Review Article

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A guide to debridement, antibiotics, and implant retention

Kenneth Vaz, Adrian Taylor, Ben Kendrick, Abtin Alvand

Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Oxford, UK
Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV)
Collection and assembly of data: None; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final approval of
manuscript: All authors.
Correspondence to: Abtin Alvand, PhD, FRCS (Tr&Orth). Consultant Orthopaedic Surgeon and Senior Clinical Lecturer, Nuffield Orthopaedic
Centre and University of Oxford, Botnar Research Centre, Old Road, Oxford, OX3 7LD, UK. Email: [email protected].

Abstract: Debridement, antibiotics, and implant retention (DAIR) is an alternative management strategy
for the treatment of periprosthetic joint infection (PJI). While infection eradication rates are lower with
DAIR, the benefits including decreased morbidity, improved functional outcomes, and decreased cost may
justify the risks when considering this form of treatment compared to traditional one or two stage exchange
arthroplasty. Implant longevity in the setting of a successful DAIR is similar to matched patients who have
not experienced a PJI. An experienced arthroplasty surgeon well versed in extensile exposure should perform
the DAIR. This procedure should not be viewed as a simple “washout.” While PJI may be considered a
surgical urgency, DAIR can be performed on a planned list if it allows for appropriate staffing and implants
for the procedure. Arthroscopic irrigation may be performed for a patient in extremis but it should not be
viewed as a definitive procedure to address PJI. Keys to a successful DAIR include accurate tissue sampling to
determine the infective organism, meticulous, radical debridement, and exchange of modular components if
possible. A multidisciplinary team (MDT) including an infectious disease specialist should be involved prior
to surgery in order to guide appropriate antimicrobial therapy throughout the patient’s course of treatment.
In the article below we present our indications, considerations, and technique for performing a DAIR for PJI
for hip and knee arthroplasty.

Keywords: Periprosthetic joint infection (PJI); total hip arthroplasty; total knee arthroplasty

Received: 01 June 2020; Accepted: 01 September 2020; Published: 15 January 2022.

doi: 10.21037/aoj-20-89
View this article at: http://dx.doi.org/10.21037/aoj-20-89

Introduction without a draining sinus (3).

Despite its benefits, DAIR has demonstrated inferior
Periprosthetic joint infection (PJI) is a devastating
infection eradication when compared to staged revision
complication associated with hip and knee arthroplasty.
surgery (1,5). Given these findings, there are a number of
Likelihood of successful treatment of PJI is multifactorial relative contraindications to DAIR that include chronic
with temporal, patient, and implant factors (1-8). While infection, infection with multi-drug resistant organisms,
2-stage revision surgery is often viewed as the gold polymicrobial infections, and fungal organisms (5,11).
standard treatment for PJI, “debridement, antibiotics, and While the decreased infection eradication rate may be
implant retention” (DAIR) has been advocated as a viable partially attributable to the aforementioned factors, it is
treatment due to the reduced morbidity and costs, and important to note that appropriate surgical technique for
improved function with equivalent implant longevity when DAIR is essential to maximizing the likelihood of success
successful (9,10). To perform a DAIR the patient must have (12,13). However, there is difficulty in analyzing the
a well-fixed implant that was functioning well prior to the existing literature due to the heterogeneous nature of what
infection, a known organism, and good quality soft tissues is perceived as constituting a DAIR. This review will discuss

© Annals of Joint. All rights reserved. Ann Joint 2022;7:5 | http://dx.doi.org/10.21037/aoj-20-89

