Conference Coverage

Periprosthetic Joint Infection Leads TKA Failure Causes in 23-Year Study of 20,523 Knees

Edited by:
Brian McCurdy

Key Highlights

  • The cumulative incidence of TKA failure at 23 years was 10.7%.
  • Periprosthetic joint infection led failure indications, followed by aseptic loosening and patellofemoral arthrosis.
  • At 12-year follow-up, infection incidence was slightly higher for procedures performed in 2011–2020 than in 2001–2010.
  • The authors identified infection as a continuing challenge and emphasized targeted prevention strategies.

Periprosthetic joint infection (PJI) was the leading cause of total knee arthroplasty (TKA) failure in an analysis of 20,523 primary procedures performed across 3 tertiary hospitals. Infection incidence did not improve over time, while some mechanical failure mechanisms became less frequent. The study was presented at the American Association of Hip and Knee Surgeons Annual Meeting in Dallas.

Investigators sought to characterize long-term failure indications and temporal trends using detailed clinical review and a standardized classification protocol. They noted that national joint registry reporting may be limited by incomplete capture of acute procedures and inconsistent classification of revision indications.

The cohort included primary TKAs performed between 2000 and 2023. Failure was defined as revision surgery or reoperation for confirmed PJI. Researchers reviewed clinical notes, radiographs, and laboratory investigations to determine failure indications using a standardized protocol.

National joint registry linkage identified patients who underwent revision outside the participating institutions. Investigators retrieved external clinical records and imaging to support accurate capture and classification. Competing-risk cumulative incidence analyses assessed failure outcomes, with comparisons between surgical eras used to evaluate changes over time.

Study Findings

At 23 years, cumulative failure incidence was 10.7% (95% CI, 8.4%–13.4%). PJI had the highest cumulative incidence among failure indications, at 2.9% (95% CI, 2.3%–3.6%). Aseptic loosening followed at 1.5% (95% CI, 1.1%–2.1%), and patellofemoral arthrosis at 0.8% (95% CI, 0.7%–1.0%).

At 12-year follow-up, TKAs performed in 2011–2020 had a slightly higher PJI incidence than those performed in 2001–2010: 2.2% versus 2%. Over the same comparison, aseptic loosening incidence decreased from 0.8% to 0.6%, and tibiofemoral instability decreased from 0.5% to 0.3%. Patellofemoral arthrosis and polyethylene wear rates remained unchanged.

Clinical Implications

According to the authors, PJI remains the principal unresolved challenge in contemporary knee arthroplasty. They emphasized that infection-related failure had not improved despite reductions in mechanical failure mechanisms and interpreted the findings as reinforcing the need for targeted prevention strategies.

Expert Commentary

“These findings identify PJI as the key unresolved challenge in contemporary knee arthroplasty and reinforce the need for targeted prevention strategies,” the researchers concluded.

Reference

Katyal A, Koh CK, Zhu M, Tay ML, Bolam SM, Young SW. Infection is now the leading cause of failure following TKA: a 23-year analysis of 20,523 knees. Paper #53. Abstract presented at the American Association of Hip and Knee Surgeons Annual Meeting, November 5–8, 2026, Dallas, TX.