BACKGROUND: Reinfection of a joint prosthesis after a two-stage revision is a serious complication, the risk of which may be higher when the procedure is performed after an unsuccessful debridement, antibiotics, and implant retention (DAIR) procedure. The available evidence is scarce and somewhat contradictory, so new studies are required.
QUESTIONS/PURPOSES: (1) Is two-stage revision performed after a prior unsuccessful DAIR associated with a higher risk of prosthetic joint reinfection compared with patients who had no DAIR but rather proceeded directly to two-stage revision? (2) Does the type of periprosthetic joint infection (PJI) (acute versus chronic) modify this association?
METHODS: We analyzed data from a previous retrospective, case-control study aimed at assessing the risk factors of reinfection of a joint prosthesis treated with two-stage revision in 12 Spanish hospitals between 2009 and 2018. We defined PJI according to the latest criteria published in 2018. We defined "acute PJI" as those occurring early (< 3 months after surgery) and of hematogenous origin and "chronic PJI" as those occurring after 3 months and of nonhematogenous origin. During the period in question, we found 89 cases and selected 171 matched controls. For each case (patients who developed a reinfection of a joint prosthesis within 2 years of reimplantation, based on last internationally accepted consensus criteria), up to two consecutive controls (patients who underwent two-stage revision who did not develop a new infection within 2 years of reimplantation) were included, matched by prosthesis location, center, and year of surgery. There were no differences in age, gender, comorbidities, type of infection, or microbiology between the groups. We analyzed how many patients among cases and controls received a previous DAIR, and we assessed the association of the previous DAIR with reinfection of a joint prosthesis by the OR and its respective 95% confidence interval (CI) obtained through logistic regression, adjusted for potential confounding factors. In addition, we performed a separate analysis depending on whether the PJI was acute or chronic.
RESULTS: After adjusting for potentially confounding variables such as age, sex, Charlson comorbidity index, and antibiotic prophylaxis, we found that two-stage revision performed after a prior unsuccessful DAIR was associated with higher odds of prosthetic joint reinfection compared with direct two-stage revision (adjusted OR 3.5 [95% CI 1.4 to 8.8]; p = 0.008). After adjusting for confounders, we found that the odds of reinfection in two-stage revision were higher after unsuccessful DAIR compared with direct two-stage revision in patients with chronic PJI (adjusted OR 4.0 [95% CI 1.4 to 11.3]; p = 0.009) than they were in patients with acute PJI (adjusted OR 2.2 [95% CI 0.7 to 7.2]; p = 0.2), but the interaction test did not show statistical significance.
CONCLUSION: Unsuccessful DAIR could be associated with a higher risk of reinfection of a joint prosthesis than in direct two-stage revision. Although no difference was found by the type of infection (acute or chronic), the association might be of greater magnitude in patients with chronic PJI, and future studies should focus on this. Although DAIR is a very attractive therapeutic option for PJI, careful selection of candidate patients is essential to avoid compromising the success of a future two-stage revision. Future prospective studies should confirm these findings and evaluate which poor prognostic factors would weigh against performing a DAIR procedure.
LEVEL OF EVIDENCE: Level III, therapeutic study.
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