Patient and Health Professional’s Perspectives of Periprosthetic Joint Infection: A Systematic Review and Meta-Ethnography

Abstract

Background:

Periprosthetic joint infection (PJI) is a major challenge for surgical teams and patients following an orthopedic surgical procedure. There is limited understanding on patient and health professional’s perception of PJI. The aim of this study was to examine the literature to better understand the perspectives of patients, and those who manage PJI.

Methods:

Published and unpublished literature databases were systematically searched from inception to June 21, 2024. Qualitative studies reporting the perspectives of living with and managing PJI were included. Data were synthesized using a meta-ethnography approach and the GRADE-CERQual tool.

Results:

Of the 584 citations identified, 10 studies (n = 91 patients; n = 70 health professionals) met the eligibility criteria and were included. Three themes, all moderate-certainty evidence, were identified from the health professional data, including the following: (1) importance of PJI; (2) impact on health professionals; and (3) support for change. From the patient data, six themes on the basis of moderate-certainty evidence were identified: (1) psychological and social impact; (2) physical impacts; (3) relationship with health professionals; (4) relationship with others; (5) uncertainty over the future; and (6) support for change. A novel line of argument was developed offering third-order constructs, on the basis of first- and second-order themes.

Conclusion:

PJIs are perceived as devastating by both patients and health professionals. They impact on all aspects of a patient’s physical, social and psychological health, each interacting on one another over the course of infection and management. Strategies to improve communication, multidisciplinary management, and personalization of care are advocated by both patients and health professionals to promote better outcomes.

Introduction

Between 2003 and 2023, more than three million people underwent arthroplasty (mostly hip and knee) in the United Kingdom alone.¹ For the majority, this is a successful operation, resolving their joint pain and symptoms. However, for some, complications such as periprosthetic joint infection (PJI) occur, requiring a revision surgical procedure. Approximately 2% of people who undergo hip or knee replacement develop PJI.² Mortality due to PJI is estimated to be 6% and 7% at Years 1 and 2, respectively.² Five-year mortality for patients with PJI is estimated to be 25%.² This is equivalent to breast, lung, and prostate cancer.³

Management of PJI is sustained antibiotic agent therapy, with or without a surgical intervention. Surgical intervention is either one- or two-stage revision. Sometimes infection cannot be eradicated, and long-term antibiotic agent suppression therapy or amputation is required.² While there is a wealth of quantitative literature regarding treatment options and risk factors for PJI,^4,5 there remains uncertainty regarding perceptions of PJI in both patients and the health professionals involved in their management. Furthermore, there remains uncertainty whether the needs and expectations of patients and health professionals in relation to PJI differ globally. One study has systematically reviewed qualitative research reporting patient needs while undergoing treatment for PJI.⁶ This focused solely on “patient” perspectives and not health professionals. Furthermore, the last search, including articles up to 2016, with an up-to-date review is now required.

The key objective of this study was to assess the current evidence base related to perceptions of patients with PJI and health professionals using a systematic review and meta-ethnography approach. Given the limited previous evidence synthesis on this topic, this will offer important, novel insights from both groups, to better understand current care needs and service recommendations from a global perspective.

Methods

Design

This systematic review satisfies the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines⁷ and the eMERGe reporting guidance.⁸ The protocol was registered before commencing (PROSPERO Ref: CRD42024560308).

Eligibility criteria

The eligibility criteria were structured using the SPIDER framework.⁹

Sample

Patients with PJI following arthroplasty. This could include patients who had undergone arthroplasty to any peripheral joint. If articles presented data on other populations, PJI needed to be present in 85% or more of the cohort, with data specifically related to peripheral joint infection extracted (when possible).

We identified articles that sampled health professionals involved in the care of this population. This could have been within the hospital setting or post-hospital discharge. This may include orthopedic surgeons, physicians, laboratory staff (including microbiologists), nurses, physiotherapists, occupational therapists, dietitians, pharmacists, or health psychologists (but not exclusively).

Design

Published literature using a qualitative research design.

Evaluation

We included studies that assessed the perceptions of patients who had experienced/were experiencing PJI toward the management of their condition, and people involved in the management of these individuals.

Research type

Qualitative or mixed-methods research, peer-reviewed studies using a qualitative research design (e.g., ethnography, phenomenology), or qualitative methods for data collection (e.g., focus group interviews, individual interviews, observations), using qualitative analysis methods (e.g., thematic analysis, framework approach), were included.

