Debridement, Antibiotics, and Implant Retention (DAIR) Utilizing Modern Techniques in the Subacute Period

ABSTRACT

Introduction

Prosthetic joint infections (PJIs) complicate 0.5-2.5% of arthroplasties and up to 25% of revision arthroplasties.For patients unable to undergo full explant, debridement, antibiotics, and implant retention (DAIR) offers a joint-sparing alternative. The ideal time for DAIR to be performed is no more than 4 weeks once symptoms arise. Infection occurring around the 4-6 week window is when it is not clear if DAIR or full explant of the prosthesis should be the mainstay. 

Methods

This retrospective study analyzed 109 DAIR cases (July 2017-May 2025) across four hospitals by three fellowship-trained orthopaedic surgeons. Reinfection and reoperation rates were evaluated up to 1 year between the ≤ 4 weeks and > 4 weeks groups using Firth logistic regression. T-tests were performed on the 4-6 week group. Demographic variables and preoperative laboratories were compared as a secondary variable. 

Results

100 patients had washout ≤ 4 weeks, 9 in > 4 weeks and 5 in the 4-6 week period. There were 41% males and 59% females in this study. The average age was 66.7 ± 11.9 years, and average BMI 30.9 ± 6.98. The median [IQR] CCI = 3 [2–4], and median [IQR] ASA = 3 [2–3]. The average ESR was 53.4 ± 32.1 mm/h, CRP 15.7 ± 27.5 mg/L, and HbA1c 5.7 ± 0.8%. Drainage from the incision site was present in 64.2% of patients, and a communicating sinus was present in 30.5%. Calcium sulfate beads were placed in 24.1% of patients, and 18 patients required flap coverage. DAIR was performed in 27.5% of THAs and 72.5% of TKAs. At 1-year, reinfection and reoperation rates also did not differ between the 4-6 week group compared to the <4 week group, p = 0.926 and p = 0.988, respectively. 

Conclusion

Patient risk factors should be taken into account when determining one-year morbidity. Modifiable risk factors, such as smoking abstinence, can affect reoperation rates. At this time, undergoing DAIR vs revision arthroplasty at the 4-6 week window may be a viable option and have comparable reinfection and reoperation rates at 1 year. 

Level of Evidence: IV

Keywords: Prosthetic joint infection, DAIR, debridement antibiotics and implant retention, total knee arthroplasty, total hip arthroplasty