Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes.

Cite this article: Bone Joint J 2024;106-B(12):1377–1384.

Aim

Antimicrobial peptides occur naturally in our intrinsic immune system. PLG0206 is a novel, engineered, 24-amino acid peptide which has broad-spectrum antimicrobial activity, including in biofilm and against multi-drug resistant pathogens (1,2). This is the first clinical study to evaluate the safety and tolerability of PLG0206 when administered via an irrigation solution in patients with periprosthetic joint infections (PJI) following total knee arthroplasty (TKA) during debridement, antibiotics, and implant retention (DAIR). Secondary objectives were to evaluate pharmacokinetics (PK), biomarkers and initial clinical efficacy at one year post-DAIR procedure.

Aim. Arthroscopic interventions have revolutionized the treatment of joint pathologies. The appropriate diagnostics and treatment are required for infections after ligament reconstructions using non-resorbable material such as tendon grafts, anchors, and sutures, prone to biofilm formation. The infection rate is around 1% for knee and shoulder, while up to 4% for Achilles tendon reconstructions. Despite high number of these procedures worldwide, there is limited evidence about the best treatment protocol. Our study aimed to provide a general protocol for the treatment of small implants for soft tissue reconstruction. Method. Between 2019 and 2023, we treated 48 infections of ligament, meniscus, and tendon reconstructions out of 7291 related procedures performed in the same time period. Early infection (<30 days) were treated with an arthroscopic debridement and implant retention (DAIR), except Achilles tendons had open DAIR, while those with delayed or chronic infection (>30 days) were treated with extensive debridement and lavage combined with one-stage exchange (OSE) or implant removal. During surgery, at least 5 microbiological s and samples for histopathology were obtained. The removed material was sonicated. After surgery, all patients were one week on iv. antibiotics, followed by oral antibiofilm antibiotics for 6 weeks including rifampicin and/or a quinolone. All patients were followed for at least 1 year. Failure was defined as the need for additional revision surgery after finished iv. antibiotic treatment. Results. Among 48 patients, 38 were early and 10 were late acute or chronic infections. The incidence of infection for our cohort was 0.7%. We observed 27 infections after ligament reconstruction of the knee, 15 of the shoulder, 5 of the ankle, and 1 infection of the elbow joint. 40 patients were treated with DAIR, 5 with OSE, and 3 with implant removal. We had 11 C. acnes, 10 S. aureus, 6 S. epidermidis, 2 P. aeruginosa, 2 S. lugdunensis, 10 mixed flora, and 3 culture-negative infections. 12 patients received antibiotics before surgery, and all culture-negative infections were related to this subgroup. We observed 2 failures, both in a combination of proximal tibial osteotomy and ligament reconstruction of the knee joint. The success rate of our protocol was 96%. Conclusions. Prompt surgical treatment followed by 6 weeks of antibiotic treatment cured 96% of infections of small implants after reconstruction procedures of knee, shoulder, and ankle joints. Our study is the first to provide a treatment protocol for infections of small implants after ligament reconstruction procedures

Aim. This is the first study to directly compare the clinical outcome of debridement, antimicrobials and implant retention (DAIR) with stabilization using new internal fixation after debridement, for patients with Fracture-related Infection (FRI). Method. Consecutive patients with FRI Consensus confirmed FRI had single-stage surgery with tissue sampling, debridement, stabilization, antimicrobial therapy and skin closure. All cases had FRIs which were unhealed at surgery. When existing implants were stable, the implant was retained but loose implants or fractures with poor reduction had implant removal and refixation with new implants. All patients had the same empiric and definitive antibiotics, the same diagnostic criteria and outcome assessment at least one year after surgery. Failure was defined as infection recurrence, reoperation or lack of fracture consolidation at one year. Results. Seventy-one patients were studied (40 DAIRs and 31 new implants, including 10 exchange nails). The two groups were well matched for age, duration of infection, BACH complexity, microbiology, bone involved and need for flap coverage. Ten patients (13.7%) died before the endpoint. Mortality was similar in both groups (DAIR 14.1% vs New Metalware 12.9%; p=0.801) but DAIR of IM nails had a higher mortality at 40% (p=0.011). Sixty-one patients were followed-up for a mean of 3.32 years (1.04-9.43). Infection was eradicated in 23/34 (67.6%) DAIR patients and 24/27 (88.9%) with new metalware (p=0.049). Overall rates of infection-free union were similar in both groups (58.8% vs 77.8%; p=0.117). DAIR of plates had significantly fewer infection-free unions compared to removal and implantation of new plates (DAIR 57.1% vs NM 91.7%; p=0.033). Conclusion. Implantation of new metalware had better eradication of infection and a strong trend towards better union rates. Treating FRI with retained or new metalware had a substantial mortality (13.7%). Choosing DAIR did not reduce this mortality and these patients more often required further surgery to treat residual infection and secure union

