Infection prevention in total knee arthroplasty: current concepts, controversies, and a clinical algorithm

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.