Debridement, antibiotics and implant retention (DAIR) treats prosthetic joint infection while leaving a stable prosthesis in place. When it succeeds, the patient keeps a functioning implant and avoids revision surgery. The difficulty is that infection has to be controlled while fixed prosthetic surfaces remain, including surfaces that may carry adherent bacteria or biofilm.
Summary
DAIR is an implant-preserving strategy for selected patients with acute PJI.
The intended benefit is infection control with the prosthesis retained, avoiding immediate revision surgery.
Failure remains substantial: pooled evidence reports failure in about one third of acute or early postoperative cases and much higher failure in late chronic infection.
Timing is only one part of selection. Implant stability, soft-tissue closure, surgical access and antimicrobial options also influence whether the prosthesis can be retained.
After failed DAIR, later revision can still succeed, although the patient has already undergone debridement and antimicrobial treatment.
When retaining the prosthesis is an option
DAIR is used selectively in acute hip and knee PJI. The IDSA guideline and the 2025 EBJIS guidance describe several conditions that support implant retention: a well-fixed and functioning prosthesis, soft tissue that can be closed, no sinus tract, and an antimicrobial strategy suited to the infecting organism (Osmon et al., 2013; Sigmund et al., 2025a; Sigmund et al., 2025b).
How DAIR performs in acute PJI
In a 2026 meta-analysis of 81 studies, 34.2% of acute or early postoperative infections and 39.1% of acute haematogenous infections failed after DAIR. Failure rose to 73.6% in late chronic infection (Abbaszadeh et al., 2026).
A 2024 systematic review found a mean success rate of 71%, with results in the individual studies ranging from 55.5% to 90% in early postoperative and acute haematogenous hip and knee PJI (Longo et al., 2024).
So what does a 71% success rate mean when the alternative is revision? In a prospective multicentre study, 433 patients treated with DAIR or two-stage revision were included in the direct comparison. The two-year outcome included infection control, prosthesis retention, joint function and mortality (Johns et al., 2025). DAIR had better outcomes when PJI was diagnosed within 90 days of arthroplasty, while two-stage revision had better outcomes after 90 days. Two-stage revision also had better outcomes in the late acute haematogenous subgroup (Johns et al., 2025).
Because treatment was chosen clinically rather than assigned, selection between DAIR and two-stage revision could still have influenced the comparison. The authors found similar baseline characteristics between groups, however, and the result persisted when they examined symptom duration, comorbidities, CRP and joint type (Johns et al., 2025).
Early postoperative versus late acute PJI
Acute PJI can appear soon after arthroplasty, or suddenly around a prosthesis that has been functioning normally for months or years. Early postoperative PJI is generally thought to originate around the time of surgery, while late acute PJI often reflects haematogenous seeding (Sigmund et al., 2025a; Sigmund et al., 2025b). Both are classified as acute PJI: one because the infection occurs soon after arthroplasty, the other because symptoms start suddenly after an uneventful period (Sigmund et al., 2025a; Sigmund et al., 2025b).
Several studies have reported lower DAIR success in late acute or haematogenous infection. In a prospective cohort of 653 patients, success was 74% in early post-implant infection and 49% in late acute infection (Davis et al., 2022). In a smaller study of 26 acute knee PJIs, success was 93% after acute postoperative infection and 58% after acute haematogenous infection (Iza et al., 2019).
A 2025 study of 122 acute knee PJIs found a different result: haematogenous infection was not associated with significantly poorer DAIR survivorship (Frear et al., 2025). Even so, a sudden onset months or years after arthroplasty should not automatically be treated the same as an early postoperative infection simply because both are classified as acute.
Time since surgery and symptom duration
Guidelines look at both time since arthroplasty and duration of symptoms. IDSA considers DAIR in patients with a well-fixed prosthesis and no sinus tract when infection occurs within about 30 days of implantation or symptoms have been present for fewer than three weeks (Osmon et al., 2013). EBJIS keeps the same distinction: early acute PJI is defined by time since arthroplasty, while late acute PJI is defined by a short symptomatic period after an initially uneventful course (Sigmund et al., 2025a; Sigmund et al., 2025b).
For late acute PJI, that short symptom history is particularly important. It gives an indication of how long bacteria may have had to adhere to the implant and establish biofilm, although it does not tell us how established that biofilm has become in an individual patient (Lu et al., 2022; Deckey et al., 2023).
What debridement can reach and remove
The aim of DAIR is to remove infected and non-viable tissue while the fixed components remain in place. What can be reached and removed depends on surgical exposure and on which modular components can be exchanged. The operation includes microbiological sampling, removal of purulence, infected synovium, necrotic tissue and loose debris, irrigation, assessment of implant stability and exchange of modular components where feasible (Deckey et al., 2023; Sigmund et al., 2025a; Sigmund et al., 2025b).
In total knee arthroplasty, removing the polyethylene liner gives better access to the posterior joint and gutters, where infected synovium and debris can otherwise be difficult to reach (Deckey et al., 2023).
Exchanging modular parts removes replaceable contaminated surfaces and can improve access for debridement. Whether that translates into better infection control is harder to show. In a meta-regression of 65 observational studies, higher rates of modular exchange were associated with better outcomes in older studies, but that association disappeared in studies performed after 2004 (Gerritsen et al., 2021). Because the analysis was at study level, the value of exchange in an individual DAIR remains unresolved.
Antibiotics when the implant stays in place
Because fixed components stay in place, some potentially contaminated prosthetic surfaces remain after debridement. Antibiotic treatment then depends on knowing which organism is present and what it is susceptible to. The IDSA guideline recommends pathogen-specific treatment, with an oral phase where appropriate. For staphylococcal PJI treated with DAIR, rifampicin is recommended as part of combination therapy because of its activity against biofilm-associated staphylococci and the risk of resistance when used alone (Osmon et al., 2013).
