A recent scoping review found no evidence supporting routine ward-level isolation or dedicated septic wards for non-multidrug-resistant organism musculoskeletal infections when standard precautions are applied, whereas targeted measures remain appropriate for multidrug-resistant organisms. An international survey revealed wide variation in attitudes and a persistent belief in supporting evidence, highlighting a gap between evidence and perception and supporting a differentiated, risk-based approach to isolation.
Purpose: Culture-negative periprosthetic joint infection (CN-PJI) poses a significant clinical challenge because antimicrobial selection relies on guesswork rather than robust clinical data. This umbrella review summarizes the prevalence of CN-PJI, diagnostic strategies (including molecular assays), treatment approaches, and outcomes. Methods: We conducted an umbrella review of published systematic reviews and meta-analyses on CN-PJI in adult hip and/or knee arthroplasties. Searches of major bibliographic databases were conducted in December 2025; two reviewers screened studies and extracted data on prevalence, reported risk factors, diagnostic criteria, use of molecular tests, specimen matrix (synovial fluid, periprosthetic tissue, and/or sonication fluid), surgical strategy, antimicrobial selection, and clinical outcomes (infection control or failure). Methodological quality was assessed with AMSTAR 2. Results: Nine reviews were included. Reported CN-PJI prevalence varied widely (11.0 %–63.6 %), reflecting substantial heterogeneity in study populations, diagnostic definitions, microbiological workflows, and pre-analytical factors. Prior antibiotic exposure before sampling was repeatedly identified as an important contributor to culture negativity. Molecular diagnostics, predominantly NGS (next-generation sequencing)-based approaches, were evaluated in five out of nine reviews, with highly variable organism detection rates depending on assay type, specimen source, and study context. Where meta-analytic estimates were available, pooled sensitivity ranged from 0.81 to 0.93, and pooled specificity ranged from 0.92 to 0.97. Treatment strategies and outcome definitions were inconsistently reported across reviews; when extractable, two-stage exchange was the most frequently described surgical strategy. Conclusions: CN-PJI remains common and variable across settings. Molecular diagnostics improve pathogen detection but do not eliminate false negatives. Reported failure rates varied across reviews and appeared to be clinically relevant, although differences in outcome definitions, treatment protocols, and follow-up duration limited direct comparison.
Introduction: Recent work in total knee arthroplasty (TKA) prosthetic joint infection (PJI) suggests that timing from hospital admission to DAIR (debridement, antibiotic, and implant retention) is a modifiable risk factor influencing treatment outcomes. The study assessed the impact of timing from admission to DAIR on clinical outcomes and treatment success in the total hip arthroplasty (THA) PJI population. Methods: A retrospective review was conducted at a specialized PJI tertiary referral centre. Patients who underwent DAIR for THA PJI between 2008 and 2021 with a minimum 2-year follow-up were included. The primary outcome was reoperation for recalcitrant PJI. Secondary outcomes included 90 d readmission, 90 d and 1-year mortality, and postoperative complications. Multivariate regression analysis identified factors associated with DAIR outcomes. Results: A total of 100 patients satisfied the inclusion criteria. The mean time from admission to DAIR was 46.4 ± 45.1 h, and 52.0 % required reoperation for recalcitrant PJI. Prolonged time from admission to DAIR was associated with increased 90 d mortality (odds ratio or OR: 1.02, CI (confidence interval) 95 %: 1.00–1.03, p= 0.04). Increasing age was associated with greater 1-year mortality (OR: 1.06, CI 95 %: 1.00–1.12, p= 0.049). McPherson host grade C compared to grade A was associated with both greater 1-year mortality (OR: 12.75, CI 95 %: 1.11–146.09, p= 0.04) and postoperative complications (OR: 7.59, CI 95 %: 1.22–47.08, p= 0.03). McPherson extremity grade II versus grade I (OR: 3.28, CI 95 %: 1.21–8.92, p= 0.02) and revision THAs (OR: 0.15, CI 95 %: 0.03–0.72, p= 0.02) were associated with postoperative complications. Lower haemoglobin levels (OR: 1.04, CI 95 %: 1.01–1.07, p= 0.004) were associated with higher reoperation risk. Conclusion: In a DAIR-treated cohort, increased time from admission to surgery was associated with greater 90 d mortality in THA PJI patients. Timely surgical intervention and optimization of modifiable risk factors are essential to improve outcomes.
