Periprosthetic joint infections after limb salvage surgery for bone sarcomas are among the most difficult complications in orthopedic oncology, and a global consortium of surgeons at the 2024 Birmingham Orthopedic Oncology Meeting (BOOM) reported wide variability in how debridement, antibiotics, and implant retention (DAIR) procedures are defined and performed. The group urged standardization of terminology to improve outcomes, enable collaborative research, and better coordinate care with medical oncologists, according to R. Lor Randall, MD, FACS.
Randall, David Linn Endowed Chair for Orthopedic Surgery and chair of the Department of Orthopedic Surgery at UC Davis Comprehensive Cancer Center, said systemic cancer therapies — including cytotoxic chemotherapy and immunomodulatory agents — increase infection risk and make close communication between medical and orthopedic oncologists essential when infection is suspected.
BOOM survey data indicate infection rates of roughly 30% to 50% after oncologic reconstruction, with wide variation in timing, surgical approach, and antibiotic duration. Investigators found inconsistent use of the term DAIR across 44 countries, describing everything from simple irrigation to extensive soft-tissue debridement and partial or complete modular component exchange.
To address this ambiguity, BOOM proposed four standardized procedural categories: poly exchange (exchange of polyethylene articulating components only, without aggressive debridement); DAIR (aggressive soft tissue debridement and washout with retention of the major implant and modular components); DAIR plus (DAIR with exchange of modular components); and DAIR plus antibiotics (DAIR with modular component exchange combined with systemic and/or local antibiotics). The classifications aim to enable meaningful comparisons of outcomes across centers.
A worldwide survey of 272 surgeons revealed striking variability in practice. Sixty-two percent routinely perform radical soft tissue debridement for PJIs, about 55% believe DAIR is usually effective while roughly 20% do not. Time thresholds for DAIR varied: 32% perform the procedure within three weeks of infection onset, 29% within six weeks, and 19% at or after 12 weeks. Antibiotic duration ranged from about 40% favoring up to six weeks to roughly one-third favoring three months or longer.
BOOM investigators concluded that DAIR can have a role in oncologic reconstruction but its success depends on context. Early infections fare better than chronic infections, and aggressive debridement emerged as the strongest predictor of success. Polyethylene-only exchanges, common in arthroplasty literature, may underperform compared with modular component exchanges in massive endoprostheses. The largest limitation is the lack of comparative, multicenter data across major sarcoma centers.
Experts called for standardized definitions to enable prospective collaborative studies and meta-analyses. Key stratification factors should include reconstruction type (biologic versus mega-prosthesis), infection timing (acute versus chronic), host physiology and immunosuppression, concurrent systemic cancer treatments, and organism type (staphylococcal species, gram-negative bacteria, fungal pathogens). Coordinated data sharing among BOOM, the Musculoskeletal Tumor Society and regional societies in Europe and the Asia-Pacific region will be necessary to move beyond single-institution series.
Staphylococcus aureus is the most common pathogen in secondary infections after limb salvage, with coagulase-negative staphylococci and mucosal organisms also implicated. Medical oncologists should remain alert for local signs of infection such as warmth, swelling, increasing tenderness or new redness, and systemic signs like fever, and promptly communicate concerns to orthopedic surgeons.
Prior or ongoing cancer therapies increase infection risk and affect presentation and healing. Cytotoxic chemotherapy and immunomodulatory agents can create immunocompromise, and comorbidities such as diabetes further raise risk. Decisions on reconstruction and timing of systemic therapy should involve close coordination between medical and orthopedic oncologists.
Secondary infections can jeopardize limb viability, delay oncologic therapy, increase morbidity, and potentially affect survival. Explanting large reconstructions carries substantial morbidity and may necessitate more aggressive interventions when infection threatens limb or life.
Best practices highlighted at BOOM include preoperative decolonization and nasal screening, meticulous intraoperative technique, and real-time multidisciplinary communication when infection is suspected. Establishing a consistent framework for DAIR and DAIR plus procedures was identified as the most important next step to enable evidence-based practice, improve outcomes, better coordinate systemic therapy, and reduce the risk of catastrophic reconstruction failure.
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