Debridement, Antibiotics And Implant Retention Procedure Research Articles

What Is the Incidence of and Outcomes After Debridement, Antibiotics, and Implant Retention (DAIR) for the Treatment of Periprosthetic Joint Infections in the AJRR Population?

Debridement, antibiotics, and implant retention (DAIR) is used to manage acute periprosthetic joint infections (PJIs) after total joint arthroplasty (TJA). Given the uncertain success of single or multiple DAIR attempts and possible long-term deleterious effects this treatment can create when trying to treat persistent infection, it is important to understand the frequency with which surgeons in the United States are attempting multiple debridements for PJI and whether those procedures are achieving the desired goal. In the context of the American Joint Replacement Registry (AJRR), we asked: (1) What proportion of patients who undergo DAIR have only one DAIR, and what percentage of those patients have more than one? (2) Of the patients who undergo one or more DAIR procedures, what is the proportion who progress to additional surgical procedures? (3) What is the cumulative incidence of medical or surgical endpoints related to infection on the affected leg (other than additional DAIR procedures)? DAIR procedures to treat PJI, defined by ICD-9/10 and CPT (Current Procedural Technology) codes, reported to the AJRR from 2012 to 2020 were merged with Centers for Medicare and Medicaid Services (CMS) data from 2012 to 2020 to determine the incidence of patients aged 65 and older who underwent additional PJI-related procedures on the same joint. Linking to CMS ensures no loss to follow-up or patient migration to a non-AJRR site. As of 2021, the AJRR captures roughly 35% of all arthroplasty procedures performed in the United States. Of the total 2.2 million procedures in the AJRR, only 0.2% of the procedures were eligible based on our inclusion criteria. Additionally, 61% of the total population is Medicare eligible, and thus, these patients are linked to CMS. Of the 5029 DAIR attempts after a TKA, 46% (2318) were performed in female patients. Similarly, there were a total of 798 DAIR attempts after a THA, and 50% (398) were performed in female patients. For the purposes of decreasing confounding factors, bilateral THAs and TKAs were excluded from the study population. When querying for eligible procedures from 2012 to 2020, the patient population was limited to those 65 years and older, and a subsequent reoperation for infection had to be reported after a primary TJA. This limited the patient population as most infections reported to AJRR resulted in a revision, and we were searching for DAIRs. Although 5827 TJAs were identified as a primary TJA with a subsequent infectious event, more than 65% (3788) of that population did not have a reported event. The following conditions were queried as secondary outcomes after the first DAIR: sepsis, cellulitis, postoperative infection, endocarditis, amputation, knee fusion, resection, drainage, arthrotomy, and debridement. To answer our first and second study questions, we used frequency testing from the available AJRR data. Because of competing risks and issues with incomplete data, we used the cumulative incidence function to evaluate the outcomes specific to study question 3. Of the patients who underwent DAIR, 93% (5406 of 5827) had one DAIR and 8% (421 of 5827) had more than one. Among the DAIR population, at least 35% of TKAs and 38% of THAs were identified as having experienced an additional PJI-related event (an additional surgical procedure on the same joint, sustained an infectious endpoint in the linked CMS-AJRR dataset, or they had died). The cumulative incidence of developing a further medical or surgical condition related to the joint that had the initial DAIR were as follows: 48% (95% CI 42% to 54%) at 8 years after a DAIR following a TKA and 42% (95% CI 37% to 46%) at 4 years after a DAIR following a THA. The timepoints for TKA and THA are different because there are more longitudinal procedure data available for TKAs regarding DAIR procedures than for THAs. In this study, we used data from the AJRR to assess the incidences of single and multiple DAIR attempts and additional surgical- and infection-related sequalae. Continued investigation is required to determine the fate of infected joints that undergo DAIR with regard to ultimate patient outcome. Future cross-sectional studies using large datasets are necessary to assess functional outcomes and determine the risk of persistent infection after DAIR more precisely. Level III, therapeutic study.

Can Periprosthetic Joint Infection of Tumor Prostheses Be Controlled With Debridement, Antibiotics, and Implant Retention?

