Impact of a Prior Debridement, Antibiotics, and Implant Retention on Outcomes of Two-Stage Exchange Knee Arthroplasty in Periprosthetic Joint Infection.

Abstract

In periprosthetic joint infection (PJI), prior studies evaluating failed debridement, antibiotics, and implant retention (DAIR) before two-stage exchange arthroplasty report conflicting outcomes and exclude cases that were initially successfully treated with DAIR. This study (1) compared success rates of two-stage exchange arthroplasty with and without a preceding failed DAIR and (2) evaluated overall success rates between these two groups when initial DAIR patients who were initially successful were included in the analysis. This multihospital retrospective cohort study evaluated patients diagnosed with PJI ≥ one year after primary total knee arthroplasty (TKA) and who received initial DAIR or two-stage between 2015 and 2022. All patients met Musculoskeletal Infection Society (MSIS) or 2018 International Consensus Meeting (ICM) criteria. We excluded patients who had prior PJI in the same joint or those who underwent more than one DAIR or two-stage exchange arthroplasty. Patients were categorized based on initial treatment: DAIR (n = 94) or two-stage exchange (n = 99). A subset of the DAIR cohort who later required a two-stage exchange due to failure (n = 22) was analyzed separately. Treatment success was defined as no reoperation and an MSIS Tier 1 or 2 outcome. Statistical analyses included t-tests, Chi-squares, Kaplan-Meier survival curves, and Cox proportional hazards models adjusted for key covariates (P < 0.05). Prior DAIR for acute PJI was not significantly associated with reduced success rates when comparing primary two-stage exchange arthroplasty to two-stage exchange arthroplasty following failed DAIR (P = 0.21), though 24-month survival probability was consistently lower. Similarly, when initial DAIR successes were included in this analysis, there were no statistical differences in survival, although success rates favored two-stage exchange arthroplasty (P = 0.27). Our results suggest that, when PJI appears acute, DAIR should be completed. While the success rate of DAIR may be low, it does not appear to substantially impact the success of subsequent two-stage exchange arthroplasty.