Risk Factors of DAIR Failure and Validation of the KLIC Score: A Multicenter Study of Four Hundred Fifty-Five Patients

Abstract

Background:

Debridement, antibiotic agents, and implant retention (DAIR) is a currently accepted approach for the treatment of early prosthetic joint infections (PJI). The success of a DAIR procedure has shown variable results throughout the published literature. Scoring systems such as the Kidney, Liver, Index surgery, Cemented prosthesis, and C-reactive protein value (KLIC) score for the selection of patients that are likely to benefit from DAIR have proved to be helpful in decision making. Our study aims to further validate the KLIC score using a large external multicentric cohort and to evaluate other risk factors for failure.

Patients and Methods:

A retrospective analysis of patients with an early acute PJI who were treated with DAIR and recorded in a database of eight Spanish university hospitals was performed. According to pre-operative variables of the KLIC study, patients were categorized into five groups: group A, ≤2 points; group B, 2.5–3.5 points; group C, 4–5 points; group D, 5.5–6.5 points; and group E, ≥7 points. Failure rates were compared between groups at 60 days and after 60 days of DAIR. Further variables for risk of failure were also analyzed.

Results:

A total of 455 patients with early acute PJI were included in the analyses. At 60 days, patients presenting with pre-operative elevated C-reactive protein serum levels, Staphylococcus aureus, and polymicrobial infections were associated with failure. Failure rates recorded were 12% for group A (n = 210), 18% for group B (n = 83), 26% for group C (n = 89), 24% for group D (n = 66), and 0% for group E (n = 7). Univariable analysis between consecutive groups of the KLIC score showed no differences for failure before 60 days of the DAIR procedure. Scheduled surgery and having the procedure performed by a specialized unit were also identified as important factors for DAIR success.

Conclusions:

Our results suggest the KLIC score was not useful for predicting failure in our cohort. Furthermore, our results indicate a specialized unit should conduct DAIR procedures.

Prosthetic joint replacement is a common and effective treatment for end-stage osteoarthritis of the hip and knee. The incidence of total joint replacement is high, with an estimated increase in the United States in 2040 for total hip arthroplasty by 284% and 401% for total knee arthroplasty, compared to the 2014 U.S. Nationwide Inpatient Sample numbers [1], mainly because of an aging population. However, total joint replacement surgery is not exempt from complications.

Peri-prosthetic joint infection remains the most serious and complex complication after joint replacement. Prosthetic joint infections (PJIs) can be classified according to Zimmerli et al. [2] as early (those that develop less than 3 months after surgery), delayed (3–24 months after surgery), or late (more than 24 months after surgery). The incidence of early PJI is reported to be 1%–2% after primary joint replacement and up to 10% in revision arthroplasties [3,4]. In most cases, a combination of antibiotic agents and surgical procedures is required for the treatment of PJI. Debridement, antibiotic agents, and implant retention (DAIR) is a currently accepted approach for the treatment of early PJIs. The success of a DAIR procedure has shown variable results throughout the published literature. The rate of infection control ranges from 14% to 100% [5 –7] partly because of the heterogeneity of cohorts studied. Furthermore, several factors have been associated with an increased risk of failure for DAIR. These include the duration of symptoms, the possibility to exchange modular components, and causative micro-organisms [8 -10].

To avoid surgical procedures with a high risk of failure, scoring systems such as the KLIC score for the selection of patients that are likely to benefit from DAIR have proved to be helpful in decision making [11]. The KLIC score includes five pre-operative factors that have been identified as independent predictors of failure: chronic renal failure (Kidney), Liver cirrhosis, Index Surgery (revision surgery or prosthesis indicated for a fracture), Cemented prosthesis, and C-reactive protein >115 mg/L (Table 1). This system allows identifying patients who are at high risk of failure according to their pre-operative score. Tornero et al. [12] initially described the primary end point of DAIR early failure at 60 days post-debridement. Our study aims to further validate the KLIC score using a large external multicentric cohort and to evaluate other risk factors of DAIR failure. Furthermore, we sought to evaluate DAIR failure not only during the first 60 days, as described by Tornero et al. [12], but also a late failure, occurring after 60 days of a DAIR procedure.

