How to reduce the risk of infection before joint replacement
Sources of infection, injections into the joint, skin care and decolonisation: what really matters before an implant is placed.
Periprosthetic joint infection is uncommon, but it is one of the most serious complications of joint replacement. The risk cannot be eliminated completely. Preparation aims to identify active sources of infection and factors that can safely be modified, rather than to order as many tests and antibiotics as possible.
Symptoms to report to your surgeon
Fever, chills, cough, a throat infection, flu, COVID-19 or a recent infectious illness;
A painful tooth, swollen gum, discharge of pus, a loose dental crown or unfinished dental treatment;
Burning or pain when passing urine, frequent urges to urinate or lower back pain;
Pustules, boils, ulcers, scratch marks, fungal infection or wounds, particularly on the limb to be operated on;
Antibiotics taken in recent weeks and the reason they were prescribed.
Not every abnormal result without symptoms requires treatment or postponement of surgery. The IDSA recommends against routine screening for, or treatment of, asymptomatic bacteriuria before elective non-urological surgery, including orthopaedic procedures: benefit has not been demonstrated, while antibiotics increase the risk of adverse effects and bacterial resistance. This does not apply to patients with symptoms of a urinary tract infection or to certain urological procedures.
Doctor's comment. Reporting an infection does not automatically mean losing your operation date. It allows the risk to be assessed in advance instead of making the decision on the day of admission.
Dental care: treat active infection rather than aiming for “perfect clearance”
Active dental infection should be treated before elective joint replacement. The 2024 AAOS/AAHKS guidance suggests an interval of at least three weeks after an active infection has resolved and after procedures that need healing, such as tooth extraction. At the same time, the evidence does not support indiscriminate tooth removal or routine preventive antibiotics for every patient with a joint implant. Preparation depends on symptoms, the dental procedure and individual risk.
Injections into the joint before surgery
Give the name of the substance and the exact date of the last injection. The strongest evidence concerns corticosteroids. A 2023 meta-analysis included 370,019 knees: an injection less than three months before total knee replacement was associated with an odds ratio for periprosthetic joint infection of 1.26 (95% CI 1.06–1.50). Another meta-analysis of hip and knee replacement reported an OR of 1.39 (95% CI 1.04–1.87) for an interval shorter than three months.
For shoulder replacement, a systematic review also found a relationship with timing: the pooled relative risk of infection after an injection within three months was 2.30, but the number and quality of studies were limited. Evidence for hyaluronic acid, PRP and other injections is less consistent. The rule that “exactly three months is enough for everyone” is therefore an oversimplification.
Important. If joint replacement is being discussed, do not have another injection into the joint without agreeing it with the operating surgeon.
Skin and hair removal
Do not shave the surgical area at home. The CDC notes that shaving irritates the skin and may make it easier for bacteria to enter. If hair interferes with the procedure, it is removed with clippers according to the clinic's protocol. Report abrasions, bites, dermatitis and any new rash.
Staphylococcus aureus and MRSA
The WHO recommends perioperative decolonisation with mupirocin, with or without chlorhexidine, for known S. aureus carriers undergoing orthopaedic surgery. This does not mean that every patient should apply mupirocin on their own. Screening, patient selection and treatment regimens depend on local protocols and bacterial resistance.
Measures that have not been established as universal precautions
Taking a preventive course of antibiotics on your own;
Treating every abnormal test result without considering symptoms and obtaining a medical assessment;
Mandatory decolonisation for all patients without considering carrier status and local protocols;
Shaving at home or applying aggressive antiseptics to the skin;
Using one fixed interval after any injection, regardless of the joint or substance involved.
Report current and recent infections.
Show the doctor any damaged skin on the limb to be operated on.
Record the date and substance of your last joint injection.
Do not start antibiotics, mupirocin or a chlorhexidine course without a prescription.
If symptoms develop after the preoperative assessment, contact the clinic again.
Important. This information does not replace individual instructions from your surgeon and anaesthetist. If the clinic's leaflet differs from general guidance, follow the personal instructions given by your treating team.
