Overview
Debridement, antibiotics and implant retention (DAIR) is a treatment option for selected early postoperative or acute hematogenous hip periprosthetic joint infections when the fixed components remain stable. The procedure combines thorough removal of infected and nonviable tissue, microbiologic sampling, exchange of modular bearing components and a directed antimicrobial plan (Campbell, Chapter 4).
Retention is a selection decision, not simply the least extensive operation. A loose prosthesis or established chronic infection generally requires an implant-removal strategy if eradication is the goal. This guide follows Campbell Technique 4.8.
Assessment and Selection
Establish the onset and duration of symptoms and distinguish early postoperative infection, acute hematogenous infection and a late chronic presentation.
Assess wound drainage, skin and soft-tissue quality, systemic illness, medical fitness and any distant infectious source.
Review radiographs for component fixation and bone loss. Intraoperative inspection must confirm that retained components are stable.
Use the full clinical, laboratory, aspiration and microbiologic assessment. A sinus communicating with the joint or repeated cultures of the same organism are strong diagnostic findings; normal-appearing skin does not exclude deep infection.
Account for organism virulence, antimicrobial susceptibility, the host and the soft-tissue envelope when choosing retention versus exchange.
(Campbell, Chapters 4 and 8.)
Indications and Reasons to Reconsider Retention
Supports consideration of DAIR | Favors a different or more extensive strategy |
|---|---|
Early postoperative or acute hematogenous presentation | Longstanding chronic infection |
Well-fixed femoral and acetabular components | Loosening of a fixed component |
Soft tissues permitting adequate debridement and closure | Compromised envelope that cannot be reconstructed adequately |
Feasible modular exchange and antimicrobial treatment | Inability to gain adequate access, exchange required parts or deliver a suitable treatment course |
Campbell describes uncertainty about the acceptable symptom-duration window for acute hematogenous infection and uses host, organism and tissue factors in addition to timing. A calendar cutoff alone should not determine eligibility (Chapter 4).
Preoperative Planning
Coordinate with infectious disease and relevant medical teams.
Identify the existing implant and arrange compatible femoral head and acetabular liner components, extraction instruments and backup options.
Plan multiple tissue and fluid samples and clearly label their anatomic sites.
Prepare sufficient instruments for the debridement and subsequent clean implantation phase.
Discuss the possibility of component removal or staged revision if fixation or infection extent makes retention unsuitable.
(Campbell, Chapter 4, Technique 4.8.)
Surgical Technique
Exposure and Assessment
Use the prior incision when appropriate and safely redevelop the fascial planes.
Open the capsule to expose the prosthesis and determine the extent of deep involvement.
Dislocate the hip under control and remove the modular femoral head and acetabular liner.
Inspect fixation of the acetabular and femoral components. If either is loose, revise the retention plan.
Remove other foreign material that is no longer necessary for stability, as appropriate to the reconstruction.
(Campbell, Chapter 4, Technique 4.8.)
Sampling and Systematic Debridement
Obtain cultures from encountered fluid collections and representative synovial and periprosthetic tissue around both the femur and acetabulum.
Debride layer by layer from the skin to the deep joint, removing nonviable tissue and unnecessary foreign material.
Expose the relevant recesses and interfaces sufficiently to avoid leaving inaccessible infected tissue.
Irrigate using the selected protocol and mechanically clean the exposed implant surfaces as described in the source.
Inspect again for missed devitalized tissue or foreign material before proceeding to reconstruction.
(Campbell, Chapter 4, Technique 4.8.)
Clean Phase and Modular Exchange
Once debridement is complete, exchange gowns, gloves and instruments. Campbell also describes the option of provisional closure followed by repeat preparation and draping.
Perform a final wound inspection after irrigation.
Insert compatible definitive head and liner components with secure seating.
Reduce the hip and assess stability, impingement and the integrity of the soft-tissue envelope.
Close the fascia and remaining layers appropriately, recognizing the condition of the previously operated tissues.
(Campbell, Chapter 4, Technique 4.8.)
Antimicrobial Treatment
Choose therapy according to cultures, susceptibility and the clinical setting in consultation with infectious disease. The antimicrobial course is integral to DAIR, but antibiotics do not compensate for incomplete debridement, retained loose components or an unsuitable chronic-infection indication. Address a hematogenous source when present (Campbell, Chapters 4 and 8).
Postoperative Assessment
Follow the wound, drainage, pain, systemic status and laboratory and culture findings together.
Review antimicrobial tolerance and the ability to complete the prescribed course.
Set loading and movement instructions according to the retained reconstruction and operative soft-tissue work.
Reassess promptly if the clinical course suggests persistent infection, unstable components or wound failure.
Maintain a defined escalation plan for repeat debridement or exchange reconstruction when eradication is not achieved.
The Campbell authors describe a double-DAIR approach in their practice for selected acute infections. This is a source-specific strategy, not evidence that every retained prosthesis can be cured by repeated washout (Chapter 4).
Pearls and Pitfalls
Exchange modular parts: removing only superficial tissue while leaving the liner in place limits access to the joint.
Confirm fixation: retention assumes stable fixed components.
Sample adequately: fluid and multiple periprosthetic sites can provide complementary microbiologic information.
Debride systematically: work through every involved layer rather than focusing only on the visible collection.
Change the plan when needed: chronic infection, loosening or inadequate soft tissues should trigger reconsideration of retention.
(Campbell, Chapter 4.)
Complications and Limitations
Persistent or recurrent infection may require implant removal and revision. Other risks include instability after modular exchange, wound failure, antimicrobial complications and medical deterioration. Success depends on the definition used, host and organism factors, timing and the quality of surgical source control; a single published success percentage is not a guarantee for an individual infection (Campbell, Chapters 4 and 8).
References
Harkess JW, Crockarell JR Jr. Arthroplasty of the hip. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2026. Chapter 4, infection and component retention, pp. 281–286, Technique 4.8.
Ford MC, Holland CT, Mihalko WM. Arthroplasty of the knee. In: Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2026. Chapter 8, general periprosthetic infection diagnosis and treatment considerations, pp. 451–454.