Table 1.

KLIC Score Scoring System

Variable		Score
K	Chronic renal failure (Kidney)	2
L	Liver failure	1.5
I	Indication for index surgery (revision or femoral neck fracture)	1.5
C	Cemented prosthesis	2
	C-reactive protein >11.5 mg/dL	2.5

Patients and Methods

A retrospective analysis of patients with an early acute knee or hip PJI who were treated with DAIR and recorded in a database of eight Spanish university hospitals was performed. The same methodology described by Tornero et al. [12] was used for the patient selection and outcome definition. Prosthetic joint infection was defined according to the Musculoskeletal Infection Society criteria [13]. All included patients were diagnosed with PJI within the first 90 days after the index surgery and the duration of symptoms was shorter than three weeks. Variables included in our analysis were age, gender, pre-operative American Society of Anesthesiologists (ASA) classification, liver cirrhosis, chronic renal failure, index surgery indication (primary, revision, or hip fracture), cemented or non-cemented arthroplasty, serum C-reactive protein, the time between PJI diagnosis and DAIR, polyethylene exchange during debridement, specialized infection unit performing debridement, scheduled or emergency debridement, causative micro-organism, antibiotic treatment, antibiotic duration, and outcome.

According to pre-operative variables of the KLIC score study, patients were categorized into five groups: group A, ≤2 points; group B, 2.5–3.5 points, group C, 4–5 points; group D, 5.5–6.5 points; and group E, ≥7 points (Table 2).

Table 2.

KLIC Group Scoring Distribution

Group A	≤2
Group B	>2 and <4
Group C	4–5
Group D	>5 and <7
Group E	≥7

KLIC = Kidney, Liver, Index surgery, Cemented prosthesis, and C-reactive protein value.

Following the criteria of Tornero et al. [12], the primary end point for failure was defined as: the patient needing additional unscheduled surgery within the first 60 days after initial debridement; infection-related death within the first 60 days after initial debridement; or the need for long-term suppressive antibiotic treatment. Additionally, a secondary end point was defined using the same criteria for patients with failure after 60 days of the DAIR procedure.

Surgical treatment

Surgical debridement was performed through the previous approach in all cases. At least six samples were obtained for microbiologic culture according to each center's protocol. All necrotic and macroscopically infected tissue was excised before a thorough lavage with 6–9 L of saline. The exchange of modular components was recorded as a variable and was performed under the preferences of the surgeon. After surgery, broad-spectrum intravenous antibiotic treatment was initiated and adjusted according to antibiogram to oral antibiotic agents. Generally, treatment was continued for six to 16 weeks according to culture results and a specific protocol for each center.

Statistical analysis

Qualitative or ordinal variables were described using absolute frequencies or percentages while quantitative variables were described as mean or median values. Categorical variables were compared using the χ² test or Fisher exact test when necessary. Each causative micro-organism was dichotomized and analyzed as an individual variable. Continuous variables were compared using the Student t-test or the Mann-Whitney U test according to the Kolmogorov-Smirnov test of normality. Age and ASA classification were also analyzed as dichotomic variables using the median measurements of our study group.

All variables that showed statistical significance for the univariate analysis were included in a multivariate logistic regression analysis to identify independent predictors for failure. Statistical significance was defined as a two-tailed p < 0.05. Statistical analyses were performed using Stata, version 16 (StataCorp LLC, College Station, TX)

Ethics approval

The ethics committee of the promoting hospital approved this study. The investigators ensure confidentiality and no re-identification for all participants. This study was conducted following the principles of the Declaration of Helsinki and all data used were managed confidentially under current legislation based on Regulation EU 2016/679 of the European Parliament and of the Council of 27 April 2016.

Results

Study population

A total of 455 patients with early acute PJI were included in the analyses. The mean age was 71.3 (standard deviation [SD], 11.6) years. Two hundred forty-four (53.6%) female patients were included. Most patients (234; 51,4%) were classified as ASA 3. Of the 455 DAIR procedures analyzed, 299 (65.7%) were cemented and 257 (56.5%) were localized at the hip joint. The mean time from diagnosis of infection to DAIR was 5.7 (6.96) days. Antibiotic treatment after the DAIR procedure was prolonged for an average of 13.2 (SD, 20.6) weeks. Patients were followed after the DAIR procedure for an average of 36.8 (SD, 31.2) months.

