Treatment of acute periprosthetic knee infections using optimized DAIR with intraosseous vancomycin, with and without calcium sulfate beads: A multicenter retrospective study

Introduction Debridement, antibiotics, and implant retention (DAIR) is a widely accepted treatment for acute periprosthetic joint infection (PJI) of the knee, although reported success rates remain variable. Optimization of surgical protocols and the use of local antibiotic strategies may improve infection control, but evidence regarding combined approaches is still limited. Objective To evaluate the clinical, functional, and infectious outcomes of an optimized DAIR protocol including radical debridement, standardized antiseptic irrigation, modular component exchange, and intraosseous vancomycin, and to assess the potential additional benefit of antibiotic-loaded calcium sulfate beads. Materials and Methods A multicenter retrospective study included patients with acute periprosthetic knee infection treated with DAIR between January 2022 and September 2023, with a minimum follow-up of 24 months. Patients were divided into two groups: optimized DAIR with intraosseous vancomycin (G1) and the same protocol combined with antibiotic-loaded calcium sulfate beads (G2). The primary outcome was treatment success according to the criteria described by Díaz-Ledezma et al. Secondary outcomes included the Knee Society Score (KSS), complications, and failure-free survival. Results Twenty-six patients were included (14 in G1 and 12 in G2). Infection control was achieved in 23 cases (88.5%). Three failures occurred (two in G1 and one in G2). No statistically significant differences were observed between groups in comparative analyses or Kaplan–Meier survival curves. Among patients with infection control, KSS improved significantly at 6 and 12 months, with no relevant functional differences between groups. No systemic complications related to intraosseous vancomycin were observed. Conclusions An optimized DAIR protocol achieved high infection control rates in acute periprosthetic knee infections. The addition of calcium sulfate beads showed a favorable trend without increasing complications, although the small sample size limits definitive conclusions.