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Introduction

  • DAIR (Debridement, Antibiotics, and Implant Retention) is a procedure used to treat periprosthetic joint infections (PJI).

  • DAIR is most effective for acute postoperative infections or acute hematogenous infections.

  • The procedure should be performed within four weeks of surgery for acute postoperative infections or within two weeks of symptom onset for acute hematogenous infections.

  • Patient selection is crucial: the implant must be well-fixed, the patient should have good quality soft tissues, and there should be no draining sinus.

  • DAIR is less invasive than two-stage revision surgery but has variable success rates depending on several factors.

Indications [1]

  • Acute Postoperative Infections: DAIR is indicated for infections occurring within four weeks of surgery.

  • Acute Hematogenous Infections: DAIR is suitable for infections that occur within two weeks of symptom onset.

  • Chronic Infections: For chronic infections, one-stage or two-stage revision surgery is generally preferred over DAIR.

  • Host Comorbidities: The patient's overall health and comorbidities should be considered when deciding on DAIR.

  • Infecting Organisms: The type of infecting organism can influence the decision to perform DAIR.

Patient Selection Criteria [2]

  • Well-Fixed Implant: The implant must be stable and well-fixed.

  • Good Quality Soft Tissues: The patient should have good quality soft tissues without a draining sinus.

  • Known Organism: The infecting organism should be identified preoperatively.

  • No Draining Sinus: Presence of a draining sinus is a contraindication for DAIR.

  • Functioning Implant: The implant should have been functioning well prior to the infection.

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Procedure Timing [1]

  • Acute Postoperative Period: DAIR should be performed within four weeks of surgery for acute postoperative infections.

  • Acute Hematogenous Infections: The procedure should be done within two weeks of symptom onset for acute hematogenous infections.

  • Urgency: While not a surgical emergency, DAIR should be performed urgently once the patient is medically optimized.

  • Early Intervention: Performing DAIR within seven days of symptom onset is associated with higher success rates.

  • Pathogen Identification: Preoperative identification of pathogens is recommended to tailor antibiotic therapy.

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Technical Aspects [1]

  • Mechanical Debridement: Thorough mechanical debridement is crucial for the success of DAIR.

  • Exchange of Modular Components: Exchanging modular components, such as polyethylene inserts, is recommended.

  • Irrigation: Adequate irrigation with antiseptic solutions is essential to reduce bacterial load.

  • Changing Drapes: Consider changing drapes and instruments after debridement to minimize contamination.

  • Methylene Blue: Methylene blue can be used to identify biofilms and guide debridement.

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Postoperative Care [1]

  • Antibiotic Therapy: Typically involves 4-6 weeks of antibiotics, starting with IV and transitioning to oral.

  • Tailored Treatment: Antibiotic therapy should be tailored based on intraoperative cultures and susceptibilities.

  • Infectious Disease Specialist: Co-management with an infectious disease specialist is recommended.

  • Duration: The International Consensus Meeting recommends a minimum of 6 weeks of antibiotic therapy after DAIR.

  • Monitoring: Regular monitoring of laboratory markers and patient response is essential.

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Outcomes [1]

  • Success Factors: Factors associated with success include early intervention, exchange of modular components, and appropriate antibiotic therapy.

  • Failure Factors: Risk factors for failure include rheumatoid arthritis, age over 80, male sex, chronic renal failure, liver cirrhosis, and chronic obstructive pulmonary disease.

  • Variable Success Rates: Success rates for DAIR can be variable and depend on multiple factors.

  • Adjunctive Therapy: The addition of rifampin for staphylococcal infections or fluoroquinolones for Gram-negative infections may improve outcomes.

  • Double DAIR: A two-stage DAIR procedure has shown higher success rates compared to a single-stage DAIR.

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