Failure at 60 days

Early failure as described by Tornero et al. [12] occurred in 79 (17.4%) patients. The results of the univariable study of variables according to outcome are shown in Table 3. No statistically significant differences were found for patient-dependent variables. Patients presenting with elevated C-reactive protein serum levels, primary arthroplasty, Staphylococcus aureus, and polymicrobial infections were associated with failure. Patients who underwent scheduled surgery that was performed by a specialized unit showed higher success rates.

Table 3.

Univariable Results According to Outcome Result for Failure at Sixty Days

	No reoperation (n = 376)	Reoperation (n = 79)	P
Mean age (SD), y	71.26 (11.68)	71.71 (11.22)	0.755
Mean time from diagnosis to DAIR (SD), d	6.01 (6.78)	4.61 (7.73)	0.109
Gender (female)	207 (55.1)	37 (46.8)	0.183
Joint (hip)	206 (54.8)	51 (64.6)	0.111
Age ≥74	170 (45.2)	42 (53.2)	0.198
ASA ≥3	219 (58.2)	44 (55.7)	0.677
Revision	108 (28.7)	14 (17.7)	0.045
Scheduled surgery	306 (82.5)	51 (65.4)	0.001
Modular component exchange	273 (73)	60 (75.9)	0.589
Specialized unit	177 (47.6)	27 (34.6)	0.036
MSSA and MRSA	96 (25.5)	32 (40.5)	0.007
Gram-negative bacteria	50 (13.3)	12 (15.2)	0.656
Pseudomonas	14 (3.7)	1 (1.3)	0.486
Enterococcus sp.	22 (5.9)	2 (2.5)	0.403
Polymicrobial	56 (14.9)	20 (25.3)	0.024
Staphylococcus aureus infection treated with rifampin	22 (39.3)	8 (40)	0.955
Gram-negative bacteria infection treated with ciprofloxacin	35 (70)	9 (75)	0.732
Chronic kidney failure	43 (11.4)	10 (12.7)	0.758
Cirrhosis	21 (5.6)	1 (1.3)	0.147
Surgery indication: revision or fracture	115 (30.6)	31 (39.2)	0.134
Cemented	254 (67.6)	45 (57)	0.071
C-reactive protein >11.5 mg/dL	123 (32.7)	42 (53.2)	0.001

SD = standard deviation; DAIR = Debridement, antibiotic agents, and implant retention; ASA = American Society of Anesthesiologists; MSSA = methicillin-sensitive Staphylococcus aureus; MRSA = methicillin-resistant Staphylococcus aureus.

Multivariable logistic regression results showed there was an increased risk of failure for DAIR during unscheduled surgery, primary arthroplasty, elevated C-reactive protein serum levels, Staphylococcus aureus infection, and polymicrobial infection. If DAIR was performed by a specialized unit and cemented arthroplasty were associated with an increased success rate (Table 4).

Table 4.

Multivariate Logistic Regression Analysis Results for Failure at Sixty Days

	OR	SE	95% CI	p
Unscheduled surgery	2.14	0.7679267	1.061725–4.325589	0.033
Specialized unit	0.56	0.1625284	0.3207223–0.9922246	0.047
Primary arthroplasty	2.34	0.8195163	1.183279–4.652578	0.015
Cemented	0.45	0.1640951	0.8589509–3.349911	0.029
Elevated C-reactive protein	2.56	0.7532159	1.438897–4.557721	0.001
Staphylococcus aureus infection	3.27	1.243369	1.554641–6.891481	0.002
Polymicrobial infection	3.57	1.395473	1.662875–7.682719	0.001

OR = odds ratio; SE = standard error; CI = confidence interval.

