Understanding the Reasons for Delayed Referral for Dair in Pji: A Multicentre Prospective Mixed-Model Study

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Introduction & Aim The earlier a periprosthetic joint infection (PJI) is detected and patients are referred to a specialised team, the less invasive the required surgical procedure and the better the prognosis in terms of joint function and infection control. However, a considerable proportion of patients are referred too late for debridement, antibiotics, and implant retention (DAIR). The aim of this project was to investigate both the proportion of delayed referrals and the underlying reasons. Methods We prospectively enrolled adults referred for PJI to seven Swiss centres between 2023 and 2026. Patients with a history and findings consistent with low-grade infection were excluded. In addition to quantitative analyses, 28 interviews were conducted for qualitative analysis. The primary endpoint was the proportion of patients referred more than 4 weeks after arthroplasty implantation or more than 3 weeks after symptom onset. Interviews were transcribed to identify reasons for delayed referral. Results Among 560 referred individuals, 26% were excluded due to low-grade infections; 357 met the eligibility criteria, and 325 patients (median age 73 years, 59% male) with 481 prosthetic joints were included in the analysis. Knee (239) and hip (190) arthroplasties were most common, followed by shoulder (41), ankle (9), and elbow (2) joints. At presentation, 215 patients (66%) were taking analgesics and 78 (24%) were receiving antibiotics. A total of 222 individuals (68%) reported a precise date of symptom onset. Overall, 164 patients (50%) presented acutely without prior signs or symptoms of PJI, while 67 (21%) had a history of postoperative wound-healing problems. The median time from symptom onset to referral was 7 days (IQR 2–20). Overall, 66 patients (20%) were referred too late for curative DAIR. The number of physician contacts prior to referral ranged from 0 to more than 4. Qualitative analysis revealed a “cycle of delay” consisting of five phases: (1) observing fluctuating symptoms – uncertainty; (2) inappropriate encounters with healthcare professionals and initial treatment – loss of trust; (3) seeking second opinions or reluctance to postpone personal plans – hesitation; (4) acceptance of invasive treatment in specialised centres; and (5) exhaustion and recovery following treatment. Conclusion Every fifth patient was referred too late for curative DAIR treatment. Following elective arthroplasty, patients and their families, as well as healthcare professionals (including those in primary care), should be adequately informed about the symptoms of PJI, the importance of timely treatment, and the appropriate referral pathway to specialised care.