Two-stage revision for periprosthetic joint infection (PJI) in patients who have undergone segmental replacement of the distal femur or proximal tibia after tumor resection can be associated with considerable morbidity, pain, and risk of complications because the procedure often results in removal of long, well-fixed stems from the diaphysis. A less-aggressive surgical approach, such as debridement, antibiotics, and implant retention (DAIR), may be attractive to patients and surgeons because of less morbidity, but the likelihood of eradicating infection in comparison to the traditional two-stage revision is not well established for oncology patients. Furthermore, the relative risk of subsequent amputation for DAIR versus two-stage revision has not been defined for this population. (1) How does DAIR compare with two-stage revision in terms of infection control for patients with distal femoral or proximal tibial segmental modular endoprostheses? (2) Is DAIR as an initial procedure associated with an increased risk of amputation compared with two-stage revision for infection? From the longitudinally maintained orthopaedic oncology surgical database at our institution, we identified 69 patients who had been treated for a clinical diagnosis of PJI at the knee between 1993 and 2015. We excluded 32% (22) of patients who did not meet at least one of the major criteria of the Musculoskeletal Infection Society (MSIS) for PJI, 3% (2) of patients who underwent immediate amputation, 3% (2) of patients who had a follow-up time of < 24 months, and 7% (5) of patients who did not have a primary tumor of the distal femur or proximal tibia. The study consisted of 38 patients, of whom eight underwent two-stage revision, 26 underwent DAIR, and four underwent extended DAIR (removal of all segmental components but with retention of stems and components fixed in bone) for their initial surgical procedure. To be considered free of infection, patients had to meet MSIS standards, including no positive cultures, drainage, or surgical debridement for a minimum of 2 years from the last operation. Factors associated with time-dependent risk of infection relapse, clearance, amputation, and patient survival were analyzed using Kaplan-Meier survivorship curves and the log-rank test to compare factors. Association of demographic and treatment factors was assessed using chi-square and Fisher exact tests. Continuous infection-free survival at 5 years was 16% (95% CI 2% to 29%) for patients undergoing DAIR compared with 75% (95% CI 45% to 100%) for patients undergoing two-stage revision (p = 0.006). The median (range) number of total surgical procedures was 3 per patient (1 to 10) for DAIR and 2 (2 to 5) for two-stage revision. Twenty-nine percent (11 of 38) of patients eventually underwent amputation. Survival without amputation was 69% (95% CI 51% to 86%) for DAIR compared with 88% (95% CI 65% to 100%) for two-stage revision at 5 years (p = 0.34). The cumulative proportion of patients achieving infection-free status (> 2 years continuously after last treatment) and limb preservation was 58% (95% CI 36% to 80%) for patients initially treated with DAIR versus 87% (95% CI 65% to 100%) for patients first treated with two-stage revision (p = 0.001). Infection control was better with two-stage revision than DAIR. The chance of eventual clearance of infection with limb preservation was better when two-stage revision was chosen as the initial treatment. However, the loss to follow-up in the two-stage revision group would likely make the true proportion of infection control lower than our estimate. Our experience would suggest that the process of infection eradication is a complex and difficult one. Most patients undergo multiple operations. Nearly one-third of patients eventually underwent amputation, and this was a serious risk for both groups. While we cannot strongly recommend one approach over the other based on our data, we would still consider the use of DAIR in patients who present with acute short duration of symptoms (< 3 weeks), no radiographic signs of erosion around fixed implants, and organisms other than Staphylococcus aureus. We would advocate the extended DAIR procedure with removal of all segmental or modular components, and we would caution patients that there is a high likelihood of needing further surgery. A prospective trial with strict adherence to indications may be needed to evaluate the relative merits of an extended DAIR procedure versus a two-stage revision. Level III, therapeutic study.

WHO DAIRS WINS?

Periprosthetic joint infection is a serious complication of primary total hip replacement (THR) with significant associated morbidity. In acute infection, Debridement, Antibiotics and Implant Retention (DAIR) may be considered. Current national guidelines recommend a DAIR should be performed by “an experienced arthroplasty surgeon┕ but do not specify the need for this to be a revision arthroplasty surgeon. We investigated outcomes in our NHS Trust of DAIR procedures performed by revision and non-revision arthroplasty surgeons.Infection registry data and patient records were analysed for all DAIR procedures of infected primary THRs between 2017 and 2021. Data collected included details of the primary surgery, the presentation with infection, the DAIR procedure and any subsequent complications including return to theatre at any time point. Routinely collected pre- and post-operative patient reported outcome measures (PROMs) were reviewed.54 periprosthetic joint infections of primary THRs received a DAIR procedure. 41 DAIRs were performed by a revision surgeon and 13 by non-revision surgeons. There was no significant difference in time from primary THR to presentation with infection, time from presentation to DAIR or pre-operative C-reactive protein between the two groups.In 21 (38.9%) patients the DAIR procedure was classed as a treatment failure; 17 patients (31.5%) returned to theatre for further revision surgery, one (2.4%) died related to infection and three (5.6%) had persistent infection but did not receive further surgery. Treatment failure was significantly higher in the non-revision surgeon group (9/13 (69.2%)) than in the revision surgeon group (12/41 (29.3%)) (p = 0.02). Overall, improvement in PROMs after DAIR was seen at both six and 12 months.The overall success rate of DAIR was 61.1% and there was a sustained improvement in PROMs after surgery. However, there was a significant difference in failure rates between revision surgeons and non-revision surgeons.

