Late Acute Hematogenous Infections after Total Knee Arthroplasty: Results of Debridement, Antibiotics, and Implant Retention

The frequency of late acute hematogenous infection (LAHI) following total knee arthroplasty (TKA) is between 0.2% and 0.5%. There is controversy over the results of patients treated for LAHIs by surgical debridement, antibiotics, and implant retention (DAIR). This narrative review of the literature aims to establish the role of DAIR in LAHIs after TKA. The published success rate (retention of the prosthesis) after DAIR is between 50% and 100%. The success rate is associated with a shorter duration of symptoms (5–14 days from the onset of symptoms). Factors associated with failure are an accompanying infection and the diagnosis of rheumatoid arthritis before the TKA is performed. It is not recommended to indicate a DAIR in patients with atrial fibrillation, chronic obstructive pulmonary disease, the presence of >15 cells per high-powered field, preoperative C-reactive protein >500 mg/L or methicillin-resistant S. aureus. In such patients, a two-stage revision arthroplasty should be recommended. Arthroscopic DAIR has a limited effect. It is most efficacious in the very early stage of acute presentations of infected TKA. It can be useful in patients with extreme frailty as an adjunct to suppressive antibiotic therapy. If carried out, high volumes of fluid should be utilized. The indications for an open DAIR are the following: duration of clinical signs and symptoms is less than 3 weeks; patients with a well-fixed implant; no abscess or sinus tract; low-virulence bacteria; elderly patients with multiple comorbidities; and nonimmunocompromised patients. Open DAIR should not be advised in cases with chronic infection (>4 weeks postoperatively, insidious beginning of symptoms).