Autoimmune and Inflammatory Diseases Associated With Increased Periprosthetic Joint Infection Risk: A Narrative Review of Pathophysiology, Risk Stratification, and Perioperative Management

Periprosthetic joint infection (PJI) is a devastating complication of total joint arthroplasty. Patients with autoimmune and inflammatory diseases, psoriasis, rheumatoid arthritis (RA), and systemic lupus erythematosus (SLE) face substantially elevated infection risk through three convergent mechanisms: skin barrier dysfunction, systemic immune dysregulation, and the immunosuppressive therapies required to control their disease. This narrative review synthesizes evidence from cohort studies, registry analyses, mechanistic investigations, and clinical practice guidelines to examine PJI pathophysiology, comparative risk quantification, microbiologic profiles, and perioperative management strategies in this high-risk population. RA patients demonstrated hazard ratios of 4.08 (95% CI 1.35-12.33) and odds ratios of 1.47 (95% CI 1.13-1.91) for PJI compared with osteoarthritis controls; psoriasis patients showed an odds ratio of 1.63 (p = 0.014) for 90-day PJI after total shoulder arthroplasty; and SLE patients carried a hazard ratio of 2.74 (95% CI 1.14-6.64) for late PJI after total hip arthroplasty. These estimates derived from heterogeneous studies and were presented descriptively rather than as pooled values. Perioperative continuation of biologic therapy increased PJI odds by 3.46-fold (95% CI 1.11-10.78), and chronic glucocorticoid use exceeding 10 mg/day approximately doubled infection risk. The microbiologic profile was distinct, with culture-negative infection reported in roughly 28%-38% of cases in a single-center case series of RA patients and methicillin-resistant Staphylococcus aureus (MRSA) colonization conferring an odds ratio of 3.43 (95% CI 1.71-6.88) for metachronous PJI. Evidence-based perioperative management required temporarily interrupting biologic agents with surgery scheduled at the end of the dosing cycle, continuing methotrexate in most patients, and applying individualized medication adjustments through multidisciplinary collaboration between orthopedic surgery, rheumatology, and infectious disease.