Impact of Intervention Timing on the Failure of Debridement, Antibiotics, and Implant Retention for Acute Postoperative Periprosthetic Joint Infections: A Contemporary United States Population-Level Analysis.

Abstract

Time to intervention is a critical determinant of failure after debridement, antibiotics, and implant retention (DAIR) in acute postoperative periprosthetic joint infection (PJI). While International Consensus Meeting (ICM) guidelines have expanded the recommended therapeutic window for DAIR from four to six weeks, emerging European data suggest extension to 12 weeks. This study evaluated the association between DAIR timing and treatment failure after primary total hip (THA) and knee (TKA) arthroplasty, leveraging a large United States database to identify an optimal timing threshold. This was a retrospective cohort study using a national claims database (2010 to 2023) of adults who had an acute postoperative PJI undergoing DAIR within 12 weeks of primary THA or TKA. Patients were stratified into two-week intervals (≤ four weeks as reference). Treatment failure was defined as any septic surgical intervention within two years. Multivariable logistic regressions adjusted for demographic and clinical factors. Segmented (joinpoint) regressions identified an inflection point of risk as a threshold for DAIR timing. Among 7,795 DAIR procedures, failure rates were similar at ≤ four weeks (37.7%) and four to six weeks (40.1%; P = 0.06), but increased significantly thereafter: six to eight weeks (45.2%), eight to 10 weeks (50.4%), and 10 to 12 weeks (55.2%) (all P < 0.001). Adjusted odds of failure were stable at four to six weeks (aOR 1.08; 95% confidence interval (CI) 0.94 to 1.25), but rose progressively, peaking at 10 to 12 weeks (aOR 2.12; 95% CI 1.73 to 2.58). Joinpoint regression identified an inflection point at approximately seven weeks post-arthroplasty, beyond which risk accelerated significantly. Joint-specific analyses demonstrated that this effect was driven by TKA, which showed progressively higher failure with increasing time to DAIR. Our findings show DAIR efficacy for acute postoperative PJI is time-dependent. While outcomes remain stable through approximately seven weeks after index arthroplasty, interventions beyond this threshold are associated with a disproportionate increase in failure risk. Our findings are in general agreement with the recommendations of the 2025 ICM.