Debridement, Antibiotics And Implant Retention Research Articles

Risk factors for recurrence of periprosthetic joint infection following operative management: a cohort study with average 5-year follow-up.

Periprosthetic joint infections (PJIs) remain challenging to eradicate even after surgical management, which in most cases involves either debridement, antibiotics and implant retention (DAIR) or single- or two-staged revision. The purpose of this study is to determine predictors of PJI recurrence after operative management for PJI, and to determine differences in recurrence-free survival between DAIR and staged revision. This is a retrospective analysis of prospectively collected data of revision hip and knee arthroplasty surgeries due to PJI between 2011 and 2018 at an academic hospital. Any patient undergoing revision surgery for PJI was included except if the index surgery information was unknown. The primary outcome was confirmed PJI recurrence. Multivariable logistic regression analysis was utilized to determine the relationship between the predictor variables and outcome variable. Log rank testing was used to compare recurrence-free survival between DAIR and staged revision. A total of 89 patients (91 joints) underwent revision surgery due to PJI. Younger age and presence of a sinus tract were statistically significant for risk of PJI recurrence. A multivariable logistic regression model including both variables was significant for predicting recurrence of PJI (χ2=10.2, P=0.006). Survival was not significantly different between patients who underwent DAIR versus a staged revision. Younger patients and those with a chronic sinus tract are at significantly higher risk of recurrent PJI. This study also demonstrated that PJI can be successfully managed in the majority of cases with DAIR or staged revision.

Incidence, functional outcomes and cure rate of hematogenous infection in a 2,498 Total Knee Arthroplasties cohort

PurposeThe primary aim of the present study is to report the late acute hematogenous (LAH) prosthetic joint infection (PJI) cure rate following Total knee arthroplasty (TKA) treated by means of debridement, antibiotics, and implant retention (DAIR) in a long-term follow-up. The secondary purpose is to report the functional outcomes at that follow-up and to compare them with a non-infected group.Material and MethodsThis study cohort consists of 2,498 TKA performed from September 2005 to April 2010 that had a minimum follow-up of 10 years. The diagnosis of PJI and classification into LAH was done in accordance with the Zimmerli criteria. The primary outcome was the failure rate, defined as death before the end of antibiotic treatment, a further surgical intervention for treatment of infection, life-long antibiotic suppressive treatment or chronic infection. The Knee Society Score (KSS) was used to evaluate clinical outcomes.ResultsTen patients were diagnosed with acute hematogenous PJI during the study period (0.4%). All of them were managed with DAIR, which was performed by a knee surgeon and/or PJI surgeon. The failure rate was 0% at the 8.5-year (SD, 2.4) follow-up mark. The KSS score was 82.1 vs. 84.1 (p n.s.) at final follow-up.ConclusionAlthough the literature suggests that TKA DAIR for LAH periprosthetic joint infection is associated with high rates of failure, the results presented here suggest a high cure rate with good functional outcomes.Level of evidenceLevel II, prospective cohort study.

A radio- and fluorescently labelled tracer for imaging and quantification of bacterial infection on orthopaedic prostheses