We did not place eligibility restrictions on publication date or country.

Search strategy

The literature search was performed by one reviewer (T.S.). We searched published literature databases, including the following: EMBASE, MEDLINE, CINAHL, and PubMed. We accessed unpublished or ongoing study data from registries, including the WHO International Clinical Trial Registry and ClinicalTrials.gov. The electronic search tactic, adopted for EMBASE, is presented as Supplementary Data S1. This search tactic was adapted for each database. Searches were performed from database inception to June 21, 2024.

We performed a forward-citation search for all included studies using the Scopus database. Second, we conducted a backward-citation search through a review of all included study’s reference lists.

Study identification

All titles and abstracts from the search tactic results were independently reviewed by two reviewers (T.S. and H.G.). The full texts of articles that were potentially eligible were reviewed independently by each reviewer to ascertain final eligibility. Any disagreements between the two reviewers were resolved through discussion.

Data extraction

Data were extracted onto a predefined data extraction form by one reviewer (T.S.) and verified by a second (H.G.). Disagreement in data extraction between the reviewers was resolved through discussion. Where the same study was reported across two or more articles, these were classified as a single study to avoid multiple counting. For each included study, data collected are summarized in Supplementary Data S2.

Critical appraisal

Two reviewers (T.S. and H.G.) independently critically appraised each included study using the Critical Appraisal Skills Program qualitative appraisal tool.¹⁰ Disagreements between reviewers in scoring items were resolved through discussion.

Data synthesis

Qualitative study data were synthesized using a meta-ethnography approach.¹¹ Following this methodology, themes were identified to examine how concepts juxtaposed or associated with one another.

We analyzed the perspectives of the following: (1) patients with PJI during their healthcare experience and (2) health professionals involved in the management of these patients irrespective of where in the care pathway their involvement occurred. Relevant themes around these two questions were grouped into categories by two reviewers (T.S. and H.G.) to identify first-order themes. Constant comparative techniques were used to compare how emergent categories related to the primary data/original texts in their similarities (reciprocal analysis) and contradictions (refutational analysis). This determined the second-order themes. These were assessed for certainty using the GRADE-CERQual tool.¹² On the basis of these, second-order review findings were graded from “high,” “moderate,” to “low” and “very low.” These findings were collapsed into interpretive themes to develop a line of argument, to gain a third-order construct.

The construction of the first-, second-, and third-order themes was made between the three reviewers (T.S., H.G., and S.A.) and consensus was reached through discussion.

Results

Search results

The results of the search tactic are presented in Figure 1. As this illustrates, 584 citations were identified. Ten studies were eligible and included in the analysis.

FIG. 1.

Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flowchart summarizing the results of the search tactic.

Characteristics of included studies

A summary of the 10 included studies is presented in Tables 1 and 2. Five studies presented data on patient participants (n = 91; 39 female/52 male), published from 2010¹³ to 2023.¹⁷ Two studies recruited patients with knee PJI,^14,17 two recruited patients with hip PJI,^15,16 while Andersson et al¹³ recruited patients with hip and knee PJI (n = 12; 86%) with two participants (14%) presenting with non-joint infections. Three studies were performed in the United Kingdom,^14–16 one in Denmark,¹⁷ and one in Sweden.¹³

Table 1.

Characteristics of Included Studies (Patients)

Study	Country origin	Data collection method	Patients
Study	Country origin	Data collection method	N	Gender (F/M)	Age (Yrs; range)	Operation	Interview duration from management	Duration of index arthroplasty to infection	Analysis approach
Andersson¹³	Sweden	In-person Interview	14	5/9	<40: 3 40–65: 5 > 65: 6	THR: 6 TKR: 2 Hemiarthroplasty: 1 ACL reconstruction: 3 Coronary bypass: 1 Abdominal hysterectomy: 1	Not stated	Not stated	Content analysis
Mallon¹⁴	UK	In-person Interview	16	7/9	59–80	Knee PJI Two-stage revision: 7 One-stage revision: 9	Not stated	<1 wk to 19 yrs	Thematic
Moore¹⁵	UK	In-person Interview	19	7/12	56–88	Hip PJI Two-stage revision: 10 One-stage revision: 9	Interviews: 2–12 mos post-hospital discharge	<1 yr — 22 yrs	Thematic
Palmer¹⁶	UK	Telephone or in-person Interview	32	15/15	51–89	Hip PJI Two-stage revision: 19 One-stage revision: 11	Interview 1: 2–4 mos after first revision (n = 30) Interview 2: 18 mos after revision (n = 17)	Not stated	Constant comparative
Rowland¹⁷	Denmark	Telephone Interviews	10	5/5	68–83	Knee PJI-two-stage revision: 5 One-stage revision: 5	PJI surgery within previous 6–12 mos	<1 wk to 7 yrs	Thematic

