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.

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. 

Bone and joint infections are common and generally require surgical treatment combined with prolonged antibiotic therapy. It is important to use an antibiotic with good bone penetration that is effective against the commonly encountered pathogens and well-tolerated. Oral tetracyclines are promising and frequently used candidates. This review summarizes the available data on the use of oral tetracyclines in bone and joint infections and highlights the limited data available.

This meta-analysis evaluates synovial fluid white blood cell count and polymorphonuclear neutrophil proportion in order to diagnose chronic peri-prosthetic joint infection. Based on 74 studies, it identifies optimal thresholds, with rule-in and rule-out thresholds enhancing diagnostic precision. Confounding factors such as fractures and inflammatory arthritis are addressed. The findings support standardized diagnostic frameworks in improving accuracy and clinical consistency.

Urgent analysis of joint fluid is a common test in patients with possible septic arthritis (bacterial infection of a joint). One aspect of this test, called the Gram stain, is considered important clinically, but previous single hospital studies have suggested it will miss a considerable number of infections. This large multi-hospital UK study assessed this test and found that it will miss 73 % of infections, questioning its value. More research on rapid tests using new technologies is required.

Implant-related osteomyelitis is common in orthopedics. Absorbable antibiotic-loaded calcium sulfate (ACS) is an alternative to nonabsorbable antibiotic depot options for osteomyelitis and fracture-related infections. This study aims to evaluate intramedullary canal filling and coating characteristics of ACS around tibial nails using a tibia SAWBONES model. This research was done to better understand the potential utility of ACS in situations requiring fixation in the setting of local infection.

Our research explores natural antimicrobials to combat orthopedic-device-related infections, a challenging issue due to antibiotic resistance. We reviewed agents from bacteria, fungi, viruses, animals, plants and minerals, evaluating their effectiveness and synergy with traditional antibiotics. Our findings suggest these natural alternatives could revolutionize infection management in orthopedic patients, offering new hope for reducing antibiotic resistance and improving treatment outcomes.

We compared the re-revision rates in rTHA and rTKA (revison total hip and knee arthroplasty) with and without AB (antibiotic) treatment in patients with UPICs (unexpected positive intraoperative cultures). The re-revision rate between the AB group and the non-AB group was similar. Postoperative AB treatment did not result in a decreased re-revision rate in patients with UPICs in presumed aseptic rTHA and rTKA. Patients with pathogens classified as a likely contaminant can be safely ignored.

Antibiotics are often used to reduce the rate of recurrent periprosthetic joint infection (PJI) in patients with prior PJI. This study found that patients treated with such prophylactic antibiotics had an increased rate of infection with antibiotic-resistant organisms in any recurrent PJIs that occurred.

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.

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.

Diabetic foot osteomyelitis is a severe diabetes complication that increases the risk of limb loss and death. This study assessed a one-stage surgical approach with primary wound closure and local antibiotics, showing favourable results. Among 97 patients, 13 needed further treatment, but only 4 required major amputation. Poor circulation was the main factor in failure. These findings challenge traditional methods and may improve quality of life, although further high-quality trials are needed.

We compared the outcomes of one-stage and two-stage revision surgeries for periprosthetic joint infections of the knee and hip joints. Patients in both groups had similar reinfection rates and functional recovery, but two-stage hip patients experienced more complications, partly due to the temporary use of cement spacers. Our findings suggest that one-stage revision may be a viable alternative to two-stage revision, potentially reducing complications without increasing reinfection risk.

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.

This study evaluates dalbavancin, an antibiotic with a long duration of action, in treating complex bone and joint infections. It does not require daily dosing, allowing patients to leave the hospital earlier and reducing costs. Dalbavancin is shown to be effective and safe, especially for patients unsuitable for oral antibiotics or outpatient therapy, achieving similar results to traditional treatments while cutting healthcare costs.

The desirability of outcome ranking (DOOR) combines joint function, infection cure and mortality into one outcome. Using the DOOR, we describe patient outcomes after prosthetic joint infection (PJI) treatment; moreover, debridement, antibiotics and implant retention (DAIR) is compared with two-stage exchange. Infections were classified as early (≤ 90 d post-arthroplasty) or late (> 90 d post-arthroplasty). For early PJI, DAIR was superior to two-stage exchange, whereas two-stage revision was superior to DAIR for late PJI.

This study explores the effectiveness of repeated debridement, antibiotics, and implant retention (DAIR) for early periprosthetic joint infections (PJIs) after total joint arthroplasty. It shows that repeated DAIR procedures may achieve over 75 % success, which indicates that this approach may have value in managing early PJIs after weighing the benefits and risks of repeated DAIR against implant removal for each patient.

