The Double DAIR: A 2-Stage Debridement with Prosthesis-Retention Protocol for Acute Periprosthetic Joint Infections
Authors: McQuivey Kade S. , Bingham Joshua , Chung Andrew , Clarke Henry , Schwartz Adam , Pollock Jordan R. , Beauchamp Christopher , Spangehl Mark J. 
Published: February 2021

Background:
Debridement and implant retention (DAIR) has variable success as a treatment for acute periprosthetic joint infection (PJI), with generally poor outcomes reported in the literature
1
. Because of the unacceptably high failure rate of DAIR, we implemented a 2-stage debridement protocol that includes the use of high-dose antibiotic beads between stages for the treatment of acute PJI. In 2 previous studies, with an average follow-up of 3.5 years in each study, we reported overall infection-control rates of 87% and 90%
2,3
.

Description:
Following exposure of the joint, cultures are obtained, and all modular components are removed, scrubbed, and soaked in an antiseptic solution. A thorough irrigation and debridement with complete synovectomy is performed, followed by temporary reinsertion of the original modular parts. High-dose antibiotic cement beads are inserted into the joint, and the joint is closed. Approximately 5 to 6 days later, a second debridement is performed, the beads are removed, and the new modular, sterile components are implanted. The patient is placed on a course of intravenous and, later, oral antibiotics, in addition to a standard postoperative rehabilitation protocol.

Alternatives:

Long-term suppressive antibiotic therapy.One-stage DAIR.One-stage exchange arthroplasty.Two-stage exchange arthroplasty.Resection arthroplasty.Amputation.

Rationale:
The treatment of acute PJI has historically consisted of a single irrigation and debridement, with exchange of modular parts and retention of the components, followed by intravenous antibiotic therapy. Despite having lower rates of patient morbidity compared with a 2-stage exchange arthroplasty, this more traditional procedure also has a higher rate of failure, with reported rates as high as 60% to 84%
4–12
. The utility of component retention continues to be a topic of debate
13
. Alternatives to component retention include both 1- and 2-stage exchange procedures. Although these modalities offer potentially higher rates of infection control, they are associated with substantial patient morbidity, particularly in patients with well-fixed implants
14–16
. Furthermore, exchange procedures may result in substantial iatrogenic bone loss, which can be problematic in revision total joint arthroplasty procedures, in which bone stock may already be limited. The double-DAIR protocol offers infection-control rates that are comparable with those of component-exchange procedures, but with the lower patient morbidity associated with component-retention procedures. Furthermore, the double-DAIR procedure provides the added benefit of retaining important bone stock.

Expected Outcomes:
The success rate for the double-DAIR procedure has been reproducible, with infection-control rates of 87% and 90% reported in 2 studies from a single cohort at our institution
2,3
. These rates represent a substantial improvement compared with a single irrigation and debridement
1
, and are on par with those reported for 2-stage exchange arthroplasty procedures
17–21
. The infection-control rates of the double-DAIR procedure did not significantly vary depending on whether infection occurred following a total knee or total hip arthroplasty. However, not surprisingly, patients who underwent debridement following a revision procedure had a lower rate of success (77.1% successful infection control) compared with patients debrided following a primary procedure (93.8% successful infection control). We could not demonstrate an association with organism and success or failure of treatment.
Although not significant, there was a trend toward an association between the time from symptom onset to initial treatment and infection control (p = 0.07)
2
. Patients with successful infection control underwent the initial debridement an average of 6.2 days after symptom onset, compared with 10.7 days in patients in whom treatment had failed. Several other studies have demonstrated that successful infection control is associated with earlier initial irrigation and debridement
22–27
. We strongly support that, in the setting of confirmed acute PJI, prompt initiation of treatment optimizes the chances for successful infection control.

Important Tips:

Thorough debridement is key to successful infection control of infection.Antibiotic-loaded bone cement has repeatedly been demonstrated to be safe, and we recommend its use
28–31
.Extended oral antibiotics following debridement with component retention can increase infection-free survivorship
32
.