ACL, anterior cruciate ligament; COPD, chronic obstructive pulmonary disease; F, female; M, male; mos, months; n, number of participants; PJI, periprosthetic joint infection; T2D, type2 diabetes; THR, total hip replacement; TKR, total knee replacement; UK, United Kingdom; USA, United States of America; Yrs, years.

Five studies presented data from health professionals (n = 70) (Table 2). This was predominantly orthopedic surgeons.^18,20,21 Awad et al¹⁹ recruited a multidisciplinary team (surgeons, nurses, microbiologists, physiotherapists), while Walter et al²² recruited a nursing cohort. Studies were published between 2017²¹ and 2022.²² Interviews gained views on PJI following hip replacement,²¹ knee replacement,²⁰ hip and knee replacement,^18–21 and general arthroplasty.²² Three studies were performed in the United Kingdom,^19–21 one study in Australia,¹⁸ and one in Germany.²²

Table 2.

Characteristics of Included Studies (Health Professionals)

Study	Country origin	Data collection method	Health professional
Study	Country origin	Data collection method	N	HCP role	Gender (F/M)	Years experience (range)	Joint replacement type	Analysis approach	Primary joint replacement volume
Ackerman¹⁸	Australia	Interviews	14	Orthopedic surgeon	0/14	15–30 (as consultant)	THR; TKR	Thematic	High: 9 Moderate: 3 Low: 2
Awad¹⁹	UK	Interviews	13	Orthopedic surgeon: 5; surgical nurse practitioners: 2; microbiologists: 5; physiotherapist: 1	N/S	Not stated	THR; TKR	Thematic	High-volume unit
Mallon²⁰	UK	Telephone Interviews	11	Orthopedic surgeons	N/S	0–20 (as consultant)	TKR	Thematic	High-volume units: 6
Moore²¹	UK	Interviews	12	Orthopedic surgeons	0/12	0–20+ (treating PJI)	THR	Thematic	High-volume units: 5
Walter²²	Germany	Interview	20	Nurses	17/3	1–27	N/S	Content	Not stated

F, female; HCP, healthcare professional; M, male; N, number of participants; N/S, not stated; PJI, periprosthetic joint infection; THR, total hip replacement; TKR, total knee replacement; UK, United Kingdom.

Critical appraisal

The results of the critical appraisal are presented in Supplementary Data S3. The 10 included studies presented moderate- to low-quality evidence.

Meta-ethnography

A summary of the meta-ethnography findings is presented in Supplementary Data S4. From the health professional data, three broad themes were identified as follows: (1) importance of PJI; (2) impact on health professionals; and (3) support for change. From the patient data, six broad themes with specific subthemes were identified as follows: (1) psychological and social impact; (2) physical impacts; (3) relationship with health professionals; (4) relationship with others; (5) uncertainty over the future; and (6) support for change. Quotes from participants are used to exemplify these themes (Table 3).

Table 3.

