Recurrent prosthetic joint infections: A review of evaluation, management, and outcomes

Periprosthetic joint infection (PJI) remains one of the most serious complications of total joint arthroplasty. While two-stage revision arthroplasty remains the most commonly utilized treatment strategy for chronic PJI in North America, recurrent infection following revision represents an increasingly encountered and particularly challenging clinical problem. These patients often have substantial host comorbidity, prior surgical burden, compromised soft tissues, and limited reconstructive options, contributing to high rates of treatment failure and morbidity. This narrative review summarizes current evidence regarding the mechanisms, evaluation, risk factors, and management of recurrent PJI. Recurrence may result from persistence of the original pathogen or reinfection with a new organism. Host-related factors, microbiologic characteristics, and surgical variables all contribute to recurrence risk. Diagnostic evaluation requires integration of clinical assessment, serum inflammatory markers, synovial fluid analysis, microbiologic testing, and emerging molecular diagnostic technologies. Treatment options include repeat two-stage revision, debridement with implant retention in selected cases, chronic suppressive antibiotic therapy, arthrodesis, resection arthroplasty, and/or amputation. Outcomes following recurrent PJI remain inferior to those reported after index revision, highlighting the importance of optimizing initial infection management and carefully individualizing treatment strategies. Continued advances in diagnostics, risk stratification, and infection management will be essential to improve outcomes in this complex patient population.