Aim. Predicting success of a Debridement, Antibiotics and Implant Retention (DAIR) procedure for Periprosthetic Joint Infection (PJI) remains a challenge. A failed DAIR might adversely affect the outcome of any future revision surgery for PJI. Hence, the ability to identify and optimise factors predictive of DAIR success would help target the procedure to the appropriate patient cohort and avoid unnecessary surgery for patients where a DAIR is unlikely to eradicate infection. Method. A retrospective review of our prospective Bone Infection Group database was performed to identify all patients who underwent a DAIR of their hip or knee arthroplasty. Diagnosis of PJI was confirmed using the Musculoskeletal Infection Society (MSIS) 2013 and the European Bone and Joint Infection Society (EBJIS) 2021 classification systems. DAIR surgery was grouped into “successful” or “unsuccessful” outcomes as per the MSIS working group outcome-reporting tool. Results. Sixty-Four consecutive patients with an acute PJI underwent a DAIR procedure between 2009 and 2020. Treatment was successful in 44 (69%). The chance of a successful DAIR was significantly greater if performed within one week of symptom onset compared to greater than one week duration (adjusted odds ratio (OR 0.11; p=0.027; 95% CI [0.02- 0.78]). The chances of a successful DAIR was not influenced by whether the surgeon was an arthroplasty or non-arthroplasty surgeon (OR 0.28; p=0.13; 95% CI [0.05- 1.48]). Isolated Streptococcus infection had a success rate of 100%; followed by Coagulasenegative Staphylococci 71% and Methicillin-susceptible Staphylococcus Aureus 65%. Polymicrobial infection had the worst outcome with a success rate of 47%. Conclusions. In our experience DAIR surgery performed within one week of symptom onset, significantly increased chances of successful infection eradication. Collaborative work is required to ensure arthroplasty patients access prompt appropriate surgical decision-making, remove barriers to early assessment and minimise delays to surgery

Aim. Periprosthetic joint infection (PJI) is one of the most devastating complications after joint replacement. It is associated with high morbidity and economic burden when misdiagnosed as an aseptic failure. Among all cases of PJI, up to 25% could yield negative cultures. Conversely, among cases of aseptic failures, up to 30% may actually be undiagnosed PJIs. In PJIs microbiological diagnosis is a key step for successful treatment. Sonication of the removed prosthesis is more sensitive than conventional periprosthetic-tissue culture, especially in patients who received antimicrobial therapy before surgery. This study aimed to compare the diagnostic value of classic sonication fluid cultures (SF-C) and sonication fluid incubation in blood culture bottle (SF-BCB). Method. Between 2016 and 2018 we analysed 160 revision procedures of joint arthroplasties. For each procedure, at least 5 microbiological and multiple histopathological samples were harvested, and explant sonication was performed which was further analysed by SF-C and SF-BCB. For SF-C classical cultivation of sonication fluid was performed. While for SF-BCB, 10 mL of sonication fluid was inoculated into aerobic and anaerobic lytic blood culture bottles. The definite diagnosis of PJI was based on the EBJIS definition. Results. Among 160 revisions, 59 PJIs were identified, 15 patients were treated with the debridement and implant retention, 7 patients with the one-stage and 35 with the two-stage exchange, remaining 2 were partial revisions. The sensitivity of SF-C and SF-BCB were 81.5% and 94.9%, respectively. The mismatch of microbe identification was observed in 5 cases. We observed positive SF-C while negative SF-BCB in 4 cases, among them having 2 positive histology. While 12 patients have negative SF-C and positive SF-BCB, among them 3 have positive and 6 negative histology. Among these 12 patients, typical low-grade microbes were identified in 9 cases (5 cases of C. acnes, 3 cases of S. epidermidis, and 1 case of S. capitis). Conclusions. The weakest point in all PJI diagnostic criteria is their sensitivity. SF-BCB demonstrates higher sensitivity in diagnosing PJI compared to SF-C. Therefore, it appears prudent to incorporate SF-BCB into the diagnostic protocol for all patients exhibiting either low-grade PJI symptoms or experiencing undiagnosed, presumably aseptic failures, where the likelihood of misdiagnosing infection is greatest

