Orthopedic Surgery

June 11, 2026

Orthopedic surgeons at Mayo Clinic's campus in Jacksonville, Florida, are implementing two advanced strategies to address one of the most persistent challenges in arthroplasty: periprosthetic joint infection (PJI). Infection may present acutely within 4 to 6 weeks after surgery or emerge months to years later as a chronic complication. Both scenarios carry substantial clinical and quality‑of‑life burdens for patients.

The team now offers two enhanced approaches for post total knee arthroplasty and post total hip arthroplasty infections: double debridement, antibiotics and implant retention, known as double DAIR, for acute infections and a one‑stage exchange for select patients with uncemented implants.

"Infection is the hardest problem we deal with as orthopedic surgeons," says Niall H. Cochrane, M.D., an orthopedic surgeon specializing in hip and knee replacement at Mayo Clinic in Florida. "The problem is that bacteria love metal and plastic, which our implants are made of. Bacteria also spread easily. You can get bacteria in your blood by simply brushing your teeth."

He notes that he has treated knee infections later traced to oral flora.

Despite ongoing research, Dr. Cochrane emphasizes that the field has seen limited innovation in post arthroplasty infection management since the 1990s. While PJI is rarely life‑threatening in isolation, recurrent or uncontrolled infections can become dangerous

"Development of a prosthetic infection means anti‑infection treatment for the rest of a patient's life," he says, adding that the patient often bears the greatest burden.

Patients with infected hip or knee implants face significant challenges, including prolonged time away from work, extended antibiotic therapy — often three months to one year — and a reinfection rate approaching 30%. Functional status varies widely depending on prior surgeries, implant type and comorbidities, though patients undergoing first‑time knee replacement often maintain reasonable function during treatment.

Managing PJI requires substantial patient resilience. Dr. Cochrane notes that most patients develop infections due to "bad luck" rather than modifiable risk factors. He prepares patients for the long course of therapy.

"I tell them it's a long road to treat the infection and that they will be dealing with this in some capacity every day for 18 months," he says. "I encourage them to stick with it."

DAIR, double DAIR and 1 stage exchange for acute infection

Mayo Clinic surgeons in Florida have expanded on the traditional debridement, antibiotics and implant retention (DAIR) approach by adopting the double DAIR, a technique developed in the early 2020s and first published by an orthopedic team at Mayo Clinic in Arizona in the Journal of Bone & Joint Surgery (JBJS) in 2021.

DAIR. This procedure remains the most widely used method for acute PJI. The procedure involves removal and replacement of the polyethylene component, followed by IV antibiotics and long‑term oral suppression. The primary limitation is the risk of recurrence.

Double DAIR. This procedure introduces a staged approach:

• Removal of the polyethylene component.
• Placement of antibiotic beads for local antimicrobial delivery during a 5- to 7‑day inpatient stay.
• Return to the OR for repeat debridement, polyethylene exchange and bead removal.

Early outcomes are promising. The JBJS publication reported infection control rates of 87% and 90% across two clinical trials with an average 3.5‑year follow‑up. A multi-site clinical trial is ongoing across Mayo Clinic's campuses in Arizona, Florida and Minnesota. Dr. Cochrane notes that accumulating evidence has already led many orthopedic surgeons to adopt the technique.

One‑stage exchange. This procedure, also called single‑stage revision arthroplasty, is an option for patients with uncemented implants who develop infection up to three months postoperatively. Implant removal allows more-comprehensive debridement than DAIR while preserving bone stock for immediate reimplantation.

2 stage exchange for chronic infection

Chronic PJI requires a more complex strategy.

"You can't just replace the plastic piece — you have to pull everything out if there's a chronic infection," Dr. Cochrane says.

The two‑stage exchange remains the gold standard in this setting. Surgeons remove the implant, place a temporary antibiotic‑laden spacer, administer systemic antibiotics and reimplant a new prosthesis approximately three months later. Patients generally achieve favorable outcomes with this approach, he notes.

Importance of specialized center

Dr. Cochrane emphasizes the value of referring patients with PJI to high‑volume centers with multidisciplinary infrastructure. Optimal care requires coordinated expertise from orthopedic surgery, infectious diseases, microbiology, pharmacy and perioperative services.

"Excellent infection care involves not only a treating orthopedic surgeon but also a strong network of institutional professionals," he says.

He underscores the importance of ongoing innovation.

"Infection is a huge problem we see every single day in orthopedics. We think about infection prevention every day, including how to optimize patients against it, " he says. "And in this field, we're thinking all the time about how to treat infection if it arises."

Ongoing clinical trials

Mayo Clinic is conducting two clinical trials focused on improving PJI outcomes:

• Rapid two‑stage exchange. In this approach, patients remain hospitalized for daily washouts and receive a new knee implant within one week.
• Monoclonal antibody therapy. This approach combines polyethylene exchange and debridement with antibodies designed to disrupt bacterial biofilm.

These efforts reflect Mayo Clinic's commitment to advancing PJI management and improving long‑term outcomes for patients after arthroplasty.

For more information

McQuivey KS, et al. The double DAIR: A 2-stage debridement with prosthesis-retention protocol for acute periprosthetic joint infections. Journal of Bone & Joint Surgery. 2021;11:e19.00071.

Refer a patient to Mayo Clinic.