A Summary of the Illustrative Patient and Health Professional Quotes

Quote [study number]	Quotes
1¹⁸	I think we are still going to have an infection issue, but I hope we will be able to combat that in other ways in future times. Certainly by 20 yrs I hope we’d have gotten better at it
2²⁰	The worst thing to happen…beyond dying a catastrophe, absolute disaster. Oh, it’s awful. It’s one of the worst things that can happen. [Really?] Beyond dying, yeah. No, it’s a catastrophe, absolute disaster. Awful, like you remember them by name. . . By-name, radiograph, appearance and quite often organism as well.
3²²	We already talk to them, but they would need much more professional support from psychosomatics or psychology similar as the oncological patients, the patients here are somehow still not in focus, nobody is aware that they also have a psychological trauma.
4¹⁵	But that’s the only thing I really panic about now, is getting another infection, because I don’t know where he’d go from there. It’d be leg off time then, wouldn’t it? [laughs]
5¹⁴	Periprosthetic infection create a biographically abnormal and profoundly disruptive experience for patients, wherein social identities are challenged and redefined
6¹⁶	I’m really tired at the end of the day, er, physically and — and emotionally drained a lot of the time, you know, cause I’m having to think continually to minimize, Right, what do I need?
7¹⁷	They kept telling me; you have to eat, you have to eat. But when everything tastes awful, then it’s very hard to get anything down. But when you do not eat what they serve you, then they cannot do anything else, can they?
8¹⁵	So, yeah, I do worry about it getting re-infected. And I still don’t feel completely I’m out of the woods yet, and yet it’s almost a year now, you know. I’d like—you, sort of, think, When can you relax?
9¹⁴	What’s the next stage, what’s going to happen … am I going to get infection back, you know, there’s only so much your knee can take
10¹³	Do you know what the doctor said to me? He showed me the X-rays, which told me nothing. He then said, There’s nothing wrong. I replied that I was in pain. You are going to have to learn to live with it, he said. I said that something had to be wrong. He said, There is nothing wrong That almost made me angry
11¹³	The doctors are so important. They take me seriously and they have always been there for me. If I hadn’t had them, I would never have survived this
12¹³	I didn’t feel particularly good about my wife having to do so much at home, and seeing that she was totally exhausted, both physically and mentally, wasn’t much fun either
13¹⁵	Your life is destroyed, absolutely destroyed. There is nothing you can do. You lose your privacy. You lose your dignity. You lose your independence. You have no life. For someone like me who lived a very physically—and I’m a very gregarious person, I would have happily—in fact I would have happily ended it all. I stood at the top of the stairs many times and thought, If I just went, could I guarantee that this would get me out of this? because it was that desperate, and I’m a very strong person.
14¹⁵	You stop doing things. I was captain of a local snooker club in [ place]. I played golf at [ place]; all of that’s gone. Gave up my golf clubs to the boys next door. Can’t play snooker because I’m afraid of pivoting on this leg. It’s not worth the risk
15¹⁵	Well we used to go out almost every week […] with our friends, we don’t seem to do

Health professionals

Theme 1: Importance of PJI

Two studies of moderate-certainty evidence^18–22 emphasized the concerns of health professionals on the growing impact of PJI. The increasing number of primary joint replacements was seen as evidence for an expected increase in PJI.¹⁸ This acknowledgment was reflected with hope that this can be mitigated with increased awareness and improved prevention strategies (Quote 1).

The importance of infection was also reflected by the strength of feeling health professionals, and specifically nurses in Germany, had toward these patients.²² There was a sentiment of empathy but also an understanding on the impact that PJI can have. Knowledge of this was seen as a challenge for some health professionals to emotionally deal with.

Theme 2: Impact on professionals

Two studies illustrated moderate-certainty evidence on the emotional impact that managing patients with PJI can have on health professionals.^19–22 While both offered insights into the personal impact these had, the focus was more external from responses in Walters et al’s²² nursing perspective compared with the internal perspectives of surgeons in Mallon et al.²⁰ For example, in Walters et al,²² nurses expressed “helplessness and upset” toward the patient predicament and the perceived burden and mental consequences living with PJI has on patients. Whereas a consistent response from surgeons in Mallon et al’s²⁰ U.K. cohort was a feeling of accountability, particularly for early infection. When PJI does occur, the impact was perceived as of deep importance to surgeons (Quote 2).

This difference in health professional’s views may be attributed to the responses nurses gave on being unable to address some of the challenges that patients felt, due to time and expertise, particularly around offering support for the psychological impacts of PJI.

Professional accountability and personal responsibility were also reported. Surgeons recalled a clear, proactive approach to monitor their practice. This was both through personal reflection and also external data through National Joint Registry reporting and examination from their own hospital’s data and surgical colleague feedback.²⁰ There was a clear recommendation from surgeons that this practice is positive and being “honest” with one’s practice was important.

Theme 3: Support for change

There was moderate-certainty evidence on support for change from four studies.^19–22

Awad et al²¹ focused on examining the perceptions of an multi-disciplinary team (MDT) approach to managing PJI in a single U.K. hospital. This consistently supported the value of improving communication across specialties, particularly orthopedics and microbiology. The formal MDT approach was promoted to offer increased standardization and centralization of care for complex patients within a geographical region. Moore et al²¹ and Mallon et al’s²⁰ U.K. surgical cohorts acknowledged that closer working within an MDT also facilitated the option of one-stage revision procedures that, without greater microbiology support, could have been challenging. However, health professional views were predominantly from orthopedic surgeons and nurses. Perspectives of other professionals such as pharmacists, microbiologists, physiotherapists, occupational therapists, and dietitians may offer additional, valuable perspectives both in early- and later stage recovery, and a recommendation for further study.

