Prosthetic joint infection (PJI) remains one of the most devastating complications of total knee arthroplasty (TKA), occurring in 1–2% of primary procedures and with higher incidence after revision. Beyond its direct impact on mobility, PJI leads to prolonged hospitalizations, repeated surgical interventions, systemic complications, and significant healthcare costs. Standard management strategies include debridement and implant retention (DAIR), one-stage revision, and two-stage revision, each with advantages and limitations. While unilateral PJI is well documented, bilateral sequential infections are exceedingly rare and create unique therapeutic challenges due to compounded morbidity, surgical complexity, and functional demands placed on the remaining limb.  The present case highlights divergent surgical strategies for a rare occurrence of sequential bilateral PJI in a multimorbid elderly patient, where one knee required arthrodesis as salvage and the other was successfully reconstructed through staged revision. Furthermore, it underscores the complexity of decision-making, the delicate balance between eradicating infection and preserving function, and the importance of multidisciplinary care in high-risk patients.

A 68-year-old male with multiple comorbidities developed an infection of his left total knee prosthesis. Initial management involved radical debridement, prosthesis removal, and insertion of a cemented antibiotic spacer. The postoperative course was complicated by poor wound healing, superficial skin breakdown, stiffness, and anterior dislocation. Given mechanical instability and poor reconstructability, he ultimately underwent arthrodesis as a salvage procedure. Months later, patient presented with pain and swelling in the contralateral knee, and evaluation confirmed PJI. He underwent first-stage revision arthroplasty with explantation, irrigation, and placement of a vancomycin-loaded antibiotic spacer. Postoperatively, his course was complicated by C. difficile colitis attributed to prolonged broad-spectrum antibiotics, necessitating regimen modification under infectious disease guidance. After stabilization, he proceeded to second-stage revision by implantation of a knee prosthesis with stemmed femoral and tibial components. Intraoperatively, collateral ligament stability, patellofemoral tracking, and proper range of motion were confirmed. Postoperative outcomes comparing the fused and revised knee were assessed via clinical examination, range of motion, and infection surveillance.

The left knee achieved stable fusion and infection eradication but at the cost of mobility, necessitating gait adaptation and external support for ambulation. The right knee demonstrated successful reimplantation, stable wound healing, and no recurrent infection at two-week follow-up. Complications of antibiotic-associated colitis delayed surgical progression, underscoring the risks of aggressive antimicrobial therapy in multimorbid patients. Comparative outcomes highlighted key trade-offs; arthrodesis provided durable infection control when reconstruction was unfeasible, whereas staged revision restored mobility but required careful multidisciplinary coordination to minimize systemic risks. Importantly, both approaches achieved infection eradication without recurrence at long-term follow-up.

Sequential bilateral PJI is a rare but instructive scenario in arthroplasty practice. Divergent strategies of treatment demonstrate how management must be individualized, considering mechanical feasibility, systemic comorbidities, and patient functional goals. This case also highlights the value of careful surgical planning, antimicrobial stewardship, and multidisciplinary collaboration to optimize outcomes in high-risk patients. Thus, presenting two contrasting yet successful outcomes in the same patient provides practical insights for managing similarly complex cases and adds to the limited literature as a basis for future research.

Asim Aldaheri is a highly experienced orthopedic consultant surgeon with nearly two decades of expertise specializing in complex hip and knee arthroplasty and arthroscopic sports procedures. He completed his orthopedic residency at McGill University in Montreal and earned his certification from the Royal College of Physicians and Surgeons of Canada (FRCS(C)). Dr. Aldaheri pursued advanced subspecialty training in hip and knee reconstruction at the University of Toronto, followed by a fellowship in sports medicine and arthroscopic surgery at St. Mary’s Hospital, McGill University. Throughout his career, he has performed a wide range of reconstructive and sports-related procedures, earning recognition for his surgical precision, clinical leadership, and dedication to innovation. Currently serving as a Senior Consultant Orthopedic Surgeon at King Fahd Armed Forces Hospital and the International Medical Center (IMC) in Jeddah, Dr. Aldaheri continues to advance orthopedic care through excellence in surgery, research, and education.