JOA - 2026-03-17 - Journal Article
Impact of a Prior Debridement, Antibiotics, and Implant Retention on Outcomes of Two-Stage Exchange Knee Arthroplasty in Periprosthetic Joint Infection.
Cisneros CL, Shannon MF, Heimroth J, Wong VR, Frear AJ, Gordon AC, Williams AA, Carlos NBT, Osifo SE, Baldoni PL, Ma Y, Urish KL
Topics
Key Takeaway
Failed DAIR prior to two-stage exchange TKA did not significantly reduce two-stage success rates (P=0.21), though 24-month survival probability was consistently lower in the failed-DAIR group.
Summary Depth
Choose how much analysis to show on this article page.
Summary
This multihospital retrospective cohort compared two-stage exchange TKA success in patients with chronic PJI (≥1 year post-primary TKA) treated with primary two-stage versus two-stage following failed DAIR, using MSIS/2018 ICM diagnostic criteria and MSIS Tier 1-2 success definitions. No statistically significant difference in treatment success was found between primary two-stage and post-failed-DAIR two-stage groups (P=0.21), nor when initial DAIR successes were incorporated into the survival analysis (P=0.27). Despite non-significance, 24-month survival probability was consistently lower in the failed-DAIR cohort, suggesting a clinically meaningful trend not captured by the available sample size.
Key Limitation
The failed-DAIR-to-two-stage subgroup (n=22) is critically underpowered, and the consistently lower 24-month survival probability in this group suggests the study lacks statistical power to distinguish clinical equivalence from a true but undetected difference in outcomes.
Original Abstract
BACKGROUND
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 initially successful DAIR cases. This study (1) compared two-stage exchange arthroplasty success with and without a preceding failed DAIR and (2) evaluated outcomes with initially successful DAIR cases included.
METHODS
This multihospital retrospective cohort study evaluated patients with PJI ≥ one year after primary total knee arthroplasty treated with initial DAIR or two-stage between 2015 and 2022. All patients met Musculoskeletal Infection Society (MSIS) or 2018 International Consensus Meeting criteria. We excluded patients who had prior PJI in the same joint or those who underwent more than one DAIR or two-stage exchange prior. Patients were categorized based on initial treatment: DAIR (n = 94) or two-stage exchange (n = 99). A subset of the DAIR cohort requiring later two-stage exchange (n = 22) was analyzed separately. Treatment success was defined as no reoperation and a MSIS Tier 1 or 2 outcome. Statistical analyses included t-tests, Chi-squares, Kaplan-Meier curves, and Cox models adjusted for key covariates (P < 0.05).
RESULTS
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-months survival probability was consistently lower. Similarly, when including initial DAIR successes in this analysis, there were no statistical differences in survival, although success rates favored two-stage exchange arthroplasty (P = 0.27).
CONCLUSIONS
Our results suggest that, when PJI appears acute, DAIR should be completed. Although DAIR success may be low, it does not appear to substantially impact the success of subsequent two-stage exchange arthroplasty.