BACKGROUND Debridement, antibiotics, and implant retention (DAIR) is used to manage acute periprosthetic joint infections (PJIs) after total joint arthroplasty (TJA). Given the uncertain success of single or multiple DAIR attempts and possible long-term deleterious effects this treatment can create when trying to treat persistent infection, it is important to understand the frequency with which surgeons in the United States are attempting multiple debridements for PJI and whether those procedures are achieving the desired goal. QUESTION/PURPOSES In the context of the American Joint Replacement Registry (AJRR), we asked: (1) What proportion of patients who undergo DAIR have only one DAIR, and what percentage of those patients have more than one? (2) Of the patients who undergo one or more DAIR procedures, what is the proportion who progress to additional surgical procedures? (3) What is the cumulative incidence of medical or surgical endpoints related to infection on the affected leg (other than additional DAIR procedures)? METHODS DAIR procedures to treat PJI, defined by ICD-9/10 and CPT (Current Procedural Technology) codes, reported to the AJRR from 2012 to 2020 were merged with Centers for Medicare and Medicaid Services (CMS) data from 2012 to 2020 to determine the incidence of patients aged 65 and older who underwent additional PJI-related procedures on the same joint. Linking to CMS ensures no loss to follow-up or patient migration to a non-AJRR site. As of 2021, the AJRR captures roughly 35% of all arthroplasty procedures performed in the United States. Of the total 2.2 million procedures in the AJRR, only 0.2% of the procedures were eligible based on our inclusion criteria. Additionally, 61% of the total population is Medicare eligible, and thus, these patients are linked to CMS. Of the 5029 DAIR attempts after a TKA, 46% (2318) were performed in female patients. Similarly, there were a total of 798 DAIR attempts after a THA, and 50% (398) were performed in female patients. For the purposes of decreasing confounding factors, bilateral THAs and TKAs were excluded from the study population. When querying for eligible procedures from 2012 to 2020, the patient population was limited to those 65 years and older, and a subsequent reoperation for infection had to be reported after a primary TJA. This limited the patient population as most infections reported to AJRR resulted in a revision, and we were searching for DAIRs. Although 5827 TJAs were identified as a primary TJA with a subsequent infectious event, more than 65% (3788) of that population did not have a reported event. The following conditions were queried as secondary outcomes after the first DAIR: sepsis, cellulitis, postoperative infection, endocarditis, amputation, knee fusion, resection, drainage, arthrotomy, and debridement. To answer our first and second study questions, we used frequency testing from the available AJRR data. Because of competing risks and issues with incomplete data, we used the cumulative incidence function to evaluate the outcomes specific to study question 3. RESULTS Of the patients who underwent DAIR, 93% (5406 of 5827) had one DAIR and 8% (421 of 5827) had more than one. Among the DAIR population, at least 35% of TKAs and 38% of THAs were identified as having experienced an additional PJI-related event (an additional surgical procedure on the same joint, sustained an infectious endpoint in the linked CMS-AJRR dataset, or they had died). The cumulative incidence of developing a further medical or surgical condition related to the joint that had the initial DAIR were as follows: 48% (95% CI 42% to 54%) at 8 years after a DAIR following a TKA and 42% (95% CI 37% to 46%) at 4 years after a DAIR following a THA. The timepoints for TKA and THA are different because there are more longitudinal procedure data available for TKAs regarding DAIR procedures than for THAs. CONCLUSION In this study, we used data from the AJRR to assess the incidences of single and multiple DAIR attempts and additional surgical- and infection-related sequalae. Continued investigation is required to determine the fate of infected joints that undergo DAIR with regard to ultimate patient outcome. Future cross-sectional studies using large datasets are necessary to assess functional outcomes and determine the risk of persistent infection after DAIR more precisely. LEVEL OF EVIDENCE Level III, therapeutic study.

