Articles | Volume 10, issue 2
https://doi.org/10.5194/jbji-10-139-2025
© Author(s) 2025. This work is distributed under
the Creative Commons Attribution 4.0 License.
the Creative Commons Attribution 4.0 License.
https://doi.org/10.5194/jbji-10-139-2025
© Author(s) 2025. This work is distributed under
the Creative Commons Attribution 4.0 License.
the Creative Commons Attribution 4.0 License.
Guidelines/recommendations/consensus paper
| 
01 Apr 2025
Guidelines/recommendations/consensus paper |
| 01 Apr 2025
| 01 Apr 2025
Debridement, antimicrobial therapy, and implant retention (DAIR) as curative surgical strategy for acute periprosthetic hip and knee infections: a summary of the position paper from the European Bone & Joint Infection Society (EBJIS)
Irene K. Sigmund
CORRESPONDING AUTHOR
Department of Orthopaedics and Traumatology, Medical University of Vienna, Vienna, Austria
Marjan Wouthuyzen-Bakker
Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
Tristan Ferry
Infectious and Tropical Diseases Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
Willem-Jan Metsemakers
Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
Department of Development and Regeneration, KU Leuven, Leuven, Belgium
Martin Clauss
Department of Orthopaedics and Trauma Surgery, Center for Musculoskeletal Infections (ZMSI), University Hospital Basel, Basel, Switzerland
Alex Soriano
Hospital Clinic of Barcelona, Barcelona, Spain
IDIBAPS, Barcelona, Spain
CIBERNIF, CIBER in Infectious Diseases, ISCIII, Madrid, Spain
Rihard Trebse
Orthopaedic Hospital Valdoltra, Ankaran, Slovenia
Ricardo Sousa
Orthopaedic Department, Porto Bone Infection Group (GRIP), ULS Santo António, Porto, Portugal
Related authors
Irene K. Sigmund, Marjan Wouthuyzen-Bakker, Tristan Ferry, Ricardo Sousa, Daniel Pérez-Prieto, Alex Soriano, Volker Alt, Willem J. Metsemakers, Martin Clauss, and Rihard Trebse
J. Bone Joint Infect., 11, 651–654, https://doi.org/10.5194/jbji-11-651-2026, https://doi.org/10.5194/jbji-11-651-2026, 2026
Short summary
Short summary
Sinus tracts are currently classified as present or absent in PJI definitions. Although appropriate for diagnosis, this binary approach does not reflect the considerable heterogeneity encountered in clinical practice. This Viewpoint highlights characteristics that may determine sinus tract complexity and proposes a framework for future standardized characterization to better inform surgical decision-making and treatment outcomes.
Laura Bessems, Jolien Onsea, Marjan Wouthuyzen-Bakker, Irene K. Sigmund, Tristan Ferry, Richard Kuehl, Martin Clauss, Alex Soriano, Ricardo Sousa, Annette Schuermans, and Willem-Jan Metsemakers
J. Bone Joint Infect., 11, 489–492, https://doi.org/10.5194/jbji-11-489-2026, https://doi.org/10.5194/jbji-11-489-2026, 2026
Short summary
Short summary
We examined whether patients with musculoskeletal infections need to be separated in hospital. A review of published studies found no support for routine isolation or dedicated wards for infections without multidrug-resistant organisms when standard precautions are applied. An international survey showed wide variation in clinician attitudes. These findings highlight a gap between evidence and perception and support a more risk-based approach.
Markus Luger, Martin McNally, Lukas Rabitsch, Reinhard Windhager, Richard Lass, and Irene Katharina Sigmund
J. Bone Joint Infect., 11, 305–313, https://doi.org/10.5194/jbji-11-305-2026, https://doi.org/10.5194/jbji-11-305-2026, 2026
Short summary
Short summary
Sinus tracts communicating with the prosthesis demonstrated high specificity and support their use as a confirmatory criterion for periprosthetic joint infection (PJI). Purulence also showed high specificity but may be better considered to be a suggestive criterion due to challenges in clinical differentiation. Both findings were associated with distinct microbiological patterns and less favourable outcomes, highlighting their clinical relevance.
Goran Georgievski, Nike Walter, Ronald Man Yeung Wong, Irene Katharina Sigmund, Ashok Kanuri, Christian Heiss, and Markus Rupp
J. Bone Joint Infect., 11, 219–228, https://doi.org/10.5194/jbji-11-219-2026, https://doi.org/10.5194/jbji-11-219-2026, 2026
Short summary
Short summary
This article outlines 20 common errors in the prevention, diagnosis, and management of fracture-related infection (FRI), highlighting their clinical consequences and providing practical recommendations for avoiding them. By addressing typical pitfalls and emphasizing standardized procedures and interdisciplinary collaboration, the article aims to improve patient safety and treatment outcomes.
Laura Bessems, Jolien Onsea, Baixing Chen, Marjan Wouthuyzen-Bakker, Irene K. Sigmund, Tristan Ferry, Richard Kuehl, Martin Clauss, Alex Soriano, Ricardo Sousa, Annette Schuermans, and Willem-Jan Metsemakers
J. Bone Joint Infect., 10, 489–500, https://doi.org/10.5194/jbji-10-489-2025, https://doi.org/10.5194/jbji-10-489-2025, 2025
Short summary
Short summary
Isolation of patients with musculoskeletal infections in orthopedic care is controversial. Evidence supports selective isolation for certain resistant pathogens but not for non-resistant pathogens, nor does it support the routine use of septic wards. Effective infection control depends on hospital-wide strategies and adherence to standard precautions, with specialized centres offering better care than dedicated isolation units.
Lukas Rabitsch, Markus Luger, Felix Lötsch, Peter Starzengruber, Florian Thalhammer, Reinhard Windhager, Birgit Willinger, and Irene Katharina Sigmund
J. Bone Joint Infect., 10, 437–446, https://doi.org/10.5194/jbji-10-437-2025, https://doi.org/10.5194/jbji-10-437-2025, 2025
Short summary
Short summary
The novel multiplex polymerase chain reaction (mPCR), BioFire® Joint Infection Panel (BF-JIP; bioMérieux, Marcy-l’Étoile, France), demonstrated similar diagnostic accuracy to conventional synovial fluid culture and can therefore serve as a valuable adjunct in diagnosing septic arthritis in adults, particularly in patients with prior antimicrobial therapy.