Background and purpose. Previous publications have reported an increased but levelling out risk of revision for infection after total hip arthroplasty (THA) in Norway. We assessed the changes in risk of major (cup and/or stem, 1- or 2-stage) and minor revisions (debridement, exchange of modular parts, antibiotics and implant retention (DAIR)) for infection after primary THAs reported to the Norwegian Arthroplasty Register (NAR) over the period 2005-2022. Patients and methods. Primary THAs reported to the NAR from 2005 to 2022 were included. Time was stratified into time periods (2005-2009, 2010-2018, 2019-2022) based on a previous publication. Cox regression analyses, adjusted for sex, age and ASA-classification, with the first revision for infection were performed. Results. 140,338 primary THAs met the inclusion criteria. 1.3% (1,785) were revised for infection during the study period. 0.5% (638) had major revisions, whereas 0.8% (1,147) had DAIRs for infection. The risk of revision for infection was 1.2 (95%CI 1.1-1.4) for 2010-2018 and 1.0 (0.8-1.1) for 2019-2022 compared to 2005-2009. Compared to 2010-2018, the risk of revision for infection was 0.8 (0.7-0.9) for 2019-2022. The risk of DAIR for infection was 1.5 (1.3-1.9) for 2010-2018 and 1.2 (1.0-1.4) for 2019-2022 compared to 2005-2009. Compared to 2010-2018, the risk of DAIR for infection was 0.8 (0.7-0.9) for 2019-2022. The risk of major revision for infection was 0.8 (0.7-1.0) for 2010-2018 and 0.8 (0.6-1.0) for 2019-2022 compared to 2005-2009. Interpretation. The overall risk of revision for infection after THA, in Norway, has decreased in the period 2019-2022. The risk for DAIR initially increased in the period 2005-2009, levelled out 2010-2018 before starting to decrease in 2019-2022. The risk of major revision for infection was reduced in the period 2005-2009 before levelling out. This shows changes in revision strategies, but may also reflect a true decrease in periprosthetic joint infection

Aims

We sought to compare functional outcomes and survival between non-smokers, former smokers, and current smokers who underwent anatomical total shoulder arthroplasty (aTSA) in a large cohort of patients.

Aims

Reverse shoulder arthroplasty (RSA) has become the most common type of shoulder arthroplasty used in the UK, and a better understanding of the outcomes after revision of a failed RSA is needed. The aim of this study was to review the current evidence systematically to determine patient-reported outcome measures and the rates of re-revision and complications for patients undergoing revision of a RSA.

Periprosthetic joint infection represents a devastating complication after total elbow arthroplasty. Several measures can be implemented before, during, and after surgery to decrease infection rates, which exceed 5%. Debridement with antibiotics and implant retention has been reported to be successful in less than one-third of acute infections, but still plays a role. For elbows with well-fixed implants, staged retention seems to be equally successful as the more commonly performed two-stage reimplantation, both with a success rate of 70% to 80%. Permanent resection or even amputation are occasionally considered. Not uncommonly, a second-stage reimplantation requires complex reconstruction of the skeleton with allografts, and the extensor mechanism may also be deficient. Further developments are needed to improve our management of infection after elbow arthroplasty. Cite this article: Bone Joint J 2024;106-B(11):1321–1326