Arthroplasty surgery of the knee and hip is performed in two to three million patients annually. Periprosthetic joint infections occur in 4% of these patients. Debridement, antibiotics, and implant retention (DAIR) surgery aimed at cleaning the infected prosthesis often fails, subsequently requiring invasive revision of the complete prosthetic reconstruction. Infection-specific imaging may help to guide DAIR. In this study, we evaluated a bacteria-specific hybrid tracer (99mTc-UBI29-41-Cy5) and its ability to visualize the bacterial load on femoral implants using clinical-grade image guidance methods. 99mTc-UBI29-41-Cy5 specificity for Stapylococcus aureus was assessed in vitro using fluorescence confocal imaging. Topical administration was used to highlight the location of S. aureus cultured on femoral prostheses using fluorescence imaging and freehand single photon emission CT (fhSPECT) scans. Gamma counting and fhSPECT were used to quantify the bacterial load and monitor cleaning with chlorhexidine. Microbiological culturing helped to relate the imaging findings with the number of (remaining) bacteria. Bacteria could be effectively stained in vitro and on prostheses, irrespective of the presence of biofilm. Infected prostheses revealed bacterial presence on the transition zone between the head and neck, and in the screw hole. Qualitative 2D fluorescence images could be complemented with quantitative 3D fhSPECT scans. Despite thorough chlorhexidine treatments, 28% to 44% of the signal remained present in the locations of the infection that were identified using imaging, which included 500 to 2,000 viable bacteria. The hybrid tracer 99mTc-UBI29-41-Cy5 allowed effective bacterial staining. Qualitative real-time fluorescence guidance could be effectively combined with nuclear imaging that enables quantitative monitoring of the effectiveness of cleaning strategies.Cite this article: Bone Joint Res2023;12(1):72-79.

Redo DAIR: The Game Is Seldom Worth the Candle.

Debridement, antibiotics and implant retention (DAIR) remains a commonly utilized technique in the treatment of acute prosthetic joint infections despite its inconsistent outcomes. The performance of a second DAIR after a failed first debridement is controversial as outcomes are uncertain and the final prognosis in the event of failure may be unfavorable. This study analyzes 84 cases of acute prosthetic (hip & knee) joint infection treated with DAIR between 2011 and 2020 at the same institution. In 12 failed cases, a second DAIR was performed, whose success rate was significantly lower than that of the first procedure (8% [95% CI, 0-38] vs. 57% [46-68]). Moreover, the ultimate outcome of the second failed DAIRs was unfavorable with eradication of the infection being achieved in none of the patients. Due to the high likelihood of failure and the potentially grim final prognosis following a second debridement, removal of the components should be considered.

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 < 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.

Periprosthetic joint infection following hip hemiarthroplasty : factors associated with infection and treatment outcome.

The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome. A retrospective review was performed of consecutive patients treated for HA PJI at a tertiary referral centre with a mean 4.5 years' follow-up (1.6 weeks to 12.9 years). Surgeries performed included debridement, antibiotics, and implant retention (DAIR) and single-stage revision. The effect of different factors on developing infection and treatment outcome was determined. A total of 1,984 HAs were performed during the study period, and 44 sustained a PJI (2.2%). Multiple logistic regression analysis revealed that a higher CCI score (odds ratio (OR) 1.56 (95% confidence interval (CI) 1.117 to 2.187); p = 0.003), peripheral vascular disease (OR 11.34 (95% CI 1.897 to 67.810); p = 0.008), cerebrovascular disease (OR 65.32 (95% CI 22.783 to 187.278); p < 0.001), diabetes (OR 4.82 (95% CI 1.903 to 12.218); p < 0.001), moderate-to-severe renal disease (OR 5.84 (95% CI 1.116 to 30.589); p = 0.037), cancer without metastasis (OR 6.42 (95% CI 1.643 to 25.006); p = 0.007), and metastatic solid tumour (OR 15.64 (95% CI 1.499 to 163.087); p = 0.022) were associated with increasing PJI risk. Upon final follow-up, 17 patients (38.6%) failed initial treatment and required further surgery for HA PJI. One-year mortality was 22.7%. Factors associated with treatment outcome included lower preoperative Hgb level (97.9 g/l (SD 11.4) vs 107.0 g/l (SD 16.1); p = 0.009), elevated CRP level (99.1 mg/l (SD 63.4) vs 56.6 mg/l (SD 47.1); p = 0.030), and type of surgery. There was lower chance of success with DAIR (42.3%) compared to revision HA (66.7%) or revision with conversion to total hip arthroplasty (100%). Early-onset PJI (≤ six weeks) was associated with a higher likelihood of treatment failure (OR 3.5 (95% CI 1.2 to 10.6); p = 0.007) along with patients treated by a non-arthroplasty surgeon (OR 2.5 (95% CI 1.2 to 5.3); p = 0.014). HA PJI initially treated with DAIR is associated with poor chances of success and its value is limited. We strongly recommend consideration of a single-stage revision arthroplasty with cemented components.Cite this article: Bone Jt Open2022;3(12):924-932.