Laura K. Certain and Irene K. Sigmund
J. Bone Joint Infect., 10, 397–402, https://doi.org/10.5194/jbji-10-397-2025, https://doi.org/10.5194/jbji-10-397-2025, 2025
Short summary
Short summary
The Musculoskeletal Infection Society (MSIS) and the European Bone and Joint Infection Society (EBJIS) are comprised of experts in preventing, diagnosing, and managing orthopedic infections. In 2023, MSIS and EBJIS surveyed their membership about their approach to various clinical aspects of these challenging conditions. The results indicate that, even among experts, there remains substantial variability of practice. This variability reflects open questions in the field.
Irene K. Sigmund, Matthew J. Dietz, Marta Sabater-Martos, Antony J. R. Palmer, Nicolas Cortés-Penfield, and the “Serum Marker Workgroup” for the Unified PJI Definition Taskforce
J. Bone Joint Infect., 10, 363–376, https://doi.org/10.5194/jbji-10-363-2025, https://doi.org/10.5194/jbji-10-363-2025, 2025
Short summary
Short summary
Serum C-reactive protein, fibrinogen, and interleukin-6 show the best performance among serum markers for diagnosing periprosthetic joint infection (PJI), but they lack sufficient accuracy to confirm or exclude infection reliably. These markers should be re-evaluated in future PJI definitions, as they are not suitable as stand-alone tests. Given their limitations and the superior diagnostic performance of synovial markers, the role of serum markers in PJI diagnosis should be reconsidered.
Irene K. Sigmund, Tristan Ferry, Ricardo Sousa, Alex Soriano, Willem-Jan Metsemakers, Martin Clauss, Rihard Trebse, and Marjan Wouthuyzen-Bakker
J. Bone Joint Infect., 10, 101–138, https://doi.org/10.5194/jbji-10-101-2025, https://doi.org/10.5194/jbji-10-101-2025, 2025
Short summary
Short summary
In this paper, we discuss the most relevant factors influencing the outcome and define indications, contraindications, and risk factors of a DAIR procedure based on the currently available literature. Furthermore, we discuss the surgical technique in combination with systemic antimicrobial therapy in patients undergoing a DAIR procedure.
Irene K. Sigmund, Marjan Wouthuyzen-Bakker, Tristan Ferry, Ricardo Sousa, Daniel Pérez-Prieto, Alex Soriano, Volker Alt, Willem J. Metsemakers, Martin Clauss, and Rihard Trebse
J. Bone Joint Infect., 11, 651–654, https://doi.org/10.5194/jbji-11-651-2026, https://doi.org/10.5194/jbji-11-651-2026, 2026
Short summary
Short summary
Sinus tracts are currently classified as present or absent in PJI definitions. Although appropriate for diagnosis, this binary approach does not reflect the considerable heterogeneity encountered in clinical practice. This Viewpoint highlights characteristics that may determine sinus tract complexity and proposes a framework for future standardized characterization to better inform surgical decision-making and treatment outcomes.
Noémie Reinert, Laura Bessems, Martin Clauss, Nader Maai, Jolien Onsea, Georges Vles, Karl Stoffel, Willem-Jan Metsemakers, and Mario Morgenstern
J. Bone Joint Infect., 11, 635–649, https://doi.org/10.5194/jbji-11-635-2026, https://doi.org/10.5194/jbji-11-635-2026, 2026
Short summary
Short summary
Infected periprosthetic fractures are severe complications in orthopedic surgery with difficult management and high failure rates. This review of 32 studies (273 patients) found limited diagnostic reliability, frequent use of staged revision surgery, and high rates of recurrent infection (21 %) and revision surgeries. Current evidence is sparse and inconsistent, highlighting the need for standardized diagnostics and larger-prospective studies.
Urban Vadnjal, Samo Roškar, René Mihalič, Mitja Rak, and Rihard Trebše
J. Bone Joint Infect., 11, 565–568, https://doi.org/10.5194/jbji-11-565-2026, https://doi.org/10.5194/jbji-11-565-2026, 2026
Short summary
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The case demonstrates the importance of having well-established hospital algorithms for fracture related infection (FRI)/periprosthetic
joint infection (PJI) treatment and strictly following them at each step. In most severe cases related to multidrug-resistant (MDR) bacteria, a multiple-stage protocol is indicated, and intra-articular infusions of antibiotics should be considered in addition to standard intravenous regimens.
joint infection (PJI) treatment and strictly following them at each step. In most severe cases related to multidrug-resistant (MDR) bacteria, a multiple-stage protocol is indicated, and intra-articular infusions of antibiotics should be considered in addition to standard intravenous regimens.
Georges F. Vles, Willem-Jan Metsemakers, Laurens Aerden, Jan Geurts, Oliver Borens, and Stijn Ghijselings
J. Bone Joint Infect., 11, 547–554, https://doi.org/10.5194/jbji-11-547-2026, https://doi.org/10.5194/jbji-11-547-2026, 2026
Short summary
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We studied three patients who had both a broken femur and a long-standing infection around an artificial hip, a rare and difficult problem. We treated them in two steps: first removing the implant, cleaning the infection, stabilizing the bone, and placing a temporary bone cement spacer; and then reimplanting the hip prosthesis once infection was controlled. In all cases, the infection cleared, the bone healed, and function improved. This approach may offer a safe way to manage these complex cases.
Laura Bessems, Jolien Onsea, Marjan Wouthuyzen-Bakker, Irene K. Sigmund, Tristan Ferry, Richard Kuehl, Martin Clauss, Alex Soriano, Ricardo Sousa, Annette Schuermans, and Willem-Jan Metsemakers
J. Bone Joint Infect., 11, 489–492, https://doi.org/10.5194/jbji-11-489-2026, https://doi.org/10.5194/jbji-11-489-2026, 2026
Short summary
Short summary
We examined whether patients with musculoskeletal infections need to be separated in hospital. A review of published studies found no support for routine isolation or dedicated wards for infections without multidrug-resistant organisms when standard precautions are applied. An international survey showed wide variation in clinician attitudes. These findings highlight a gap between evidence and perception and support a more risk-based approach.