Introduction: Periprosthetic joint infection (PJI) remains a major complication of joint arthroplasty, requiring rapid and accurate pathogen identification to guide appropriate antimicrobial therapy. Conventional culture is limited by prolonged turnaround times and reduced sensitivity, particularly following antibiotic exposure. This study evaluated the diagnostic performance and clinical relevance of Molecular Culture®Methods: SF samples from patients undergoing hip or knee revision arthroplasty (2019–2023) were retrospectively analysed. Patients were classified as PJI or non-PJI according to European Bone and Joint Infection Society criteria. MC results were compared with conventional SF culture. Positive percentage agreement (PPA) and negative percentage agreement (NPA) were calculated using culture as the reference standard. Clinical agreement was assessed using all available microbiological results and relevant clinical information, including recent antibiotic exposure. Results: A total of 203 SF samples from 172 patients were included. Analytical PPA and NPA of MC were 68.1 % (95 % CI, 59.9–75.3) and 84.6 % (95 % CI, 73.9–91.4), respectively. Following clinical correlation, PPA and NPA at patient level were 73.2 % (95 % CI, 64.9–80.2) and 95.6 % (95 % CI, 85.2–98.8), respectively. MC identified 11 additional clinically relevant pathogens and provided results within approximately 4 h. Conclusions: MC demonstrated high clinically adjusted agreement and faster turnaround times than conventional culture, supporting its role as an adjunctive diagnostic tool for PJI. Its value may be greatest in patients with uncertain infection status or prior antimicrobial exposure, where rapid exclusion of infection could facilitate earlier optimisation of antimicrobial therapy.
Background: Prosthetic joint infection (PJI) complicates 0.5 %–2.0 % of total joint arthroplasties and remains the leading cause of implant failure. Bacterial biofilm confers marked antimicrobial resistance, and current strategies, including debridement, antibiotics, and implant retention (DAIR), carry a pooled failure rate of ∼ 36 %. Novel biofilm-disrupting adjuncts are urgently needed. Purpose: The aim is to examine preclinical evidence of bromelain and N-acetylcysteine (BromAc) as a combination antibiofilm therapy in PJI management and to critically appraise its translational readiness. Methods: A narrative literature search was conducted for studies examining N-acetylcysteine, bromelain, and BromAc in the context of biofilm disruption on orthopaedic prosthetic materials. Eligible studies were appraised qualitatively for pathogen, substrate, exposure conditions, outcome measures, and methodological limitations to allow comparative interpretation rather than narrative summary alone. Results: N-acetylcysteine demonstrates concentration-dependent antibiofilm activity, achieving approximately 50 % biofilm reduction on polyethylene and 20 % on titanium at minimum inhibitory concentrations, rising to 81.5 % eradication of staphylococcal biofilms at higher concentrations in non-orthopaedic substrates. Bromelain achieves significant biofilm reduction from orthopaedic hardware via proteolytic degradation of extracellular polymeric substance protein scaffolds. In the principal proof-of-concept study on hernia mesh, BromAc achieved > 80 % biofilm removal (quantified by crystal violet biomass reduction) across three Pseudomonas aeruginosaConclusions: BromAc represents a mechanistically rational adjunctive therapy for PJI, targeting distinct biofilm matrix components. However, current evidence is largely preclinical, much of it derived from non-orthopaedic substrates and pathogens, and several supporting datasets are unpublished sponsor data. Important translational gaps remain in peer-reviewed staphylococcal validation on prosthetic materials, formulation stability (particularly the susceptibility of N-acetylcysteine to oxidation in aqueous solution), intra-articular safety with respect to cartilage and osseointegration, and the absence of an in vivo orthopaedic implant model. These limitations must be resolved before clinical translation can be responsibly considered.