Supporting holistic care needs were emphasized in Walter et al’s²² findings. This stressed nurses’ perceptions of insufficient time to support patients and their family members/friends as carers, for education, preparation for longer term management, and to offer psychological support. For the latter, a comparison with other patient groups, notably oncology, was made (Quote 3).

Improved education also included a need to manage patient expectations and promote treatment self-efficacy. Walter et al²² reported nurse’s perceptions that patients frequently underestimate treatment challenges. They recommended a “key-worker” approach to overcome some of these challenges. There was limited evidence on how this could be implemented into clinical practice. Further research to explore what such “key-workers” should do and how they can be embedded within practice is recommended.

Moore et al²¹ specifically explored the role of one-stage to two-stage revision procedures. They reported surgical perceptions on the potential “pros and cons” of these procedures and the patient-specific decision-making not only about the infection, comorbidities, patient circumstance, hospital bed availability and staffing, but also their surgical background and perceptions of best-care for these patients.²¹

There was repeated acknowledgment of equipoise on surgical practice, with a consistent call for research and trial data. While authors acknowledged there may be a shift toward one-stage revision procedures, perceived uncertainty remained until robust published evidence and observed colleagues’ success rates were available.²¹

Patients

Theme 1: Psychological impact

All five studies,^13–17 offering moderate-certainty evidence, acknowledged major psychological and social impacts to experiencing a PJI, irrespective of country of origin or type of joint infected.

The risk that PJI could lead to long-term, permanent disability and potential death was recognized as a source of anxiety in Rowland et al’s¹⁷ sample, compounded by uncertainties over the future (Quote 4).¹³

The invasive nature of treatment, duration, and reliance on medical care were reported across studies as a source of distress.^16,17 Where patients were able to receive antibiotic agent therapy at home, this was regarded as a positive option,¹⁶ with prolonged hospital stay seen as a source of isolation and mental strain.¹⁷

Embarrassment was reported from participants in both Mallon et al¹⁴ and Moore et al’s cohorts,¹⁵ both in the resultant disability that PJI caused and the impact this had on their relationship with friends and family members.

Three studies of moderate-certainty evidence, offering an international perspective, highlighted how PJI created a new sense of perceived health vulnerability.^13,14,17 This was considered a “shift” from expected outcomes¹⁴ with lives “put on hold.” For others, an acceptance that long-term, PJI changed their outlook on life both physically and psychologically.^13,14 This was clearly interpreted by Mallon et al¹⁴(Quote 5).

Theme 2: Physical implications

All studies, providing moderate-certainty evidence, highlighted pain as an overarching symptom, both at initial diagnosis and longer term. This was associated with physical and emotional fatigue (Quote 6).^14,16,17

Prolonged antibiotic agent therapy and general deconditioning were associated with weight loss, reduced appetite, and nausea. This was also associated with helplessness (Quote 7).¹⁴

Participants who had recovered frequently reported “doing more” but not as much as before PJI.¹⁶ There was a sense of a deterioration in overall health because of treatment, highlighting the impact of antibiotic agent therapy on the gastrointestinal system.^13,15

Theme 3: Uncertainties for future

On the basis of moderate-certainty evidence, a consistent message was uncertainty regarding the future.^13–17 For some, fear of re-infection created anxiety that this would occur again (Quote 8; Quote 9).¹⁷

The nature of the diagnosis also enhanced this uncertainty through the “unexpected” or “spontaneous nature” of infection, particularly in the absence of an explanation.¹⁵

Uncertainty also surrounded management, as patients were unsure about the treatment response and if or when surgical intervention would be required. This was aggravated with periods of “waiting” between operations for a two-stage revision procedure.¹⁵

Three studies^13–15 acknowledged the financial implications that PJI had for some participants. Examples of loss of income from reducing or ceasing work, costs associated with hospital visits, changes to home circumstances both in home adaptations and, in one case, the move to a different home.¹⁵ Importantly, no studies reported the direct costs of care that may have been more evident in countries where private health providers have a greater role in care delivery. Greater understanding on the economic impact of PJI on patients is a research recommendation.

