Articles | Volume 9, issue 5
https://doi.org/10.5194/jbji-9-241-2024
© Author(s) 2024. This work is distributed under
the Creative Commons Attribution 4.0 License.
the Creative Commons Attribution 4.0 License.
https://doi.org/10.5194/jbji-9-241-2024
© Author(s) 2024. This work is distributed under
the Creative Commons Attribution 4.0 License.
the Creative Commons Attribution 4.0 License.
A combined debridement, antibiotics, and implant retention (DAIR) procedure with flap coverage for acute soft tissue defects following total knee arthroplasty: a retrospective study
Laia Boadas-Gironès
CORRESPONDING AUTHOR
Orthopedic Surgery and Traumatology, Hospital Clínic de Barcelona, C/ Villarroel 170, 08036 Barcelona, Spain
Marta Sabater-Martos
Orthopedic Surgery and Traumatology, Hospital Clínic de Barcelona, C/ Villarroel 170, 08036 Barcelona, Spain
Marc Ferrer-Banus
Orthopedic Surgery and Traumatology, Hospital Clínic de Barcelona, C/ Villarroel 170, 08036 Barcelona, Spain
Àlex Soriano-Viladomiu
Infectious Diseases, Hospital Clínic de Barcelona, C/ Villarroel 170, 08036 Barcelona, Spain
Juan Carlos Martínez-Pastor
Orthopedic Surgery and Traumatology, Hospital Clínic de Barcelona, C/ Villarroel 170, 08036 Barcelona, Spain
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Marta Sabater-Martos, Oscar Garcia, Laia Boadas, Laura Morata, Alex Soriano, and Juan Carlos Martínez-Pastor
J. Bone Joint Infect., 10, 41–49, https://doi.org/10.5194/jbji-10-41-2025, https://doi.org/10.5194/jbji-10-41-2025, 2025
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This is a retrospective diagnostic study in acute postoperative prosthetic joint infection in total knee arthroplasty that wants to determine diagnostic accuracy of synovial glucose and serum-to-synovial glucose ratio in acute postoperative infection. Both tests demonstrated good diagnostic potential. Notably, these biomarkers exhibited superior accuracy compared to the combination of C-reactive protein, synovial white blood cell count and polymorphonuclear percentage.
Irene K. Sigmund, Marjan Wouthuyzen-Bakker, Tristan Ferry, Willem J. Metsemakers, Martin Clauss, Alex Soriano, Rihard Trebse, and Ricardo Sousa
J. Bone Joint Infect., 10, 139–142, https://doi.org/10.5194/jbji-10-139-2025, https://doi.org/10.5194/jbji-10-139-2025, 2025
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This is a summary of our position paper on debridement, antimicrobial therapy, and implant retention (DAIR) procedures as a curative treatment strategy for acute periprosthetic hip and knee infections. It includes the defined indications as well as the contraindications of DAIR procedures when eradication/cure is intended, based on the currently available literature.
Irene K. Sigmund, Tristan Ferry, Ricardo Sousa, Alex Soriano, Willem J. Metsemakers, Martin Clauss, Rihard Trebse, and Marjan Wouthuyzen-Bakker
J. Bone Joint Infect., 10, 101–138, https://doi.org/10.5194/jbji-10-101-2025, https://doi.org/10.5194/jbji-10-101-2025, 2025
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In this paper, we discuss the most relevant factors influencing the outcome and define indications, contraindications, and risk factors of a DAIR procedure based on the currently available literature. Furthermore, we discuss the surgical technique in combination with systemic antimicrobial therapy in patients undergoing a DAIR procedure.
Marta Sabater-Martos, Oscar Garcia, Laia Boadas, Laura Morata, Alex Soriano, and Juan Carlos Martínez-Pastor
J. Bone Joint Infect., 10, 41–49, https://doi.org/10.5194/jbji-10-41-2025, https://doi.org/10.5194/jbji-10-41-2025, 2025
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This is a retrospective diagnostic study in acute postoperative prosthetic joint infection in total knee arthroplasty that wants to determine diagnostic accuracy of synovial glucose and serum-to-synovial glucose ratio in acute postoperative infection. Both tests demonstrated good diagnostic potential. Notably, these biomarkers exhibited superior accuracy compared to the combination of C-reactive protein, synovial white blood cell count and polymorphonuclear percentage.
Seung-Jae Yoon, Paul C. Jutte, Alex Soriano, Ricardo Sousa, Wierd P. Zijlstra, and Marjan Wouthuyzen-Bakker
J. Bone Joint Infect., 9, 231–239, https://doi.org/10.5194/jbji-9-231-2024, https://doi.org/10.5194/jbji-9-231-2024, 2024
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This study validated three models for predicting infection after hip and knee replacement surgery. By analyzing data from 2684 patients in the Netherlands, Portugal, and Spain, we found that the models developed by Tan, Del Toro, and Bülow effectively identified high-risk patients. These models can be used to enhance preoperative counseling and to tailor infection prevention measures individually, potentially improving outcomes and reducing healthcare costs.