Background: Sonication fluid culture (SFC) of osteosynthesis material may be a valuable adjunct tool to diagnose fracture-related infection (FRI). This study aims to evaluate the added diagnostic value of SFC as a diagnostic tool. The diagnostic value of SFC was assessed by evaluating its impact on confirming microbiological results and changing diagnosis. Methods: We analysed patients undergoing osteosynthesis hardware removal between 2012 and 2021. We categorized patients using FRI consensus criteria: suspected FRI or confirmed FRI. The sensitivity and specificity of tissue cultures and SFC were assessed. The added value of SFC was determined as the number of cases where SFC was essential for confirming FRI and the influence on antibiotic therapy selection. Results: We included 96 patients with three or more tissue cultures. Based on diagnosis without SFC, we found 14 aseptic, 35 suggestive FRI cases, and 47 confirmed FRI cases. Following SFC results, four cases changed diagnosis from aseptic to suggestive FRI, and three cases changed from suggestive FRI to confirmed FRI. The sensitivity of tissue culture was 74 %, and the specificity was 98 %. The sensitivity of SFC was 84 %, and the specificity was 83 %. Combining tissue cultures with SFC significantly increased sensitivity compared with tissue cultures alone, from 74 % to 88 % (p<0.001). In 21 confirmed FRIs (42 %), SFC results were concordant with tissue cultures and would not alter FRI management. SFC detected an additional virulent pathogen in three confirmed FRIs (6 %) and low-virulent pathogens in eight confirmed FRIs (16 %) which could influence the antibiotic regimen.Conclusions:
Introduction: Culture-negative periprosthetic joint infection (CN-PJI) remains a major diagnostic and therapeutic challenge because antimicrobial and surgical management are often empirical. Methods: We performed a systematic review and meta-analysis to evaluate treatment strategies and outcomes of CN-PJI. MEDLINE and Scopus were searched through 3 July 2025, and 27 cohort studies including 1399 CN-PJI patients were included. Results: Random-effect meta-analyses showed a pooled treatment success proportion of 83.6 % (95 % CI, 78.2–87.9), a pooled failure proportion of 17.2 % (95 % CI, 12.6–22.9), and a pooled mortality proportion of 2.4 % (95 % CI, 1.3–4.6). Subgroup analyses demonstrated lower success and higher failure with debridement, antibiotics, and implant retention compared with one-stage and two-stage exchange arthroplasty. Hip CN-PJI showed higher reported success than knee CN-PJI. Antimicrobial regimens were highly heterogeneous and were not suitable for pooled analysis. Conclusion: Overall, CN-PJI may have favorable outcomes, particularly with exchange arthroplasty, but prospective studies with standardized definitions and treatment reporting are needed.
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Bone and joint infections secondary to CandidaCandida albicans.
Background: Periprosthetic joint infection (PJI) remains a devastating complication after hemiarthroplasty in elderly patients with femoral neck fractures. Early identification of high-risk patients is important. The systemic immune–inflammation index (SII), calculated as platelet × neutrophil 
Native vertebral osteomyelitis (NVO) remains a diagnostic challenge due to its non-specific presentation and the limited sensitivity of culture-based methods. Blood cultures and image-guided biopsies are considered the diagnostic standards, but their yield is often low, especially in patients who have received prior antibiotics or are infected with fastidious microorganisms. Recent molecular techniques, including polymerase chain reaction (PCR) and next-generation sequencing (NGS), have improved pathogen detection and enabled more targeted antimicrobial therapy.In this narrative review, we summarize the diagnostic methods used in NVO, including conventional microbiological and molecular approaches, and present their strengths and limitations based on previous studies. We particularly focus on situations where molecular diagnostic techniques, such as 16S rRNA PCR, NGS, and microbial cell-free DNA testing, outperform traditional culture-based methods in sensitivity, while their specificity may be comparatively lower. Combining these molecular tools with standard diagnostic procedures may improve pathogen detection, guide targeted treatment, and enhance diagnostic accuracy in culture-negative or antibiotic-pretreated cases. Understanding the advantages and limitations of each diagnostic method can help clinicians to choose the most appropriate testing strategy, reduce diagnostic delays, and improve patient management in suspected NVO.
Background: Periprosthetic joint infection (PJI) is a devastating complication of arthroplasty and is difficult to diagnose accurately. This study aims to explore the value of neutrophil extracellular traps in synovial fluid (SF-NETs, web-like structures released by neutrophils as a critical innate immune response) for diagnosing PJI. Methods: A retrospective cohort study was conducted, enrolling post-arthroplasty subjects from January 2018 to December 2023. Three components of SF-NETs (cell-free double-strand DNA, SF-dsDNA; citrullinated histone H3, SF-CitH3; SF-Nucleosome) and SF-NETs1+2+Results: A total of 64 of 153 included subjects were diagnosed as PJI. SF-dsDNA and SF-CitH3 had significantly higher levels in the PJI group compared to the non-PJI group (P < 0.001) and showed positive correlations with SF-WBC, SF-PMN % and SF-PMN (0.4 < ρ < 0.7), while SF-Nucleosome had no significant difference. Sensitivity and specificity of SF-NETs1+, SF-NETs2+× SF-NETs
Background: Gram-negative (GN) bacteria are an increasingly recognized cause of prosthetic joint infection (PJI), accounting for 10 %–20 % of cases. However, epidemiological data from European centres remain limited. This study aimed to evaluate the incidence, risk factors, microbiological profile, and treatment outcomes of GN PJI in several European tertiary referral hospitals. Methods: We conducted a retrospective multicentre study including all culture-positive hip and knee PJIs diagnosed between 2014 and 2018 at three tertiary hospitals in Italy, Spain, and Switzerland. Demographic characteristics, comorbidities, surgical management, microbiological data including antimicrobial susceptibility, and treatment outcomes were analysed. Treatment success was defined as absence of persistent or recurrent infection requiring additional surgery, prosthesis removal, infection-related mortality, or long-term suppressive antibiotic therapy. Results: Among 780 confirmed PJIs, 71 (9.1 %) were caused by GN bacteria. The most frequent pathogens were polymicrobial infections (29.6 %), Escherichia coliPseudomonas aeruginosaConclusions: GN PJI incidence was comparable to that of previous reports. These infections occur more often in elderly patients with comorbidities. Two-stage revision remains the most effective surgical strategy, and ciprofloxacin continues to be a key component of antimicrobial therapy for susceptible GN infections.