Debridement, Antibiotics, and Implant Retention in Unicompartmental Knee Arthroplasty Infection

BackgroundThis multicenter study sought to further investigate the method and outcome of debridement, antibiotics, and implant retention (DAIR) for the management of unicompartmental knee periprosthetic joint infection (PJI). MethodsThis retrospective study was performed on 52 patients who underwent DAIR for PJI of a unicompartmental knee arthroplasty (UKA) across 4 academic medical centers, all performed by fellowship-trained arthroplasty surgeons. Patient demographics, American Society of Anesthesiologists score, infecting organism, operative data, antibiotic data, and success in infection control at 1 year were collected. ResultsThe average time from index surgery to diagnosis of PJI was 11.1 weeks (range, 1.4 to 48). There was no correlation between time of diagnosis and success at 1 year (R = 0.09, P = .46). There was an association between surgical synovectomy and the eradication of infection (R = 0.28, P = .04). Overall, there was an 80.8% (42 of 52) infection-controlled success rate at 1 year from the DAIR procedure. All DAIR failures went on to require another procedure, either 1-stage (2 of 10) or 2-stage (8 of 10) revision to total knee arthroplasty (TKA). Of the DAIR successes, 6 (14.3%) went on to require conversion to TKA for progression of arthritis within 5 years. ConclusionsThis study demonstrates that DAIR is a safe and moderately effective procedure in the setting of acute PJI of UKA across institutions, with a success rate consistent with DAIR for TKA. The data suggest that a wide exposure and thorough synovectomy be incorporated during the DAIR UKA to improve the likelihood of successful eradication of PJI at the 1-year mark. Level of EvidenceLevel III.

Debridement, antibiotics and implant retention (DAIR) following hip and knee arthroplasty: results and findings of a multidisciplinary approach from a non-specialist prosthetic infection centre.

Prosthetic joint infection (PJI) is a catastrophic complication following arthroplasty surgery. Recently a debridement, antibiotics and implant retention (DAIR) procedure has gained popularity for PJI where a thorough debridement, irrigation and modular component exchange is undertaken. We present the outcome for DAIR, data collected prospectively, in a busy orthopaedic unit but not one specialising in PJI. All patients with PJI were included without loss of data or patients from 2012 to 2018 with a minimum follow-up of 5 years. Four total knee replacements, 17 total hip replacements, one revision total hip replacement and three hip hemiarthroplasties are included with an average duration from onset of symptoms to the DAIR procedure of 11 days (range 1-22 days). Staphylococcus aureus (24%) and Staphylococcus epidermidis (32%) were the most common causative organisms, and the most common antibiotic regimens included intravenous teicoplanin and flucloxacillin. Average follow-up was 67 months (range 9-104 months). Only four patients went on to require revision surgery. An analysis of midterm patient outcome measures for 6 of the total hip replacement (THR) DAIR patients were compared with a database of 792 THRs (with a minimum two-year follow-up) carried out by the same surgeon revealed no significant difference in Oxford hip scores at one-year post-surgery (OHS DAIR 36.2 vs 39 for control group). This study includes 25 consecutive patients treated with DAIR with only one reinfection, with a mean follow-up period of 5 years. Using a strict protocol, DAIR appears to offer a successful treatment strategy for the management of early PJI.

Early Staphylococcal Periprosthetic Joint Infection (PJI) Treated with Debridement, Antibiotics, and Implant Retention (DAIR): Inferior Outcomes in Patients with Staphylococci Resistant to Rifampicin.

