A Second Surgical Debridement for Acute Periprosthetic Joint Infections Should Not Be Discarded

Double DAIR Protocol for Acute Periprosthetic Joint Infection: A 15-Year Institutional Experience

INTRODUCTION

Recently, the double debridement, antibiotics, and implant retention (DAIR) using antibiotic-loaded bone cement beads for the treatment of acute periprosthetic joint infection (PJI) has gained traction following promising reports in the literature. The purpose of this study was to examine the clinical outcomes of this protocol and identify predictors of failure following completion of a double DAIR procedure.

METHODS

This retrospective study identified all patients who underwent a double DAIR protocol for the management of acute PJI (≤ 28 days from either index arthroplasty or symptom onset) at a single institution. Acute PJI was defined using the 2013 Musculoskeletal Infection Society criteria. All patients had a minimum of 1-year follow-up. Treatment failure was defined as either reoperation secondary to infection, PJI-related mortality, or signs of persistent infection at the latest follow-up.

RESULTS

There were 128 patients (69 knees, 59 hips) included in the final analyses. At a mean follow-up time of 4.8 ± 3.9 years, 86.1% of infected primaries and 71.4% of infected revision patients were found to have experienced treatment success. When adjusting for covariates, multivariate regression analyses identified revision arthroplasty (OR [odds ratio], 7.6; P = 0.002), acute hematogenous PJI (OR, 7.1; P = 0.048), and positive culture at second debridement (OR, 5.0; P = 0.039) as independent predictors of failure following completion of a double DAIR procedure.

CONCLUSION

We found that 86.1% of infected primaries and 71.4% of infected revisions that received a double DAIR for acute PJI were infection-free at the latest follow-up. Upon regression analyses, revision arthroplasty, acute hematogenous PJI, and a positive culture at second debridement were found to be independent predictors of treatment failure in this patient population.

Debridement, antibiotics and implant retention: are all approaches to periprosthetic joint infection equal? Same procedures, different outcomes

BACKGROUND

The reported success rate of debridement, antibiotics, and implant retention (DAIR) for periprosthetic joint infection varies considerably between studies, despite institutions reporting use of the same procedure. In this narrative review, we aim to delineate the differences between the various DAIR approaches and highlight why they influence the outcome.

OBJECTIVES

We performed a PubMed and internet search investigating the different approaches for DAIR and their associated outcomes.

SOURCES

Twenty-two studies with defined infection criteria, consisting of 50 or more periprosthetic joint infection cases and a follow-up of 1 year or longer, were included.

CONTENT

Most studies did not report whether the presence of a sinus tract was a criterion for not performing DAIR, and the use of biofilm-active agents for curative DAIR was only reported in a few studies. The duration of infection as criterion for early postoperative and acute haematogenous infection varied between studies. The epidemiology of host factors and microorganisms, healthcare systems, patient-doctor interactions, and decision-making processes for surgical interventions vary worldwide, and so do the indications for DAIR.

IMPLICATIONS

Studies should precisely declare the indication for DAIR, the variables that influence decision-making for treatment options, the surgical technique applied, and the type and duration of antimicrobial therapy. Such an approach will increase the quality of research data and allow the development of recognized subcategories of DAIR.

Outcomes of the Subsequent Periprosthetic Joint Infection Revisions after a Failed Debridement, Antibiotics and Implant Retention: A Multicentric Study of 197 Patients

