The DAIR-procedure in fracture-related infection–When and how

This narrative review discusses treatment strategies and key considerations guiding decisions in the surgical management of fracture-related infections (FRI). Treatment options primarily revolve around two approaches: debridement antibiotics and implant retention (DAIR), or implant exchange, either in a one or multiple-stage strategy. Several considerations, including time since infection onset, implant type, stability, causative pathogens, host physiology, and soft tissue conditions, inform the choice of surgical intervention for FRI. Current literature supports the preference for a DAIR approach in cases with a short duration of ongoing symptoms, a stable implant with satisfactory fracture reduction, and a viable soft tissue envelope. Conversely, one- or multiple-stage implant exchange is deemed beneficial in instances of compromised local and systemic host physiology, mature biofilm, difficult-to-treat pathogens, intramedullary implants, and cases involving reinfections or failed DAIR procedures. Notably, these recommendations draw parallels from periprosthetic joint infection treatment strategies, constrained by the limited availability of randomized controlled trials comparing these options specifically in acute FRI. In conclusion, future perspectives call for extensive investigations into biofilm maturation and the impact of time on treatment outcomes. Additionally, there is a need for a standardized classification system for FRI to enhance the comparability of treatment outcomes in FRI management.