Marta Sabater-Martos, Marc Ferrer, Laura Morata, Alex Soriano, and Juan Carlos Martínez-Pastor
J. Bone Joint Infect., 9, 17–26, https://doi.org/10.5194/jbji-9-17-2024, https://doi.org/10.5194/jbji-9-17-2024, 2024
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This is a meta-analysis of six studies describing the cutoff values of white blood cell count and polymorphonuclear percentage in synovial fluid for the diagnosis of acute postoperative peri-prosthetic joint infection (PJI).
We found that both the WBC count and PMN percentage are good markers for diagnosis of acute postoperative PJI. However, the synovial WBC count is more powerful in diagnosing acute postoperative PJI.
We found that both the WBC count and PMN percentage are good markers for diagnosis of acute postoperative PJI. However, the synovial WBC count is more powerful in diagnosing acute postoperative PJI.
Christen Ravn, Jeroen Neyt, Natividad Benito, Miguel Araújo Abreu, Yvonne Achermann, Svetlana Bozhkova, Liselotte Coorevits, Matteo Carlo Ferrari, Karianne Wiger Gammelsrud, Ulf-Joachim Gerlach, Efthymia Giannitsioti, Martin Gottliebsen, Nis Pedersen Jørgensen, Tomislav Madjarevic, Leonard Marais, Aditya Menon, Dirk Jan Moojen, Markus Pääkkönen, Marko Pokorn, Daniel Pérez-Prieto, Nora Renz, Jesús Saavedra-Lozano, Marta Sabater-Martos, Parham Sendi, Staffan Tevell, Charles Vogely, Alex Soriano, and the SANJO guideline group
J. Bone Joint Infect., 8, 29–37, https://doi.org/10.5194/jbji-8-29-2023, https://doi.org/10.5194/jbji-8-29-2023, 2023
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Management of septic arthritis in native joints (SANJO) is often conducted by clinicians of different specialties, experience levels, and at all hours of the day. The SANJO guideline group makes evidence-based recommendations for diagnosis, microbiological investigation, initial surgery, empirical antibiotic treatment, early mobilization, evaluation of outcomes, and treatment failure. Special considerations were made for children, tuberculosis, and SANJO after cruciate ligament reconstruction.
Efthymia Giannitsioti, Mauro José Salles, Andreas Mavrogenis, Dolors Rodriguez-Pardo, Ibai Los-Arcos, Alba Ribera, Javier Ariza, María Dolores del Toro, Sophie Nguyen, Eric Senneville, Eric Bonnet, Monica Chan, Maria Bruna Pasticci, Sabine Petersdorf, Natividad Benito, Nuala O' Connell, Antonio Blanco García, Gábor Skaliczki, Pierre Tattevin, Zeliha Kocak Tufan, Nikolaos Pantazis, Panayiotis D. Megaloikonomos, Panayiotis Papagelopoulos, Alejandro Soriano, Antonios Papadopoulos, and the ESGIAI collaborators study group
J. Bone Joint Infect., 7, 279–288, https://doi.org/10.5194/jbji-7-279-2022, https://doi.org/10.5194/jbji-7-279-2022, 2022
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Our multicentre study on a lower-limb osteosynthesis-associated infection (OAI) cohort by multidrug (MDR) and extensively drug (XDR) resistant Gram-negative bacteria found the following: implant retention with debridement was mostly performed in early OAI; 50.9 % of patients achieved remission of infection; remission reached 50 % (MDR) vs. 25 % (XDR) in early OAI and 60 % (MDR) vs. 44.4 % (XDR) in late OAI; age (> 60) and multiple surgeries were independent factors influencing lack of remission.
Ernesto Muñoz-Mahamud, Eduard Tornero, José A. Estrada, Jenaro A. Fernández-Valencia, Juan C. Martínez-Pastor, and Álex Soriano
J. Bone Joint Infect., 7, 109–115, https://doi.org/10.5194/jbji-7-109-2022, https://doi.org/10.5194/jbji-7-109-2022, 2022
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A patient with normal D-dimer value has a low risk of prosthetic joint infection, so serum D-dimer assessment should always be considered as a useful test to rule out chronic prosthetic joint infection (especially in those cases caused by low-virulence microorganisms in which conventional tests may lead to misdiagnosis). Conversely, the platelet count to mean platelet volume ratio may be of limited value for accurately diagnosing prosthetic joint infection.
