PERIPROSTHETIC JOINT INFECTION MANAGEMENT IN ITALY: A NATIONAL SURVEY REVEALING GAPS, VARIABILITY, AND THE NEED FOR SPECIALIZED CARE

Aim Periprosthetic joint infections (PJIs) remain one of the most challenging complications in arthroplasty, requiring complex diagnostic pathways, multidisciplinary management, and substantial healthcare resources. Despite the publication of international recommendations, real-world practice often differs across institutions depending on local expertise, organizational structure, and access to specialist support. To better characterize the current national landscape, the Italian Orthopedics and Traumatology Society (SIOT) conducted a survey aimed at exploring clinical practice patterns, organizational resources, and surgeon perceptions regarding PJI management in Italy. Methods A 32-item structured online questionnaire was developed by a multidisciplinary panel. The survey investigated demographic characteristics, institutional context, availability of infectious disease support, annual PJI caseload, diagnostic pathways, preferred surgical strategies, use of irrigation solutions and local antibiotic carriers, salvage procedures, and long-term suppressive antimicrobial therapy. The questionnaire was distributed to society members between April and June 2025. Of the 353 responses received, 313 respondents reporting routine involvement in PJI management were included in the final analysis. Results The results showed marked heterogeneity in both organizational structure and treatment strategies. Most respondents worked in the National Health Service, but more than 20% reported no regular access to infectious disease specialists, highlighting an important structural gap in multidisciplinary care. In addition, most surgeons managed fewer than 10 PJI cases per year, suggesting that a large proportion of infections are treated in low-volume settings. From a surgical perspective, two-stage revision was universally accepted, while DAIR was widely considered appropriate under selected timing criteria, demonstrating strong adherence to European Bone and Joint Infection Society recommendations. One-stage revision, although increasingly supported by international literature, was less commonly adopted, likely reflecting organizational barriers, limited experience, and medico-legal concerns. Considerable variability was further observed in perioperative practices, particularly regarding irrigation protocols and the use of local antibiotic delivery systems. Saline and diluted povidone-iodine were the most commonly adopted irrigation solutions, while antibiotic-loaded cement and calcium sulfate carriers were widely used as adjuncts to systemic therapy. Salvage procedures such as Girdlestone resection arthroplasty and knee arthrodesis remained viable options in refractory cases, and suppressive antimicrobial therapy was frequently considered when curative surgery was not feasible. Conclusions Overall, the survey highlights significant disparities in PJI management across Italy and strongly supports the need for coordinated national strategies, including universal access to infectious disease expertise, development of dedicated Bone Infection Units, centralization of complex cases, and greater standardization of diagnostic and therapeutic pathways.