In this article we discuss how gut microbiota can affect the outcomes of a total joint arthroplasty. Total joint arthroplasty is a safe procedure for improving the quality of life in patients affected by arthrosis. Periprosthetic joint infection (PJI) is relatively rare but represents one of the most common causes of implant failure requiring revision surgery. Recently, there has been a major interest in the role of gut microbiome, in particular dysbiosis, as a risk factor for PJI.

Proteus is a rare form of bacteria in periprosthetic joint infection (PJI) following knee and hip arthroplasties. In this study, we investigated culture-positive revision surgeries from 2008 until 2024. Proteus species were mainly found in hip arthroplasties. Furthermore, the infections of Proteus species were mainly prevalent in chronic revisions alongside multiple bacteria. Given their chronic and polymicrobial nature, the outcome of Proteus-associated PJIs is poor. 

We retrospectively compared outcomes of two-stage revision with three common spacer types. No significant difference in failure rate was seen across groups, contributing evidence of similar efficacy. Articulating spacers showed a greater range of motion than static spacers, and static spacers were associated with a higher adverse event rate, directly showing potential advantages and disadvantages of each variant. A trend toward a longer interstage duration for prosthetic spacers may reflect greater functionality.

Serum C-reactive protein, fibrinogen, and interleukin-6 show the best performance among serum markers for diagnosing periprosthetic joint infection (PJI), but they lack sufficient accuracy to confirm or exclude infection reliably. These markers should be re-evaluated in future PJI definitions, as they are not suitable as stand-alone tests. Given their limitations and the superior diagnostic performance of synovial markers, the role of serum markers in PJI diagnosis should be reconsidered.

Patients with rheumatoid arthritis have a high treatment failure rate when faced with a late acute periprosthetic joint infection. Because of the rarity of the condition, we performed a multicenter case-control study. We identified predictors of treatment failure to ultimately improve the treatment outcome. Exchange of modular components seems important in this patient group, likely due to a higher rate of positive blood cultures compared to control patients.

This retrospective study compared debridement and implant retention failure for three types of acute knee replacement infection and analyzed outcomes for patients in a cohort with low medical risk. No differences in failure rate were seen between types in the overall sample or “optimal” cohort. Staphylococcus aureus was less common in later infection, while Streptococcus was less frequent in earlier infection. In an optimal patient, similar outcomes between types may suggest that medical factors do not alter risk.

Bone and joint infections often require prolonged antibiotic treatments over 12 weeks. Dalbavancin, an intravenous antibiotic given at spaced intervals, offers a promising option. Our study developed a method to optimize dosing schedules using two blood tests to measure drug levels. This ensures effective treatment while avoiding excessive accumulation. These findings suggest dalbavancin is a safe, effective choice for managing long-term infections.

We report the first case of axillary nerve neuropathy in an adult secondary to shoulder septic arthritis with abscess formation. Prompt surgical drainage, lavage, and targeted antibiotic therapy led to full recovery. This case also highlights the risks of intra-articular injections, particularly in immunocompromised patients, and underscores the importance of maintaining a high index of suspicion for septic arthritis in this population, even when the classic signs are absent.

This study's aim was to analyse the healing and failure rates of one-stage knee replacement in patients with positive and negative preoperative cultures and sinus presence.  We concluded that culture-negative infections or the presence of a sinus tract showed similar results compared to patients that had undergone the same procedure with positive cultures or spared soft tissue.

Our goal was to evaluate the results of two-stage revision of hip periprosthetic joint infection (PJI) over a 20-year period. Our arthroplasty unit is the largest in Ireland. We obtained data for a large number of cases (158 hips) with mid-term to long-term follow-up. Our analysis has found an infection-free survival rate of 84.2 % at 10 years, which was comparable with the best available outcomes. Most of the previously published risk factors were not predictive of failure in our study.

We present a case of post-traumatic fracture-related infection with the unusual bacteria Metamycoplasma hominis, usually only seen in people with impaired immune systems. Treatment required multiple surgeries, combined with 10 weeks of treatment with the antibiotics doxycycline and clindamycin. There are no guidelines on treatment, but we recommend a multi-disciplinary team approach, with prolonged antibiotic treatment personalised to the patient based on sensitivities of the organism.

Synovial fluid pH, lactate, and glucose levels have been studied in native joint septic arthritis, but their diagnostic value in periprosthetic joint infection (PJI) remains insufficiently explored. This prospective study of 100 patients assessed their utility for PJI diagnosis. PJI cases showed significantly lower synovial pH and glucose levels but higher lactate levels. The combined analysis of all three biomarkers yielded a negative predictive value of 84 % for PJI diagnosis.