For over a decade, modular titanium fluted tapered (TFT) stems have demonstrated excellent clinical success for femoral revision total hip arthroplasty (THA) surgery. The aim of this study was to report the short-term outcomes of a novel modern monoblock TFT stem used for revision and complex primary THA with a minimum of 2 years follow-up. We identified 126 patients who received a single monoblock TFT stem - 26 patients for complex THA (failed fracture fixation) and 100 patients for revision THA. The reasons for revision THA included 40 for previous prosthetic joint infection (PJI), 42 for aseptic loosening, 9 for trunnionosis, 9 for periprosthetic fractures. The Paprosky grading for femoral bone loss at the time of surgery and the measured subsidence of femoral stems at 3 months follow-up were determined. We evaluated the number and indications for re-operations. The mean time from surgery was 3.9 years (range 2.0 to 6.9 years). A paired t-test analysis showed significant improvement from pre-operative versus post-operative clinical outcome scores (p<0.001) for HHS (38.76 +/- 15.24vs. 83.42 +/- 15.38), WOMAC (45.6 ± 19.0 vs. 69.9 ± 21.3) and SF-12 Physical component (31.7 ± 8.1 vs. 37.8 ± 11.3) and SF-12 Mental component (48.2 ± 12.2 vs. 51.6 ± 12.5). The Paprosky grading for femoral bone loss was Grade 1 (3.9%), Grade 2 (35.7%), Grade 3A (47.6%), Grade 3B (11.1%) and Grade 4 (1.6%) cases. There were 18 re-operations (14.7%) with 13 for PJI (7 treated with implant retention, 6 treated with a two-staged revision), 4 for instability and one for acetabular aseptic loosening. There were no aseptic failures of the stem. This novel modern monoblock TFT stem provided reliable femoral fixation and has increasingly supplanted the use of modular TFT stems for complex primary and revision surgery in our institution

Aims

In metal-on-metal (MoM) hip arthroplasties and resurfacings, mechanically induced corrosion can lead to elevated serum metal ions, a local inflammatory response, and formation of pseudotumours, ultimately requiring revision. The size and diametral clearance of anatomical (ADM) and modular (MDM) dual-mobility polyethylene bearings match those of Birmingham hip MoM components. If the acetabular component is satisfactorily positioned, well integrated into the bone, and has no surface damage, this presents the opportunity for revision with exchange of the metal head for ADM/MDM polyethylene bearings without removal of the acetabular component.

The June 2024 Knee Roundup³⁶⁰ looks at: The estimated lifetime risk of revision after primary knee arthroplasty influenced by age, sex, and indication; Should high-risk patients seek out care from high-volume surgeons?; Stability and fracture rates in medial unicondylar knee arthroplasties; Rethinking antibiotic prophylaxis for dental procedures post-arthroplasty; Evaluating DAIR: a viable alternative for acute periprosthetic joint infection; The characteristics and predictors of mortality in periprosthetic fractures around the knee; Patient health-related quality of life deteriorates significantly while waiting six to 12 months for total hip or knee arthroplasty; The importance of looking for diversity in knee implants.

Introduction. We report the functional outcome and survivorship of the Hintegra Total Ankle Replacement (TAR), in consecutive cases by multiple surgeons in a single UK institution. Between 2010–2014 the Hintegra TAR held 7.1% UK market share and surgeons should be aware of failure mechanisms. Methods. We conducted a retrospective review of prospectively collected data for 70 consecutive Hintegra TAR cases in a single institution between 2010–2014. Data collected included patient demographics, complications, reoperations, patient reported outcome measures (PROMS: AOS, MOX-FQ, pain VAS) and patient satisfaction. Results. The 70 patients (54 male/ 16 female) had an average age of 69 (range 48–84 years). Mean follow up was 76 months (range 60–04), 10 patients died during the follow up. Implant survivorship was 81.4% at most recent follow up. The commonest radiographic finding was periprosthetic cysts (n=28, 40%), size range (7–40mm), location of cysts: isolated talus (n=14), isolated tibia (n=6), mixed (n=8). 10 failed TARs were revised to Inbone TAR at a mean of 48 months (range 9–69). 3 Failed TARs were revised to arthrodesis (2 tibiotalar fusions, 1 hindfoot nail). 11 patients required reoperation with implant retention: 8 periprosthetic cyst debridement and grafting at a mean of 61 months (range 27–91), 1 lateral gutter debridement and 1 periprosthetic fracture ORIF. PROMS data was available for all patients. Overall patients showed marked improvement in functional outcome scores between pre-operative and final follow up questionnaires. Mean pre-op AOS: 62, MOX-FQ: 68 and pain VAS: 67.5 with mean final follow up scores of: AOS: 35, MOX-FQ: 36 and pain VAS: 30. Conclusion. Our experience demonstrates improved PROMS following ankle arthroplasty for patients with a mean follow up of 6.4 years. Implant survivorship is similar to other TAR studies. We have identified a high incidence of periprosthetic cysts and would recommend ongoing surveillance of these patients