Furthermore, to investigate the dependence between variables, we performed a correlation matrix that showed the correlation between primary arthroplasty, specialized infection unit, and scheduled or emergency surgery. An additional univariable analysis between specialized infection unit and primary arthroplasty showed statistically significant differences (p < 0.001) between variables: 60% of revision arthroplasties were debrided by a specialized infection unit compared with 40% of primary arthroplasties. A subgroup analysis was then used to determine if there were outcome differences concerning DAIR performed by a specialized unit. When DAIR was performed by a specialized unit, there were no differences in failure rates between primary and revision arthroplasties (14.5% vs. 11%; p = 0.474). When DAIR was carried out by a non-specialized unit, there were also no differences between groups (22.8% vs. 12.2%; p = 0.102).

Failure after 60 days

Late failure after 60 days was recorded in 44 (11.7%) patients, after excluding patients with an early failure after DAIR. Variables studied are shown in Table 5. Patients with hip infections showed higher success rates compared with those with knee infections. Chronic kidney failure and elevated C-reactive proteint serum levels were associated with higher late failure rates.

Table 5.

Univariable Results According to Outcome Result for Failure after Sixty Days

	No reoperation (n = 332)	Reoperation (n = 44)	p
Mean age (SD), y	71.22 (12.02)	71.59 (8.82)	0.802
Mean time from diagnosis to DAIR (SD), d	5.90 (6.66)	6.80 (7.60)	0.412
Gender (female)	182 (54.8)	25 (56.8)	0.802
Joint (hip)	188 (56.6)	18 (40.9)	0.049
Age ≥74	149 (44.9)	21 (47.7)	0.721
ASA ≥3	188 (56.6)	31 (70.5)	0.081
Revision	93 (28)	15 (34.1)	0.402
Scheduled surgery	270 (82.6)	36 (81.8)	0.902
Modular component exchange	238 (72.1)	35 (79.5)	0.297
Specialized unit	161 (49.1)	16 (36.4)	0.113
MSSA and MRSA	83 (25)	13 (29.6)	0.516
Gram-negative bacteria	45 (13.6)	5 (11.4)	0.816
Pseudomonas	12 (3.6)	2 (4.5)	0.673
Enterococcus sp.	19 (5.7)	3 (6.8)	0.732
Polymicrobial	51 (15.4)	5 (11.4)	0.653
Staphylococcus aureus infection treated with rifampin	22 (43.1)	0 (0)	0.145
Gram-negative bacteria infection treated with ciprofloxacin	32 (71.1)	3 (60)	0.629
Chronic kidney failure	34 (10.2)	9 (20.5)	0.045
Cirrhosis	17 (5.1)	4 (9.1)	0.289
Surgery indication: revision or fracture	103 (31)	12 (27.3)	0.612
Cemented	224 (67.5)	30 (68.2)	0.924
C-reactive protein >11.5 mg/dL	101 (30.4)	22 (50)	0.009

For failure after 60 days, the multiple logistic regression model showed an increased risk of failure for elevated C-reactive protein (odds ratio [OR], 2.13; p = 0.039) and a decreased risk when DAIR was performed by a specialized unit (OR, 0.47; p = 0.037).

KLIC score validation

Patients with early failure at 60 days were categorized into five groups, according to pre-operative variables used for the KLIC score study: group A, ≤2 points; group B, 2.5–3.5 points; group C, 4–5 points; group D, 5.5–6.5 points; and group E, ≥7 points. Failure rates recorded were 12% for group A (n = 210), 18% for group B (n = 83), 26% for group C (n = 89), 24% for group D (n = 66), and 0% for group E (n = 7) (Fig. 1). Univariable analysis between consecutive groups of the KLIC score showed no statistically significant differences for failure before 60 days of the DAIR procedure.

FIG. 1.

Failure rates per Kidney, Liver, Index surgery, Cemented prosthesis, and C-reactive protein value (KLIC) study group at 60 days.

To evaluate the KLIC score as a tool for failure after 60 days following a DAIR procedure, patients with late failure were also categorized into groups and analyzed. Failure rates recorded were 10% for group A (n = 185), 4% for group B (n = 68), 20% for group C (n = 66), 16% for group D (n = 50), and 29% for group E (n = 7) (Fig. 2). Univariable analysis between consecutive groups of the KLIC score only showed statistically significant differences between groups B and C (p = 0.006) for failure after 60 days of the DAIR procedure.

FIG. 2.