Impact of prior failed irrigation and debridement on outcomes of subsequent two-stage revision arthroplasty: a systematic review and meta-analysis.

This study aimed at examining if prior failed debridement, antibiotics, and implant retention (DAIR) for prosthetic joint infection have an impact on the success of subsequent two-stage revision arthroplasty (2SRA). Search was conducted on PubMed, Embase, and Google Scholar up to 14th April 2022 for studies comparing 2SRA with and without a history of DAIR. Six retrospective studies were included. The success of 2SRA was defined as either absence of additional surgical intervention for infection or absence of antibiotic suppression or both. We noted no statistically significant difference in the odds of success between failed DAIR and no DAIR group, albeit with an inclination of reduced success with prior failed DAIR (OR 0.63 95% CI 0.33, 1.19 I2=66% p=0.16). Five studies reported adjusted outcomes. The meta-analysis demonstrated no statistically significant difference in the odds of success between failed DAIR and no DAIR groups (OR 0.57 95% CI 0.26, 1.26 I2=66% p=0.17). During sensitivity analysis, the removal of a single study changed the effect size indicating significantly lower success rates in failed DAIR group. Our results indicate that patients undergoing 2SRA after failed DAIR may have a non-significant tendency of lower success rates as compared to patients directly undergoing 2SRA. However, current evidence is scarce and fraught with several limitations and there is a need for further research to delineate the impact of failed DAIR on the success of 2SRA.

A Comparison of Outcomes of Culture positive and Culture negative Acute Knee Prosthetic Joint Infection following Debridement, Antibiotics and Implant Retention (DAIR).

We aim to compare the outcome of culture-positive (CP PJI) and culture-negative (CN PJI) acute knee prosthetic joint infection (PJI) following debridement, antibiotics and implant retention (DAIR) with polyethylene insert exchange. We also aim to analyze the factors associated with the successful outcome of DAIR and the influence of failed DAIR on the outcome of subsequent two-stage revision arthroplasty. We performed a retrospective review of 36 consecutive patients who underwent DAIR for acute PJI between January 2013 and January 2018. The patient's demographic data, McPherson grade, surgical details, laboratory and microbiology data were retrieved from the medical records. All the patients have been followed up for a minimum of 3years or until re-operation, revision or death and any complications, incidence of DAIR failure, revision and mortality were noted. The mean follow-up was 4.9 ± 2.4years. Among the 36 patients, 16 had CP PJI and 20 had CN PJI. Among the 16 patients with CP PJI, 8 patients had success with DAIR and 8 patients had a recurrence of infection (50%) at a mean of 21months (range, 2weeks to 55months). Among the 20 patients with CN PJI, 14 patients had success with DAIR and 6 patients had a recurrence of infection [30% (6/20)] at a mean of 69months (range, 13-221months) (p < .05). The Kaplan-Meir survival analysis showed survivorship did not vary significantly between both groups (p > .05). Univariate regression analysis showed symptom duration of more than one month found to be significantly associated with the DAIR failure. There was no difference in failure rate after DAIR between age, Charlson comorbidity index, early postoperative versus acute hematogenous group and type of organism grown. Ten out of 14 DAIR failures were successfully managed with two-stage revision surgery with no recurrence of infection till the final follow-up. In the remaining 4 patients, one underwent re-debridement, two underwent arthrodesis and one was left with an antibiotic cement spacer. DAIR with polyethylene exchange will give comparable results irrespective of the culture positivity. Symptom duration of more than 30days for DAIR is significantly associated with DAIR failure. DAIR failures can be successfully managed with two-stage revision.