Page 2 of 5 Annals of Joint, 2020

accurately identify the causative organism(s), thus to

optimise post-operative antibiotic therapy, and to eradicate
the infection. We recommend gaining samples in the
first portion of the operation to minimize the chance of
contamination through delayed exposure. In practice
however, the exposure required to access all parts of the
joint forms a large part of the debridement.
A “no-touch” sampling technique should be used to
prevent contamination of microbiological samples to ensure
appropriate culture directed antibiotics. Each sample is
obtained with a new set of clean instruments to minimize
Figure 1 Standard sampling tray. A clean forceps and knife are used risk of contamination (Figure 1). Once samples are obtained,
for each individual sample to minimize risk of cross-contamination. antibiotics can be administered per pre-operative consultation
with infectious disease specialists. A total of 5 or 6 paired
samples should be sent to microbiology and histology. This
the technical aspects of DAIR procedure with particular is the optimum number that has been shown to obtain the
reference to hip and knee arthroplasty. The principles can greatest yield in terms of diagnostic accuracy (14).
be applied to any PJI as the basic principles are universally All modular components should be exchanged whenever
applicable. We will also cover joint specific issues in hip possible in order to reduce bioburden, gain access to all
and knee arthroplasty. aspects of well-fixed implants, and allow exposure for
a radical synovectomy. Given improved outcomes with
modular exchange as opposed to leaving implants in-
General principles situ, preoperative planning, including obtaining previous
First and foremost, DAIR should not be viewed as a simple operative reports is necessary to ensure appropriate new
“washout” and left to a junior member of the team to be modular implants are available prior to intervention (9).
Care should also be taken in complex constructs, e.g. hinged
performed out of hours. It should be viewed as a formal
knee replacement or constrained acetabular liners, to ensure
revision procedure and performed by an experienced
the equipment is available to disassemble the construct
arthroplasty surgeon on a planned surgical list where
safely without damage to the remaining components.
possible. Furthermore, arthroscopic intervention should
Generous lavage of the joint cavity is undertaken to
not be considered a definitive treatment for PJI as multiple
further minimize bioburden. In the setting of a DAIR we
studies have demonstrated that it has a significantly higher
typically use a minimum of 5 litres of 0.05% chlorhexidine
rate of failure compared to formal open DAIR (5). In
gluconate (CHG) as our irritant as it has been shown to be
rare circumstances when a patient is in extremis due to
more effective at reducing biofilm in vitro when compared
sepsis, emergency arthroscopic washout may be used as
with saline lavage (15). We also typically utilize a 3-minute
a temporizing lifesaving measure for a patient that is not minimum dilute 0.35% povidone-Iodine (PI) soak as
medically well enough to undergo a formal DAIR or the previously described in the primary setting (17.5 mL of
relevant experienced surgical team are not available. This sterile 10% PI for every 500 mL of normal saline lavage) (16).
will enable stabilization of the patient in order to plan Absorbable antibiotic loaded calcium phosphate
DAIR or formal revision surgery on a planned list. pellets can be used as an additional adjunct allowing local
There are several important surgical principles that are concentrations of antibiotics in the joint cavity significantly
common to both hip and knee DAIR. Adequate exposure, higher than the minimum bactericidal concentration (17).
including extensile exposure if needed, should allow for Topical delivery of antibiotics from these beads over several
evaluation of the entire prosthetic-bone interface. If the weeks potentially lyse remaining bacteria even if protected
implants are loose or compromised, then DAIR should by remnant biofilm (18). The pellets soften and have not
be abandoned and the surgeon should proceed with 1- or demonstrated significant 3rd body wear (19). The joint
2- stage revision. capsule can be closed over a deep drain to manage any dead
The operative technique has two important aims. To space. We have utilized drains with less frequency given the

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Annals of Joint, 2020 Page 3 of 5

A B

Figure 2 Synovectomy being performed first of the suprapatellar pouch (A) and then the peripatellar space, fat pad, and lateral gutter (B).

routine use of tranexamic acid and to minimize loss of local a soft nailbrush with CHG to disrupt any biofilm.
antibiotics eluted from the calcium sulfate beads (20). While we routinely use CHG pulsatile lavage in the
Antibiotic coated absorbable suture is utilized deep setting of a total knee replacement, in the setting of
for closure to minimize colonization of remnant foreign unicompartmental knee replacement (UKR), the surgeon
material. Depending on patient factors a closed incision should consider plain saline wash with gravity flow to
negative pressure wound dressing may also be utilized to aid avoid potential chemical or mechanical damage to retained
in wound healing (21). cartilage surfaces in other compartments.
Broad-spectrum antibiotics are commenced after tissue After a thorough debridement and lavage the joint cavity
sampling and continued in consultation with infectious is then packed with lap sponges soaked in dilute betadine
disease specialists. to prevent undue damage to the femoral and tibial articular
surfaces. The surgical incision can either be provisionally
closed or covered with a sterile occlusive dressing. The
Knee
surgeon and staff should then rescrub. The limb should
The joint is aspirated following skin incision but prior to be reprepped and redraped. Clean instruments should be
arthrotomy of the joint capsule to reduce the risk of skin opened.
contamination. Care must be taken not to insert the suction The cavity is washed with at least three more litres of
catheter into the joint after the arthrotomy is made in order lavage and any remaining suspect tissue is debrided. Trialing
to avoid contamination of samples. Paired samples are of modular components can be undertaken before selection
systematically taken from the suprapatellar pouch, medial and implantation of new components. It is then possible to
and lateral gutters, posterior capsule, and prosthetic-bone proceed with closure as described previously.
membrane.
A radical synovectomy is then performed of the
Hip
suprapatellar recess, medial, and lateral gutters (Figure 2).
This debridement also allows for improved exposure. Care DAIR should ideally be performed through the same
should be taken to preserve the collateral ligaments if a approach that was previously utilized to minimize further
hinged implant is not in place. The implant-bone interface contamination of soft tissues and to avoid potential for
should be thoroughly debrided to evaluate whether the increased hip instability but only if the surgeon is experienced
components are still well-fixed. enough to perform exposure as needed through that
The joint cavity is then irrigated with at least five litres particular approach. The hip joint is then aspirated after
of lavage and the implant surfaces should be scrubbed with dissection down to the capsule prior to arthrotomy. Paired

