Salvage procedure for chronic periprosthetic knee infection: the application of DAIR results in better remission rates and infection-free survivorship when used with topical degradable calcium-based antibiotics

  • Y. GramlichEmail author
  • T. Johnson
  • M. Kemmerer
  • G. Walter
  • R. Hoffmann
  • A. Klug



Debridement, systemic antibiotics and implant retention (DAIR) is very successful for early periprosthetic joint infection (PJI), but can fail in late-onset cases. We selected patients with PJI who were unsuitable for two-stage exchange total knee arthroplasty (TKA) and compared the outcomes of DAIR with or without degradable calcium-based antibiotics.


All patients fulfilled the criteria for late-onset PJI of TKA, as defined by an International Consensus Meeting in 2013, but were unsuitable for multistage procedures and TKA exchange due to operative risk. Fifty-six patients (mean age: 70.6 years, SD ± 10.8), in two historical collectives, were treated using a single-stage algorithm consisting of DAIR without antibiotics (control group, n = 33, 2012–2014), or by DAIR following the implantation of degradable antibiotics as indicated by an antibiogram (intervention group, n = 23, 2014–2017). OSTEOSET® (admixed vancomycin/tobramycin), and HERAFILL-gentamicin® were used as carrier systems. The primary endpoint was re-infection or surgical intervention after DAIR.


There were no significant differences between the two groups in terms of mean age, Charlson comorbidity index or the rate of mixed infections. Overall, 65.2% of patients achieved remission in the intervention group compared with only 18.2% in the control group (p < 0.001); 50% of re-infections in the intervention group even occurred after 36 months. Kaplan–Meier analysis showed that, compared with controls, the intervention group experienced significantly longer 3-year infection-free survival.


DAIR shows poor efficacy in difficult-to-treat cases, as demonstrated in our control group, which had a re-infection rate of 81.8%. In contrast, a DAIR group receiving topical calcium-based antibiotics showed significantly higher 3-year infection-free survival. Therefore, the combination of DAIR and degradable antibiogram-based local antibiotics is a reasonable salvage procedure for this body of patients. This is important as the number of severely sick patients who are too old for appropriate PJI treatment is estimated to increase significantly due to demographic change.


HERAFILL OSTEOSET PJI Periprosthetic infection DAIR Implant retention 



This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interests.

Ethical approval

The study was approved by the institutional review board (IRB Approval: LAEKH-FF-14-2018). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Supplementary material

Supplementary material 1 (PDF 38 kb) Supplementary Table: The Charlson comorbidity index. The table shows a full dataset relating to comorbidities for the intervention and control groups, and overall. There were no statistically significant differences between the two groups in terms of the Charlson comorbidity index.


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  • Y. Gramlich
    • 1
    Email author
  • T. Johnson
    • 1
  • M. Kemmerer
    • 1
  • G. Walter
    • 1
  • R. Hoffmann
    • 1
  • A. Klug
    • 1
  1. 1.Department of Trauma and Orthopedic SurgeryBerufsgenossenschaftliche Unfallklinik Frankfurt am MainFrankfurt am MainGermany

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