It is unknown how rifampicin resistance in staphylococci causing a periprosthetic joint infection (PJI) affects outcomes after debridement, antibiotics, and implant retention (DAIR). We thus aimed to compare the risk of relapse in DAIR-treated early PJI caused by staphylococci with or without rifampicin resistance. In total, 81 patients affected by early PJI were included, and all patients were treated surgically with DAIR. This was repeated if needed. The endpoint of relapse-free survival was estimated using the Kaplan-Meier method, and Cox regression models were fitted to assess the risk of infection relapse for patients infected with rifampicin-resistant bacteria, adjusted for age, sex, type of joint, and type of index surgery. In patients with rifampicin-resistant staphylococci, relapse was seen in 80% after one DAIR procedure and in 70% after two DAIR procedures. In patients with rifampicin-sensitive bacteria, 51% had an infection relapse after one DAIR procedure and 33% had an infection relapse after two DAIR procedures. Patients with rifampicin-resistant staphylococcal PJI thus had an increased adjusted risk of infection relapse of 1.9 (95% CI: 1.1-3.6, p = 0.04) after one DAIR procedure compared to patients with rifampicin-sensitive bacteria and a 4.1-fold (95% CI: 1.2-14.1, p = 0.03) increase in risk of infection relapse after two DAIR procedures. Staphylococcal resistance to rifampicin is associated with inferior outcomes after DAIR. These findings suggest that DAIR may not be a useful strategy in early PJI caused by rifampicin-resistant staphylococci.

Hydrogel Coating versus Calcium Sulphate Beads as a Local Antibiotic Carrier for Debridement Procedures in Acute Periprosthetic Joint Infection: A Preliminary Study.

Periprosthetic joint infections (PJI) are among the most difficult complications to treat in orthopaedic surgery. Debridement, antibiotics, and implant retention (DAIR) represent an efficient strategy for acute PJI, especially when resorbable local antibiotic carriers and coatings are used. The aim of this pilot study was to evaluate the difference between using antibiotic-loaded hydrogel (ALH) and calcium sulphate (CS) beads in the DAIR procedure. We analysed 16 patients who had been treated since 2018 for acute PJI, namely eight patients with knee PJI (50%), seven with hip PJI (43.7%), and one with shoulder PJI (6.2%). Nine patients were treated with the Debridement, Antibiotic Coating and Retention of the Implant (DACRI) method, while seven were treated with the Debridement, Antibiotic Pearls, Retention of the Implant (DAPRI) method. We found no significant differences between the two groups in terms of age, sex, the American Society of Anesthesiologists risk score, Charlson Comorbidity Index, localisation, days from onset to diagnosis and pathogenesis. Furthermore, no differences were found between the DACRI and DAPRI groups in terms of infection control (15 patients, 93.75% with p = 0.36) and last C-Reactive Protein values (p = 0.26), with a mean follow-up of 26.1 ± 7.7 months. Treatment for one patient affected by knee Candida albicans PJI in the DACRI group was not successful. In conclusion, DAPRI and DACRI appear to be safe and effective treatments for PJIs. This evidence will encourage the development of new clinical research into local carriers and coatings for use in acute implant-associated infections.

Investigation of the effect of rifampicin resistance and risk factors on recovery rates after DAIR procedure in patients with prosthetic joint infection

BackgroundRifampicin plays a key role in the management of prosthetic joint infections (PJIs), however, the emergence of rifampicin resistance is associated with less favourable clinical outcomes. The purpose of this study was to investigate the impact of rifampicin resistance and other patient-related factors on recovery rates among patients with PJI undergoing debridement, antibiotics and implant retention (DAIR).MethodsWe reviewed medical records and microbiology reports of 67 patients (37 males and 30 females) undergoing DAIR due to PJI between 2014 and 2021. Patient-related factors, co-morbidities and microbiological reports were collected and reviewed. Forty-four patients had hip, 21 had knee, 1 had shoulder and 1 had elbow joint infection. Obtained data were statistically analysed with a logistic regression model.ResultsRifampicin-sensitive organism was isolated in 47 cases. Recovery rate was 72.3% in the sensitive and 76.9% in the resistant group. We found no significant effect of rifampicin resistance on the probability of recovery. Age and diabetes mellitus showed negative clinical impact on recovery. Staphylococcus aureus and coagulase-negative Staphylococci were predominant in the rifampicin-sensitive (66.6% of the isolates) and Gram-negative rods in the resistant group (65.2%).ConclusionsBased on our results, higher age and diabetes mellitus may have a clinically relevant negative impact on clinical outcome, however, this effect was not statistically significant. This may be due to the limited number of patients included in this study. We observed no clinically relevant effect of rifampicin-resistance, sex and body mass index (BMI) on recovery rates among patients undergoing DAIR due to PJI.