Markus Luger, Martin McNally, Lukas Rabitsch, Reinhard Windhager, Richard Lass, and Irene Katharina Sigmund
J. Bone Joint Infect., 11, 305–313, https://doi.org/10.5194/jbji-11-305-2026, https://doi.org/10.5194/jbji-11-305-2026, 2026
Short summary
Short summary
Sinus tracts communicating with the prosthesis demonstrated high specificity and support their use as a confirmatory criterion for periprosthetic joint infection (PJI). Purulence also showed high specificity but may be better considered to be a suggestive criterion due to challenges in clinical differentiation. Both findings were associated with distinct microbiological patterns and less favourable outcomes, highlighting their clinical relevance.
Goran Georgievski, Nike Walter, Ronald Man Yeung Wong, Irene Katharina Sigmund, Ashok Kanuri, Christian Heiss, and Markus Rupp
J. Bone Joint Infect., 11, 219–228, https://doi.org/10.5194/jbji-11-219-2026, https://doi.org/10.5194/jbji-11-219-2026, 2026
Short summary
Short summary
This article outlines 20 common errors in the prevention, diagnosis, and management of fracture-related infection (FRI), highlighting their clinical consequences and providing practical recommendations for avoiding them. By addressing typical pitfalls and emphasizing standardized procedures and interdisciplinary collaboration, the article aims to improve patient safety and treatment outcomes.
Sander Bruyninckx, Stijn Ghijselings, Melissa Depypere, Alex Soriano, Willem-Jan Metsemakers, and Georges Vles
J. Bone Joint Infect., 11, 207–217, https://doi.org/10.5194/jbji-11-207-2026, https://doi.org/10.5194/jbji-11-207-2026, 2026
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When infection around an artificial hip or knee is suspected, joint fluid sampling is essential but often unsuccessful. We performed a systematic review to evaluate whether rinsing the joint with sterile salt water after an unsuccessful attempt improves diagnosis. Our findings show that this approach is safe, yields testable fluid in nearly all cases, and identifies infection in about one in five patients that would otherwise be missed.
Willem-Jan Metsemakers, Austin T. Fragomen, Mario Morgenstern, Steffen B. Rosslenbroich, Stephen M. Quinnan, Pablo S. Corona, Mitchell Bernstein, and Kevin Tetsworth
J. Bone Joint Infect., 11, 191–206, https://doi.org/10.5194/jbji-11-191-2026, https://doi.org/10.5194/jbji-11-191-2026, 2026
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Segmental bone loss remains a major challenge, often worsened by fracture-related infection (FRI). Surgical debridement and tissue cultures are key initial steps. Bone transport, utilizing distraction osteogenesis, remains a key therapeutic strategy. Innovations like integrated fixation and motorized nails reduce patient morbidity. Management relies on a multidisciplinary approach. This review explores current and emerging concepts in the field of bone transport, focusing on FRI.
Melissa Depypere, Jonathan Sliepen, Jolien Onsea, Yves Debaveye, T. Fintan Moriarty, Elena Della Bella, Emmanuel André, Johan Van Weyenbergh, and Willem-Jan Metsemakers
J. Bone Joint Infect., 11, 161–173, https://doi.org/10.5194/jbji-11-161-2026, https://doi.org/10.5194/jbji-11-161-2026, 2026
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The aim of this proof-of-concept study was to investigate host immune gene expression through transcriptome profiling in patients with fracture-related infection and to explore the feasibility of detecting 16S rRNA and biofilm-associated genes, an approach not previously applied using this method. This technique revealed distinct immune activation patterns in fracture-related infection (FRI) and enabled the identification of pathogens that were missed by conventional culture techniques.
Christian Merz, Jan Klaas, Rik Osinga, Parham Sendi, Richard Alexander Kuehl, Mario Morgenstern, and Martin Clauss
J. Bone Joint Infect., 11, 113–121, https://doi.org/10.5194/jbji-11-113-2026, https://doi.org/10.5194/jbji-11-113-2026, 2026
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Founded in 2019, the Center for Musculoskeletal Infections at University Hospital Basel was established to implement standardized, multidisciplinary care for orthopaedic and trauma-related infections. This retrospective analysis of hip and knee periprosthetic joint infections (2019–2022) illustrates the feasibility and effectiveness of this structured approach, with infection control achieved in the majority of patients despite case complexity.
Niels Vanvelk, Esther M. M. Van Lieshout, Leendert H. T. Nugteren, A. Cornelis Plaisier, Rosalya Van der Pot, Corine Bethlehem, Willem-Jan Metsemakers, William T. Obremskey, and Michael H. J. Verhofstad
J. Bone Joint Infect., 11, 95–103, https://doi.org/10.5194/jbji-11-95-2026, https://doi.org/10.5194/jbji-11-95-2026, 2026
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Although local antibiotic administration is used to prevent and treat fracture-related infections, concerns remain about systemic absorption and potential renal toxicity. This study assessed serum levels and renal function after local gentamicin or vancomycin use. Gentamicin exceeded the lower limit of quantification in 17% of cases but remained below toxic levels. Vancomycin was undetectable. These findings suggest that local antibiotic administration does not harm renal function.
Ernesto Muñoz-Mahamud, Melissa Rivera, Ana Belén Larque, Laura Morata, Andrés Combalia, Alfonso Alías, Jenaro Ángel Fernández-Valencia, and Álex Soriano
J. Bone Joint Infect., 11, 43–52, https://doi.org/10.5194/jbji-11-43-2026, https://doi.org/10.5194/jbji-11-43-2026, 2026
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Several factors have been linked to failure in chronic prosthetic joint infection revisions. We hypothesize that osteomyelitis in septic hip revisions is underestimated and may significantly impact outcomes. In this series, 30.8 % of septic revisions exhibited bone samples consistent with osteitis, mainly associated with prolonged unsuccessful surgical and antibiotic treatments, the presence of a sinus tract, and subsequent failure after implant removal.