Our 10-year multicenter study examines the epidemiology, presentation, management, and outcomes of elbow native joint septic arthritis, a rare condition with risks like reoperation and mortality. Common symptoms included pain and swelling. Synovial fluid white blood cell counts were often low, with monosodium urate crystals also noted. Staphylococcus aureus was the main pathogen, and 72.2 % of patients underwent open debridement.

We performed a mixing lab study describing 20 additional mixing formulas with mixing/set times in creating antimicrobial CaSO₄ beads used for local delivery in periprosthetic joint infections, fracture-related infections, and other bone site infections. Most new formulas were focused on antifungal and antimycobacterial therapy. This information is to be utilized as an open-access reference for all physicians involved in the treatment of musculoskeletal infections.

Patients with a periprosthetic infection (PJI) have a bad functional outcome and can suffer from a PJI-triggered psychological burden.  Although this has been studied, it is still unclear how to properly screen patients for mental disorders caused by a PJI. Our study showed that the hospital anxiety and depression scale – total (HADS-T) is a valid screening tool for PJI patients and that PJI patients with high HADS-T scores should specifically be offered psychological support.

Arthrofibrosis after total knee arthroplasty (TKA) remains a challenging complication. We analysed 19 TKA cases, isolating low-virulence pathogens in 43 % of them. Although a causal link with low-grade peri-prosthetic joint infection (PJI) is unconfirmed, our findings support its potential role in arthrofibrosis. If validated, this could shift the therapeutic approach toward PJI-oriented management.

Fracture-related infections (FRIs) and periprosthetic joint infections (PJIs) fail to recover pathogens, posing a diagnostic challenge and impacting treatment. This new method involves homogenising biopsies with beads to release bacteria, followed by inoculation in blood culture bottles using an automated system. This technique shows similar sensitivity to conventional methods, with improved specificity and faster pathogen detection. To date, no other studies have reported an optimized method for incubating biopsies from patients with FRIs.

In recent decades, there has been a growing emphasis on the use of local antibiotics in orthopaedic surgery, but development of new technologies has been limited. In this study we observe that a 1.5 mL injection of the novel technology CarboCell G/C into the bone provides very high levels of the antibiotics gentamicin and clindamycin in bones, with almost no spill to the bloodstream. These findings bolster the prospect of new and improved technologies for combatting orthopaedic infections.

We explore optimising antibiotic use to prevent infections in endoprosthetic replacement for bone tumours. We found 26 % of infections were linked to initial surgery, with most due to secondary factors like wound complications. The main bacteria are Staphylococcus aureus and coagulase-negative staphylococci. Our findings suggest targeting these bacteria with prophylactic antibiotics and applying measures to prevent secondary infections to improve infection control in orthopaedic oncology.

This retrospective study shows that autogenous non-vascularized bone graft is a viable option for managing post-osteomyelitis bone defects in children in low-resource settings. Bone union was achieved in all cases at the last follow-up (minimum of 7 years). Recurrence of infection was seen in two cases. Studies into this specific technique are important as it does not require super-specialized centres or skills, both of which are scarce in low-resource settings.

Our results indicate that certain parameters such as diabetes, low albumin levels, and prolonged duration of surgery are associated with a higher risk of infection in patients undergoing musculoskeletal tumor resection and megaprosthetic reconstruction. Strategies targeted towards glycemic control and nutritional status optimization are of great significance, while parameters that can affect the operating time can also have a positive impact on periprosthetic joint infection prevention.

Many studies evaluating infection tests after joint replacement focus only on patients who have surgery, but not all painful joints are operated on. This can lead to biased results. Our comment highlights this issue and suggests that including patients who do not have surgery but are monitored over time can give a clearer picture. This helps ensure that infection tests are more accurate when used in everyday medical practice, not just in surgical cases.

To improve the existing knowledge and treatment of bone and joint infections, it is essential to unite medical disciplines and bridge the gap between basic and clinical sciences. In 2018, the Centrum fOr translational Medicine on Bone and joint INfEctions (COMBINE) was created to facilitate collaboration among Danish scientists and researchers dedicated to bone and joint infection research. This paper aims to share the COMBINE approach and values.

This study provides the largest available, multicenter estimate of chronic osteomyelitis incidence in the United States. Incidence was generally steady over time, although a slight reduction was noted during the COVID-19 pandemic.

This review assessed the effectiveness of single- and two-stage procedures for treating long-bone fracture-related infections, focusing on unhealed fractures without critical-sized bone defects. A total of 35 studies with 985 patients showed bone-healing rates of 80% for single-stage procedures and 77% for two-stage procedures. Infection eradication rates were 87% for single-stage approaches and 81% for two-stage approaches. The current evidence is inconclusive and lacks sufficient data to favor either approach.