Background: The impact of prior unsuccessful debridement, antibiotics, and implant retention (DAIR) procedures on subsequent revisions is uncertain, with conflicting evidence. Despite 85% consensus against the second DAIR procedure following the 2018 International Consensus Meeting, a 2020 study reported high success rates for the aforementioned second DAIR procedure. Methods: We conducted a multicenter observational study reviewing data from patients with failed DAIR procedures between 2005 and 2021. Patients diagnosed with acute periprosthetic joint infection of the hip or knee were included, following ICM criteria. Failure was defined as uncontrolled infection leading to additional surgeries, prosthesis removal, infection-related mortality, or suppressive antibiotic therapy. Demographic, surgical, and microbiological variables were recorded. Results: Among 197 patients from 10 institutions with failed DAIR procedures were included: 88 (44.7%) received a second DAIR, 21 (10.7%) underwent one-stage revision, and 77 (39.1%) underwent two-stage revision. One-stage revision success rate was 76.2%, with no identified predictors of failure. Two-stage revision success rate was 79.3%; factors associated with failure included polymicrobial infections (p = 0.025) and revision procedures (p = 0.049). Second DAIR success rate was 54.5%; factors associated with failure included non-specialized surgical teams in the first DAIR (p = 0.034), non-exchange of mobile components (p = 0.0038), polymicrobial infections (p = 0.043), and antibiotic resistance (p = 0.035). Excluding patients with these risk factors increased the success rate to 83.3%. Conclusions: Second DAIR's overall success rate was 54.5%, significantly increasing to 83.3% when excluding patients with identified risk factors. These findings suggest considering second DAIR in carefully selected patients without these risk factors. Our study found success rates of 76.2% and 79.3% for one- and two-stage revisions, respectively, aligning closely with published data.

Success rate of single versus multiple debridement, antibiotics, and implant retention (DAIR) in hip and knee periprosthetic joint infection: a systematic review and meta-analysis

PURPOSE

This systematic review aimed to compare outcomes between multiple and single debridement, antibiotics, and implant retention (DAIR) procedures for early periprosthetic joint infection (PJI) in hip and knee arthroplasty.

METHODS

Four databases were searched from inception till January 2024 for original studies investigating the outcomes of multiple DAIR in hip and knee PJI. The primary outcome was the success rate in eradicating joint infection. This review was conducted per PRISMA guidelines.

RESULTS

A total of 9 observational studies with 1104 participants were included, with a mean age and BMI of 58.37 years (95%CI: 25.77-90.98) and 31.43 kg/m2 (95%CI: 28.89-34.98), respectively. The mean follow-up period was 58.37 months (95%CI: 25.77-90.98), and the average MINORS score assigned to the review was 17.6 ± 3.46, indicating a low overall risk of bias. An equivalent success rate between single and double DAIR was observed, at 67% (95%CI: 64-71%) and 70% (95%CI: 48-86%), respectively, with no statistically significant difference between the two treatment modalities (p = 0.740). Additionally, the success rate for triple DAIR ranged from 50 to 60%.

CONCLUSION

This study suggests that double DAIR is a valid treatment option for acute PJI after TKA and THA, with a success rate comparable to single DAIR (70% vs. 67%, p = 0.740). Triple DAIR achieved success rates ranging from 50 to 60%. However, caution is warranted when interpreting these results due to heterogeneity in host comorbidity factors, DAIR protocols, and antibiotic regimens.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Optimizing debridement and implant retention in acute periprosthetic joint infections

Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes.

Impact of unplanned second debridement, antibiotics and implant retention on long-term outcomes in knee exchange arthroplasty: Elevated risk of failure and reinfection

Purpose

This study investigates the outcomes of two-stage exchange arthroplasty (EA) for periprosthetic joint infection (PJI) following initial or unplanned repeat debridement antibiotics, and implant retention (DAIR).

Methods

We retrospectively reviewed cases of knee arthroplasty infection treated with two-stage EA after DAIR, spanning from January 1994 to December 2010. A total of 138 patients were included, comprising 112 with initial DAIR and 26 with an unplanned second DAIR. Data on demographics, comorbidities, infection characteristics and causative organisms were analyzed. The primary outcome was implant failure or reinfection, observed over a minimum follow-up of 10 years.

