Does a DAIR procedure or staged revision surgery provide better outcomes for PJI?
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DAIR is viable treatment for acute PJI
PJI is a dreaded complication of primary and revision total joint arthroplasty, with an estimated incidence of 1% to 2% in primary arthroplasty and up to 10% in revision procedures.
The occurrence of PJI has been found to be associated with an increased risk of mortality and morbidity in both total hip and total knee arthroplasty and poses a significant public health challenge. With an expected increase in the demand for THA and TKA in the coming decade, the number of associated PJIs is also projected to rise. To further complicate matters, the diagnosis and treatment of PJI is challenging with no currently existing gold-standard test or treatment guideline consensus.
Acute PJI is usually treated either with DAIR (debridement, antibiotics and implant retention; with or without modular component exchange) or implant revision (one- or two-stage). Although DAIR is associated with highly variable success rates (30% to 80%), we recently reported that DAIR with modular component exchange was successful in treating selected patients with acute hematogenous PJI. Similarly, acute culture-negative PJI treated with DAIR and modular component exchange was found to have reinfection rates similar to culture-positive PJI, making DAIR and modular component exchange a viable treatment option for both techniques. Alternatively, two-stage revision may be considered in cases with culture-negative PJI, as it has been shown to have a high success rate (70% to 95%) in these patients. However, two-stage revisions have also been found to be associated with high patient morbidity and mortality.
Conversely, DAIR has a limited role in the treatment of chronic PJI due to the formation of biofilm. Two-stage revision is considered the gold standard of treatment for chronic PJI; however, our recent study reported that one-stage revision is associated with superior functional outcomes vs. two-stage revision, with similar clinical outcomes reinfection and mortality rates in selected patients. Furthermore, we reported one-stage revision is equally effective in the treatment of chronic culture-negative PJI as a two-stage revision procedure. This suggests that culture negativity might not be an absolute contraindication to one-stage revision in select patients. However, two-stage revision is the mainstay of treatment in cases of significant soft tissue compromise and multi-resistant organisms.
In conclusion, DAIR with modular component exchange is a viable treatment option for acute PJI. In chronic PJI, one-stage revision is associated with superior functional outcomes with reinfection and mortality rates that are similar to two-stage revision in selected patients.
- References:
- Aggarwal VK, et al. Indian J Orthop. 2013;doi:10.4103/0019-5413.106884.
- Berend KR, et al. Clin Orthop Relat Res. 2013;doi:10.1007/s11999-012-2595-x.
- Boddapati V, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2017.09.021.
- Charette RS, et al. Curr Rev Musculoskelet Med. 2018;doi:10.1007/s12178-018-9495-y.
- Chen W, et al. J Am Acad Orthop Surg. 2021;doi:10.5435/JAAOS-D-20-00939.
- Goswami K, et al. Curr Rev Musculoskelet Med. 2018;doi:10.1007/s12178-018-9513-0.
- Kildow BJ, et al. J Clin Med. 2022;doi:10.3390/jcm11061657.
- Kurtz SM, et al. Clin Orthop Relat Res. 2010;doi:10.1007/s11999-009-1013-5.
- Sloan M, et al. J Bone Joint Surg Am. 2018;doi:10.2106/JBJS.17.01617.
- Staats A, et al. Ann Jt. 2021;doi:10.21037/aoj-20-85.
- Tirumala V, et al. Arch Orthop Trauma Surg. 2021;doi:10.1007/s00402-021-03810-6.
- Tirumala V, et al. J Arthroplasty. 2021;doi:10.1016/j.arth.2020.08.065.
- van den Kieboom J, et al. Bone Joint J. 2021;doi:10.1302/0301-620X.103B.BJJ-2020-1480.R2.
- Wildeman P, et al. Clin Orthop Relat Res. 2021;doi:10.1097/CORR.0000000000001838.
Young-Min Kwon, MD, PhD, is a professor at Harvard Medical School and vice chair of the department of orthopedic surgery at Massachusetts General Hospital in Boston.
Treatment depends on indications
There are several accepted treatments for PJI. Each surgery is associated with its own unique benefits and challenges, in addition to having specific indications.
Open DAIR minimizes the morbidity of implant removal and subsequent surgeries, when successful. However, indications for DAIR are limited and include: (1) early postoperative PJI; (2) acute hematogenous PJI, defined as symptoms present less than 3 to 4 weeks; and (3) a stable implant with appropriate soft tissue for coverage. Risk factors for failure of DAIR include hematogenous PJI, diabetes, MRSA, pseudomonas and polymicrobial infections.
A double DAIR procedure may be indicated when patients meet indications for a component exchange procedure but cannot medically tolerate such an invasive surgery. This procedure offers infection control rates that are comparable to component exchange procedures, but with the added benefit of lower patient morbidity. Indications for double DAIR include those for DAIR, plus revision of mega prosthesis infection with limited bone stock where implant removal would lead to a compromised extremity.
One-stage exchange arthroplasty offers one surgical procedure, a shorter recovery and decreased patient burden and cost. Indications for one-stage procedures include positively identified pathogens and antibiotic sensitivities, and sufficient bone stock with adequate soft tissue coverage. In circumstances where a patient is medically unable to tolerate a second revision procedure, a 1.5-stage procedure may be performed. A recent study reported no significant differences in reinfection, reoperation or success rates between the 1.5-stage and two-stage revision TKA cohorts.
Two-stage exchange arthroplasty is the most widely used technique for chronic PJI, especially in cases involving fungal, polymicrobial and resistant bacteria. Disadvantages of this procedure include increased cost, second procedure morbidity, joint contractures and decreased quality of life. Because previous studies have failed to show any statistically significant differences in reinfection rates for one- vs. two-stage revisions, there are currently two ongoing trials that will answer this question and hopefully provide better guidance on how patients will benefit from each available procedure to treat PJI.
- References:
- McQuivey KS, et al. JBJS Essent Surg Tech. 2021;doi:10.2106/JBJS.ST.19.00071.
- Shohat N, et al. J Bone Joint Surg Am. 2019;doi:10.2106/JBJS.18.00381.
- Siddiqi A, et al. J Arthroplasty. 2019;doi:10.1016/j.arth.2019.07.007.
Carlos A. Higuera, MD, and Justin Limtong, DO, are from Cleveland Clinic Florida in Weston, Florida.
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