Articles | Volume 11, issue 4
https://doi.org/10.5194/jbji-11-555-2026
© Author(s) 2026. 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-11-555-2026
© Author(s) 2026. This work is distributed under
the Creative Commons Attribution 4.0 License.
the Creative Commons Attribution 4.0 License.
Sonication versus peri-implant tissue culture in fracture-related infection: diagnostic performance and therapeutic consequences in a single-center cohort
Belal Abdo
Department of Trauma, Hand and Reconstructive Surgery, Justus Liebig University Giessen, University Hospital of Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany
Daniel Strack
Department of Cardiac and Vascular Surgery, Justus Liebig University Giessen, University Hospital of Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany
Marcel Schäuffele
Department of Trauma, Hand and Reconstructive Surgery, Justus Liebig University Giessen, University Hospital of Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany
Tim Ludwig Tüngler
Department of Trauma, Hand and Reconstructive Surgery, Justus Liebig University Giessen, University Hospital of Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany
Can Imirzalioglu
Institute of Medical Microbiology, Justus Liebig University Giessen, University Hospital of Giessen, Schubertstr. 81, 35392 Giessen, Germany
Anita Windhorst
Institute of Medical Informatics, Justus-Liebig-University Giessen, Rudolf-Buchheim-Str. 6, 35392 Giessen, Germany
Moritz Fritzenwanker
Institute of Medical Microbiology, Justus Liebig University Giessen, University Hospital of Giessen, Schubertstr. 81, 35392 Giessen, Germany
Christian Heiss
Department of Trauma, Hand and Reconstructive Surgery, Justus Liebig University Giessen, University Hospital of Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany
Experimental Trauma Surgery, Justus Liebig University Giessen, Aulweg 128, 35392 Giessen, Germany
Biruni University, Istanbul, Türkiye
Markus Rupp
CORRESPONDING AUTHOR
Department of Trauma, Hand and Reconstructive Surgery, Justus Liebig University Giessen, University Hospital of Giessen, Rudolf-Buchheim-Str. 7, 35392 Giessen, Germany
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Dominik Szymski, Susanne Baertl, Nike Walter, Markus Rupp, Katja Hierl, and Volker Alt
J. Bone Joint Infect., 11, 523–533, https://doi.org/10.5194/jbji-11-523-2026, https://doi.org/10.5194/jbji-11-523-2026, 2026
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A health-economic study estimating the cost of septic re-revision surgery for periprosthetic joint infections (PJIs) across 30 European countries. Using 2023 Eurostat data plus a 13-country reimbursement survey, the study estimates 22 794 PJIs and 8629 septic re-revisions in 2023, costing ~€123.6 million (95% CI €102–156 million). Two-stage exchanges drive 82.8% of costs. Cutting PJI incidence by 25% could save €27.9 million/year; shifting half of two-stage cases to one-stage a further €22.6 million.
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
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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.
Lorenz Huber, Hasan S. Aguicenoglu, Susanne Baertl, Julia Elisabeth Lenz, Kristina Gerhardinger, Frank Hanses, Florian Zeman, Nike Walter, Volker Alt, and Markus Rupp
J. Bone Joint Infect., 11, 175–183, https://doi.org/10.5194/jbji-11-175-2026, https://doi.org/10.5194/jbji-11-175-2026, 2026
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Septic arthritis is a dangerous joint infection that requires rapid treatment. We analysed patient data to test common blood and synovial fluid markers and a newly developed composite score combining these markers. The score demonstrated higher sensitivity than individual tests alone within this dataset. Prospective validation in larger cohorts is required before clinical application.
Markus Rupp, Nike Walter, Dominik Szymski, Christian Taeger, Martin Franz Langer, and Volker Alt
J. Bone Joint Infect., 8, 165–173, https://doi.org/10.5194/jbji-8-165-2023, https://doi.org/10.5194/jbji-8-165-2023, 2023
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The antibiotic bead pouch is a useful technique for temporary soft tissue coverage. After the introduction of negative wound pressure therapy, it has fallen into oblivion. However, the technique has several advantages, which are highlighted in the present review article. After debridement, the antibiotic beads deliver high dosages of antibiotics suitable for bone cements. This enables a sterile wound, which might help to avoid either infection or progress of infection.
Cited articles
Anagnostopoulos, A., Bossard, D. A., Ledergerber, B., Zingg, P. O., Zinkernagel, A. S., Gerber, C., and Achermann, Y.: Perioperative Antibiotic Prophylaxis Has No Effect on Time to Positivity and Proportion of Positive Samples: a Cohort Study of 64 Cutibacterium acnes Bone and Joint Infections, J. Clin. Microbiol., 56, e01576-17, https://doi.org/10.1128/JCM.01576-17, 2018.
Bellova, P., Knop-Hammad, V., Königshausen, M., Mempel, E., Frieler, S., Gessmann, J., Schildhauer, T. A., and Baecker, H.: Sonication of retrieved implants improves sensitivity in the diagnosis of periprosthetic joint infection, BMC Musculoskel. Dis., 20, 623, https://doi.org/10.1186/s12891-019-3006-1, 2019.
