthroplasty 2022;37:S931-S936.
39. Kim JH, Kim HJ, Lee DH. NPWT meta-analysis. J Arthroplasty 2019;34:2804–14.
40. Liu T, Tao Y, Zhao R, et al. Skin closure methods in TKA. Arthroplasty 2024;6:51.
41. Kulkarni S, Goodbun M, Chowdhury M, Stather PW. Dermabond Prineo. J Wound Care 2025;34:220–26.
42. Velázquez-Velázquez JL, Santos-Flores A, et al. Silver dressings. Mater Sci Eng C 2015;49:604–611.
43. Liang Z, Ding Z, Wang D, et al. Cryotherapy meta-analysis. Orthop Surg 2024;16:2897–915.
44. Quesnot A, Mouchel S, Salah SB, et al. Cryotherapy RCT. BMC Musculoskelet Disord 2024;25:182.
45. Thijs E, Schotanus MGM, Bemelmans YFL, Kort NP. Cryotherapy and opioid reduction. Knee Surg Sports Traumatol Arthrosc 2019;27:1204–12.
46. Brouwers HFG, de Vries AJ, et al. Cryotherapy benefits. Knee Surg Sports Traumatol Arthrosc 2022;30:2698–706.
47. Coviello M, Abate A, Ippolito F, et al. Cold flow device. Medicina 2022;58:1537.
48. Galat DD, McGovern SC, Hanssen AD, et al. Hematoma complications. J Bone Joint Surg Am 2008;90:2331–6.
49. Christensen LMR, Arnesen CE, Möller S, Hyldig N. Compression therapy. Int J Orthop Trauma Nurs 2021;41:100815.
50. Wu D, Fu K, Jiang G, et al. Compression stockings. BMC Musculoskelet Disord 2025;26:733.
51. Holt BT, Parks NL, Engh GA, Lawrence JM. Drain vs no drain. Orthopedics. 1997;20:1121–4.
52. Liu J, Cao JG, Wang L, Ma XL. Fibrin sealant meta-analysis. Int J Surg 2014;12:95–102.
53. Rahayu U, Ibrahim K, Herman H. Patient education in orthopaedics. Patient Prefer Adherence 2025;19:1881–91.
54. Rovere G, De Mauro D, D'Orio M, et al. Use of muscular flaps for the treatment of hip prosthetic joint infection: a systematic review. BMC Musculoskelet Disord 2021;22:1059.
55. De Marco D, Messina F, Meschini C, et al. Periprosthetic knee fractures in an elderly population: open reduction and internal fixation vs distal femur megaprostheses. Orthop Rev (Pavia) 2022;14:33772.
56. Oliva MS, Muratori F, Vitiello R, et al. Cemented vs uncemented megaprostheses in proximal femur metastases: a multicentric comparative study. BMC Musculoskelet Disord 2022;22:1068.
57. Bosco F, Rovere G, Burgio C, et al. Accuracy and learning curve of imageless robotic-assisted total knee arthroplasty. J Orthop 2025;66:77-83.
58. Rovere G, Meschini C, Piazza P, et al. Proximal humerus fractures treatment in adult patients with bone metastasis. Eur Rev Med Pharmacol Sci 2022;26:100-5.
59. Mocini F, Rovere G, De Mauro D, et al. Newer generation straight humeral nails allow faster bone healing and better functional outcome at mid-term. J Orthop Surg Res 2021;16:631.
60. Romeo M, Rovere G, Stramazzo L, et al Single use instruments for total knee arthroplasty. Med Glas (Zenica) 2021;18:247-251.
61. Farsetti P, De Maio F, Potenza V, et al. Lower limb lengthening over an intramedullary nail: a long-term follow-up study of 28 cases. J Orthop Traumatol 2019;20:30.
62. Ippolito E, Valentini MB, Lala R, et al. Changing pattern of femoral deformity during growth in polyostotic fibrous dysplasia of the bone: an analysis of 46 cases. J Pediatr Orthop 2016;36:488-93.
63. De Maio F, Corsi A, Roggini M, et al. Congenital unilateral posteromedial bowing of the tibia and fibula: insights regarding pathogenesis from prenatal pathology. A case report. J Bone Joint Surg Am 2005;87:1601-5.
64. Meschini C, Cauteruccio M, Oliva MS, et al. Hip and knee replacement in patients with ochronosis: Clinical experience and literature review. Orthop Rev (Pavia) 2020;12:8687.
65. Rovere G, Bosco F, Miceli A, et al. Adoption of blockchain as a step forward in orthopedic practice. Eur J Transl Myol 2024;34:12197.
66. Vitiello R, Bocchi MB, Gessi M, Greco T, Cianni L, de Maio F, Pesce V, Maccauro G, Perisano C. Induced membrane by silver-coated knee megaprosthesis: keep or toss? J Biol Regul Homeost Agents 2020;34:101-106.
CRediT authorship contribution
Giuseppe Rovere, Francesco Bosco, Claudia Cuttaia and Ludovico Lucenti, conceptualization; Luigi Meccariello, Andrea Perna, Giuseppe Rovere, and Francesco Bosco, methodology, software, formal analysis, data curation;Andrea Perna, Michele Mercurio, Giuseppe Marongiu, Andrea Fidanza, Amarildo Smakaj, and Domenico De Mauro, validation, writing – original draft preparation; Lara Cristiano, Francesco Bosco, Claudia Cuttaia and Ludovico Lucenti, investigation; Pasquale Farsetti, Fernando De Maio and Lawrence Camarda, resources; writing – Giuseppe Rovere, Francesco Bosco, Claudia Cuttai and Ludovico Lucenti review and editing; Luigi Meccariello, Lawrence Camarda , Andrea Perna , Giuseppe Rovere, visualization; Giuseppe Rovere, supervision; Giuseppe Rovere and Lawrence Camarda project administra- tion; all authors have read and agreed to the published ver sion of the manuscript
Supporting Agencies
How to Cite
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.