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

Abstract

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 > 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.