Bellova, P., Knop-Hammad, V., Königshausen, M., Schildhauer, T. A., Gessmann, J., and Baecker, H.: Sonication in the diagnosis of fracture-related infections (FRI) – a retrospective study on 230 retrieved implants, J. Orthop. Surg. Res., 16, 310, https://doi.org/10.1186/s13018-021-02460-z, 2021.
Corrigan, R. A., Sliepen, J., Dudareva, M., IJpma, F. F. A., Govaert, G., Atkins, B. L., Rentenaar, R., Wouthuyzen-Bakker, M., and McNally, M.: Causative Pathogens Do Not Differ between Early, Delayed or Late Fracture-Related Infections, Antibiotics, 11, 943, https://doi.org/10.3390/antibiotics11070943, 2022.
Depypere, M., Sliepen, J., Onsea, J., Debaveye, Y., Govaert, G. A. M., IJpma, F. F. A., Zimmerli, W., and Metsemakers, W.-J.: The Microbiological Etiology of Fracture-Related Infection, Front. Cell. Infect. Mi., 12, 934485, https://doi.org/10.3389/fcimb.2022.934485, 2022.
Dudareva, M., Barrett, L., Figtree, M., Scarborough, M., Watanabe, M., Newnham, R., Wallis, R., Oakley, S., Kendrick, B., Stubbs, D., McNally, M. A., Bejon, P., Atkins, B. A., Taylor, A., and Brent, A. J.: Sonication versus tissue sampling for diagnosis of prosthetic joint and other orthopedic device-related infections, J. Clin. Microbiol., 56, e00688-18, https://doi.org/10.1128/JCM.00688-18, 2018.
Govaert, G. A. M., Kuehl, R., Atkins, B. L., Trampuz, A., Morgenstern, M., Obremskey, W. T., Verhofstad, M. H. J., McNally, M. A., and Metsemakers, W.-J.: Diagnosing Fracture-Related Infection: Current Concepts and Recommendations, J. Orthop. Trauma, 34, 8–17, https://doi.org/10.1097/BOT.0000000000001614, 2020.
Holinka, J., Bauer, L., Hirschl, A. M., Graninger, W., Windhager, R., and Presterl, E.: Sonication cultures of explanted components as an add-on test to routinely conducted microbiological diagnostics improve pathogen detection, J. Orthop. Res., 29, 617–622, https://doi.org/10.1002/JOR.21286, 2011.
Kapadia, B. H., Berg, R. A., Daley, J. A., Fritz, J., Bhave, A., and Mont, M. A.: Periprosthetic joint infection, Lancet, 387, 386–394, https://doi.org/10.1016/S0140-6736(14)61798-0, 2016.
Metsemakers, W. J., Morgenstern, M., McNally, M. A., Moriarty, T. F., McFadyen, I., Scarborough, M., Athanasou, N. A., Ochsner, P. E., Kuehl, R., Raschke, M., Borens, O., Xie, Z., Velkes, S., Hungerer, S., Kates, S. L., Zalavras, C., Giannoudis, P. V., Richards, R. G., and Verhofstad, M. H. J.: Fracture-related infection: A consensus on definition from an international expert group, Injury, 49, 505–510, https://doi.org/10.1016/j.injury.2017.08.040 , 2018.
Oliva, A., Miele, M. C., Al Ismail, D., Di Timoteo, F., De Angelis, M., Rosa, L., Cutone, A., Venditti, M., Mascellino, M. T., Valenti, P., and Mastroianni, C. M.: Challenges in the Microbiological Diagnosis of Implant-Associated Infections: A Summary of the Current Knowledge, Front. Microbiol., 12, 750460, https://doi.org/10.3389/fmicb.2021.750460, 2021.
Onsea, J., Depypere, M., Govaert, G., Kuehl, R., Vandendriessche, T., Morgenstern, M., McNally, M., Trampuz, A., and Metsemakers, W.: Accuracy of Tissue and Sonication Fluid Sampling for the Diagnosis of Fracture-Related Infection: A Systematic Review and Critical Appraisal, J. Bone Joint Infect., 3, 173–181, https://doi.org/10.7150/jbji.27840, 2018.
Otchwemah, R., Lefering, R., Marche, B., Tjardes, T., Wendel, A. F., Weichert, V., Dudda, M., and Steinhausen, E.: Systematic investigation and comparison of diagnostic methods in implant-related infections and infectious non-unions in trauma surgery – results of a prospective study, Eur. J. Trauma Emerg. S., 51, 243, https://doi.org/10.1007/s00068-025-02900-z , 2025.
Portillo, M. E., Salvadó, M., Trampuz, A., Siverio, A., Alier, A., Sorli, L., Martínez, S., Pérez-Prieto, D., Horcajada, J. P., and Puig-Verdie, L.: Improved diagnosis of orthopedic implant-associated infection by inoculation of sonication fluid into blood culture bottles, J. Clin. Microbiol., 53, 1622–1627, https://doi.org/10.1128/JCM.03683-14, 2015.
