Does Prior Failed Debridement Compromise the Outcome of Subsequent Two-Stage Revision Done for Periprosthetic Joint Infection Following Total Knee Arthroplasty?

Background There has been a debate regarding the outcomes of 2-stage revision total knee arthroplasty (TKA) when debridement, antibiotics, irrigation, and implant retention (DAIR) had been carried out previously. The purpose of this study is to evaluate the influence of prior failed DAIR (F-DAIR) on the outcomes of 2-stage revision TKA done for periprosthetic joint infection (PJI). Methods This is a retrospective study of a consecutive series of 184 knees that completed 2-stage revision TKA for PJI, operated by a single surgeon between January 2000 and July 2011. The cohort was divided into 2 groups: (1) with previous F-DAIR (88 knees) and (2) direct 2-stage revision (96 knees). Results At an average follow-up of 5.3 years, the failure rate was 23.86% (21/88 knees) in the F-DAIR group and 15.62% (15/96) in the direct 2-stage revision group. Prior F-DAIR procedure was associated with approximately twice the risk of failure compared to direct 2-stage surgery (hazards ratio 1.94, 95% confidence interval 1.01-3.714, P = .047). Excluding PJIs caused by methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermidis, and Pseudomonas from analysis revealed similar failure rates between the 2 groups. The Knee Society Clinical Score, Knee Society Functional Score, and final range of motion at final follow-up were lower in the F-DAIR group. Incidence of culture negativity and infection with resistant organisms was higher in the F-DAIR group. The rates of eradication of methicillin-resistant Staphylococcus aureus and Pseudomonas infection were much lower in the F-DAIR group. Conclusion A failed prior DAIR results in higher failure rates, lower functional outcome, and increased risk of wound-related complications.