Periprosthetic joint infections (PJIs) following limb salvage surgery for bone sarcomas remain among the most challenging complications in orthopedic oncology. At the 2024 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, underscoring the need to standardize terminology to improve outcomes, enable collaborative research, and better coordinate care with medical oncologists, according to R. Lor Randall, MD, FACS.
“The systemic treatments we’re giving these patients also contribute to the risk profile for a secondary infection; the chemotherapy and the immunomodulatory therapy are paramount to good oncologic outcomes, but there needs to be really good communication between medical oncology and orthopedic oncology when infection is suspected,” Randall said in an interview with OncLive®.
Randall is the David Linn Endowed Chair for Orthopedic Surgery, the chair of the Department of Orthopedic Surgery, and a professor in the Department of Orthopedic Surgery at UC Davis Comprehensive Cancer Center in Sacramento, California.
In the interview, Randall discussed the challenges of managing PJIs after limb salvage surgery, highlighted findings from the BOOM global study, and explained why standardizing DAIR definitions is critical for multidisciplinary sarcoma care.
Highlights and Take-Home Points: The State of PJIs and DAIR Strategies
- Global survey data show infection rates between 30% and 50% after oncologic reconstruction, with wide variation in timing, surgical approach, and antibiotic duration.
- BOOM identified inconsistent use of the term DAIR across 44 countries, prompting the creation of 4 standardized procedural categories to enable meaningful comparison of outcomes.
- Infection management directly affects chemotherapy timing, limb viability, and survival, making early recognition and communication between medical and orthopedic oncologists essential.
OncLive: What is one of the main controversies in orthopedic oncology?
Randall: BOOM was a consensus meeting held in 20241 in which over 300 investigators from around the world came together in Birmingham, England, to talk about controversies in orthopedic oncology. [One of the topics discussed] was a procedure called DAIR.2 PJIs are one of the most difficult complications we face. Unlike arthroplasty, our reconstructions often involve massive implants. When you do a total hip replacement or total knee replacement, [you’re mainly dealing with] the surfaces of the joints, but when you take out a big bone sarcoma, you have these massive endoprosthetics. When [these endoprosthetics] become infected, it becomes really debilitating for a patient. We sometimes will also use biologic reconstructions and other extensive procedures [with these massive implants], and [when] you dial in chemotherapy and radiation, it can really be a triple threat for these patients.
A global survey was done at the BOOM consortium meeting. [Attendees] agreed that infection rates can vary depending upon host and comorbidities, and whether patients get concomitant chemotherapy or radiation. The range [of infection] is around 30% to 50% and the core challenge is being able to tease out how DAIR [is defined in this setting]. There’s no shared language and no shared strategy. One of the most important findings of the study that was performed by BOOM is a lack of standardized terminology. Across 44 countries using DAIR, [the study] described everything from simple irrigation and washout to extensive debridement of soft tissues to partial or complete modular component exchange. The terminology was somewhat ambiguous, making it hard to compare outcomes for patients.
What classifications were proposed to help standardize ambiguous DAIR terminology at the meeting?
At this meeting, we came together and made 4 distinct categories to standardize the definitions and fix this gap. Poly exchange refers to polyethylene-only exchange without aggressive debridement. These massive endoprosthetics have a metal shaft, but there are plastic articulations, polyethylene. It’s a very sophisticated, high–load-bearing substance that allows the articulations to function like a native joint. Sometimes [the procedure requires] just a simple poly exchange, other times it [calls for] a true DAIR, which stands for aggressive soft tissue debridement, washing it out, and modular component retention. So, we don’t take out this big prosthesis. Then we classified DAIR plus, which [includes] DAIR, but we do change out the modular components. These massive endoprosthetics have junctions where you have what’s fixed to the bone and what’s [fixed to] the segment, and then the articulation. And they come in modular components, so they can be partially exchanged. The fourth category was DAIR plus antibiotics, which [involves] DAIR with the component exchange of the modular aspects with systemic and/or local antibiotics. We were able to at least categorize the different types of procedures that were being done across the world.
What did survey results from the BOOM meeting reveal about the use of DAIR-based procedures?
This worldwide survey of 272 surgeons revealed striking variability; 62% of surgeons routinely perform radical soft tissue debridement when managing PJIs, and approximately 55% believe DAIR works most of the time, but 20% think it doesn’t work. Time thresholds for implementation of these DAIR-[based] procedures varied as well. A total of 32% [of surgeons] will [perform the procedure] within 3 weeks of the inciting infection, 29% within 6 weeks, and only 19% 12 weeks or [after] presentation of the infection. Antibiotic duration ranged broadly from one-third favoring 3 months or more [to approximately] 40% favoring up to 6 weeks. There’s great heterogeneity there, which reflects a gap in knowledge as well as a systems gap. Surgeons are compelled to adapt to patient complexity [and] limited biologic reserve, and this can have catastrophic consequences.
Could DAIR have a role in oncologic reconstruction? What factors might predict its success?
A major insight from this study is that DAIR does have a role in oncologic reconstruction, but its success depends heavily on context. Early infections fare better than chronic infections. Aggressive debridement remains the strongest predictor of DAIR success. Polyethylene-only exchanges, which we see often in the arthroplasty literature, may underperform compared with modular component exchanges because of the massive nature of these prostheses. The biggest limitation is the absence of comparative data across these major sarcoma centers, leaving surgeons to rely on experience rather than evidence.