Results

The overall success rate for two-stage EA was 87% (119/138 patients). Factors identified for treatment failure included reinfection with the same pathogen for unplanned second DAIR (hazard ratio [HR] = 3.41; 95% confidence interval [CI] = 1.35-4.38; p = 0.004), higher reinfection rates in patients undergoing EA after an unplanned second DAIR, especially with a prior history of PJI within 2 years (HR = 4.23; 95% CI = 2.39-5.31; p = 0.002), pre-first DAIR C-reactive protein (CRP) levels over 100 mg/dL (HR = 2.52; 95% CI = 1.98-3.42; p = 0.003) and recurrence with the same pathogen (HR = 2.35; 95% CI = 1.32-4.24; p = 0.007). Additional factors such as male gender (HR = 3.92; 95% CI = 1.21-5.25; p = 0.007) and osteoporosis (T score < -2.5; HR = 3.27; 95% CI = 1.23-5.28; p = 0.005) were identified as risk factors for implant failure in all EA cases.

Conclusions

This study identifies key risk factors for worse knee EA outcomes following DAIR, including a pre-first DAIR CRP level over 100 mg/L, same pathogen recurrence, and PJI history within 2 years. It shows implant failure rates remain constant across EA cases, regardless of DAIR sequence, particularly with risk factors like male gender and severe osteoporosis (T score < -2.5). These results underscore the need for careful evaluation before an unplanned second DAIR, given its significant impact on EA success.

Level of Evidence

Level III.

Successful Implant Retention in a Chronified Hematogenous Bilateral Periprosthetic Hip Joint Infection With Enterococcus faecalis

We present a case with bilateral hematogenous hip periprosthetic joint infection with Enterococci which could be treated successfully with implant retention despite chronification and partial loosening. A debridement and replacement of the modular components was carried out with replacement of a loose acetabular cup on the right side. Considering poor local infection control, antibiotic treatment was enhanced by local application of vancomycin. In the present case, treatment of chronic enterococcal periprosthetic joint infection while preserving the implants was successful despite unfavorable odds. Considering the duration of infection, causative microorganism, and loosening of one of the implants, staged exchange of both hip replacements would have been the standard procedure. This case illustrates that some concepts have to be challenged from time to time.

Proceedings of the United Kingdom Periprosthetic Joint Infection Meeting 2022: Combined and Arthroplasty Sessions

Considerable variation in practice exists in the prevention, diagnosis, and treatment of periprosthetic joint infection (PJI), which is a devastating complication for patients and surgeons. The consensus principle has been increasingly embraced by the orthopaedic community to help guide practice, especially where high-level evidence remains unavailable. The third United Kingdom Periprosthetic Joint Infection (UK PJI) Meeting was held in Glasgow on April 1, 2022, with more than 180 delegates in attendance, representing orthopaedics, microbiology, infectious diseases, plastic surgery, anesthetics, and allied health professions, including pharmacy and arthroplasty nurses. The meeting comprised a combined session for all delegates, and separate breakout sessions for arthroplasty and fracture-related infection. Consensus questions for each session were prepared in advance by the UK PJI working group, based upon topics that were proposed at previous UK PJI Meetings, and delegates participated in an anonymized electronic voting process. We present the findings of the combined and arthroplasty sessions of the meeting in this article, and each consensus topic is discussed in relation to the contemporary literature.

Debridement, Antibiotics and Implant Retention: A Systematic Review of Strategies for Treatment of Early Infections after Revision Total Knee Arthroplasty

GOAL

The purpose of this review is to provide a systematic and comprehensive overview of the available literature on the treatment of an early prosthetic joint infection (PJI) after revision total knee arthroplasty (TKA) and provide treatment guidelines.

METHODS

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The search was conducted using the electronic databases of PubMed, Trip, Cochrane, Embase, LILACS and SciElo. After the inclusion of the relevant articles, we extracted the data and results to compose a treatment algorithm for early and acute PJI after revision TKA.

RESULTS

After applying the in- and exclusion criteria, seven articles were included in this systematic review focusing on debridement, antibiotics and implant retention (DAIR) for PJI following revision TKA, of which one was prospective and six were retrospective. All studies were qualified as level IV evidence.

