Outcomes of Debridement, Antibiotics, and Implant Retention in the Management of Infected Total Knee Arthroplasty: Analysis of 5,178 Cases from the National Australian Registry

Nicolai K Kristensen; Stuart A Callary; Renjy Nelson; Dylan Harries; Michelle Lorimer; Paul Smith; David Campbell

doi:10.1016/j.arth.2024.12.016

Outcomes of Debridement, Antibiotics, and Implant Retention in the Management of Infected Total Knee Arthroplasty: Analysis of 5,178 Cases from the National Australian Registry

J Arthroplasty. 2024 Dec 20:S0883-5403(24)01318-4. doi: 10.1016/j.arth.2024.12.016. Online ahead of print.

Authors

Nicolai K Kristensen¹, Stuart A Callary², Renjy Nelson³, Dylan Harries⁴, Michelle Lorimer⁴, Paul Smith⁵, David Campbell⁶

Affiliations

¹ Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Orthopedic Surgery, Central Hospital Unit, Denmark; Department of Orthopaedic Surgery, Horsens Regional Hospital, Denmark. Electronic address: [email protected].
² Centre for Orthopaedic and Trauma Research, The University of Adelaide, Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Australia.
³ Department of Infectious Diseases, Royal Adelaide Hospital, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Australia.
⁴ South Australian Health and Medical Research Institute, Adelaide, Australia.
⁵ Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Department of Orthopaedic Surgery, Canberra Hospital, Canberra, ACT, Australia; Trauma and Orthopaedic Research Unit, Australian National University, School of Medicine and Psychology, Canberra, ACT, 2601 Australia.
⁶ Centre for Orthopaedic and Trauma Research, The University of Adelaide, Australia.

PMID: 39710215
DOI: 10.1016/j.arth.2024.12.016

Abstract

Introduction: Periprosthetic joint infection (PJI) is a devastating and severe complication of total knee arthroplasty (TKA). The Australian Joint Registry reports an increasing number of debridement, antibiotics, and implant retention (DAIR) procedures, underscoring the need to comprehend outcomes for informed treatment decisions. This study aimed to determine outcome of DAIR procedures, evaluate time since primary TKA, and identify patient-related factors associated with DAIR failure.

Methods: We conducted a national registry-based cohort study using data from 1999 to 2021. We included 8,642 revisions for infection, of which 5,178 were DAIR procedures (60%) predominantly performed within four weeks of primary surgery. We assessed outcomes using Kaplan-Meier estimates and Cox proportional hazard models.

Results: Post-DAIR, the cumulative percent second revision (CPR) in the DAIR cohort was 20% at year one, increasing to 36% at year 17. Early DAIR procedures had a lower post-DAIR revision rate until three months after primary TKA. A DAIR performed within two weeks after primary TKA compared to three months had a HR [hazard ratio]: 0.74 (95% CI [confidence interval]: 0.62 to 0.88). After four weeks, the post-DAIR revision rate did not deteriorate and was similar for further time periods from the primary. Men had an age-adjusted hazard ratio of 1.28 (95% CI: 1.14 to 1.43, P < 0.001) for DAIR failure compared to women. There was a significantly higher hazard ratio for post-DAIR revision in patients younger than 75 years of age, compared to patients aged ≥ 75 years.

Conclusion: These findings underscore the critical influence of patient-related factors and the timing of DAIR treatment on the need for additional surgery. DAIR after four weeks had an increased risk of subsequent revision, and older women undergoing early DAIR interventions had more favorable outcomes. Understanding these nuances aids in optimizing PJI management strategies, offering insights for decision-making.

Keywords: DAIR; Periprosthetic Joint Infection; Primary Knee Arthroplasty; Revision.