Letter: Outcomes of the Subsequent Periprosthetic Joint Infection Revisions after a Failed Debridement,Antibiotics,and Implant Retention: A Multicentric Study of 197 Patients

To the Editor:

We read with great interest an article titled “Outcomes of the Subsequent Periprosthetic Joint Infection Revisions after a Failed Debridement, Antibiotics and Implant Retention: A Multicentric Study of 197 Patients.” ¹ The authors made significant contributions by investigating the outcomes of subsequent surgeries following failed DAIR for periprosthetic joint infection (PJI), comparing second debridement, antibiotics and implant retention (DAIR) with one- and two-stage revisions. They also identified risk factors associated with treatment failure and proposed that a second DAIR could be a viable option for carefully selected patients without these risk factors. However, we would like to highlight several key points that we believe are crucial for readers to fully understand the study’s implications. These points are discussed in more detail below.

According to the authors, cases diagnosed with PJI within the first 90 days following the index surgery were included. However, it remains unclear how much time elapsed between a failed DAIR procedure and the subsequent surgery. Studies have shown that the timing of surgery has a significant impact on the success rate of DAIR procedures. If a second DAIR is performed a long time after the failure of the first, it could significantly affect its success rate ² and, consequently, the accuracy of the conclusions.

The use of antibiotics is one of the most crucial components in the treatment of PJI. ³ However, the article does not specify the antibiotic regimen for these patients, including the type, dosage, administration method, or duration of use. This omission could also impact the accuracy of the study’s findings.

Although the article describes the baseline characteristics of the patients, several important factors that could influence the treatment outcomes of PJI are not addressed. These include the presence of comorbidities such as diabetes, the condition of the soft tissues, and whether there is malnutrition. Furthermore, details regarding the surgical procedure are not provided, such as the types of irrigants used, whether drains were placed for irrigation or suction, and other related procedures. Given that this is a multicenter study, treatment protocols may vary significantly, which could influence the results.

In recent years, 1.5-stage exchange arthroplasty has become increasingly applied in patients with PJI, with promising outcomes. ⁴ This method reduces the number of surgeries and associated complications, significantly improves patient prognosis, and decreases both patient trauma and economic burden. It has broad indications, a high infection-free survival rate, and has become one of the effective treatments for PJI. However, as of now, including in this study, there is no research specifically addressing the use of 1.5-stage exchange arthroplasty in cases of failed DAIR procedures. At our medical center, a small number of failed DAIR procedures have been treated with 1.5-stage exchange arthroplasty, yielding reliable short-term results, although further studies are needed. We hope that future research will provide more insights to further refine the treatment strategies for failed DAIR procedures.

Despite the arguments presented in this discussion, the article’s contributions are undeniably substantial. Nevertheless, as dedicated researchers, we must acknowledge that there is always room for improvement. Should any confounding factors come to light, it is imperative that they be thoroughly accounted for, thereby enhancing our overall understanding of the study.