CONCLUSIONS

The current literature suggests that DAIR is a valid treatment option for early infections after revision TKA with success rates of 50-70%. Repeat DAIR shows success rates of around 50%. Further research should be aimed at predicting successful (repeat/two-stage) DAIRs in larger study populations, antibiotic regimes and the cost effectiveness of a second DAIR after revision TKA.

Metagenomic Next-Generation Sequencing for Periprosthetic Joint Infections

Periprosthetic joint infection (PJI) after arthroplasty is a major complication, which requires significant resources, resulting in high costs for the medical system. In recent years, significant progress has been made in the diagnosis and treatment of periprosthetic infections, the identification of the pathogen being the central element in the establishment of targeted antibiotic therapy. Next-generation sequencing (NGS) or metagenomic NGS (mNGS) represents a promising, fast alternative, with increased specificity and sensitivity compared to identification methods using conventional culture media, thus enabling an increased rate of identification of pathogenic microorganisms and antibiotic resistance genes (ARG). The purpose of this article was to highlight new molecular diagnostic methods for periprosthetic joint infections and their involvement in treatment efficiency. NGS technologies are cutting-edge techniques that may challenge the PJI diagnostic model.

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.

A protocol for periprosthetic joint infections from the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands

Periprosthetic joint infection (PJI) is a devastating complication of joint arthroplasty surgery. Treatment success depends on accurate diagnostics, adequate surgical experience and interdisciplinary consultation between orthopedic surgeons, plastic surgeons, infectious disease specialists and medical microbiologists. For this purpose, we initiated the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands in 2014. The establishment of a mutual diagnostic and treatment protocol for PJI in our region has enabled mutual understanding, has supported agreement on how to treat specific patients, and has led to clarity for smaller hospitals in our region for when to refer patients without jeopardizing important initial treatment locally. Furthermore, a mutual PJI patient database has enabled the improvement of our protocol, based on medicine-based evidence from our scientific data. In this paper we describe our NINJA protocol.

Level of evidence: III

Debridement, antibiotics, and implant retention after revision arthroplasty : antibiotic mismatch, timing, and repeated DAIR associated with poor outcome

AIMS

Debridement, antibiotics, and implant retention (DAIR) is a widely accepted form of surgical treatment for patients with an early periprosthetic joint infection (PJI) after primary arthroplasty. The outcome of DAIR after revision arthroplasty, however, has not been reported. The aim of this study was to report the success rate of DAIR after revision arthroplasty with a follow-up of two years.

METHODS

This retrospective study, conducted at the Sint Maartenskliniek, Nijmegen, the Netherlands, included 88 patients who underwent DAIR within 90 days of revision total hip or total knee arthroplasty between 2012 and 2019. Details of the surgical procedures and PJI were collected. Univariate analysis and a subgroup analysis of the culture-positive group were performed. Kaplan-Meier survivorship curves were constructed.

RESULTS

The overall success rate of DAIR, with respect to the retention of components and the cure of infection, was 68% after two years. DAIR performed with an interval of > 30 days after the index revision procedure (odds ratio (OR) 0.24 (95% confidence interval (CI) 0.08 to 0.72); p = 0.008), a repeated DAIR within 90 days (OR 0.37 (95% CI 0.14 to 0.97); p = 0.040), and the use of an immunosuppressive agent (OR 0.13 (95% CI 0.02 to 0.67); p = 0.012) were associated with a significantly reduced success rate. In the culture-positive group, a mismatch between the antibiotic treatment and the susceptibility of the organism was associated with a significantly lower success rate (OR 0.13 (95% CI 0.03 to 0.62); p = 0.007).

CONCLUSION

DAIR is an acceptable form of surgical treatment for patients with a suspected early PJI after revision arthroplasty of the hip or knee. DAIRs performed after a prolonged interval, multiple DAIRs, and antibiotic mismatches were significantly associated with an increased risk of failure. Optimization of the host immune response and the prevention of antibiotic mismatch are modifiable factors that may improve the outcome. The high rate of mismatches was an important finding, underlining the need for a review of the local microbiological data, which might improve the outcome. Cite this article: Bone Joint J 2022;104-B(4):464-471.