Palliative arthroscopic debridement with continuous irrigation forinfected total knee arthroplastyin high mortality riskpatients.

This study aimed to evaluate the infection control rate of palliative arthroscopic debridement, antibiotics, and implant retention (DAIR) for the high mortality risk or terminal cancer stage patients. From March 2018 to August 2021, 21 patients met the following inclusion criteria: old age of more than 80, diagnosed as a terminal stage of cancer, high risk of mortality and morbidity representing as Charlson comorbidity index (CCI) ≥ 5, low daily activity with disabled extremity, and re-infection after two-stage revision. Each patient underwent arthroscopic DAIR and additional continuous irrigation for 48hours. The need for subsequent re-arthroscopic DAIR or two-stage revision was determined by the post-operative trends of C-reactive protein (CRP) levels. Infection control was defined as continuing controlled status of infection based on clinical and laboratory results by one or two times of arthroscopic DAIR within initial two months. Treatment failure was defined as more than three times arthroscopic debridement, two-stage revision surgery, or expired due to uncontrolled infection. Arthroscopic DAIR controlled the infection in 19 (90.5%) of the 21 cases. The other knee underwent a total of three times of re-arthroscopic DAIR and the other one underwent two-stage revision. Although five patients expired during the follow-up period due to worsening medical problems or terminal cancer, there were no deaths from uncontrolled infection, sepsis, or surgery-related complications. Arthroscopic debridement with continuous irrigation for the infection TKA with high mortality risk or terminal cancer patients showed a 90.5% infection control rate. For high-risk patients, arthroscopic debridement with continuous irrigation can be an alternative treatment to improve the quality of life during survival.

Custom-made triflanged implants in reconstruction of severe acetabular bone loss with pelvic discontinuity after total hip arthroplasty consecutive cohort study : two to 11 years of follow-up.

Pelvic discontinuity is a rare but increasingly common complication of total hip arthroplasty (THA). This single-centre study evaluated the performance of custom-made triflange acetabular components in acetabular reconstruction with pelvic discontinuity by determining: 1) revision and overall implant survival rates; 2) discontinuity healing rate; and 3) Harris Hip Score (HHS). Retrospectively collected data of 38 patients (39 hips) with pelvic discontinuity treated with revision THA using a custom-made triflange acetabular component were analyzed. Minimum follow-up was two years (mean 5.1 years (2 to 11)). There were eight subsequent surgical interventions. Two failures (5%) of the triflange acetabular components were both revised because of deep infection. There were seven (18%) patients with dislocation, and five (13%) of these were treated with a constraint liner. One patient had a debridement, antibiotics, and implant retention (DAIR) procedure. In 34 (92%) hips the custom-made triflange component was considered stable, with a healed pelvic discontinuity with no aseptic loosening at midterm follow-up. Mean HHS was 80.5 (48 to 96). The performance of the custom triflange implant in this study is encouraging, with high rates of discontinuity healing and osteointegration of the acetabular implant with no aseptic loosening at midterm follow-up. However, complications are not uncommon, particularly instability which we successfully addressed with constrained liners.Cite this article: Bone Jt Open2022;3(11):867-876.

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.

Rates and Predictors of Treatment Failure in Staphylococcus aureus Prosthetic Joint Infections According to Different Management Strategies: A Multinational Cohort Study-The ARTHR-IS Study Group.

