Principles of mechanical and chemical debridement with implant retention

Abstract

Background Periprosthetic joint infection (PJI) is one of the most common causes of early revision for total hip and knee arthroplasty. Mechanical and chemical debridement typically referred to as debridement, antibiotics, and implant retention (DAIR) can be a successful technique to eradicate PJI in acute postoperative or acute hematogenous infections. This review will focus specifically on the indications, techniques, and outcomes of DAIR. Discussion The success of mechanical and chemical debridement, or a DAIR operation, is reliant on a combination of appropriate patient selection and meticulous technique. There are many technical considerations to take into consideration. One of the most important factors in the success of the DAIR procedure is the adequacy of mechanical debridement. Techniques are surgeon-specific and perhaps contribute to the large variability in the literature on the success of DAIR. Factors that have been shown to be associated with success include the exchange of modular components, performing the procedure within seven days or less of symptom onset, and possibly adjunctive rifampin or fluoroquinolone therapy, though this remains controversial. Factors that have been associated with failure include rheumatoid arthritis, age greater than 80 years, male sex, chronic renal failure, liver cirrhosis, and chronic obstructive pulmonary disease. Conclusions DAIR is an effective treatment option for the management of an acute postoperative or hematogenous PJI in the appropriately selected patient with well-fixed implants.

What Is the Most Effective Treatment for Periprosthetic Joint Infection After Total Joint Arthroplasty in Patients with Rheumatoid Arthritis?

“…A valuable avenue for further research is further evaluation of OSR in this population, considering the established benefits of a single procedure, a shorter antibiotic course, and decreased cost 13 ; results from the larger cohort demonstrated OSR may be equivalent to TSR in patients with RA; however, limited number of patients undergoing OSR in our smaller data set precluded further analysis. Interestingly, our results suggest that TSR has potential efficacy even in the acute setting; however, current literature on non-RA patient populations indicates that DAIR should be used the first-line option for infection in this context, given decreased morbidity, difficulty of surgery, and biofilm burden at that time 34,[53][54][55][56][57] . Ultimately, further research is needed to perform a more robust comparison of DAIR vs. TSR in the acute setting in the RA population, considering their higher propensity for severe infection, before providing definitive recommendations.…”

“…Thus, we propose consideration of TSR, or perhaps at least reconsideration of electing DAIR, for all RA patients with PJI, including after both THA and TKA, particularly in the chronic setting. The use of DAIR, given its advantages of lower morbidity and decreased technical demand compared with the alternative procedures 56,57 , should still be used in the correct clinical context, particularly among patients for whom extensive surgery may be risky or in the acute setting when biofilm has yet to be formed. It is important to emphasize that these findings and conclusions should be considered in context of the limitations listed above.…”

Hydrogel Coating versus Calcium Sulphate Beads as a Local Antibiotic Carrier for Debridement Procedures in Acute Periprosthetic Joint Infection: A Preliminary Study

“…Similar low-quality evidence was presented for changing drapes and surgical setup between the “dirty” and “clean” parts of the procedure. Theoretically, this operation could decrease contamination of the surgical site [ 27 ]. The exchange of modular components is another intraoperative measure that theoretically reduces biofilm presence and improves debridement of the intraarticular space, especially in knee PJIs, where polyethylene removal allows access to the posterior capsule [ 28 ].…”

“…All surgeries were conducted by the first and senior authors (DDM and CV) with the same surgical equipment and the same debridement and irrigation protocol, beginning with previous scar excision, especially in postoperative cases. A methylene blue dye injection was performed before capsulotomy directly into the joint space to facilitate debridement [ 27 ]. If a sinus tract was present, a methylene blue dye injection was performed to guide the fistulectomy.…”

Editorial: Management of PJI/SSI after joint arthroplasty

“…This infection was successfully managed using the DAIR, underlining the importance of considering both common and rare pathogens in the differential diagnosis of PJI. Further emphasizing the effectiveness of the DAIR method, Spangehl et al [ 30 ]. argued for its use as a first-line treatment for acute PJI, subject to appropriate technical considerations and patient selection.…”