Puig-Verdié, L., Alentorn-Geli, E., González-Cuevas, A., Sorlí, L., Salvadó, M., Alier, A., Pelfort, X., Portillo, M. E., and Horcajada, J. P.: Implant sonication increases the diagnostic accuracy of infection in patients with delayed, but not early, orthopaedic implant failure, Bone Joint J., 95-B, 244–249, https://doi.org/10.1302/0301-620X.95B2.30486, 2013.
Rupp, M., Walter, N., Bärtl, S., Heyd, R., Hitzenbichler, F., and Alt, V.: Fracture-Related Infection – Epidemiology, Etiology, Diagnosis, Prevention, and Treatment, Dtsch. Arztebl. Int., 121, 17–24, https://doi.org/10.3238/arztebl.m2023.0233, 2024.
Silva, N. B. S., Marques, L. A., and Röder, D. D. B.: Diagnosis of biofilm infections: current methods used, challenges and perspectives for the future, J. Appl. Microbiol., 131, 2148–2160, https://doi.org/10.1111/JAM.15049, 2021.
Tani, S., Lepetsos, P., Stylianakis, A., Vlamis, J., Birbas, K., and Kaklamanos, I.: Superiority of the sonication method against conventional periprosthetic tissue cultures for diagnosis of prosthetic joint infections, Eur. J. Orthop. Surg. Tr., 28, 51–57, https://doi.org/10.1007/S00590-017-2012-Y, 2018.
Trampuz, A., Piper, K. E., Jacobson, M. J., Hanssen, A. D., Unni, K. K., Osmon, D. R., Mandrekar, J. N., Cockerill, F. R., Steckelberg, J. M., Greenleaf, J. F., and Patel, R.: Sonication of Removed Hip and Knee Prostheses for Diagnosis of Infection, N. Engl. J. Med., 357, 654–663, https://doi.org/10.1056/NEJMoa061588, 2007.
Trenkwalder, K., Erichsen, S., Weisemann, F., Augat, P., Militz, M., von Rüden, C., and SAND Research Group: The value of sonication in the differential diagnosis of septic and aseptic femoral and tibial shaft nonunion in comparison to conventional tissue culture and histopathology: a prospective multicenter clinical study, J. Orthop. Trauma., 24, 25, https://doi.org/10.1186/s10195-023-00708-4, 2023.
Unsworth, A., Young, B., Scarborough, M., and McNally, M.: A Comparison of Causative Pathogens in Bone and Prosthetic Joint Infections: Implications for Antimicrobial Therapy, Antibiotics, 13, 1125, https://doi.org/10.3390/ANTIBIOTICS13121125, 2024.
Velasquez, A. X. B., Klautau, G. B., Kurihara, M. N. L., Santos, I. N. M., Campos, L. B., Silva, M. M., Oliveira, I. S., Durigon, T. S., Seriacopi, L. S., and Salles, M. J.: Improving the microbiological diagnosis of fracture-related infection and prosthetic joint infection through culturing sonication fluid in Bactec blood culture bottles, Braz. J. Microbiol., 55, 3591–3601, https://doi.org/10.1007/S42770-024-01545-1, 2024.
Walter, N., Neubauer, I., Baertl, S., Alt, V., and Rupp, M.: Direct Healthcare Cost of Fracture-related Infection Treatment, JB JS Open Access, 10, e24.00133, https://doi.org/10.2106/JBJS.OA.24.00133, 2025.
Watanabe, S., Kamono, E., Choe, H., Ike, H., Inaba, Y., and Kobayashi, N.: Differences in Diagnostic Sensitivity of Cultures Between Sample Types in Periprosthetic Joint Infections: A Systematic Review and Meta-Analysis, J. Arthroplasty, 39, 1939–1945, https://doi.org/10.1016/j.arth.2024.03.016, 2024.
Weinert-Stein, K. E., Slater, J. C., Sagi, H. C., Powers-Fletcher, M., and Palacio, F.: 316. Application of New Consensus Definition Identifies High Numbers of Fracture Related Infections with Negative Cultures, Open Forum Infect. Dis., 7, S230, https://doi.org/10.1093/OFID/OFAA439.512, 2020.
Yano, M. H., Klautau, G. B., Da Silva, C. B., Nigro, S., Avanzi, O., Mercadante, M. T., and Salles, M. J. C.: Improved diagnosis of infection associated with osteosynthesis by use of sonication of fracture fixation implants, J. Clin. Microbiol., 52, 4176–4182, https://doi.org/10.1128/JCM.02140-14, 2014.
Short summary
Fracture-related infections after bone surgery are difficult to diagnose because bacteria can attach to metal implants and become hard to detect, especially when antibiotics have already been given. We compared two laboratory methods used to identify bacteria on removed implants in 157 patients. Each method alone missed some infections, but using both together improved detection and helped guide antibiotic treatment. Our findings support combining diagnostic approaches to improve patient care.
Fracture-related infections after bone surgery are difficult to diagnose because bacteria can...