What next steps are needed to achieve consensus on the definition of PJIs and DAIR procedures?
Standardization is essential. Without unified definitions, multicenter trials and meta-analyses are impossible. BOOM proposed nomenclature as a critical step toward global coherence. We need to stratify our patients in reconstructions. We need to look at the reconstruction type, specifically biologic vs these mega-prostheses, infection timing, acute vs chronic, host physiology, accounting for systemic treatments, immunosuppression, and other oncologic variables, in addition to organism types such as staph, which is the most common, gram negative, and maybe fungal.
Doing this will allow us to have a prospective collaborative effort, because these are uncommon procedures, but the relative infection rate compared with the arthroplasty literature is high. We need to be able to get beyond individual institutional data sets. We need BOOM and the Musculoskeletal Tumor Society in the United States and then the European societies and the Asian Pacific groups to coordinate their data sets. This will allow us to improve our outcomes by being able to understand better the soft tissue management, the antibiotic const, the antibiotic latent constructs, and be able to potentially even recognize infections earlier based upon risk factor.
What are the most common secondary infections seen after limb salvage surgery, and what risk factors should medical oncologists be most aware of?
[Staphylococcus] aureus is by far the most common infection we see; sometimes S epidermidis and other skin flora, but mucosal bugs are also an issue. There are talks about nasal swabs and things of that sort in terms of what medical oncologists need to be aware of. They’re not responsible for [managing] the wounds, but [they should be prepared to ask] cursory questions, if not evaluate the area in question, to determine whether there’s any warmth, new swelling, or redness, and then alert the orthopedic oncologist as to that finding.
How do prior or ongoing cancer therapies affect infection risk, presentation, and healing following limb salvage procedures?
If patients are on cytotoxic chemotherapy, that can create an immunocompromised situation. Immunomodulation therapies, by definition, can potentially increase the risk of infection. Coordination of these modalities with the orthopedic oncologist, factoring in comorbidities such as diabetes and other conditions that might affect the immune system, is important when the medical and orthopedic oncologists are deciding what the best course of action is for the reconstruction.
What early clinical or imaging signs should prompt oncologists to suspect a secondary infection and refer patients back to orthopedic surgery promptly?
If the patient is post operative, they should ask, “How is the surgical area? How is it feeling? [Is there] any warmth, [have you had] any fevers?” Most of these [infections] would be picked up in a standard review of systems by the medical oncologist. [It’s important to have] that added finesse and question the [patient about the] surgical site for warmth, swelling, or increasing tenderness, and then any fevers.
How do secondary infections affect long-term functional outcomes in limb preservation? When does infection shift the risk-benefit ratio toward a more aggressive intervention?
That’s the crux of what we’re trying to figure out. These are big defects with artificial components, or sometimes biologic components put in place of the area where we have to do the resection, [so] to have to explant these devices or constructs is a huge source of morbidity for these patients and puts the limb at risk. Because these infections can be so extensive, they can also put the patient at risk because of the systemic sequelae of an immunocompromised host. [Infections can also] delay additional therapy, which can be limb, life, and oncologically threatening.
What best practices for multidisciplinary coordination can help prevent and manage secondary infections more effectively?
We’re trying to tease out best practices given what we outlined at the BOOM meeting, but orthopedic oncologists remain vigilant in doing scrub down techniques for the patient ahead of surgery, nasal swabbing, and things of that sort to check for abnormal bacterial counts in a variety of sites that put the host at risk. Fervent communication with the medical oncologist and the orthopedic oncologist needs to happen in real time if there are concerns about an emerging secondary infection.
What take-home message would you like to share with colleagues?
PJI after tumor reconstruction for bone sarcomas is completely different from that in routine arthroplasty. The BOOM global study shows that widespread practice variations exist. Although there’s a lack of consensus, there’s a shared willingness among surgeons to unify definitions and work toward evidence-based practices. Establishing a consistent conceptual and procedural framework for DAIR and DAIR plus in modular exchange is the most important next step in improving outcomes for our patients.
With respect to medical oncologists who we partner with to take care of patients with bone sarcomas, this [process] can influence the timing of chemotherapy, immunotherapy, and targeted agents, so there needs to be increased awareness from both the medical oncologists as well as the sarcoma surgeons to be able to stratify for infection risk, wound biology, and the viability of limb salvage reconstructions. When we understand DAIR strategies more stringently, we’re likely to succeed or fail in a much more precise way, a much more predictive way, and this will help medical oncologists coordinate systemic therapy, anticipate complications, and advocate for earlier surgical reevaluations when they’re starting to suspect that there might be an infection and potentially avoid a catastrophic reconstruction failure, which would be a huge impact to not only the patient’s quality of life, but potentially their overall survival.
References
- Jeys L, Botello E, Boyle RA, et al. A modified Delphi consensus on periprosthetic infection in orthopaedic oncology: a report from the Birmingham Orthopaedic Oncology Meeting (BOOM). Bone Jone J. 2025;107-B(12):1352-1359. doi:10.1302/0301-620X.107B12.BJJ-2024-1039.R4
- Khan Z, Khan ZA, Zamora T, et al. What is debridement, antibiotics, and implant retention in orthopaedic oncology? Bone Jt Open. 2025;6(11):1495-1503. doi:10.1302/2633-1462.611.BJO-2025-0114.R2