Graham S. Goh, Elise R. Naufal, Michelle M. Dowsey, Sina Babazadeh, Jesse E. Otero, Carlos A. Higuera-Rueda, Marjan Wouthuyzen-Bakker, and Orthopaedic Device Infection Network (ODIN)
J. Bone Joint Infect., 10, 553–559, https://doi.org/10.5194/jbji-10-553-2025, https://doi.org/10.5194/jbji-10-553-2025, 2025
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A multi-center study of 563 periprosthetic joint infections (PJIs) found that 16.5 % were culture negative. These patients more often had prior revision or PJI, longer symptom duration and fewer systemic signs. On multivariable analysis, symptom duration >12 weeks was the only independent risk factor (odds ratio 2.24). The findings support the fact that culture-negative infections present insidiously, informing diagnostic strategies.
Benjamin R. Paul, David G. Deckey, Alex Soriano, Andy Miller, and Thorsten M. Seyler
J. Bone Joint Infect., 10, 525–541, https://doi.org/10.5194/jbji-10-525-2025, https://doi.org/10.5194/jbji-10-525-2025, 2025
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A total of 51 studies were reviewed to compare the alpha-defensin enzyme-linked immunosorbent assay (ELISA) and the lateral flow test for diagnosing joint replacement infections. Both tests are highly specific and accurately confirm infection, but ELISA showed greater sensitivity (87.8 % vs. 81.8 %), making it better for detection. These findings support the continued use of ELISA as the preferred diagnostic method.
Laura Bessems, Jolien Onsea, Baixing Chen, Marjan Wouthuyzen-Bakker, Irene K. Sigmund, Tristan Ferry, Richard Kuehl, Martin Clauss, Alex Soriano, Ricardo Sousa, Annette Schuermans, and Willem-Jan Metsemakers
J. Bone Joint Infect., 10, 489–500, https://doi.org/10.5194/jbji-10-489-2025, https://doi.org/10.5194/jbji-10-489-2025, 2025
Short summary
Short summary
Isolation of patients with musculoskeletal infections in orthopedic care is controversial. Evidence supports selective isolation for certain resistant pathogens but not for non-resistant pathogens, nor does it support the routine use of septic wards. Effective infection control depends on hospital-wide strategies and adherence to standard precautions, with specialized centres offering better care than dedicated isolation units.
Lukas Rabitsch, Markus Luger, Felix Lötsch, Peter Starzengruber, Florian Thalhammer, Reinhard Windhager, Birgit Willinger, and Irene Katharina Sigmund
J. Bone Joint Infect., 10, 437–446, https://doi.org/10.5194/jbji-10-437-2025, https://doi.org/10.5194/jbji-10-437-2025, 2025
Short summary
Short summary
The novel multiplex polymerase chain reaction (mPCR), BioFire® Joint Infection Panel (BF-JIP; bioMérieux, Marcy-l’Étoile, France), demonstrated similar diagnostic accuracy to conventional synovial fluid culture and can therefore serve as a valuable adjunct in diagnosing septic arthritis in adults, particularly in patients with prior antimicrobial therapy.
Laura K. Certain and Irene K. Sigmund
J. Bone Joint Infect., 10, 397–402, https://doi.org/10.5194/jbji-10-397-2025, https://doi.org/10.5194/jbji-10-397-2025, 2025
Short summary
Short summary
The Musculoskeletal Infection Society (MSIS) and the European Bone and Joint Infection Society (EBJIS) are comprised of experts in preventing, diagnosing, and managing orthopedic infections. In 2023, MSIS and EBJIS surveyed their membership about their approach to various clinical aspects of these challenging conditions. The results indicate that, even among experts, there remains substantial variability of practice. This variability reflects open questions in the field.
Joana Contente, Carlos Ferreira, Mário Silva, Guilherme Madeira, Ana Ribau, and Ricardo Sousa
J. Bone Joint Infect., 10, 403–410, https://doi.org/10.5194/jbji-10-403-2025, https://doi.org/10.5194/jbji-10-403-2025, 2025
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We assessed whether two debated scoring tools, KLIC and CRIME-80, could predict the failure of a treatment called debridement, antibiotics, and implant retention (DAIR) in prosthetic joint infections. We reviewed data from 102 patients. Neither score reliably predicted failure, even when the treatment was repeated. Our results highlight the limited clinical utility of these scores and support the need for better tools to guide treatment decisions in joint infections.
Irene K. Sigmund, Matthew J. Dietz, Marta Sabater-Martos, Antony J. R. Palmer, Nicolas Cortés-Penfield, and the “Serum Marker Workgroup” for the Unified PJI Definition Taskforce
J. Bone Joint Infect., 10, 363–376, https://doi.org/10.5194/jbji-10-363-2025, https://doi.org/10.5194/jbji-10-363-2025, 2025
Short summary
Short summary
Serum C-reactive protein, fibrinogen, and interleukin-6 show the best performance among serum markers for diagnosing periprosthetic joint infection (PJI), but they lack sufficient accuracy to confirm or exclude infection reliably. These markers should be re-evaluated in future PJI definitions, as they are not suitable as stand-alone tests. Given their limitations and the superior diagnostic performance of synovial markers, the role of serum markers in PJI diagnosis should be reconsidered.
Jonathan Sliepen, Michelle A. S. Buijs, Jolien Onsea, Geertje A. M. Govaert, Frank F. A. IJpma, Jean-Paul P. M. de Vries, Bart C. H. Van der Wal, Charalampos Zalavras, and Willem-Jan Metsemakers
J. Bone Joint Infect., 10, 347–361, https://doi.org/10.5194/jbji-10-347-2025, https://doi.org/10.5194/jbji-10-347-2025, 2025
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This review assessed the effectiveness of single- and two-stage procedures for treating long-bone fracture-related infections, focusing on unhealed fractures without critical-sized bone defects. A total of 35 studies with 985 patients showed bone-healing rates of 80% for single-stage procedures and 77% for two-stage procedures. Infection eradication rates were 87% for single-stage approaches and 81% for two-stage approaches. The current evidence is inconclusive and lacks sufficient data to favor either approach.
