High Failure Rates Following Repeat Two-Stage Revision for Chronic Knee Periprosthetic Joint Infection: A Multicenter Study

BACKGROUND: Recurrent periprosthetic joint infection (PJI) after two-stage revision total knee arthroplasty remains challenging. Repeat two-stage revision is a salvage option, but outcomes are poorly defined. This multicenter study evaluated the success of repeat two-stage knee revision for chronic PJI. METHODS: A retrospective review of prospectively maintained databases at two tertiary centers identified 61 patients treated between 1995 and 2022. There were 13 (21.3%) who did not undergo reimplantation, leaving 48 patients (31% women) who had a mean follow-up of 12.1 years. The primary outcome was treatment success per 2019 Musculoskeletal Infection Society tier 1 criteria. Kaplan-Meier analysis estimated implant survivorship; Cox regression identified predictors of failure. RESULTS: Treatment success was achieved in 21 of 48 cases (39.6%). Among 27 failures, 21 underwent further infection surgery, two remained on lifelong suppressive antibiotics, and four had aseptic revision. Amputation was required in 11 patients (22.9%). The five- and 10-year implant survival for all-cause revision was 63.2 and 42.3%, respectively; for PJI-specific revision, they were 65.1 and 47.7%, respectively. Younger age was the only independent predictor of failure (odds ratio 0.898 per year; 95% confidence interval 0.836 to 0.965; P = 0.003). Excluding culture-negative cases, 31% had a new infecting organism at repeat revision, and polymicrobial infection increased (12.5%). CONCLUSIONS: Repeat two-stage revision for recurrent knee PJI yields low infection control rates and major morbidity, including a 23% amputation rate. Younger patients are at greater risk of failure. These findings underscore the need for careful patient selection and exploration of alternative strategies.