Guidelines have improved the management of prosthetic joint infections (PJI). However, it is necessary to reassess the incidence and risk factors for treatment failure (TF) of Staphylococcusaureus PJI (SA-PJI) including functional loss, which has so far been neglected as an outcome. A retrospective cohort study of SA-PJI was performed in 19 European hospitals between 2014 and 2016. The outcome variable was TF, including related mortality, clinical failure and functional loss both after the initial surgical procedure and after all procedures at 18months. Predictors of TF were identified by logistic regression. Landmark analysis was used to avoid immortal time bias with rifampicin when debridement, antibiotics and implant retention (DAIR) was performed. One hundred twenty cases of SA-PJI were included. TF rates after the first and all surgical procedures performed were 32.8% and 24.2%, respectively. After all procedures, functional loss was 6.0% for DAIR and 17.2% for prosthesis removal. Variables independently associated with TF for the first procedure were Charlson ≥ 2, haemoglobin < 10g/dL, bacteraemia, polymicrobial infection and additional debridement(s). For DAIR, TF was also associated with a body mass index (BMI) > 30kg/m2 and delay of DAIR, while rifampicin use was protective. For all procedures, the variables associated with TF were haemoglobin < 10g/dL, hip fracture and additional joint surgery not related to persistent infection. TF remains common in SA-PJI. Functional loss accounted for a substantial proportion of treatment failures, particularly after prosthesis removal. Use of rifampicin after DAIR was associated with a protective effect. Among the risk factors identified, anaemia and obesity have not frequently been reported in previous studies. This study is registered at clinicaltrials.gov, registration no. NCT03826108.

Fix and replace: Simultaneous fracture fixation and hip replacement for acetabular fractures in older patients

IntroductionDisplaced acetabular fractures in the elderly present significant treatment challenges. The ‘fix and replace’ concept involves open reduction and internal fixation of the acetabulum, providing bony stability to accept the press-fit of an acetabular cup, with a cemented femoral stem. This allows early mobilisation and the advantages this confers. This study of 57 patients treated with fix and replace describes our technique, outcomes, and survival analysis. MethodsA retrospective review of 57 ‘fix and replace’ procedures in patients aged over 60 was performed. Data was collected on mechanism, fracture type, demographics, time to surgery, comorbidity index, complications, EQ-5D and Oxford hip scores (OHS). Radiographs were reviewed for fracture healing, implant loosening, cup migration, and heterotopic ossification. Results57 patients aged 60 to 95 had fix and replace surgery. The median ASA score was 3. The mean Charlson Index was 4.8. 45 patients had a low-energy fall, 6 had a road traffic accident, 3 fell off a bicycle, and 1 mechanism was unclear. The fracture patterns were anterior column posterior hemitransverse (67%), associated both columns (9%), posterior column (9%), posterior column and posterior wall (9%), and transverse (2%). The mean time to surgery was 8.4 days (0–14). 26 out of 57 (46%) received a blood transfusion. Mean length of stay was 17.6 days (7–86). The mean follow-up was 35.5 months. 4 dislocations were treated with closed reduction, whilst 1 required excision arthroplasty. 2 infections resolved with debridement, antibiotics, and implant retention (DAIR), whilst 1 required a two-stage revision. 1 acetabular component had migrated requiring revision. The median pre-injury OHS was 44 (26–48) compared to 37.3 (28–48) at 1 year. There were no deaths at 30-days, whilst at 1 year 7 patients had died. Kaplan Meier survival analysis showed mean survival was 1984.5 days. Implant survival was 90% at 1 year. ConclusionWhile fix and replace is conceptually attractive, this medically complex patient group requires considerable support peri‑ and post-operatively. Further studies are required to provide clinicians with more information to decide on how best to provide a holistic management strategy for such injuries in this frail patient cohort.

Effectiveness of Different Antimicrobial Strategies for Staphylococcal Prosthetic Joint Infection: Results From a Large Prospective Registry-Based Cohort Study