Ann-Sophie Jacob, Jolien Onsea, Laura Bessems, Pauline Spoormans, Georges Vles, Willem-Jan Metsemakers, Sien Ombelet, and Melissa Depypere
J. Bone Joint Infect., 10, 317–326, https://doi.org/10.5194/jbji-10-317-2025, https://doi.org/10.5194/jbji-10-317-2025, 2025
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Fracture-related infections (FRIs) and periprosthetic joint infections (PJIs) fail to recover pathogens, posing a diagnostic challenge and impacting treatment. This new method involves homogenising biopsies with beads to release bacteria, followed by inoculation in blood culture bottles using an automated system. This technique shows similar sensitivity to conventional methods, with improved specificity and faster pathogen detection. To date, no other studies have reported an optimized method for incubating biopsies from patients with FRIs.
Marta Sabater-Martos, Laura Morata, Josep Maria Segur, Alex Soriano, and Juan Carlos Martínez-Pastor
J. Bone Joint Infect., 10, 237–241, https://doi.org/10.5194/jbji-10-237-2025, https://doi.org/10.5194/jbji-10-237-2025, 2025
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This study's aim was to analyse the healing and failure rates of one-stage knee replacement in patients with positive and negative preoperative cultures and sinus presence. We concluded that culture-negative infections or the presence of a sinus tract showed similar results compared to patients that had undergone the same procedure with positive cultures or spared soft tissue.
Hendrika M. Schenk, Marine Sebillotte, Jose Lomas, Adrian Taylor, Eva Benavent, Oscar Murillo, Marta Fernandez-Sampedro, Kaisa Huotari, Craig Aboltins, Rihard Trebse, Alex Soriano, Marjan Wouthuyzen-Bakker, and on behalf of the ESCMID Study Group on Implant Associated Infections (ESGIAI)
J. Bone Joint Infect., 10, 217–224, https://doi.org/10.5194/jbji-10-217-2025, https://doi.org/10.5194/jbji-10-217-2025, 2025
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Patients with rheumatoid arthritis have a high treatment failure rate when faced with a late acute periprosthetic joint infection. Because of the rarity of the condition, we performed a multicenter case-control study. We identified predictors of treatment failure to ultimately improve the treatment outcome. Exchange of modular components seems important in this patient group, likely due to a higher rate of positive blood cultures compared to control patients.
Marta Sabater-Martos, Martin Clauss, Ana Ribau, Ricardo Sousa, and on behalf of the Leukocyte Count Synovial Fluid working group for the Unified PJI definition task force
J. Bone Joint Infect., 10, 165–184, https://doi.org/10.5194/jbji-10-165-2025, https://doi.org/10.5194/jbji-10-165-2025, 2025
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This meta-analysis evaluates synovial fluid white blood cell count and polymorphonuclear neutrophil proportion in order to diagnose chronic peri-prosthetic joint infection. Based on 74 studies, it identifies optimal thresholds, with rule-in and rule-out thresholds enhancing diagnostic precision. Confounding factors such as fractures and inflammatory arthritis are addressed. The findings support standardized diagnostic frameworks in improving accuracy and clinical consistency.
Irene K. Sigmund, Tristan Ferry, Ricardo Sousa, Alex Soriano, Willem-Jan Metsemakers, Martin Clauss, Rihard Trebse, and Marjan Wouthuyzen-Bakker
J. Bone Joint Infect., 10, 101–138, https://doi.org/10.5194/jbji-10-101-2025, https://doi.org/10.5194/jbji-10-101-2025, 2025
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In this paper, we discuss the most relevant factors influencing the outcome and define indications, contraindications, and risk factors of a DAIR procedure based on the currently available literature. Furthermore, we discuss the surgical technique in combination with systemic antimicrobial therapy in patients undergoing a DAIR procedure.
Sebastian Simon, Marjan Wouthuyzen-Bakker, Susana Gardete Hartmann, Jennyfer A. Mitterer, Sujeesh Sebastian, Stephanie Huber, Bernhard J. H. Frank, and Jochen G. Hofstaetter
J. Bone Joint Infect., 10, 51–59, https://doi.org/10.5194/jbji-10-51-2025, https://doi.org/10.5194/jbji-10-51-2025, 2025
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We compared the re-revision rates in rTHA and rTKA (revison total hip and knee arthroplasty) with and without AB (antibiotic) treatment in patients with UPICs (unexpected positive intraoperative cultures). The re-revision rate between the AB group and the non-AB group was similar. Postoperative AB treatment did not result in a decreased re-revision rate in patients with UPICs in presumed aseptic rTHA and rTKA. Patients with pathogens classified as a likely contaminant can be safely ignored.
Marta Sabater-Martos, Oscar Garcia, Laia Boadas, Laura Morata, Alex Soriano, and Juan Carlos Martínez-Pastor
J. Bone Joint Infect., 10, 41–49, https://doi.org/10.5194/jbji-10-41-2025, https://doi.org/10.5194/jbji-10-41-2025, 2025
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This is a retrospective diagnostic study in acute postoperative prosthetic joint infection in total knee arthroplasty that wants to determine diagnostic accuracy of synovial glucose and serum-to-synovial glucose ratio in acute postoperative infection. Both tests demonstrated good diagnostic potential. Notably, these biomarkers exhibited superior accuracy compared to the combination of C-reactive protein, synovial white blood cell count and polymorphonuclear percentage.
Baixing Chen, T. Fintan Moriarty, Hans Steenackers, Georges F. Vles, Jolien Onsea, Thijs Vackier, Isabel Spriet, Rob Lavigne, R. Geoff Richards, and Willem-Jan Metsemakers
J. Bone Joint Infect., 9, 249–260, https://doi.org/10.5194/jbji-9-249-2024, https://doi.org/10.5194/jbji-9-249-2024, 2024
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Our research explores natural antimicrobials to combat orthopedic-device-related infections, a challenging issue due to antibiotic resistance. We reviewed agents from bacteria, fungi, viruses, animals, plants and minerals, evaluating their effectiveness and synergy with traditional antibiotics. Our findings suggest these natural alternatives could revolutionize infection management in orthopedic patients, offering new hope for reducing antibiotic resistance and improving treatment outcomes.
Laia Boadas-Gironès, Marta Sabater-Martos, Marc Ferrer-Banus, Àlex Soriano-Viladomiu, and Juan Carlos Martínez-Pastor
J. Bone Joint Infect., 9, 241–248, https://doi.org/10.5194/jbji-9-241-2024, https://doi.org/10.5194/jbji-9-241-2024, 2024
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When acute soft tissue defects are present after knee arthroplasty, the infection risk is high. A gastrocnemius flap is used for anterior defects, and it is not usually combined with debridement surgery unless infection is clear. We examined the benefit of combining coverage treatment with debridement surgery, DAIR, comparing the isolated traditional coverage treatment. The results suggested a higher healing rate in the combined treatment, so we recommended it.
