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A Second Surgical Debridement for Acute Periprosthetic Joint Infections Should Not Be Discarded
Marjan Wouthuyzen-Bakker1, Claudia A M Löwik2, Joris J W Ploegmakers2
1Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
Background:
In acute periprosthetic joint infections (PJIs), a second surgical debridement (debridement, antibiotics, and implant retention [DAIR]) is generally not recommended after a failed first one. We identified the failure rate of a second DAIR and aimed to identify patients in whom an additional debridement might still be beneficial.
Methods:
Patients with acute PJI of the hip or knee and treated with DAIR between 2006 and 2016 were retrospectively evaluated. A second DAIR was routinely performed provided that the soft tissue was intact. Failure of a second DAIR was described as (1) the need for additional surgical intervention to achieve infection control, (2) the need for antibiotic suppressive therapy due to persistent clinical and/or biochemical signs of infection, or (3) PJI related death.
Results:
From the 455 cases treated with DAIR, 144 cases underwent a second debridement (34.6%). Thirty-seven cases failed (37/144, 25.7%). The implant needed to be removed in 23 cases (23/144, 16%). Positive cultures during the second DAIR (odds ratio 3.16, 95% confidence interval 1.29-7.74) and chronic renal insufficiency (odds ratio 13.6, 95% confidence interval 2.03-91.33) were independent predictors for failure in the multivariate analysis. No difference in failure was observed between persistent infection with the same microorganism and reinfection with a new microorganism (failure rate 31.6% vs 34.6%, P = .83).
Conclusion:
A second DAIR had a low failure rate in our cohort of patients and the implant could be retained in the majority of them. Therefore, a second DAIR should not be discarded in acute PJIs.
Insights
A second debridement, antibiotics, and implant retention (DAIR) for acute periprosthetic joint infections (PJIs) has a low failure rate. This procedure should be considered, especially when soft tissue is intact, as implants can often be retained.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Biomedical Engineering
Background:
- Acute periprosthetic joint infections (PJIs) often lead to implant removal after initial treatment failure.
- A second debridement, antibiotics, and implant retention (DAIR) is typically not recommended following a failed first attempt.
Purpose of the Study:
- To determine the failure rate of a second DAIR procedure for acute PJIs.
- To identify patient factors that predict the success or failure of a second DAIR.
Main Methods:
- Retrospective evaluation of patients with acute hip or knee PJIs treated with DAIR between 2006 and 2016.
- A second DAIR was performed if soft tissue integrity was maintained.
- Failure was defined by the need for further surgery, suppressive antibiotics, or PJI-related death.
Main Results:
- Out of 455 initial DAIR cases, 144 underwent a second debridement, with 37 (25.7%) failures.
- Implant removal was necessary in 16% of cases undergoing a second DAIR.
- Positive intraoperative cultures and chronic renal insufficiency were independent predictors of failure.
Conclusions:
- A second DAIR for acute PJIs demonstrates a low failure rate, with successful implant retention in most cases.
- The procedure should not be dismissed as a treatment option for acute PJIs, even after a prior failed attempt.
- Careful patient selection may further optimize outcomes for repeat DAIR procedures.
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