Theme 4: Relationship with health professionals

Four studies presenting moderate-certainty evidence, reported changes in relationships between patients and health professionals.^13–15,17 Diagnosis of infection was repeatedly viewed as a pivotal event. There were examples of differing options between patients and their general practitioners or surgical team members. Patients reported seeking confirmation that “something was not right.”^14,15,17 This in-itself created uncertainty and associated anxieties.¹³ Participants reported having to challenge health professionals when diagnosis was delayed or if they felt they were not being taken seriously (Quote 10).^14,17

This was countered with a feeling of being “pleased” and “relief” when a diagnosis was made.¹⁴ In contrast, Andersson et al¹³ reported that when providing support and guidance, trust in health professionals was evident (Quote 11).

There were conflicting views on “blame” toward health professionals. Andersson et al’s¹³ sample from Sweden reported that when there were “suspicions” that the origin of infection was from the operation, patients “blamed” their surgeon,¹⁴ with fear of “facing a life with chronic disability.”¹³ In contrast, others within the same sample felt “unlucky,” suggesting PJI was a chance event.¹⁴

Theme 5: Relationship to others

Four studies presenting moderate-certainty evidence reported changes to relationships because of PJI.^14,15,17

Those who had friends and family members who became their carers considered this change in role and identity a challenging experience. Patients who were previously independent reported becoming reliant on friends/family members and formal carers to assist with many day-to-day activities.^14,16 This was largely attributed to physical disability but caused anxiety, depression, and strain on relationships (Quote 12).^13,15

Participants reported a loss of dignity,¹⁵ embarrassment, and frustration in needing to ask for help (Quote 13).^13,15

There was also fear and anxiety regarding how patients were perceived by others. An example of this was illustrated by Moore et al¹⁵ where one patient recalled a leaky wound and bulky dressings that were visible and perceived as stigmatizing.

Curtailing social opportunities were seen as a source of distress, with isolation created either from being in hospital or house-bound,^16,17 or from being physically unable to engage in activities previously valued (Quote 14; Quote 15).^14,16

Theme 6: Support for change

All five studies presenting moderate-certainty evidence offered patient insights into how changes could be made to improve PJI care. Improved communication was considered a key area. Key-workers as a central point of contact were suggested as one approach to addressing patient expectations following hospital discharge.^13,16 Lack of information and guidance led to greater uncertainty¹⁵ and limited preparedness for both them and their friends/family members as carers.¹⁵

Rehabilitation and post-discharge recovery were largely considered insufficient. While some expressed satisfaction, the majority, particularly from the United Kingdom,^14–16 reported variable rehabilitation, with limited support. Participants reported rehabilitation largely mirroring provision after an uncomplicated primary joint replacement, against a backdrop of greater disability and recovery needs after PJI.¹⁶ The lack of personalization of rehabilitation to the patient’s specific needs was highlighted and requiring greater understanding in future research.

Line of argument

Figure 2 illustrates the meta-ethnography line of argument. Patients and health professionals perceive PJI as devastating. The data illustrate uncertainties on why PJI occurs and how to best manage individual care needs. Five key interacting perspectives arose from experiencing PJI, each one influencing the other with fluctuating impacts on physical, psychological, and social status. Both patients and health professionals identified approaches to improve the experience of PJI care, with a shared goal of better managing the consequences of PJI.

FIG. 2.

Line of argument schema.

Conclusions

PJIs are devastating for both patients and health professionals. The impact of these is not underestimated. They affect all aspects of a patient’s physical, social, and psychological health, with each interacting on one another over the course of infection. Strategies to improve communication, multi-disciplinary care, and personalization of management are advocated by both patients and health professionals to ensure that better outcomes can be promoted.

Footnotes

Authors’ Contributions

T.S. and H.G. researched the topic and devised the study; T.S. and H.G. collected the data and performed the analysis; T.S., H.G., S.A., and P.H. interpreted the data; T.S., H.G., S.A., and P.H. provided the first draft of the article. T.S., H.G., S.A., and P.H. contributed equally to article preparation. T.S. acts as a guarantor.

Ethics Approval

None required for this systematic review.

Provenance and Peer Review

Not commissioned.

Data Availability

The data that support the findings of this study may be available from the corresponding author (T.S.) upon reasonable request.

Patient Consent for Publication

Not required.

Author Disclosure Statement

None declared.

Funding Information

No funding was received for the conduct of this study.

Supplementary Material

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