Seung-Jae Yoon, Paul C. Jutte, Alex Soriano, Ricardo Sousa, Wierd P. Zijlstra, and Marjan Wouthuyzen-Bakker
J. Bone Joint Infect., 9, 231–239, https://doi.org/10.5194/jbji-9-231-2024, https://doi.org/10.5194/jbji-9-231-2024, 2024
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This study validated three models for predicting infection after hip and knee replacement surgery. By analyzing data from 2684 patients in the Netherlands, Portugal, and Spain, we found that the models developed by Tan, Del Toro, and Bülow effectively identified high-risk patients. These models can be used to enhance preoperative counseling and to tailor infection prevention measures individually, potentially improving outcomes and reducing healthcare costs.
Alexandra Wallimann, Yvonne Achermann, Ciara Ferris, Mario Morgenstern, Martin Clauss, Vincent Stadelmann, Hannes Andreas Rüdiger, Liam O'Mahony, and Thomas Fintan Moriarty
J. Bone Joint Infect., 9, 191–196, https://doi.org/10.5194/jbji-9-191-2024, https://doi.org/10.5194/jbji-9-191-2024, 2024
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Skin commensal bacteria such as staphylococci are often the source of orthopaedic-device-related infections. Rifampicin is a widely used antibiotic in the treatment of these infections. The results of this study show that oral rifampicin therapy leads to a consistent and persistent induction of resistance in commensal staphylococci on the skin and in the nose for a prolonged time.
Noémie Reinert, Katinka Wetzel, Fabian Franzeck, Mario Morgenstern, Markus Aschwanden, Thomas Wolff, Martin Clauss, and Parham Sendi
J. Bone Joint Infect., 9, 183–190, https://doi.org/10.5194/jbji-9-183-2024, https://doi.org/10.5194/jbji-9-183-2024, 2024
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We assessed concordance of in-house guidelines for diagnostic principles and antibiotic treatment duration (ABT) 2 years after their implementation. The goal was to standardize diagnostic and treatment principles: are we doing what we recommend? The adherence to recommendations in terms of biopsy sampling was good, moderate for histopathology and poor for anatomic labeling. In terms of ABT duration, the adherence was good, but further shortening for surgically cured cases is necessary.
Fred Ruythooren, Stijn Ghijselings, Melissa Depypere, Willem-Jan Metsemakers, Liesbet Henckaerts, Nathalie Noppe, and Georges Vles
J. Bone Joint Infect., 9, 167–171, https://doi.org/10.5194/jbji-9-167-2024, https://doi.org/10.5194/jbji-9-167-2024, 2024
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The article examines a unique case of Ureaplasma urealyticum causing osteomyelitis in the greater trochanter of a 26-year-old male treated with ocrelizumab for multiple sclerosis. It emphasizes the necessity of a multidisciplinary approach and advanced PCR diagnostics to manage such rare opportunistic infections effectively, highlighting the challenges faced due to the immunosuppressive nature of monoclonal antibody therapies of this kind.
Stéphanie Pascual, Brooklyn Noble, Nusreen Ahmad-Saeed, Catherine Aldridge, Simone Ambretti, Sharon Amit, Rachel Annett, Shaan Ashk O'Shea, Anna Maria Barbui, Gavin Barlow, Lucinda Barrett, Mario Berth, Alessandro Bondi, Nicola Boran, Sara E. Boyd, Catarina Chaves, Martin Clauss, Peter Davies, Ileana T. Dianzo-Delgado, Jaime Esteban, Stefan Fuchs, Lennart Friis-Hansen, Daniel Goldenberger, Andrej Kraševac Glaser, Juha O. Groonroos, Ines Hoffmann, Tomer Hoffmann, Harriet Hughes, Marina Ivanova, Peter Jezek, Gwennan Jones, Zeynep Ceren Karahan, Cornelia Lass-Flörl, Frédéric Laurent, Laura Leach, Matilde Lee Horsbøll Pedersen, Caroline Loiez, Maureen Lynch, Robert J. Maloney, Martin Marsh, Olivia Milburn, Shanine Mitchell, Luke S. P. Moore, Lynn Moffat, Marianna Murdjeva, Michael E. Murphy, Deepa Nayar, Giacomo Nigrisoli, Fionnuala O'Sullivan, Büşra Öz, Teresa Peach, Christina Petridou, Mojgan Prinz, Mitja Rak, Niamh Reidy, Gian Maria Rossolini, Anne-Laure Roux, Patricia Ruiz-Garbajosa, Kordo Saeed, Llanos Salar-Vidal, Carlos Salas Venero, Mathyruban Selvaratnam, Eric Senneville, Peter Starzengruber, Ben Talbot, Vanessa Taylor, Rihard Trebše, Deborah Wearmouth, Birgit Willinger, Marjan Wouthuyzen-Bakker, Brianne Couturier, and Florence Allantaz
J. Bone Joint Infect., 9, 87–97, https://doi.org/10.5194/jbji-9-87-2024, https://doi.org/10.5194/jbji-9-87-2024, 2024
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This study conducted in multiple sites across Europe aimed to evaluate the BIOFIRE Joint Infection (JI) Panel, a new technology that uses multiplex PCR to detect microorganisms in synovial fluid of patients with suspicion of joint infections in 1 h, in comparison with synovial fluid culture. Results showed an overall agreement of 85 % to 88.4 % between the two methods. The JI Panel detected additional organisms, and the positive user experience highlights its clinical significance.