DEBRIDEMENT, ANTIBIOTICS, AND IMPLANT RETENTION IS SUCCESSFUL IN THE MANAGEMENT OF ACUTELY INFECTED UNICOMPARTMENTAL KNEE ARTHROPLASTY: A CASE SERIES

AbstractBackgroundInfections are rare and poorly studied complications of unicompartmental knee athroplasty (UKA) surgery. They are significantly less common compared to infections after total knee arthroplasties (TKAs). Optimal management of periprosthetic joint infections (PJIs) after a UKA is not clearly defined in the literature. We present the results of a multicentre retrospective series of UKA PJIs treated with Debridement, Antibiotics and Implant Retention (DAIR).MethodologyPatients presenting between January 2016 and December 2019 with early UKA infection were identified at three specialist centres using the Musculoskeletal Infection Society (MSIS) criteria. All patients underwent a standardized treatment protocol consisting of the DAIR procedure and antibiotic therapy comprising two weeks of intravenous (IV) antibiotics followed by six weeks of oral therapy. The main outcome measure was overall survivorship free from reoperation for infection.ResultsA total of 3225 UKAs (2793 (86.2%) medial and 432 (13.8%) lateral UKAs) were performed between January 2016 and December 2019. Nineteen patients had early infections necessitating DAIR. The mean follow-up period was 32.5 months. DAIR showed an overall survivorship free from septic reoperation of 84.2%, with an overall survivorship free from all-cause reoperation of 78.95%. The most common bacteria were Coagulase-negative Staphylococci, Staphylococcus aureus and Group B Streptococci. Three patients required a second DAIR procedure but remained free from re-infection at follow-up obviating the need for more demanding, staged revision surgery.ConclusionsIn infected UKAs, the DAIR procedure produces a high rate of success, with a high survivorship of the implant.

What's New in Musculoskeletal Infection.

What's New in Musculoskeletal Infection.

Debridement, antibiotics and implant retention (DAIR) is successful in the management of acutely infected unicompartmental knee arthroplasty: a case series

Background Infections are rare and poorly studied complications of unicompartmental knee arthroplasty (UKA) surgery. They are significantly less common compared to infections after total knee arthroplasties (TKAs). Optimal management of periprosthetic joint infections (PJIs) after a UKA is not clearly defined in the literature. This article presents the results of the largest multicentre clinical study of UKA PJIs treated with Debridement, Antibiotics and Implant Retention (DAIR). Materials and Methods In this retrospective case series, patients presenting between January 2016 and December 2019 with early UKA infection were identified at three specialist centres using the Musculoskeletal Infection Society (MSIS) criteria. All patients underwent a standardized treatment protocol consisting of the DAIR procedure and antibiotic therapy comprising two weeks of intravenous (IV) antibiotics followed by six weeks of oral therapy. The main outcome measure was overall survivorship free from reoperation for infection. Results A total of 3225 UKAs (2793 (86.2%) medial and 432 (13.8%) lateral UKAs) were performed between January 2016 and December 2019. Nineteen patients had early infections necessitating DAIR. The mean follow-up period was 32.5 months. DAIR showed an overall survivorship free from septic reoperation of 84.2%, with overall survivorship free from all-cause reoperation of 78.95%. The most common bacteria were Coagulase-negative Staphylococci, Staphylococcus aureus and Group B Streptococci. Three patients required a second DAIR procedure but remained free from re-infection at follow-up obviating the need for more demanding, staged revision surgery. Conclusions In infected UKAs, the DAIR procedure produces a high rate of success, with a high survivorship of the implant. Key messages Debridement, Antibiotics and Implant Retention (DAIR) is a successful and minimally invasive surgical option for the management of periprosthetic joint infections (PJIs) after UKA. The surface area available for bacteria to colonise is much smaller in UKAs compared to total knee arthroplasties (TKAs), and this may account for the higher success rates of the DAIR procedure in infected UKAs versus infected TKAs. A second DAIR procedure can be considered in the management of the early recurrence of PJIs with a well-fixed UKA.

982. Microbiologic Composition and Failure Rates of Prosthetic Hip and Knee Infections Managed with Debridement, Antibiotics and Implant Retention.