BackgroundTreatment of staphylococcal prosthetic joint infection (PJI) usually consists of surgical debridement and prolonged rifampicin combination therapy. Tailored antimicrobial treatment alternatives are needed due to frequent side effects and drug-drug interactions with rifampicin combination therapy. We aimed to assess the effectiveness of several alternative antibiotic strategies in patients with staphylococcal PJI.MethodsIn this prospective, multicenter registry-based study, all consecutive patients with a staphylococcal PJI, treated with debridement, antibiotics and implant retention (DAIR) or 1-stage revision surgery between January 1, 2015 and November 3, 2020, were included. Patients were treated with a long-term rifampicin combination strategy (in 2 centers) or a short-term rifampicin combination strategy (in 3 centers). Antimicrobial treatment strategies in these centers were defined before the start of the registry. Patients were stratified in different groups, depending on the used antimicrobial strategy. Cox proportional hazards models were used to compare outcome between the groups.ResultsTwo hundred patients were included and stratified in 1 long-term rifampicin group (traditional rifampicin combination therapy) or 1 of 3 short-term rifampicin groups (clindamycin or flucloxacillin or vancomycin monotherapy, including rifampicin for only 5 postoperative days). Adjusted hazard ratios (aHRs) for failure in patients treated with short-term rifampicin and either flucloxacillin or clindamycin were almost equal to patients treated with long-term rifampicin combination therapy (aHR = 1.21; 95% confidence interval, .34–4.40).ConclusionsA short-term rifampicin strategy with either clindamycin or flucloxacillin and only 5 days of rifampicin was found to be as effective as traditional long-term rifampicin combination therapy. A randomized controlled trial is needed to further address efficacy and safety of alternative treatment strategies for staphylococcal PJI.

The role of antibiotic calcium sulfate beads in acute periprosthetic knee infection: a retrospective cohort study

BackgroundThe study aimed to compare debridement, antibiotics, and implant retention (DAIR) vs. debridement antibiotic bead and retention of the implant (DABRI) in terms of infection-free success rate and treatment cost for acute periprosthetic joint infections after total knee arthroplasty (TKA).MethodBetween 2017 and 2020, 32 patients with acute periprosthetic joint infection who were treated by total knee arthroplasty were retrospectively reviewed. The patients were divided into a DAIR group (n=15) and a DABRI group (n=17). During the DABRI, additional calcium ulphate antibiotic beads were used. Patient age, the Musculoskeletal Infection Society score, microorganisms involved, and success rate were assessed. ResultsThe mean age of DAIR group (n=15) was 69 years, with 7 being male, and 8 female. The mean follow-up period lasted 30 months. The success rate was 80% (12/15). The mean age of DABRI group (n=17) was 64 years, with 10 patients being male and 7 female. The mean follow-up period was 16 months. The success rate was 88% (15/17). There were no significant differences in patient age (P>0.05), the Musculoskeletal Infection Society score (P>0.05), and success rate (P>0.05). A significant difference was found in the follow-up period between the two groups (P<0.05).ConclusionBoth DAIR and DABRI could be used to treat acute periprosthetic joint infections and the outcomes and treatment costs of the two procedures were comparable. Additional use of calcium sulfate beads was safe, but might not improve the treatment result. Randomized controlled studies are warranted for the routine use.

Effectiveness and Optimal Duration of Adjunctive Rifampin Treatment in the Management of Staphylococcus aureus Prosthetic Joint Infections After Debridement, Antibiotics, and Implant Retention.

BackgroundRifampin is recommended as adjunctive therapy for patients with a Staphylococcus aureus prosthetic joint infection (PJI) managed with debridement, antibiotics, and implant retention (DAIR), with no solid consensus on the optimal duration of therapy. Our study assessed the effectiveness and optimal duration of rifampin for S aureus PJI using Veterans Health Administration (VHA) data.MethodsWe conducted a retrospective cohort study of patients with S aureus PJI managed with DAIR between 2003 and 2019 in VHA hospitals. Patients who died within 14 days after DAIR were excluded. The primary outcome was a time to microbiological recurrence from 15 days up to 2 years after DAIR. Rifampin use was analyzed as a time-varying exposure, and time-dependent hazard ratios (HRs) for recurrence were calculated according to the duration of rifampin treatment.ResultsAmong 4624 patients, 842 (18.2%) received at least 1 dose of rifampin; 1785 (38.6%) experienced recurrence within 2 years. Rifampin treatment was associated with significantly lower HRs for recurrence during the first 90 days of treatment (HR, 0.60 [95% confidence interval {CI}, .45–.79]) and between days 91 and 180 (HR, 0.16 [95% CI, .04–.66]) but no statistically significant protective effect was observed with longer than 180 days (HR, 0.57 [95% CI, .18–1.81]). The benefit of rifampin was observed for subgroups including knee PJI, methicillin-susceptible or -resistant S aureus infection, and early or late PJI.ConclusionsThis study supports current guidelines that recommend adjunctive rifampin use for up to 6 months among patients with S aureus PJI treated with DAIR.