In practice, rifampicin is not always an option: resistance, intolerance, hepatotoxicity or drug interactions may prevent its use, and fluoroquinolones are not suitable for every patient either. Evidence for alternative oral combinations is thin. A 2024 systematic review found only six eligible studies of oral relay therapy after DAIR for acute staphylococcal PJI, with too much heterogeneity to rank the companion regimens reliably (Gachet et al., 2024).
When fixed components remain, antibiotics have to control bacteria left beyond the reach of debridement. That becomes much harder if the organism is unidentified, resistant or poorly covered by the available regimen.
When DAIR is more likely to fail
In acute haematogenous PJI treated with DAIR, diabetes and polymicrobial infection have been reported as independent risk factors for failure (Chen et al., 2021). Other cohorts have linked poorer DAIR outcomes with older age and chronic obstructive pulmonary disease, although the findings are not consistent across all studies (Sigmund et al., 2025a).
In a recent cohort of 48 acute hip PJIs, infection control was achieved in 57.1% of polymicrobial infections compared with 87.5% of monomicrobial infections (Lamo-Espinosa et al., 2026). The difference is large, but it comes from a cohort of only 48 patients with few failures. That makes polymicrobial infection a warning sign; an exclusion criterion would require stronger evidence.
In a cohort of 164 patients undergoing surgery for hip PJI, wound drainage beyond 14 days was associated with treatment failure (Telias et al., 2026). This was not a DAIR-only cohort, so the finding is more relevant to the condition of the soft tissues than to DAIR success specifically.
An early presentation may support choosing DAIR, but polymicrobial infection, a compromised host or poor soft tissues can make infection control difficult.
Success, suppression and revision after DAIR
The best outcome after DAIR is infection control with a functioning prosthesis still in place and no need for chronic suppressive antibiotics or later implant removal. In a 117-patient cohort, 74% of patients with successful DAIR walked unaided or with one stick at final follow-up, compared with 32.7% after DAIR failure (Cobo et al., 2011).
The same cohort also shows why “success” after DAIR needs some unpacking. Cure with implant salvage was achieved in 57.3%, 12.8% remained on chronic suppressive antibiotics and 29.9% underwent implant removal (Cobo et al., 2011). In a separate cohort of 291 patients with postoperative acute PJI, 62.2% still had the implant in place at five years without clinical signs of infection or suppressive antibiotics, while 25.8% had undergone revision (Perdomo-Lizarraga et al., 2025).
If DAIR fails, later revision can still succeed. In infected knee arthroplasties, two-stage revision after failed DAIR was associated with lower final Knee Society and WOMAC scores than successful DAIR or direct two-stage revision, although the scores remained in good or excellent ranges. Failed DAIR was not associated with a higher reinfection risk after later two-stage revision (Öztürk et al., 2021).
In a multicentre cohort of 197 patients after failed DAIR, subsequent one-stage revision succeeded in 76.2% and two-stage revision in 79.3% (Auñón et al., 2025).
When a second DAIR is considered
A second DAIR may be considered when infection control is incomplete after the first debridement, provided the prosthesis remains stable, the soft tissues can still be managed and the organism remains treatable. Retaining the implant is still the aim, but another debridement also means further surgery and more antibiotic treatment. If it fails again, the patient may still need revision after having undergone another attempt at implant retention.
A 2024 meta-analysis of nine observational studies, including 1,104 patients, reported success rates of 67% in single-DAIR cohorts and 70% in double-DAIR cohorts, with no statistically significant difference between them (Salman et al., 2024).
After a first DAIR has failed, it is difficult to know how often a second DAIR will succeed. The 70% from the meta-analysis came from selected double-DAIR cohorts, not specifically from patients whose first DAIR had failed. In the 2025 multicentre study, 88 patients did undergo a second DAIR after failure of the first, and 54.5% were successfully treated (Auñón et al., 2025).
So a second DAIR can still work after the first has failed, but success was only just over 50% in this cohort. Almost half of the patients needed another treatment after the second attempt.
Reported success after a third DAIR was around 50% to 60% (Salman et al., 2024). On its own, that may not sound particularly low. But by this point the patient has already undergone two attempts at infection control with implant retention, and the review found no evidence that a third DAIR improved outcomes compared with single or double DAIR. Another failed attempt also means another operation and further delay before revision.
Closing note
With DAIR, the aim is to control the infection while leaving stable fixed components in place. If that succeeds, the patient may avoid implant removal, staged revision, loss of bone stock and a much larger reconstruction.
The difficulty is that an “acute” presentation does not by itself tell us whether retention is the best choice. Time since arthroplasty and symptom duration both play a role, but so do implant stability, the condition of the soft tissues, how thoroughly the joint can be debrided and whether the organism can be treated effectively. When several of those factors are unfavourable, the chance of controlling the infection while keeping the prosthesis falls.
References
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Auñón Á, Bernaus M, Veloso M, et al. Outcomes of the Subsequent Periprosthetic Joint Infection Revisions after a Failed Debridement, Antibiotics and Implant Retention: A Multicentric Study of 197 Patients. Surg Infect (Larchmt). 2025;26(2):57–62.
Chen W, Klemt C, Smith EJ, et al. Outcomes and Risk Factors Associated With Failures of Debridement, Antibiotics, and Implant Retention in Patients With Acute Hematogenous Periprosthetic Joint Infection. J Am Acad Orthop Surg. 2021;29(23):1024–1030.
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