Karel-Jan Dag François Lensen, Rosa Escudero-Sanchez, Javier Cobo, Rihard Trebše, Camelia Gubavu, Sara Tedeschi, Jose M. Lomas, Cedric Arvieux, Dolors Rodriguez-Pardo, Massimo Fantoni, Maria Jose Garcia Pais, Francisco Jover, Mauro José Costa Salles, Ignacio Sancho, Marta Fernandez Sampedro, Alex Soriano, Marjan Wouthuyzen-Bakker, and ESCMID Study Group of Implant Associated Infections (ESGIAI)
J. Bone Joint Infect., 6, 313–319, https://doi.org/10.5194/jbji-6-313-2021, https://doi.org/10.5194/jbji-6-313-2021, 2021
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Our data suggest that, in periprosthetic joint infection (PJI) patients with a draining sinus, suppressive antibiotic treatment (SAT) can be considered on an individual basis. SAT may reduce pain and favour the closure of the sinus tract in certain individuals, but the prescription of SAT does not appear to have any influence on the prevention of prosthetic loosening and other infectious complications.
Ernesto Muñoz-Mahamud, Jenaro Ángel Fernández-Valencia, Andreu Combalia, Laura Morata, and Álex Soriano
J. Bone Joint Infect., 6, 85–90, https://doi.org/10.5194/jbji-6-85-2021, https://doi.org/10.5194/jbji-6-85-2021, 2021
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A plausible cause of persistent infection after septic hip revision may be the presence of nonviable osteomyelitic bone. We present our initial experience in hip revision for chronic infection in which fluorescent tetracycline bone labeling was used as an additional aid to provide a visual index of surgical bone debridement. In the present series, the use of this technique successfully aided the surgeon to detect the presence of nonviable bone.
Karel-Jan Lensen, Rosa Escudero-Sanchez, Javier Cobo, Alex Soriano, and Marjan Wouthuyzen-Bakker
J. Bone Joint Infect., 6, 43–45, https://doi.org/10.5194/jbji-6-43-2020, https://doi.org/10.5194/jbji-6-43-2020, 2020
Related subject area
Subject: Prosthesis failure | Topic: All topics
Chronic prosthetic joint infections with a draining sinus. Who should receive suppressive antibiotic treatment?
Karel-Jan Lensen, Rosa Escudero-Sanchez, Javier Cobo, Alex Soriano, and Marjan Wouthuyzen-Bakker
J. Bone Joint Infect., 6, 43–45, https://doi.org/10.5194/jbji-6-43-2020, https://doi.org/10.5194/jbji-6-43-2020, 2020
Cited articles
Baertl, S., Rupp, M., Kerschbaum, M., Morgenstern, M., Baumann, F., Pfeifer, C., Worlicek, M., Popp, D., Amanatullah, D. F., and Alt, V.: The PJI-TNM classification for periprosthetic joint infections, Bone Joint Res., 13, 19–27, https://doi.org/10.1302/2046-3758.131.BJR-2023-0012.R2, 2024. a
Corten, K., Struelens, B., Evans, B., Graham, E., Bourne, R. B., and MacDonald, S. J.: Gastrocnemius flap reconstruction of soft tissue defects following infected total knee replacement, Bone Joint J., 95-B, 1217–1221, https://doi.org/10.1302/0301-620X.95B9.31476, 2013. a
Coughlan, A. and Taylor, F.: Classifications in Brief: The McPherson Classification of Periprosthetic Infection, Clin. Orthop. Relat. Res., 478, 903–908, https://doi.org/10.1097/CORR.0000000000001133, 2020. a
Galat, D. D., McGovern, S. C., Larson, D. R., Harrington, J. R., Hanssen, A. D., and Clarke, H. D.: Surgical treatment of early wound complications following primary total knee arthroplasty, J. Bone Joint Surg. Am., 91, 48–54, https://doi.org/10.2106/JBJS.G.01371, 2009. a
Harrison, C., Alvand, A., Chan, J., West, E., Matthews, P., Taylor, A., Giele, H., McNally, M., and Ramsden, A.: The gastrocnemius flap in the management of infected knee prostheses: experience of 115 cases over 21 years in a single centre, Orthop. Proc., 100-B, 21, Supp_17, 2018. a
Hotchen, A. J., Wismayer, M. G., Robertson-Waters, E., McDonnell, S. M., Kendrick, B., Taylor, A., Alvand, A., and McNally, M.: The Joint-Specific BACH classification: A predictor of outcome in prosthetic joint infection, EClinicalMedicine, 42, 10119, https://doi.org/10.1016/j.eclinm.2021.101192, 2021. a
