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Objective:To analyze the risk factors leading to the failure of early periprosthetic joint infection (PJI) treated by debridement, antibiotics and implant retention (DAIR) combined with intra-articular injection of antibiotics.Methods:A total of 100 patients who received DAIR combined with intra-articular injection of antibiotics between January 2010 and October 2020 in the Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, were retrospectively analyzed. There were 47 males and 53 females, with an average age of 62.8±13.0 years (26-84 years). 75 patients were diagnosed as PJI after primary surgery while 25 PJI after revision or debridement, involving 41 hips and 59 knees. According to the clinical outcomes, the patients were divided into the cured group (78 cases) and the uncured group (22 cases). Risk factors were screened by univariate analysis on their gender, age, body mass index, site of infection (hip/knee), synovial white blood cell count, erythrocyte sedimentation rate (ESR), C reactive protein (CRP), time of infection, types of pathogenic bacteria (gram-positive bacteria, gram-negative bacteria or fungi), preoperative sinus tract and previous surgical history. For the factors with P<0.20, multivariate binary logistic regression analysis was performed to determine the independent risk factors. Kaplan-Meier survival curve was drawn and any cause that led to treatment failure was seen as the end point event. Calculate prosthetic survival time and 10-year survival rate. Results:The average follow-up was 59.8±40.6 months (0.3-129.0 months). The infection control rate of DAIR combined with intra-articular injection of antibiotics in the treatment of early PJI was 78% (78/100). The univariate analysis showed that the successful rate of non-fungal infection group (81%, 77/95) was significantly higher than the fungal infection group (20%, 1/5) and the successful rate of the group without previous surgical history (85.3%, 64/75) was significantly higher than that with previous surgical history (56.0%, 14/25, χ 2=7.07, P=0.008; χ 2=9.40, P=0.002). The multivariate binary Logistic regression analysis showed that fungal infection [ OR=0.08, 95% CI(0.01, 0.79), P=0.031] and history of previous surgical intervention [ OR=0.25, 95% CI(0.09, 0.73), P=0.001] were independent risk factors for treatment failure. Kaplan-Meier survival curves showed that the survival time of the prosthesis was 96.83±5.30 months, and the 10-year survival rate was 68.1%. Meanwhile, the survival rate of patients with fungal infection and previous surgical history was significantly lower than that of patients without fungal infection or previous surgical history, the difference was statistically significant (χ 2=15.49, P<0.001; χ 2=8.91, P=0.030). Conclusion:The time of PJI, bacterial virulence and species, and preoperative inflammatory indicators had no effect on the outcome of DAIR combined with intra-articular injection of antibiotics in the treatment of early PJI. However, DAIR was not recommended for patients with a history of surgical intervention and fungal infection.
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Periprosthetic joint infection （PJI） following joint arthroplasty is devastating and technique-demanding. At present， the surgical treatment for PJI includes debridement， antibiotics， and implant retention （DAIR）， single- or two-stage revision， arthrodesis， and amputation. DAIR is appealing to both surgeons and patients as it can avoid unnecessary implants removal， making it less time-consuming and less invasive. In this article， we review the current knowledge in surgical timing， intraoperative details and antibiotics strategy of DAIR.
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BACKGROUND: Compared with revision surgery, debridement antibiotics irrigation and implant retention for treatment of periprosthetic joint infection has the advantages of fewer traumas, shorter time, and lower cost. However, the indications and perioperative management are still controversial. OBJECTIVE: To review the application of preoperative indication, intraoperative operation and postoperative antibiotic application of debridement antibiotics irrigation and implant retention for the periprosthetic joint infection. METHODS: PubMed, Web of Science, Embase, and The Cochrane Library database were retrieved from 2000 to 2018. The key words were “total knee arthroplasty, periprosthetic joint infection, diagnose, treatment”. Chinese literature was searched in the Wanfang database and CNKI from 2000 to 2018, and the keywords were “arthroplasty, postoperative infection, debridement antibiotics irrigation and implant retention”. Relevant literatures were screened, and the success rate of retained prosthesis in the treatment of infection after joint replacement was counted. The most accurate diagnostic criteria and the most effective treatment methods were summarized. RESULTS AND CONCLUSION: At present, there is no unified international standard for the diagnosis of periprosthetic joint infection after joint replacement. Many organizations have put forward some consensus and guidelines. Parvizi et al. proposed new diagnostic criteria for periprosthetic joint infection based on other consensus and guidelines, which is highly sensitive and specific, and has been accepted by most people. Debridement antibiotics irrigation and implant retention is suitable for patients with stable and well-fixed prosthesis, short symptom duration, good soft tissue, and no sinus tract formation. During the operation, the infected necrotic tissue and the suspected infected tissue should be thoroughly removed. The iodine-blood water should be soaked for half an hour; the new gasket should be replaced; and the sterilized towel should be replaced with a new set of surgical tools. According to the results of postoperative culture, sensitive antibiotics were combined and rifampin was taken orally out of hospital for 4 months. Debridement antibiotics irrigation and implant retention is the best method for the treatment of periprosthetic joint infection, and has the advantages of less pain, less cost, high acceptance and avoiding revision.