Late Acute Hematogenous Infections after Total Knee Arthroplasty: Results of Debridement, Antibiotics, and Implant Retention



Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain


The frequency of late acute hematogenous infection (LAHI) following total knee arthroplasty (TKA) is between 0.2%
and 0.5%. There is controversy over the results of patients treated for LAHIs by surgical debridement, antibiotics, and
implant retention (DAIR). This narrative review of the literature aims to establish the role of DAIR in LAHIs after TKA.
The published success rate (retention of the prosthesis) after DAIR is between 50% and 100%. The success rate is
associated with a shorter duration of symptoms (5–14 days from the onset of symptoms). Factors associated with
failure are an accompanying infection and the diagnosis of rheumatoid arthritis before the TKA is performed. It is not
recommended to indicate a DAIR in patients with atrial fibrillation, chronic obstructive pulmonary disease, the presence
of >15 cells per high-powered field, preoperative C-reactive protein >500 mg/L or methicillin-resistant S. aureus. In
such patients, a two-stage revision arthroplasty should be recommended. Arthroscopic DAIR has a limited effect. It is
most efficacious in the very early stage of acute presentations of infected TKA. It can be useful in patients with extreme
frailty as an adjunct to suppressive antibiotic therapy. If carried out, high volumes of fluid should be utilized. The
indications for an open DAIR are the following: duration of clinical signs and symptoms is less than 3 weeks; patients
with a well-fixed implant; no abscess or sinus tract; low-virulence bacteria; elderly patients with multiple comorbidities;
and nonimmunocompromised patients. Open DAIR should not be advised in cases with chronic infection (>4 weeks
postoperatively, insidious beginning of symptoms).
Level of evidence: III


1. Cook JL, Scott RD, Long WJ. Late Hematogenous
Infections After Total Knee Arthroplasty–Experience
with 3013 Consecutive Total Knees. The journal of
knee surgery. 2007; 20(01):27-33.
2. Mohamad M, Uçkay I, Hannouche D, Miozzari H.
Particularities of Staphylococcus lugdunensis in
orthopaedic infections. Infectious Diseases. 2018;
3. Franklin PD, Miozzari H, Christofilopoulos P,
Hoffmeyer P, Ayers DC, Lübbeke A. Important patient
characteristics differ prior to total knee arthroplasty
and total hip arthroplasty between Switzerland and
the United States. BMC musculoskeletal disorders.
2017; 18(1):14.
4. Ratto N, Arrigoni C, Rosso F, Bruzzone M, Dettoni
F, Bonasia DE, et al. Total knee arthroplasty and
infection: how surgeons can reduce the risks. EFORT
Open Reviews. 2016; 1(9):339-44.
5. Winkler H. Treatment of chronic orthopaedic
infection. EFORT Open Reviews. 2017; 2(5):110-6.
6. Izakovicova P, Borens O, Trampuz A. Periprosthetic
joint infection: current concepts and outlook. EFORT
open reviews. 2019; 4(7):482-94.
7. Davidson DJ, Spratt D, Liddle AD. Implant materials
and prosthetic joint infection: the battle with the
biofilm. EFORT open reviews. 2019; 4(11):633-9.
8. Renaud A, Lavigne M, Vendittoli PA. Periprosthetic
joint infections at a teaching hospital in 1990–2007.
Canadian Journal of Surgery. 2012; 55(6):394.
9. He R, Yang L, Guo L, Chen H, Zhang Y, Jiang DM.
Management of acute hematogenous infection
following total knee arthroplasty: a case series of 11
patients. Orthopaedic Surgery. 2016; 8(4):475-82.
10. Burnett RS, Aggarwal A, Givens SA, McClure JT,
Morgan PM, Barrack RL. Prophylactic antibiotics do
not affect cultures in the treatment of an infected
TKA: a prospective trial. Clinical Orthopaedics and
Related Research®. 2010; 468(1):127.
11. Westberg M, Grøgaard B, Snorrason F. Infection
after Constrained Condylar Knee Arthroplasty:
Incidence and microbiological findings in 100
consecutive complex primary and revision total knee
arthroplasties. Journal of bone and joint infection.
2018; 3(5):260.
12. Koh IJ, Han SB, In Y, Oh KJ, Lee DH, Kim TK. Open 
debridement and prosthesis retention is a viable
treatment option for acute periprosthetic joint
infection after total knee arthroplasty. Archives of
Orthopaedic and Trauma Surgery. 2015; 135(6):
13. Chiu FY, Chen CM. Surgical debridement and
parenteral antibiotics in infected revision total knee
arthroplasty. Clinical Orthopaedics and Related
Research®. 2007; 461:130-5.
14. Stryker LS, Abdel MP, Hanssen AD. Predictive
value of inflammatory markers for irrigation and
debridement of acute TKA infection. Orthopedics.
2013; 36(6):765-70.
15. Miles J, Parratt MT. Arthroscopic Debridement of
Infected Total Knee Arthroplasty. InThe Infected Total
Knee Arthroplasty 2018 (pp. 127-131). Springer,
16. Encinas-Ullán CA, Martí􀆴nez-Lloreda Á􀆵 , Rodrí􀆴guez-
Merchán EC. Open Debridement and Polyethylene
Exchange (ODPE) in the Infected Total Knee
Arthroplasty. InThe Infected Total Knee Arthroplasty
2018 (pp. 133-138). Springer, Cham.
17. Konigsberg BS, Della Valle CJ, Ting NT, Qiu F, Sporer
SM. Acute hematogenous infection following total hip
and knee arthroplasty. The Journal of arthroplasty.
2014; 29(3):469-72.
18. Son WS, Shon OJ, Lee DC, Park SJ, Yang HS. Efficacy
of open debridement and polyethylene exchange in
strictly selected patients with infection after total
knee arthroplasty. Knee Surgery & Related Research.
2017; 29(3):172.
19. Song X, Li X, Song J, Xu C, Li R, Li H, et al. Clinical
research of debridement with prosthesis retention
for periprosthetic joint infection after arthroplasty.
Zhongguo xiu fu chong jian wai ke za zhi= Zhongguo
xiufu chongjian waike zazhi= Chinese journal
of reparative and reconstructive surgery. 2018;
20. Bene N, Li X, Nandi S. Factors affecting failure of
irrigation and debridement with liner exchange in
total knee arthroplasty infection. The Knee. 2018;
21. Calanna F, Chen F, Risitano S, Vorhies JS, Franceschini
M, Giori NJ, et al. Debridement, antibiotic pearls,
and retention of the implant (DAPRI): A modified 
technique for implant retention in total knee
arthroplasty PJI treatment. Journal of Orthopaedic
Surgery. 2019; 27(3):2309499019874413.
22. Debarge R, Nicolle MC, Pinaroli A, Ait SS, Neyret P.
Surgical site infection after total knee arthroplasty:
a monocenter analysis of 923 first-intention
implantations. Revue de chirurgie orthopedique et
reparatrice de l’appareil moteur. 2007; 93(6):582.