Failure rates per Kidney, Liver, Index surgery, Cemented prosthesis, and C-reactive protein value (KLIC) study group after 60 days.

Discussion

DAIR is a currently accepted strategy for the treatment of acute PJIs. Success rates for this procedure have shown variable results according to the current literature. Many studies have reported several factors associated with an increased risk of failure including duration of symptoms [14], the possibility to exchange modular components [15], and causative micro-organisms [9]. Recently, criteria for failure have been proposed to pre-operatively assess patients at high risk, particularly the KLIC score.

The main objective of our study was to externally validate the KLIC score in a large external multicenter cohort. When using the same variables and methodology described by Tornero et al. [12], our results show a progressively increased risk of failure for groups A, B, and C followed by a decrease in this tendency for patients in groups D and E. These results suggest the KLIC score was not useful for predicting failure in our cohort. A study performed by Duffy et al. [16] analyzed the KLIC score in a total of 59 patients with prosthetic knee infections demonstrating there was no correlation between low scores (<7) and treatment outcome.

On the other hand, when we used the KLIC score to evaluate failure after 60 days, patients in group E showed an increased risk. These findings suggest the end point at 60 days might be key to understanding the difference in our results and could have an impact on the validity and utility of the KLIC score.

In a similar validation study, Löwik et al. [11] show that the KLIC score is a relatively good pre-operative risk score for predicting failure, although additional variables other than the ones included in the KLIC score were predictive of failure. This may be due to differences in studied populations and emphasizes the need for external validation tests. In a recent study performed in the United States, the KLIC score performed poorly in predicting DAIR failure for PJI at 90 days or two years [17]. Nonetheless, the authors of this study consider there were major differences in the definition of failure between studies.

Risk scores can be helpful for the decision-making process for the treatment of PJI. However, it is important to validate these tools before they can be implemented in clinical practice. Differences in studied cohorts could provide the variation in results suggested by our study results. A considerable difference between cohorts studied is the lower percentage of patients with cirrhosis included in our study compared with Tornero et al. [12] (4.8% vs. 10.3%). There were also differences in joint location, having a greater number of hips included in our study (56.5 vs. 38.3). This could lead to a lower percentage of patients with cemented arthroplasties in our study (65.7% vs. 74.3%), which could have a direct effect on the KLIC score group classification. Interestingly, the rate of modular component exchange was very similar in both studies (73.2% vs. 72.9%).

Pre-operative risk factors for predicting failure described throughout the current literature include patient-dependent variables, such as ASA classification [18], and infection-dependent variables, such as duration of symptoms [19], causative micro-organism, or inflammatory parameters [20]. Elevated C-reactive protein in serum has been one of the most studied risk factors and our results are in the concordance of the current literature, having patients with elevated C-reactive protein at a higher risk of late failure (after 60 days of DAIR). Infections caused by S. aureus had higher failure rates for early failure, but not for late failure. We believe this could have to do with the nature of Staphylococcus aureus infections. The current literature illustrates that the likelihood of failure for Staphylococcus aureus infections, and particularly methicillin-resistant Staphylococcus aureus (MRSA) infections, is higher during the first weeks after debridement [15]. Furthermore, although clinical data is supporting the use of combination rifampin therapy [21,22], the addition of rifampin for Staphylococcus aureus infections did not seem to affect the outcome in our cohort. However, our results regarding rifampin need to be considered carefully because our sample size is not large enough to establish differences. Patients with gram-negative bacteria infections were not at a higher risk of failure. Early PJIs caused by gram-negative bacteria and treated with a DAIR procedure have shown high success rates, especially in cases of fluoroquinolone susceptibility and antimicrobial treatment [23]. Our results did not show outcome differences for gram-negative bacteria infections treated with fluoroquinolones.

Additional risk factors related to the surgery have not been studied exhaustively. The exchange of modular components during surgery has been recommended at the last International Consensus Meeting (ICM) [24]. Several studies support the exchange of modular components to reduce the rate of surgical site infection recurrence after DAIR [5,25]. Although our results do not show significant differences, the authors of this study agree with the ICM recommendations, considering removal of these components allows for better joint visualization, facilitates proper debridement and potential bioburden removal. Compared with the original KLIC score study, Tornero et al. [12] also report there are no differences between groups with polyethylene exchange during debridement in their univariate analysis for risk factors.

