DAIR: Debridement, Antibiotics and Implant Retention
DAIR is a surgical treatment for early periprosthetic joint infection (PJI) that aims to eradicate infection while preserving the existing hip or knee replacement. Careful patient selection is critical to success. Mr Hussain performs DAIR at the Royal Orthopaedic Hospital Birmingham.
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ENDO-Klinik Hamburg
Overview
What Is DAIR?
DAIR stands for Debridement, Antibiotics and Implant Retention. It is a surgical treatment for periprosthetic joint infection (PJI) that, unlike two-stage revision surgery, aims to eradicate the infection without removing the existing hip or knee replacement implant.
The fundamental principle of DAIR is that, in early infection, before bacteria have had time to form a mature, treatment-resistant biofilm on the implant surface, it may be possible to clear the infection through thorough surgical debridement of infected tissue, exchange of all removable (modular) implant components, and a prolonged course of antibiotics targeted at the causative organism. If successful, the patient avoids the significantly greater complexity and recovery burden of a full implant removal and two-stage reconstruction.
DAIR is not appropriate for all patients with PJI. The timing of infection, the condition of the implant, the nature of the causative organism, and the patient's overall health all influence the likelihood of success. Choosing the wrong patient for DAIR risks a failed procedure and a more complicated subsequent two-stage revision. Careful pre-operative assessment and shared decision-making are essential.
- Preserves the existing implant if infection is caught early enough
- Avoids the burden of two major staged operations and an interim antibiotic spacer period
- Requires thorough debridement, not simply antibiotics alone
- Modular component exchange (liner, head, tibial insert) is an essential part of the procedure
- Followed by a prolonged course of targeted oral antibiotics guided by microbiology
Patient Selection
Who Is Suitable for DAIR?
Correct patient selection is the single most important determinant of DAIR success. The following criteria guide the decision to offer DAIR in preference to two-stage revision surgery.
Early Infection Timing
DAIR is most appropriate for acute early infection within 4 to 6 weeks of the primary joint replacement surgery, or for acute haematogenous infection (bacteria arriving via the bloodstream from a distant source) where symptoms have been present for fewer than 3 weeks. Beyond these timeframes, bacteria form a mature biofilm on the implant surface that resists antibiotic penetration, making implant retention much less likely to succeed.
Stable, Well-Fixed Implant
The existing joint replacement must be well fixed and structurally sound. If the implant is loose (whether from infection or aseptic loosening), it must be removed: DAIR is contraindicated with a loose implant. A well-fixed implant can only be assessed by clinical examination, imaging, and intraoperative findings. An implant that tests as well fixed intraoperatively can be safely retained; an unstable implant cannot.
No Sinus Tract Present
The presence of a sinus tract (a discharging wound or channel from the skin surface to the joint) is a contraindication to DAIR. A sinus tract indicates established, chronic infection with biofilm maturation that makes implant retention almost certain to fail. Two-stage revision is the appropriate treatment in this situation.
Susceptible Organism
The causative bacterium and its antibiotic sensitivity profile significantly affect DAIR success rates. Organisms amenable to antibiotics that penetrate biofilm, particularly rifampicin-containing combinations for staphylococcal infections, are more favourable for DAIR. Highly resistant organisms such as MRSA (methicillin-resistant Staphylococcus aureus), fungal infections, or infections with unknown organisms (culture-negative PJI) have substantially lower DAIR success rates and may favour two-stage revision.
Adequate Host Factors
The patient's immune status and overall health influence the ability to clear infection. Severe immunocompromise (from conditions such as uncontrolled diabetes, high-dose corticosteroid therapy, haematological malignancy, or end-stage renal or liver disease) reduces the likelihood of DAIR success and may favour a more definitive approach. A thorough pre-operative medical assessment helps stratify individual risk.
Exchangeable Modular Components
DAIR includes the exchange of all accessible modular components: the polyethylene liner and femoral head in a hip replacement, and the tibial polyethylene insert in a knee replacement. Exchanging these components removes the contaminated surfaces that are most accessible to bacteria and cannot be adequately decontaminated by lavage alone. If implant design does not permit modular component exchange, the decision to proceed with DAIR must be revisited.
The Operation
The DAIR Procedure
DAIR is performed under general or spinal anaesthesia. The joint is approached through the previous surgical incision where possible. The procedure follows a systematic sequence:
- Thorough debridement: all infected, necrotic, and devitalised tissue is excised. Synovium, granulation tissue, and any pseudocapsule are removed completely. Multiple tissue samples are sent to microbiology for culture and sensitivity to confirm the organism and guide antibiotic selection.
- Modular component exchange: the polyethylene liner and femoral head (hip) or tibial insert (knee) are removed and replaced with new components. This step removes the most heavily contaminated modular surfaces that cannot be effectively decontaminated by lavage.
- Copious lavage: the joint is irrigated with large volumes of normal saline using pulsed lavage to mechanically remove residual bacteria, debris, and inflammatory products.
- Wound closure: the wound is closed over a drain. Some surgeons use dilute antiseptic wash in addition to saline lavage, though the evidence base for this is limited.
- Prolonged antibiotic therapy: following surgery, a course of targeted antibiotics is prescribed, typically for 3 to 6 months, guided by the microbiology team and infectious disease specialists. For staphylococcal infections, rifampicin-combination therapy is the cornerstone of treatment, as rifampicin penetrates biofilm.
Choosing the Right Treatment
DAIR vs Two-Stage Revision
Both DAIR and two-stage revision surgery have an important role in managing periprosthetic joint infection. The decision depends on the duration and nature of infection, organism characteristics, implant stability, and patient factors. Neither approach is universally superior; the right treatment is the one matched to the individual clinical situation.
Choose DAIR When:
Infection is early (within 4 to 6 weeks of surgery, or acute haematogenous with short symptom duration), the implant is well fixed, there is no sinus tract, and the organism is sensitive to biofilm-penetrating antibiotics. In well-selected patients, DAIR offers a chance to eradicate infection with a single operation and without the complexity of staged reconstruction.
Published success rates in appropriately selected patients range from 60 to 80%, though outcomes vary significantly with organism type and patient factors.
Choose Two-Stage Revision When:
Infection is established or chronic (more than 4 to 6 weeks), a sinus tract is present, the organism is resistant, or the implant is loose. Two-stage revision is also appropriate when DAIR has already failed: implant removal, spacer, and antibiotics are then followed by reimplantation.
Two-stage revision has higher published success rates (85 to 92%) for established infection, at the cost of greater operative complexity, two major procedures, and an interim spacer period.
Revision Surgery in Birmingham
Why Choose Mr Hussain for Revision Surgery?
Mr Hussain holds a subspecialty fellowship from ENDO-Klinik Hamburg, one of the world's leading centres for revision arthroplasty, and has contributed 33 peer-reviewed publications to the orthopaedic literature. His practice at the Royal Orthopaedic Hospital, Priory Hospital Edgbaston, and Harborne Hospital is built on a foundation of 5,000+ procedures and a Doctify rating of 4.98 from 498 verified reviews.
Patient Questions
Frequently Asked Questions
Ready to Discuss Your Revision Surgery?
Book a private consultation with Mr Hussain at the Royal Orthopaedic Hospital, Priory Hospital Edgbaston, or Harborne Hospital.