Introduction. Debridement, antibiotics irrigation and implant retention (DAIR) is a common management strategy for hip and knee prosthetic joint infections (PJI). However, failure rates remain high, which has led to the development of predictive tools to help determine success. These tools include KLIC and CRIME80 for acute-postoperative (AP) and acute haematogenous (AH) PJI respectively. We investigated whether these tools were applicable to a Waikato cohort. Method. We performed a retrospective cohort study that evaluated patients who underwent DAIR between January 2010 and June 2020 at Waikato Hospital. Pre-operative KLIC and CRIME80 scores were calculated and compared to success of operation. Failure was defined as: (i) need for further surgery, (ii) need for suppressive antibiotics, (iii) death due to the infection. Logistic regression models were used to calculate the area under the curve (AUC). Results. 117 eligible patients underwent DAIR, 53 in the AP cohort and 64 in the AH cohort. Failure rate at 2 years post-op was 43% in the AP cohort and 59% in the AH cohort. In the AP cohort a KLIC score of <4 had a DAIR failure rate of 28.6%, while those who scored ³4 had a failure rate of 72.2% (p=0.002). In the AH cohort a CRIME80 score of <3 had a DAIR failure rate of 48% while those who scored ³3 had a 100% failure rate (p<0.001). Discussion. This study represents the first external validation of the KLIC and CRIME80 scores for predicting DAIR failure in an Australasian population. The results indicate that both KLIC and CRIME80 scoring tools are valuable aids for the clinician seeking to determine the optimal management strategy in patients with AP or AH PJI

Periprosthetic joint infection is a serious complication of primary total hip replacement (THR) with significant associated morbidity. In acute infection, Debridement, Antibiotics and Implant Retention (DAIR) may be considered. Current national guidelines recommend a DAIR should be performed by “an experienced arthroplasty surgeon┕ but do not specify the need for this to be a revision arthroplasty surgeon. We investigated outcomes in our NHS Trust of DAIR procedures performed by revision and non-revision arthroplasty surgeons. Infection registry data and patient records were analysed for all DAIR procedures of infected primary THRs between 2017 and 2021. Data collected included details of the primary surgery, the presentation with infection, the DAIR procedure and any subsequent complications including return to theatre at any time point. Routinely collected pre- and post-operative patient reported outcome measures (PROMs) were reviewed. 54 periprosthetic joint infections of primary THRs received a DAIR procedure. 41 DAIRs were performed by a revision surgeon and 13 by non-revision surgeons. There was no significant difference in time from primary THR to presentation with infection, time from presentation to DAIR or pre-operative C-reactive protein between the two groups. In 21 (38.9%) patients the DAIR procedure was classed as a treatment failure; 17 patients (31.5%) returned to theatre for further revision surgery, one (2.4%) died related to infection and three (5.6%) had persistent infection but did not receive further surgery. Treatment failure was significantly higher in the non-revision surgeon group (9/13 (69.2%)) than in the revision surgeon group (12/41 (29.3%)) (p = 0.02). Overall, improvement in PROMs after DAIR was seen at both six and 12 months. The overall success rate of DAIR was 61.1% and there was a sustained improvement in PROMs after surgery. However, there was a significant difference in failure rates between revision surgeons and non-revision surgeons

Aims

Fracture-related infection (FRI) is commonly classified based on the time of onset of symptoms. Early infections (< two weeks) are treated with debridement, antibiotics, and implant retention (DAIR). For late infections (> ten weeks), guidelines recommend implant removal due to tolerant biofilms. For delayed infections (two to ten weeks), recommendations are unclear. In this study we compared infection clearance and bone healing in early and delayed FRI treated with DAIR in a rabbit model.

Aim

The time to onset of symptoms after fracture fixation is still commonly used to classify fracture-related infections (FRI). Early infections (<2 weeks) can often be treated with debridement, systemic antibiotics, irrigation, and implant preservation (DAIR). Late infections (>10 weeks) typically require implant removal as mature, antibiotic-tolerant biofilms have formed. However, the recommendations for delayed infections (2–10 weeks) are not clearly defined. Here, infection healing and bone healing in early and delayed FRI is investigated in a rabbit model with a standardized DAIR procedure.