Huotari, K., Peltola, M., and Jämsen, E.: The incidence of late prosthetic joint infections: A registry-based study of 112,708 primary hip and knee replacements, Acta Orthopaedica, 86, 321–325, https://doi.org/10.3109/17453674.2015.1035173, 2015. a
Kwiecien, G. J., Lamaris, G., Gharb, B. B., Murray, T., Hendrickson, M. F., Zins, J. E., and Isakow, R.: Long-Term Outcomes of Total Knee Arthroplasty following Soft-Tissue Defect Reconstruction with Muscle and Fasciocutaneous Flaps, Plast. Reconstr. Surg., 137, 177–186, https://doi.org/10.1097/PRS.0000000000001929, 2016. a
Laing, J. H., Hancock, K., and Harrison, D. H.: The exposed total knee replacement prosthesis: a new classification and treatment algorithm, Br. J. Plast. Surg., 45, 66–69, https://doi.org/10.1016/0007-1226(92)90120-m, 1992. a
Leckenby, J. I. and Grobbelaar, A. O.: Strategies for Soft-Tissue Management of Complex Joint Revision Arthroplasty: A 10-Year Experience, Plast. Reconstr. Surg., 138, 1344–1351, https://doi.org/10.1097/PRS.0000000000002762, 2016. a, b, c
Lenguerrand, E., Whitehouse, M. R., Beswick, A. D., Jones, S. A., Porter, M. L., and Blom, A. W.: Revision for prosthetic joint infection following hip arthroplasty, Bone Joint Res., 6, 391–398, https://doi.org/10.1302/2046-3758.66.BJR-2017-0003.R1, 2017. a
Papaioannou, K., Lallos, S., Mavrogenis, A., Vasiliadis, E., Savvidou, O., and Efstathopoulos, N.: Unilateral or bilateral V-Y fasciocutaneous flaps for the coverage of soft tissue defects following total knee arthroplasty, J. Orthop. Surg. Res., 4, 5–82, https://doi.org/10.1186/1749-799X-5-82, 2010. a
Ries, M. D. and Bozic, K. J.: Medial gastrocnemius flap coverage for treatment of skin necrosis after total knee arthroplasty, Clin. Orthop. Relat. Res., 446, 186–192, https://doi.org/10.1097/01.blo.0000218723.21720.51, 2006. a
Sanders, R. and O'Neill, T.: The gastrocnemius myocutaneous flap used as a cover for the exposed knee prosthesis, J. Bone Joint Surg. Br., 63, 383–386, https://doi.org/10.1302/0301-620X.63B3.7263750, 1981. a
Suda, A. J., Cieslik, A., Grützner, P. A., Münzberg, M., and Heppert, V.: Flaps for closure of soft tissue defects in infected revision knee arthroplasty, Int. Orthop., 38, 1387–1392, https://doi.org/10.1007/s00264-014-2316-z, 2014. a
Tetreault, M. W., Della Valle, C. J., Bohl, D. D., Lodha, S. J., Biswas, D., and Wysocki, R. W.: What Factors Influence the Success of Medial Gastrocnemius Flaps in the Treatment of Infected TKAs?, Clin. Orthop. Relat. Res., 474, 752–763, https://doi.org/10.1007/s11999-015-4624-z, 2016. a, b, c, d
Theil, C., Stock, M. E., Gosheger, G., Moellenbeck, B., Schwarze, J., and Schmidt-Braekling, T.: Gastrocnemius Muscle Flaps for Soft Tissue Coverage in Periprosthetic Knee Joint Infection, J. Arthroplasty, 35, 3730–3736, https://doi.org/10.1016/j.arth.2020.06.074, 2020. a
Tornero, E., Morata, L., Martínez-Pastor, J. C., Bori, G., Climent, C., García-Velez, D. M., García-Ramiro, S., Bosch, J., Mensa, J., and Soriano, A.: Klic: Klic-Score for Predicting Early Failure in Prosthetic Joint Infections Treated With Debridement Implant Retention and Antibiotics, Clin. Microbiol. Infect., 21, 9–78, https://doi.org/10.1016/j.cmi.2015.04.012, 2015.
Warren, S. I., Murtaugh, T., Lakra, A., Reda, L., Shah, R. P., Geller, J. A., and Cooper, H. J.: Treatment of Periprosthetic Knee Infection with Concurrent Rotational Muscle Flap Coverage is Associated with High Failure Rates, J. Arthroplasty, 33, 3263–3267, https://doi.org/10.1016/j.arth.2018.05.021, 2018. a, b
Short summary
When acute soft tissue defects are present after knee arthroplasty, the infection risk is high. A gastrocnemius flap is used for anterior defects, and it is not usually combined with debridement surgery unless infection is clear. We examined the benefit of combining coverage treatment with debridement surgery, DAIR, comparing the isolated traditional coverage treatment. The results suggested a higher healing rate in the combined treatment, so we recommended it.
When acute soft tissue defects are present after knee arthroplasty, the infection risk is high....