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.

Repeat revision TKR for failed management of peri-prosthetic infection has long-term success but often require multiple operations: a case control study.

Prosthetic joint infection (PJI) is associated with poor outcomes and catastrophic complications. The aim of this study was to present the outcomes of re-revision surgery for PJI of the knee following previous failed two-stage exchange arthroplasty. A retrospective analysis was performed of 32 patients who underwent re-revision knee arthroplasty, having already undergone at least one previous two-stage exchange for PJI with a minimum follow-up of two-years for alive patients. Outcomes were compared to a matched control of two-stage revisions for PJI of a primary knee replacement also containing 32 patients. Outcomes investigated were eradication of infection, re-operation, mortality and limb-salvage rate. Successful eradication of infection was achieved in 50% of patients following re-revision surgery, compared with 91% following two-stage exchange of primary knee replacement for PJI (p < 0.001). Fourteen (44%) patients required further re-operation compared with three (9%) patients in the primary group (p = 0.006). Amputation was performed in one case (3%) with thirteen patients (92%) who had infection controlled by debridement, antibiotics and implant retention (DAIR), further revision surgery or arthrodesis. Two patients died with infection (6%) and the long-term rate for infection control was 91%. The mean number of procedures following surgery for the re-revision group was 2.8 (0-9) compared with 0.13 (0-1) for the primary two-stage group (p < 0.001). Five-year patient survival was 90.6% (95% CI 77.1-100). The limb-salvage rate for the re-revision cohort was 97%. Outcomes for re-revision knee arthroplasty for PJI have higher re-operation and failure rates, but no worse mortality than in revisions of primary knee replacements. Failures can successfully be managed by further operation.

Worse outcome of debridement, antibiotics, and implant retention in acute hematogenous infections than in postsurgical infections after total knee arthroplasty: a multicenter study

BackgroundWe sought to determine (1) the success rate of debridement, antibiotics, and implant retention (DAIR) for acute periprosthetic joint infection (PJI) of the knee in patients with acute postsurgical infection and in those with acute hematogenous infection via a multicenter study, (2) the factors related to the failure of DAIR for overall acute PJI and acute hematogenous PJI via subgroup analysis, and (3) whether the PJI recurrence patterns differed between the two groups over time after DAIR.MethodsThis retrospective multicenter study included 101 acute knee PJI. Acute postsurgical PJI was defined as PJI diagnosed < 3 months following initial knee arthroplasty surgery. DAIR was performed for 34 cases of acute postsurgical PJIs (postsurgical group) and 67 cases of acute hematogenous PJIs (hematogenous group). The success rates between groups were compared, and factors related to DAIR failure were analyzed.ResultsThe overall success rate of DAIR was 77%. The success rate tended to be higher in the postsurgical group than in the hematogenous group (p = 0.060). However, there was no significant factor related to DAIR failure in the subgroup analysis of acute hematogenous PJIs. In the postsurgical group, the recurrence of PJI occurred until 3 months, whereas in the hematogenous group, recurrence occurred for up to 2 years.ConclusionsThe failure rate tended to be higher in the acute hematogenous PJI group than in the acute postsurgical PJI group. Since acute hematogenous infections may recur for a longer period than postsurgical infections, careful follow-up is required after DAIR.