Aim. Currently, gram-negative bacteria (GNB), including multidrug-resistant (MDR-GNB) pathogens, are gaining importance in the aetiology of prosthetic joint infection (PJI). To characterize the antimicrobial resistance patterns of Gram-negative bacteria (GNB) causing hip prosthetic joint infections in elderly patients treated at a Brazilian tertiary academic hospital. Method. This is a retrospective, cross-sectional study of patients over 60 years of age undergoing hip arthroplasty from 2018 to 2023 at a tertiary academic trauma, which were diagnosed with hip prosthetic joint infection. PJI diagnosed was based on EBJIS criteria, in which intraoperative tissue cultures identified the pathogens. Demographics, reason for arthroplasty, type of implant and susceptibility patterns using disk diffusion method were analysed. Results. Overall, among 17 elderly patients diagnosed with hip infected arthroplasty, 45 bacterial isolated were identified. Debridement, irrigation, antibiotic and implant retention (DAIR) procedures due to uncontrolled infection occurred in 47.0% (n=8/17), and five patients underwent more than two DAIR surgeries. Tissue cultures yielded eleven different bacterial species, with GNB accounted for 64.4% (n=29/45) of pathogens. Klebsiella pneumoniae, Acinetobacter baumannii, Escherichia coli, and Pseudomonas aeruginosa were identified in 34.5% (n=10/29), 17.25% (n=5/29), 13.8% (n=4/29), and 13.8% (n=4/29), respectively. In the resistance profile analysis, E. coli was most sensitive to antibiotics, whereas K. pneumoniae showed resistance rates higher than 70% for cephalosporins, carbapenems, and quinolones. All A. baumannii isolates were resistant to meropenem, and 80% of these isolates were resistant to amikacin. Conclusions. This study emphasizes the role of GNB in the microbiological profile of PJI among elderly patients at a tertiary hospital in a Brazilian centre. The present study portrays a worryingly higher rates of MDR-GNB, mainly to quinolones and cephalosporins resistance which have been the cornerstone of PJI antibiotic treatment. In addition, higher rates carbapenems and aminoglycosides resistance shows a threat to antibiotic treatment of PJI. More global studies need to be carried out to show a likely change in the microbial epidemiology of PJI

Aims. Fracture-Related Infection (FRI) is a severe complication caused by microbial infection of bone. It is imperative to gain more insight into the potentials and limitations of Debridement, Antibiotics and Implant Retention (DAIR) to improve future FRI treatment. The aims of this study were to: 1) determine how time to surgery affects the success rate of DAIR procedures of the lower leg performed within 12 weeks after the initial fracture fixation operation and 2) evaluate whether appropriate systemic antimicrobial therapy affects the success rate of a DAIR procedure. Methods. This multinational retrospective cohort study included patients of at least 18-years of age who developed an FRI of the lower leg within 12 weeks after the initial fracture fixation operation, between January 1st 2015 to July 1st 2020. DAIR success was defined by the absence of recurrence of infection, preservation of the affected limb and retention of implants during the initial treatment. The antimicrobial regimen was considered appropriate if the pathogen(s) was susceptible to the given treatment at the correct dose as per guideline. Logistic regression modelling was used to assess factors that could contribute to the DAIR success rate. Results. A total of 120 patients were included, of whom 70 DAIR patients and 50 non-DAIR patients. Within a median follow-up of 35.5 months, 21.4% of DAIR patients developed a recurrent FRI compared to 12.0% of non-DAIR patients. The DAIR procedure was successful in 45 patients (64.3%). According to the Willenegger and Roth classification, DAIR success was achieved in 66.7% (n=16/24) of patients with an early infection (<2 weeks), 64.4% (n=29/45) of patients with a delayed infection (2–10 weeks) and 0.0% (0/1) of patients with a late infection (>10 weeks). Univariate analysis showed that the duration of infection was not associated with DAIR success in this cohort (p=0.136; OR: 0.977; 95%CI: [0.947–1.007]). However, an appropriate antimicrobial regimen was associated with success of DAIR (p=0.029; OR: 3.231; 95%CI: [1.138–9.506]). Conclusions. Although the results should be interpreted with caution, an increased duration of infection was not associated with a decreased success rate of a DAIR procedure in patients with FRI of the lower leg. The results of this study highlight the multifactorial contribution to the success of a DAIR procedure and emphasize the importance of adequate antimicrobial treatment. Therefore, time to surgery should not be the only key-factor when considering a DAIR procedure to treat FRI