Abstract Background Success rates of prosthetic joint infections (PJI) managed by debridement, antibiotics, and implant retention (DAIR) vary according to recent literature. Our aim is to evaluate the success/failure rate of PJI managed by DAIR with respect to the microbiologic composition, antimicrobial selection, and treatment duration. Methods A single-center retrospective cross-sectional study was conducted from January 2017 to December 2021. All patients ≥ 18 years of age who underwent DAIR were identified from an existing internal database. Patients were included if they received at least 3 weeks but no more than 8 weeks of parenteral therapy with or without consolidative or chronic therapy. Data collection was completed via chart review including demographics, microbiologic data, antimicrobial therapy and outcomes. Failure was defined as any subsequent need for surgical intervention, infection related mortality, persistent infection, new infection, or probable treatment failure measured at a minimum of two year follow up from index DAIR. Results A total of 49 patients were included (15 hip, 34 knee) with 21 failures (43%) and 28 in remission (57%). Table 1 shows the breakdown of cases including time to PJI from index procedure, duration of symptoms prior to DAIR procedure, chronic antibiotics, and microbiologic composition. DAIR procedure occurred &amp;lt; 3 weeks from onset of symptoms in 43 patients (88%) but no observed difference in outcomes was seen based on patient’s time to PJI or symptoms duration. Staphylococcus aureus was the most common pathogen identified, n=14 (29%) and encompassed 43% of the total failures. Mean antimicrobial therapy was 42 and 180 days for parenteral and oral respectively with 17 (35%) patients on chronic/indefinite therapy. Of the failures, 48% occurred while on parenteral therapy. Need for further surgical intervention was the leading cause of failure at 37%. Conclusion Despite early intervention, our study found a failure rate of 43% in patients with knee and hip PJI managed with DAIR. We observed similar success rates across multiple organisms and antimicrobial treatments. Further evaluation of failure cases would help to inform which patients are the best candidates for DAIR procedures. Disclosures All Authors: No reported disclosures.

Outcome and risk factors for recurrence of early onset fracture-related infections treated with debridement, antibiotics and implant retention: Results of a large retrospective multicentre cohort study

IntroductionEarly Fracture-Related Infections (FRIs) are a common entity in hospitals treating trauma patients and are often treated with a Debridement, Antibiotics and Implant Retention (DAIR) procedure. Aims of this study were to 1) evaluate the recurrence rate after DAIR procedures for early onset FRI, 2) establish the number of surgical procedures to gain control of the initial infection and 3) identify independent predictors for recurrence in this cohort. MethodsA retrospective multicentre cohort study was conducted in two level 1 trauma centres. Consecutive patients who underwent a DAIR procedure between January 1st 2015 and July 1st 2020 for confirmed FRI with an onset of <6 weeks after the latest osseous operation were included. Recorded data included patient demographics, treatment characteristics and follow-up. Univariate and multivariate logistic regression analyses were performed to assess predictors for recurrent FRI. ResultsA total of 141 patients with early FRI were included in this study with a median age of 54.0 years (interquartile range (IQR) 34.5–64.0). The recurrence rate of FRI was 13% (n = 19) at one year follow-up and 18% (n = 25) at 23.1 months (IQR 15.3–36.4) follow-up. Infection control was achieved in 94% (n = 127/135) of cases. In total, 73 patients (52%) underwent at least two surgical procedures to treat the ongoing initial episode of FRI, of whom 54 patients (74%) required two to three procedures and 17 patients (23%) four to five procedures. Predictors for recurrent FRI were use of an intramedullary nail during index operation (odds ratio (OR) 4.0 (95% confidence interval (CI) 1.1–13.8)), need for additional surgical procedures to treat ongoing infection during the treatment period following the first presentation of early FRI (OR 1.9 (95% CI 1.1–3.5)) and a decreased Injury Severity Score (ISS) (inverted OR 1.1 (95% CI 1.0–1.1)). ConclusionThe recurrence rate after treatment of early onset FRI in patients treated with a DAIR procedure was 18% at 23.1 months follow-up. At least two surgical procedures to gain control of the initial infection were needed in 52% of patients. Independent predictors for recurrent FRI were the use of an intramedullary nail during index operation, need for additional surgical procedures and a decreased ISS.

Accuracy of a Novel Preoperative Failure Risk Model for Debridement Antibiotics and Implant Retention (DAIR) in Acute Prosthetic Joint Infection.

Given the variable success of the debridement, antibiotics and implant retention (DAIR) procedure in patients with acute prosthetic joint infection (PJI), an accurate selection of candidates is critical. In this study, we set about calculating the predictive value of a novel algorithm for predicting outcome following DAIR developed by Shohat et al. Sixty-four patients who underwent debridement for (early and late) acute PJI in a tertiary-level university hospital were selected, and the aforementioned algorithm was retrospectively applied. Patients with model scores of 40–50%, 50–60%, 60–70%, 70–80% and 80–90% displayed success rates of 33.34%, 41.18%, 57.9%, 78.27% and 100%, respectively. The receiver operating characteristic curve showed an area under the curve of 0.69. The calibration intercept value was 0, and the calibration slope value was 1. Failure rates were significantly higher for the following variables: revision surgery (p = 0.012) index surgery for reasons other than osteoarthritis (p = 0.01), and C-reactive protein level >30 mg/L (p = 0.042). This analysis demonstrated that the Shohat algorithm is associated with an optimal calibration value and a moderate predictive value for failure of a DAIR procedure in patients with acute PJI. Its validation is recommended before it can be routinely applied in daily practice.