Céline Dupieux, Ghislaine Descours, Paul Verhoeven, Florence Grattard, Yvonne Benito, François Vandenesch, Céline Cazorla, Tristan Ferry, Sébastien Lustig, Bertrand Boyer, Sandrine Boisset, Anne Carricajo, Frédéric Laurent, and PIRLA investigator group
J. Bone Joint Infect., 9, 37–48, https://doi.org/10.5194/jbji-9-37-2024, https://doi.org/10.5194/jbji-9-37-2024, 2024
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We define an algorithm to optimize bone and joint infection diagnosis in adults on synovial fluid samples. This prospective multi-center study included a large number of synovial fluids and compared the performance of classical culture on different media, inoculation of synovial fluid in blood culture bottles, and broad-range and specific PCR. We proposed an algorithm associating culture onto three solid media and into blood culture bottles and 16S, Staphylococcus, and Streptococcus PCR.
Jordi Cools, Stijn Ghijselings, Fred Ruythooren, Sander Jentjens, Nathalie Noppe, Willem-Jan Metsemakers, and Georges Vles
J. Bone Joint Infect., 9, 27–35, https://doi.org/10.5194/jbji-9-27-2024, https://doi.org/10.5194/jbji-9-27-2024, 2024
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Septic arthritis (SA) of the native adult hip is a rare orthopaedic emergency. To date, the role of advanced imaging has been confined to supporting or opposing diagnosis; however, implications for surgical decision-making and outcomes have not yet been established. We found that extra-articular abscesses are present in two out of three patients and require varying anatomical approaches. Therefore, we recommend routinely performing advanced imaging in all adults with SA of the native hip joint.
Marta Sabater-Martos, Marc Ferrer, Laura Morata, Alex Soriano, and Juan Carlos Martínez-Pastor
J. Bone Joint Infect., 9, 17–26, https://doi.org/10.5194/jbji-9-17-2024, https://doi.org/10.5194/jbji-9-17-2024, 2024
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This is a meta-analysis of six studies describing the cutoff values of white blood cell count and polymorphonuclear percentage in synovial fluid for the diagnosis of acute postoperative peri-prosthetic joint infection (PJI).
We found that both the WBC count and PMN percentage are good markers for diagnosis of acute postoperative PJI. However, the synovial WBC count is more powerful in diagnosing acute postoperative PJI.
We found that both the WBC count and PMN percentage are good markers for diagnosis of acute postoperative PJI. However, the synovial WBC count is more powerful in diagnosing acute postoperative PJI.
Fred Ruythooren, Stijn Ghijselings, Jordi Cools, Melissa Depypere, Paul De Munter, Willem-Jan Metsemakers, and Georges Vles
J. Bone Joint Infect., 8, 209–218, https://doi.org/10.5194/jbji-8-209-2023, https://doi.org/10.5194/jbji-8-209-2023, 2023
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A total of 41 patients who underwent surgical treatment for septic arthritis (SA) of the native hip were studied. We show that patients with SA of the native hip can be divided in three distinct clinical subgroups based on route of infection. Route of infection is directly related to the chance of femoral head preservation and should, therefore, be the basis for decision-making. Only patients with blood-borne infections in an undamaged hip had a reasonable chance of femoral head preservation.
Niels Vanvelk, Esther M. M. Van Lieshout, Jolien Onsea, Jonathan Sliepen, Geertje Govaert, Frank F. A. IJpma, Melissa Depypere, Jamie Ferguson, Martin McNally, William T. Obremskey, Charalampos Zalavras, Michael H. J. Verhofstad, and Willem-Jan Metsemakers
J. Bone Joint Infect., 8, 133–142, https://doi.org/10.5194/jbji-8-133-2023, https://doi.org/10.5194/jbji-8-133-2023, 2023
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This international retrospective cohort study displays the diagnostic characteristics of 609 patients who were treated for fracture-related infection (FRI). Clinical confirmatory criteria were present in 77% of patients. In the remaining patients, the decision to operatively collect deep tissue cultures had to be based on a set of suggestive criteria. The combined use of these suggestive criteria should guide treating physicians in the management pathway of FRI.
Sara Elisa Diniz, Ana Ribau, André Vinha, José Carlos Oliveira, Miguel Araújo Abreu, and Ricardo Sousa
J. Bone Joint Infect., 8, 109–118, https://doi.org/10.5194/jbji-8-109-2023, https://doi.org/10.5194/jbji-8-109-2023, 2023
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While there is no gold standard test to diagnose periprosthetic joint infection (PJI), we believe synovial fluid analysis, especially preoperatively, is a critical step in differentiating between infection and aseptic failure. Adding simple and inexpensive biomarkers such as synovial C-reactive protein (CRP) or adenosine deaminase (ADA) and combined interpretation can be helpful in the context of inconclusive results.
Jorrit Willem Adriaan Schoenmakers, Rosanne de Boer, Lilli Gard, Greetje Anna Kampinga, Marleen van Oosten, Jan Maarten van Dijl, Paulus Christiaan Jutte, and Marjan Wouthuyzen-Bakker
J. Bone Joint Infect., 8, 45–50, https://doi.org/10.5194/jbji-8-45-2023, https://doi.org/10.5194/jbji-8-45-2023, 2023
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In a first evaluation, the accuracy of a novel multiplex PCR (polymerase chain reaction) panel for rapid detection of pathogens in patients with a clinical suspicion of acute septic arthritis of native and prosthetic joints is assessed. Clear benefit is seen in patients with a suspected native septic arthritis and late acute prosthetic joint infection. This indicates that the panel allows for fast tailoring of antibiotics and may prompt the surgeon for surgical lavage in doubtful clinical cases.
Christen Ravn, Jeroen Neyt, Natividad Benito, Miguel Araújo Abreu, Yvonne Achermann, Svetlana Bozhkova, Liselotte Coorevits, Matteo Carlo Ferrari, Karianne Wiger Gammelsrud, Ulf-Joachim Gerlach, Efthymia Giannitsioti, Martin Gottliebsen, Nis Pedersen Jørgensen, Tomislav Madjarevic, Leonard Marais, Aditya Menon, Dirk Jan Moojen, Markus Pääkkönen, Marko Pokorn, Daniel Pérez-Prieto, Nora Renz, Jesús Saavedra-Lozano, Marta Sabater-Martos, Parham Sendi, Staffan Tevell, Charles Vogely, Alex Soriano, and the SANJO guideline group
J. Bone Joint Infect., 8, 29–37, https://doi.org/10.5194/jbji-8-29-2023, https://doi.org/10.5194/jbji-8-29-2023, 2023
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Management of septic arthritis in native joints (SANJO) is often conducted by clinicians of different specialties, experience levels, and at all hours of the day. The SANJO guideline group makes evidence-based recommendations for diagnosis, microbiological investigation, initial surgery, empirical antibiotic treatment, early mobilization, evaluation of outcomes, and treatment failure. Special considerations were made for children, tuberculosis, and SANJO after cruciate ligament reconstruction.
