Debridement, antibiotics, and implant retention (DAIR) in periprosthetic joint infection (PJI)

Background: Periprosthetic joint infection (PJI) remains a significant complication following total joint arthroplasty. Debridement, antibiotics, and implant retention (DAIR) is a primary treatment strategy for acute PJI, offering lower morbidity and reduced costs compared to staged revision. However, success rates vary widely, and failure complicates subsequent infection eradication.

Objective: This review evaluates the indications, prognostic factors, and surgical techniques associated with DAIR success and failure in hip and knee arthroplasty.

Key Points: Optimal candidates for DAIR present with acute symptoms (<4-6 weeks), well-fixed prostheses, and adequate soft tissue. Factors associated with treatment failure include age over 80 years, rheumatoid arthritis, elevated inflammatory markers (CRP >65 mg/dL; ESR >107.5 mm/hr), and systemic sepsis. Microbiological challenges, particularly Methicillin-resistant Staphylococcus aureus (MRSA) and polymicrobial infections, significantly reduce success rates. Essential surgical components include radical debridement, obtaining five culture samples, and mandatory exchange of modular components to address the biofilm. In hip DAIR, the risk of dislocation (14-26.6%) can be mitigated by increasing femoral head size or offset. While repeated DAIR remains controversial, some protocols report success with a "double DAIR" approach. Emerging machine learning algorithms utilizing variables such as immune status and bacterial profile demonstrate potential in predicting clinical outcomes.

Conclusion: DAIR success is contingent upon rigorous patient selection and standardized surgical execution. Integrating advanced predictive tools and machine learning may facilitate personalized treatment algorithms to improve outcomes in PJI management.