173 Debridement, Antibiotics and Implant Retention (DAIR) in the Management of Prosthetic Joint Infections Following Primary Hip and Knee Arthroplaty: A DGH Experience

Abstract Aim Prosthetic joint infections (PJI) are a devastating complication of arthroplasty surgery. Current gold standard one or two-stage revision, poses sincere surgical challenges and carry significant patient morbidity. If diagnosed promptly, a debridement, antibiotics, and implant retention (DAIR) procedure can be performed. We report the results of our experience with the DAIR procedure in a District General Hospital setting. Method Our study comprises of a single centre retrospective review of a prospectively updated database. All patients who underwent a DAIR procedure following hip or knee arthroplasty from August 2012 to July 2019 were included in the study with no exclusions. Results Four total knee replacements, sixteen total hip replacements (THR), two revision THR and three hemiarthroplasties were included in the study. Average duration from onset of symptoms to DAIR was 22 days for immediate post-operative patients and 6 days in patients presenting later with an acute infection. All patients had exchange of modular components during the DAIR procedure. Out of 25 DAIR procedures, 23 identified a positive microbiology culture. Most common causative organisms identified were Staphylococcos aureus (23%) and Staphylococcus epidermidis (23%). Average follow up in clinic was 55 months. 76% of patients had a stable post-operative recovery with no recurrence of infection. One patient required a revision THR for aseptic loosening; one patient required a knee arthrodesis and four patients died. Conclusions Infection was successfully eradicated in 19 patients. The success reported within the literature stem predominantly from tertiary units. Our study reflects this success in a DGH setting.

Higher 1-year risk of implant removal for culture-positive than for culture-negative DAIR patients following 359 primary hip or knee arthroplasties.

Background and purpose: To date, the value of culture results after debridement, antibiotics, and implant retention (DAIR) for early (suspected) prosthetic joint infection (PJI) as risk indicators in terms of prosthesis retention is not clear. At the 1-year follow-up, the relative risk of prosthesis removal was determined for culture-positive and culture-negative DAIR patients after primary total hip or knee arthroplasty. The secondary aim of this work was to explore differences in patient characteristics, infection characteristics, and outcomes between these two groups. Methods: A retrospective regional registry study was performed in a group of 359 patients (positive cultures: ; negative cultures: ) undergoing DAIR for high suspicion of early PJI in the period from 2014 to 2019. Differences in patient characteristics, the number of deceased patients, and the number of subsequent DAIR treatments between the culture-positive and culture-negative DAIR groups were analysed using independent tests, Mann–Whitney tests, Pearson's chi-square tests, and Fisher's exact tests. Results: The overall implant survival rate following DAIR was 89 %. The relative risk of prosthesis removal was 7.4 times higher (95 % confidence interval (CI) 1.0–53.1) in the culture-positive DAIR group (37 of 299, 12.4 %) compared with the culture-negative DAIR group (1 of 60, 1.7 %). The culture-positive group had a higher body mass index (), a rate of wound leakage of d (), and more subsequent DAIR treatments (). Interpretation: As implant survival results after DAIR are favourable, the threshold to perform a DAIR procedure for early (suspected) PJI should be low in order to retain the prosthesis. A DAIR procedure in the case of negative cultures does not seem to have unfavourable results in terms of prosthesis retention.

Rat bite fever in a total knee arthroplasty: an unusual case of periprosthetic joint infection

BackgroundPeriprosthetic joint infection (PJI) is a serious complication of orthopedic arthroplasty surgery. Rat bite fever is a rare infection with Streptobacillus moniliformis (S. moniliformis). Rat bite fever can lead to serious complications such as pyogenic infection of joints, bacteremia, endocarditis and even death. We hereby present the first case of a patient with a total knee arthroplasty, infected with S. moniliformis, successfully treated by surgical debridement, antibiotics and implant retention (DAIR).Case presentationThe patient was a 64-year-old female. S. moniliformis was isolated from blood cultures and an aspirate of the left knee by 16S rRNA gene polymerase chain reaction technique. It was assumed that the S. moniliformis had a systemic origin and secondarily infected the knee due to fever nine days before the onset of symptoms of the knee. The patient was successfully managed with DAIR and intravenous administration of ceftriaxone for six weeks and oral doxycycline for another six weeks.ConclusionsS. moniliformis is a rare pathogen and is difficult to culture. The 16S rRNA sequencing is helpful in the determination of a causative microorganism in the case of a culture-negative PJI. A DAIR procedure in combination with 12 weeks of antibiotics could successfully treat S. moniliformis prosthetic joint infection.