Efthymia Giannitsioti, Mauro José Salles, Andreas Mavrogenis, Dolors Rodriguez-Pardo, Ibai Los-Arcos, Alba Ribera, Javier Ariza, María Dolores del Toro, Sophie Nguyen, Eric Senneville, Eric Bonnet, Monica Chan, Maria Bruna Pasticci, Sabine Petersdorf, Natividad Benito, Nuala O' Connell, Antonio Blanco García, Gábor Skaliczki, Pierre Tattevin, Zeliha Kocak Tufan, Nikolaos Pantazis, Panayiotis D. Megaloikonomos, Panayiotis Papagelopoulos, Alejandro Soriano, Antonios Papadopoulos, and the ESGIAI collaborators study group
J. Bone Joint Infect., 7, 279–288, https://doi.org/10.5194/jbji-7-279-2022, https://doi.org/10.5194/jbji-7-279-2022, 2022
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Our multicentre study on a lower-limb osteosynthesis-associated infection (OAI) cohort by multidrug (MDR) and extensively drug (XDR) resistant Gram-negative bacteria found the following: implant retention with debridement was mostly performed in early OAI; 50.9 % of patients achieved remission of infection; remission reached 50 % (MDR) vs. 25 % (XDR) in early OAI and 60 % (MDR) vs. 44.4 % (XDR) in late OAI; age (> 60) and multiple surgeries were independent factors influencing lack of remission.
Parham Sendi and Tristan Ferry
J. Bone Joint Infect., 7, 187–189, https://doi.org/10.5194/jbji-7-187-2022, https://doi.org/10.5194/jbji-7-187-2022, 2022
Clément Javaux, Clémentine Daveau, Clotilde Bettinger, Mathieu Daurade, Céline Dupieux-Chabert, Fabien Craighero, Carine Fuchsmann, Philippe Céruse, Arnaud Gleizal, Nicolas Sigaux, Tristan Ferry, Florent Valour, and the Lyon BJI study group
J. Bone Joint Infect., 7, 127–136, https://doi.org/10.5194/jbji-7-127-2022, https://doi.org/10.5194/jbji-7-127-2022, 2022
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We describe 48 osteocutaneous-flap-related osteomyelitis cases, mostly presenting with early, local signs of infection and/or bone exposure. Main pathogens were Gram-negative bacilli, streptococci, S. aureus, enterococci, and anaerobes, justifying a broad-spectrum empirical antimicrobial therapy. Despite surgery and a 3-month antimicrobial therapy, a 50 % failure rate was recorded, associated with a delayed infectious disease specialist referral and advocating for multidisciplinary management.
Ernesto Muñoz-Mahamud, Eduard Tornero, José A. Estrada, Jenaro A. Fernández-Valencia, Juan C. Martínez-Pastor, and Álex Soriano
J. Bone Joint Infect., 7, 109–115, https://doi.org/10.5194/jbji-7-109-2022, https://doi.org/10.5194/jbji-7-109-2022, 2022
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A patient with normal D-dimer value has a low risk of prosthetic joint infection, so serum D-dimer assessment should always be considered as a useful test to rule out chronic prosthetic joint infection (especially in those cases caused by low-virulence microorganisms in which conventional tests may lead to misdiagnosis). Conversely, the platelet count to mean platelet volume ratio may be of limited value for accurately diagnosing prosthetic joint infection.
Marjan Wouthuyzen-Bakker and Alexander L. Boerboom
J. Bone Joint Infect., 7, 33–34, https://doi.org/10.5194/jbji-7-33-2022, https://doi.org/10.5194/jbji-7-33-2022, 2022
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This case illustrates the clinical picture of a worn-out elbow prosthesis resulting in severe metallosis and a subsequent periprosthetic joint infection.
Karsten D. Ottink, Stefan J. Gelderman, Marjan Wouthuyzen-Bakker, Joris J. W. Ploegmakers, Andor W. J. M. Glaudemans, and Paul C. Jutte
J. Bone Joint Infect., 7, 1–9, https://doi.org/10.5194/jbji-7-1-2022, https://doi.org/10.5194/jbji-7-1-2022, 2022
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A low-grade periprosthetic joint infection (PJI) may be difficult to diagnose, and nuclear imaging could help in the diagnosis. However, its diagnostic value is unclear. We retrospectively evaluated this diagnostic value. We conclude that in patients presenting with nonspecific symptoms and a low a priori chance of PJI based on clinical evaluation, nuclear imaging is of no clear added value in diagnosing a PJI.
Simon Martin Heinrich, Parham Sendi, and Martin Clauss
J. Bone Joint Infect., 6, 423–424, https://doi.org/10.5194/jbji-6-423-2021, https://doi.org/10.5194/jbji-6-423-2021, 2021
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We report on an 83-year-old woman who had an open removal of a baker's cyst several months after total knee arthroplasty. The following wound healing problem was first misinterpreted as being superficial. With an injection of methylene blue and a contrast medium, we showed the extent of the sinus tract, proving the periprosthetic joint infection.
Cited articles
Sigmund, I. K., Ferry, T., Sousa, R., Soriano, A., Metsemakers, W. J., Clauss, M., Trebse, R., and Wouthuyzen-Bakker, M.: Debridement, antimicrobial therapy, and implant retention (DAIR) as curative strategy for acute periprosthetic hip and knee infections: a position paper of the European Bone & Joint Infection Society (EBJIS), J. Bone Joint Infect., 10, 101–138, https://doi.org/10.5194/jbji-10-101-2025, 2025.
Short summary
This is a summary of our position paper on debridement, antimicrobial therapy, and implant retention (DAIR) procedures as a curative treatment strategy for acute periprosthetic hip and knee infections. It includes the defined indications as well as the contraindications of DAIR procedures when eradication/cure is intended, based on the currently available literature.
This is a summary of our position paper on debridement, antimicrobial therapy, and implant...