中文翻译：

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清创、抗生素和植入物保留 （DAIR） 治疗 AJRR 人群假体周围关节感染的发生率和结局如何？


背景 清创、抗生素和植入物保留 （DAIR） 用于治疗全关节置换术 （TJA） 后的急性假体周围关节感染 （PJI）。鉴于单次或多次 DAIR 尝试的成功率不确定，以及这种治疗在尝试治疗持续感染时可能产生的长期有害影响，了解美国外科医生尝试 PJI 多次清创术的频率以及这些手术是否达到预期目标非常重要。问题/目的 在美国关节置换登记处 （AJRR） 的背景下，我们询问： （1） 接受 DAIR 的患者中有多少比例只有一个 DAIR，这些患者中有多少百分比有多个 DAIR？（2） 在接受一项或多项 DAIR 手术的患者中，进展为额外外科手术的比例是多少？（3） 与受影响腿部感染相关的医疗或手术终点的累积发生率是多少（额外的 DAIR 手术除外）？方法 治疗 PJI 的 DAIR 程序，由 ICD-9/10 和 CPT（当前程序技术）代码定义，从 2012 年到 2020 年向 AJRR 报告，与 2012 年至 2020 年的医疗保险和医疗补助服务中心 （CMS） 数据合并，以确定 65 岁及以上患者的发生率在同一关节上接受额外的 PJI 相关手术。链接到 CMS 可确保不会对随访或患者迁移到非 AJRR 站点造成损失。截至 2021 年，AJRR 捕获了在美国进行的所有关节置换术的大约 35%。在 AJRR 的 220 万例手术中，根据我们的纳入标准，只有 0.2% 的手术符合条件。 此外，总人口的 61% 符合 Medicare 资格，因此，这些患者与 CMS 相关联。在 TKA 后的 5029 次 DAIR 尝试中，46% （2318） 是在女性患者中进行的。同样，THA 后共有 798 次 DAIR 尝试，其中 50% （398） 是在女性患者中进行的。为了减少混杂因素，双侧 THA 和 TKA 被排除在研究人群之外。在查询 2012 年至 2020 年符合条件的手术时，患者群体仅限于 65 岁及以上的人群，并且在原发性 TJA 后必须报告随后的感染再次手术。这限制了患者群体，因为向 AJRR 报告的大多数感染都导致了修订，我们正在寻找 DAIR。尽管 5827 例 TJA 被确定为原发性 TJA 并随后发生感染事件，但该人群中超过 65% （3788） 没有报告事件。在第一次 DAIR 后，将以下情况作为次要结局进行查询： 败血症、蜂窝织炎、术后感染、心内膜炎、截肢、膝关节融合术、切除、引流、关节切开术和清创术。为了回答我们的第一个和第二个研究问题，我们使用了可用 AJRR 数据的频率测试。由于竞争风险和数据不完整的问题，我们使用累积发生函数来评估特定于研究问题 3 的结局。结果 在接受 DAIR 的患者中，93% （5827 例中的 5406 例） 有 1 例 DAIR，8% （5827 例中的 421 例） 有不止 1 例。在 DAIR 人群中，至少 35% 的 TKA 和 38% 的 THA 被确定为经历了额外的 PJI 相关事件（同一关节的额外外科手术，在链接的 CMS-AJRR 数据集中维持感染终点，或者他们已经死亡）。 发生与具有初始 DAIR 的关节相关的进一步内科或外科疾病的累积发生率如下：TKA 后 DAIR 后 8 年为 48% （95% CI 42%， 54%），THA 后 DAIR 后 4 年为 42% （95% CI 37%， 46%）。TKA 和 THA 的时间点不同，因为与 THA 相比，TKA 可用于 DAIR 程序的纵向程序数据更多。结论 在这项研究中，我们使用来自 AJRR 的数据来评估单次和多次 DAIR 尝试以及其他手术和感染相关后遗症的发生率。需要继续调查以确定接受 DAIR 的受感染关节对最终患者结果的命运。未来使用大型数据集的横断面研究对于评估功能结局和更精确地确定 DAIR 后持续感染的风险是必要的。证据级别 III 级，治疗研究。