Local antibiotic treatment with calcium sulfate as carrier material improves the outcome of debridement, antibiotics, and implant retention procedures for periprosthetic joint infections after hip arthroplasty – a retrospective study

Abstract. Purpose: Debridement, antibiotics, and implant retention (DAIR) is an established treatment modality in periprosthetic joint infections (PJIs), but success rates vary. This study compared the success of DAIR for PJIs after a total hip arthroplasty (THA), with or without local antibiotic delivery with CaSO4 as the carrier material. Methods: A retrospective review of DAIR for PJIs after THA performed between 2010 and 2018, including 41 patients is conducted. A total of 27 patients were treated by DAIR with local antibiotics with CaSO4 as the carrier material, and 14 patients were treated by a standard DAIR. The endpoints were treatment failure, defined as the need for a reoperation, either a second DAIR or a prosthesis removal or exchange due to persistent or recurrent infection, the initiation of a long-term suppressive antibiotic treatment, or death related to infection. Results: Considering any reoperation as an outcome, 11 of 14 cases treated without AB-CaSO4 (79 %) and 4 of the 27 cases treated with AB-CaSO4 failed (15 %). Considering revision as an outcome, 9 out of 14 cases treated without AB-CaSO4 (64 %) and 4 of the 27 cases treated with AB-CaSO4 (15 %) failed. A Kaplan–Meier survival analysis showed that local antibiotic delivery with CaSO4 as the carrier material led to a significantly longer infection-free survival, considering any surgical revision (p<0.0001; hazard ratio 8.9 (95 % CI 2.8–28.2)) or revision with component exchange (p=0.0015; hazard ratio 5.6 (95 % CI 1.7–18.2)) as the endpoint. Conclusion: The addition of local antibiotics with CaSO4 as the carrier material to DAIR for PJIs after THA significantly increases success rates, such as infection-free survival, any reoperation, and revision with component exchange in particular.

Experiences during Switching from Two-Stage to One-Stage Revision Arthroplasty for Chronic Total Knee Arthroplasty Infection

The objective of this study was to evaluate our preliminary results after changing our surgical strategy from 2-stage revision arthroplasty to 1-stage revision arthroplasty for patients with chronic knee periprosthetic joint infection. We conducted a prospective study of knee arthroplasty patients that had been diagnosed with chronic infection and treated using a 1-stage revision regardless of the traditional criteria applied for indication thereof. We evaluated two main variables: infection control and economic costs. The definitive diagnosis of infection of the revision was determined by using the criteria proposed by the Musculoskeletal Infection Society. The costs were calculated as average costs in USD, as described by Srivastava (2019), for 1-stage or 2-stage revisions. Eighteen patients were included in the study, and infection was controlled in 17 patients. The total economic savings for our hospital from these 18 patients amounted to USD 291,152. This clinical success has led to major changes in how our hospital approaches the treatment of chronically infected knee replacements, in addition to substantial economic advantages for the hospital.

[Periprosthetic joint infections : Latest developments, strategies and treatment algorithms]

BACKGROUND

Due to their multidimensional consequences, periprosthetic joint infections are a serious complication in arthroplasty. There are disagreements in the literature regarding their classification. At the same time, a consequence for the practical procedure cannot always be derived.

THERAPEUTIC PROCEDURES

In addition to debridement with antibiotics and implant retention, there are options for a one or two-stage change in the therapeutic procedure. Although the preservation of implants is only possible in the case of acute infections with a short duration of symptoms, prosthesis changes are indicated with a longer symptom duration. For both procedures, there are interinstitutional deviating indication criteria, weighing pros and cons. Both have specific problems, such as, in particular, the duration of the antibiotics course, the question of anchoring the prosthesis and, in the case of a two-stage procedure, the shape of the spacer.