Our results identify risk factors that have been previously described [9,14,15], but also recognize the importance of scheduled surgery and having the procedure performed by a specialized infection unit as success indicators for DAIR. Correlation analysis showed an association between the type of arthroplasty (primary or revision) and the surgical team performing the debridement (specialized vs non-specialized unit). The preliminary univariate analysis showed patients in the revision arthroplasty group had a lower risk of failure. This association can be explained because revision arthroplasty patients had debridement more frequently performed by a specialized infection unit compared with patients with a primary arthroplasty. The current literature regarding these two factors is scarce, but our results suggest, having recognized PJI as a complex and challenging entity that requires a coordinated and collaborative approach, a specialized unit should conduct DAIR procedures.

Limitations to our study include its retrospective design. The multicenter nature of this study enables a higher number of patients to be included in the study but, on the other hand, it does not account for small differences in treatment protocols and surgical procedure techniques that may vary from one center to another.

Recently, new tools for predicting outcomes following DAIR have been developed by using a machine learning algorithm [26]. New developments in Bigdata technology could also play a role in the way of detecting patients with a high risk of failure after DAIR.

Take home message

Criteria for failure of DAIR after early periprosthetic joint infection have been proposed to pre-operatively assess patients at high risk, particularly the KLIC score.

Additional risk factors related to the surgical procedure have not been studied exhaustively.

Our study results suggest the KLIC score was not useful for predicting early failure.

We identified scheduled surgery and having the procedure performed by a specialized unit as important factors for DAIR success.

Footnotes

Acknowledgments

The ethics committee of the promoting hospital approved this study. The investigators ensure confidentiality and no reidentification for all participants. This study was conducted following the principles of the Declaration of Helsinki and all data used was managed confidentially under current legislation based on Regulation EU 2016/679 of the European Parliament and of the Council of 27 April 2016. All data was collected from eight Spanish university hospitals:

Hospital Universitari Mutua Terrassa, Terrassa, Spain; Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain; Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona. Sabadell, Spain; Hospital Universitario de Cruces, Barakaldo, Spain; Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain; Hospital General del Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain; Clínica Universidad de Navarra, Pamplona, Spain; and Hospital Universitario y Politécnico La Fe, Valencia, Spain.

Funding Information

The research leading to these results did not receive any funding.

Author Disclosure Statement

Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

References

Singh

, Yu

, Chen

, et al. Rates of total joint replacement in the United States: Future projections to 2020–2040 Using the National Inpatient Sample. J Rheumatol, 2019; 46:1134–1140.

Zimmerli

, Trampuz

, Ochsner

. Prosthetic-joint infections. N Engl J Med, 2004; 351:1645–1654.

Kurtz

, Ong

, Lau

, et al. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res, 2010; 468:52–56.

Kunutsor

, Whitehouse

, Blom

, et al. Re-infection outcomes following one- and two-stage surgical revision of infected hip prosthesis: A systematic review and meta-analysis. PLoS One, 2015; 10:e0139166.

Tsang

, Ting

, Simpson

AHRW

, et al. Outcomes following debridement, antibiotics and implant retention in the management of periprosthetic infections of the hip: A review of cohort studies. Bone Joint J, 2017; 99-B:1458–1466.

Sendi

, Lötscher

, Kessler

, et al. Debridement and implant retention in the management of hip periprosthetic joint infection: Outcomes following guided and rapid treatment at a single centre. Bone Joint J, 2017; 99-B:330–336.

Grammatopoulos

, Kendrick

, McNally

, et al. Outcome Following Debridement, Antibiotics, and Implant Retention in Hip Periprosthetic Joint Infection: An 18-year experience. J Arthroplasty, 2017; 32:2248–2255.

Urish

, Bullock

, Kreger

, et al. A multicenter study of irrigation and debridement in total knee arthroplasty periprosthetic joint infection: Treatment failure is high. J Arthroplasty, 2018; 33:1154–119.

