Dr Randall on the Debate Over DAIR Procedures for Periprosthetic Joint Infection Management

"Because these are massive segmental replacements, to take out these endoprosthetics and putting in a spacer or not putting in a spacer really debilitates these patients and impairs their quality of life. This [DAIR]... from a functional standpoint, makes sense, but it's really debated quite a bit."

R. Lor Randall, MD, FACS, the David Linn Endowed Chair for Orthopedic Surgery, the chair of the Department of Orthopedic Surgery, and a professor at UC Davis Comprehensive Cancer Center, discussed key findings from the Birmingham Orthopedic Oncology Meeting (BOOM), a global consortium of surgeons reported wide variability in how debridement, antibiotics, and implant retention (DAIR) procedures are defined and performed.

In January 2024, 309 delegates from 53 countries participated in a 2-day consensus meeting in Birmingham, United Kingdom, to establish consensus on clear guidance for clinicians dealing with infection control and other day-to-day challenges in sarcoma management. A follow-up meeting was held in January 2026 in Cape Town, South Africa to specifically discuss challenges associated with regarding periprosthetic joint infection in orthopedic oncology reconstructions for patients with chondrosarcoma.

Debridement, antibiotics, and implant retention (DAIR)—which involves surgically cleaning the site and administering targeted antibiotics while leaving the implant in place—is functionally attractive, its ability to successfully clear a deep infection is heavily debated, Randall began. This "DAIR dilemma" arises because these orthopedic reconstructions often involve massive segmental replacements, he explained. He noted that removing these endoprosthetic implants to place a spacer is a highly debilitating process that significantly impairs a patient's quality of life.

The consensus findings from the meeting established that DAIR is an acceptable strategy for managing acute infections of short duration caused by susceptible organisms. However, this recommendation only achieved "weak consensus" due to significant international variability in how the procedure is defined and performed. For instance, some surgeons routinely exchange modular components during the procedure, while others utilize debridement and retention alone, Randall shared. He also pointed out that health care economics and resource availability in different global regions heavily influence these surgical choices.

Ultimately, although data suggest that long-term infection control is lower with DAIR compared with a full staged revision, this drawback must be balanced against the extreme morbidity of removing the prosthesis, Randall said. He concluded that the current variability in techniques highlights the ongoing need for shared, evidence-based answers to the practical problems faced by sarcoma units worldwide to optimize patient outcomes.