© Annals of Joint. All rights reserved. Ann Joint 2022;7:5 | http://dx.doi.org/10.21037/aoj-20-89

Page 4 of 5 Annals of Joint, 2020

samples are then taken from the posterior capsule, anterior chosen antibiotics should be the best broad-spectrum choice
capsule and the bone-implant interface of the femoral for the relevant population and the common organisms
and acetabular components. The hip is dislocated and the seen in that cohort. Antibiotics are typically narrowed
modular femoral head and acetabular liner are removed in if gram-negative organisms have not been isolated after
order to gain full access to the remaining components. The 48–72 hours. A definitive antibiotic plan including duration
fifth sample is taken from behind the removed liner (if a can be made after extended cultures are completed. Post-
modular cementless component is in situ). operative oral or intravenous antibiotic therapy is typically
A thorough synovectomy is then performed until the for three months. When possible we use oral antibiotics as
entirety of the acetabular and femoral bone-component they have demonstrated similar efficacy in the treatment of
interfaces can be inspected. It can be difficult to establish PJI and osteomyelitis with significantly increased ease of
whether a cementless component should be kept or a formal administration and cost (22). The use of a multidisciplinary
revision undertaken as there can be significant proximal team (MDT) can help to further ensure consistent
membrane with distal fixation. A pragmatic approach is to outcomes and has even demonstrated improved infection
use a scalpel blade pushed into the implant/bone interface. eradication when utilized for two-stage exchange and
If solid fixation is encountered the stem can be retained should be consulted for all cases of confirmed and suspected
as adequate debridement of the interface can be achieved. PJI (23).
If the interface is deeper than the blade length then
explantation should be considered.
Acknowledgments
The trunnion and acetabular shell are then scrubbed with
a soft nail brush with CHG to disrupt any possible biofilm. Funding: None.
If there is significant trunnion damage or damage to the
acetabular shell then DAIR should be abandoned in favor of
Footnote
1- or 2-stage revision. The joint cavity is then irrigated with
at least five liters of lavage followed by a dilute 0.35% PI Provenance and Peer Review: This article was commissioned
soak. by the Guest Editors (Nemandra A Sandiford, Massimo
After a thorough debridement and lavage the joint Francescini and Daniel Kendoff) for the series “Prosthetic
cavity is packed with lap sponges soaked in dilute 0.35% Joint Infection” published in Annals of Joint. The article has
PI to maintain the joint space and minimize damage to the undergone external peer review.
trunnion and inner acetabular shell. The surgical incision
is then either provisionally closed or covered with a sterile Conflicts of Interest: All authors have completed the ICMJE
occlusive dressing. The surgeon and staff should then uniform disclosure form (available at http://dx.doi.
rescrub. The limb should be reprepped and redraped. org/10.21037/aoj-20-89). The series “Prosthetic Joint
Clean instruments should be opened. The cavity is Infection” was commissioned by the editorial office without
washed with three more liters of lavage and any remaining any funding or sponsorship. The authors have no other
suspect tissue is debrided. A trial liner and head can then conflicts of interest to declare.
be placed to reassess for hip stability with final implants
then seated in place. Larger bearings, dual mobility, or Ethical Statement: The authors are accountable for all
constrained options may need to be considered depending aspects of the work in ensuring that questions related
on patient factors and modularity available in the implant to the accuracy or integrity of any part of the work are
system used. We then proceed with closure as described appropriately investigated and resolved.
previously.
Open Access Statement: This is an Open Access article
distributed in accordance with the Creative Commons
Conclusions
Attribution-NonCommercial-NoDerivs 4.0 International
DAIR is an attractive option in the treatment of PJI but License (CC BY-NC-ND 4.0), which permits the non-
surgical technique is essential to ensuring success both in commercial replication and distribution of the article with
terms of minimizing bioburden and allowing for accurate the strict proviso that no changes or edits are made and the
microbiology to treat with appropriate antibiotics. The original work is properly cited (including links to both the

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Annals of Joint, 2020 Page 5 of 5

formal publication through the relevant DOI and the license). Infection: Epidemiology, Diagnosis and Treatment. Knee
See: https://creativecommons.org/licenses/by-nc-nd/4.0/. Surg Relat Res 2017;29:155-64.
14. Atkins BL, Athanasou N, Deeks JJ, et al. Prospective
Evaluation of Criteria for Microbiological Diagnosis of
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© Annals of Joint. All rights reserved. Ann Joint 2022;7:5 | http://dx.doi.org/10.21037/aoj-20-89