Truth or DAIR? A review of debridement, antibiotics and implant retention

Debridement, antibiotics and implant retention (DAIR) is a viable treatment option in early postoperative and acute haematogenous periprosthetic joint infections (PJIs) with a stable implant. Despite lower success rates compared to one- and two-stage revisions, DAIR maintains satisfactory outcomes in selected patient groups and, if successful, has similar functional outcomes to primary arthroplasty. DAIR remains an attractive treatment option, providing satisfactory outcomes with decreased healthcare costs, reduced surgical burden on the patient and shorter hospital stays. With success rates of 37-90%, various factors need to be considered when deciding on DAIR as the appropriate treatment option for PJI. The risk of DAIR failure needs to be weighed against the potential benefits of DAIR success. Factors that increase success rates include an open DAIR procedure performed for a low-virulence, antibiotic-sensitive organism, within a short duration between symptom onset and/or index surgery and DAIR. The procedure involves intraoperative exchange of mobile components and copious wound irrigation, followed by an appropriate antibiotic regimen for a minimum of six weeks that can be administered either intravenously or orally in a well-optimised host, without significant soft tissue defects or contraindications to surgery. Factors increasing the risk for DAIR failure include chronic/late PJIs with resistant organisms, especially methicillin-resistant Staphylococcus aureus (MRSA) in poor hosts with significant comorbidities, such as chronic obstructive pulmonary disease (COPD), liver cirrhosis, rheumatoid arthritis, advanced age &gt; 80 years, patients with fracture indications for arthroplasty and those who cannot tolerate rifampicin- and fluoroquinolone-based antibiotic regimens. Unfortunately, there is no definitive factor to serve as an indication of whether DAIR will be successful, but with recent data showing that a failed DAIR procedure does not lower success in future staged revisions, then even in the face of a 50% success rate, DAIR can maintain its role as an initial treatment option in the management of PJIs

Irrigation and Debridement With Implant Retention: Does Chronicity of Symptoms Matter?

Periprosthetic joint infection (PJI) remains a rare, yet devastating complication of total joint arthroplasty (TJA). Chronic infection is generally considered a contraindication to debridement, antibiotics, and implant retention (DAIR); however, outcomes stratified by chronicity have not been well documented. A retrospective review of all DAIR cases performed at a single institution from 2008 to 2015 was performed. Chronicity of PJI was categorized as acute postoperative, chronic, or acute hematogenous. Failure after DAIR, defined as re-revision for infection recurrence with the same organism, was evaluated between the 3 chronicity groups at 90 days as well as at a minimum 2-year follow-up. Overall, 248 patients undergoing DAIR for total hip arthroplasty or total knee arthroplasty PJI were included. Categorization of PJI was acute (acute postoperative) in 59 cases (24%), chronic in 54 (22%), and acute hematogenous in 135 (54%). DAIR survivorship was 47% (range 0.3-10 years). Overall, there were 118 (47.6%) treatment failures after DAIR with a minimum of 2-year follow-up. There was no difference in failure rate between total hip or total knee arthroplasty patients (P= .07). Patients infected with Staphylococcus conferred a higher risk of failure for all DAIR procedures regardless of chronicity category. Identification of microbial species prior to undertaking DAIR may be more clinically relevant than stratification according to chronicity category when considering treatment options.

When and How to Retain Implants in Periprosthetic Joint Infection

Debridement, antibiotics, and implant retention (DAIR) is an evolving treatment option for periprosthetic joint infection (PJI). Modern treatment includes a variety of surgical protocols and further utility in non-traditional cases, including chronic PJI with unresectable prosthesis. From a technical perspective, DAIR execution is directed to decrease bioburden intraoperatively, and newer adjuvants include intraoperative disinfectants, the staged DAIR procedure, and intraosseous antibiotics. The authors prefer a “double draping” setup, thorough debridement, intraosseous antibiotic administration, multi-solution irrigation, and staging for a second DAIR procedure when appropriate. Postoperative care with negative pressure wound therapy is often utilized for healing and protective benefits while antibiotics are directed by cultures. Chronic suppressive therapy is often implemented. As DAIR efficacy improves and indications broaden, its clinical utility continues to expand.