Rodríguez-Pardo

, Pigrau

, Lora-Tamayo

, et al. Gram-negative prosthetic joint infection: Outcome of a debridement, antibiotics and implant retention approach. A large multicentre study. Clin Microbiol Infect, 2014; 20:O911–O919.

10.

Narayanan

, Anoushiravani

, Elbuluk

, et al. Irrigation and debridement for early periprosthetic knee infection: Is it effective?. J Arthroplasty, 2018; 33:1872–1878.

11.

Löwik

CAM

, Jutte

, Tornero

, et al. Predicting failure in early acute prosthetic joint infection treated with debridement, antibiotics, and implant retention: External validation of the KLIC score. J Arthroplasty, 2018; 33:2582–2587.

12.

Tornero

, Morata

, Martínez-Pastor

, et al. KLIC-score for predicting early failure in prosthetic joint infections treated with debridement, implant retention and antibiotics. Clin Microbiol Infect, 2015; 21:786.e9–786.e17.

13.

Parvizi

, Zmistowski

, Berbari

, et al. New definition for periprosthetic joint infection: From the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res, 2011; 469:2992–2994.

14.

Kuiper

, van den Bekerom

, van der Stappen

, et al. 2-stage revision recommended for treatment of fungal hip and knee prosthetic joint infections. Acta Orthop, 2013; 84:517–523.

15.

Lora-Tamayo

, Murillo

, Iribarren

, et al. A large multicenter study of methicillin-susceptible and methicillin-resistant Staphylococcus aureus prosthetic joint infections managed with implant retention. Clin Infect Dis, 2013; 56:182–194.

16.

Dx Duffy

, Ahearn

, Darley

, et al. Analysis of the KLIC-score: An outcome predictor tool for prosthetic joint infections treated with debridement, antibiotics and implant retention. J Bone Joint Infect, 2018; 3:150–155.

17.

Chalmers

, Kapadia

, Chiu

Y-F

, et al. Accuracy of predictive algorithms in total hip and knee arthroplasty acute periprosthetic joint infections treated with debridement, antibiotics, and implant retention (DAIR). J Arthroplasty, 2021; 36:2558–2566.

18.

Azzam

, Seeley

, Ghanem

, et al. Irrigation and debridement in the management of prosthetic joint infection: Traditional indications revisited. J Arthroplasty, 2010; 25:1022–1027.

19.

Kim

, Bae

, Lee

, et al. The parameters affecting the success of irrigation and debridement with component retention in the treatment of acutely infected total knee arthroplasty. Clin Orthop Surg, 2015; 7:69–76.

20.

Vilchez

, Martínez-Pastor

, García-Ramiro

, et al. Outcome and predictors of treatment failure in early post-surgical prosthetic joint infections due to Staphylococcus aureus treated with debridement. Clin Microbiol Infect, 2011; 17:439–444.

21.

Becker

, Kreitmann

, Triffaut-Fillit

, et al. Duration of rifampin therapy is a key determinant of improved outcomes in early-onset acute prosthetic joint infection due to Staphylococcus treated with a debridement, antibiotics and implant retention (DAIR): A retrospective multicenter study in France. J Bone Joint Infect, 2020; 5:28–34.

22.

Zimmerli

, Widmer

, Blatter

, et al. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: A randomized controlled trial. Foreign-body infection (FBI) study group. JAMA, 1998; 279:1537–1541.

23.

Martínez-Pastor

, Muñoz-Mahamud

, Vilchez

, et al. Outcome of acute prosthetic joint infections due to gram-negative bacilli treated with open debridement and retention of the prosthesis. Antimicrob Agents Chemother, 2009; 53:4772–4777.

24.

Argenson

, Arndt

, Babis

, et al. Hip and knee section, treatment, debridement and retention of implant: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty, 2019; 34:S399–S419.

25.

Kuiper

, Willink

, Moojen

, et al. Treatment of acute periprosthetic infections with prosthesis retention: Review of current concepts. World J Orthop, 2014; 5:667–676.

26.

Shohat

, Goswami

, Tan

, et al. 2020 Frank Stinchfield Award: Identifying who will fail following irrigation and debridement for prosthetic joint infection. Bone Joint J, 2020; 102-B(7 Suppl B):11–19.