Topical intrawound vancomycin powder has been widely adopted in orthopaedic surgery as an adjunct for the prevention of surgical site infection (SSI) and periprosthetic joint infection (PJI). Retrospective cohorts and derived meta-analyses have long suggested a consistent benefit, and the technique became established practice at many institutions. Over the past 5 years, prospective randomised evidence has added an important corrective to this picture. The VPIP trial (Saba et al., 2025) randomised 1901 high-risk patients undergoing primary hip or knee arthroplasty across 17 US centres and found no benefit of vancomycin, dilute povidone-iodine, or their combination over saline for any 3-month infection endpoint; a biostatistical projection to 80 000 patients left the number needed to treat near 500, and enrolment was closed for statistical futility. The VANCO trial in high-risk tibial fractures (O'Toole et al., 2021) narrowly missed its primary endpoint (P=0.06) but demonstrated a significant post hoc reduction in gram-positive deep infections without gram-negative shift. Mechanistic data indicate that sub-inhibitory vancomycin concentrations increase Staphylococcus aureus
Background: Optimal outcomes in periprosthetic joint infection (PJI) and other complex orthopaedic infections depend on longitudinal, multidisciplinary input from infectious disease (ID) specialists. Much of this work is not directly billable, and the financial structures that support it have not been systematically described in any healthcare system. Methods: We distributed an anonymous online cross-sectional survey to ID physician members of the Musculoskeletal Infection Society (MSIS) and the Infectious Diseases Society of America Bone and Joint Interest (IDSA-BOJO) group between 12 December 2025 and 30 January 2026. The survey captured practice setting, clinical and non-clinical orthopaedic ID responsibilities, and sources of compensation and protected time. Data were analysed descriptively; no inferential statistical testing was performed. Results: Fifty-two ID physicians responded, 94 % from US academic medical centres. Median ID clinical effort was 70 % (IQR 60 %–81 %); of this, a median of 55 % (IQR 40 %–90 %) was devoted to orthopaedic infections. Compensation was most commonly a base salary plus productivity incentives (53 %) or base salary alone (40 %) and was funded by medicine/ID in 88 % of cases. Care coordination (90 %), curbside consultation (85 %), trainee education (77 %), and guideline development (71 %) were performed; 83 % of respondents received no protected time or dedicated funding for any of these non-billable activities. Conclusions: In this descriptive, hypothesis-generating national survey of highly subspecialized US ID physicians, compensation structures were dominated by clinical productivity and rarely included protected time for the non-billable coordination work that underpins modern multidisciplinary PJI care. These findings should be interpreted in the context of a small, academic-predominant sample and of substantial international variation in healthcare financing, and they support the need for larger international studies of how orthopaedic ID expertise is funded and protected.
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Background: Periprosthetic joint infections (PJIs) remain a significant complication following total hip arthroplasties (THAs), affecting patient outcomes and healthcare costs. The accurate classification of PJIs is crucial for guiding treatment decisions and improving patient management. The TNM classification system, commonly used in oncology, has previously been adapted for PJI to enhance our understanding of infection severity and is progressively used as PJI-TNM. Purpose: This study evaluates the applicability of the PJI-TNM classification in a cohort of 185 periprosthetic hip joint infections, including 84 acute and 101 chronic cases. Methods: In this retrospective study, we analyzed 84 cases of acute and 101 cases of chronic periprosthetic hip joint infections. Each case was independently classified according to the PJI-TNM framework by three observers. A second round of scoring was performed 90 d later to assess the intra-observer concordance. The objective was to evaluate the utility of this classification in distinguishing between acute and chronic infections, predicting outcomes, and informing treatment strategies. Furthermore, intra- and inter-observer reliability were evaluated. Results: For acute PJIs we found a high inter-observer and intra-observer reliability for both the first and second evaluation (κ 0.78 and 0.89, respectively). In addition, the intra-observer analysis showed a very good correlation (κ 0.86–0.96). For chronic PJIs the intra-observer reliability was κκConclusion: The PJI-TNM classification demonstrated strong intra-observer and substantial inter-observer reliability across both acute and chronic infections, supporting its use as a robust and reproducible framework for PJI classification.
Background: Discrepancies exist between preoperative synovial aspirations and intraoperative cultures. It is unclear whether the results of preoperative arthrocentesis add diagnostic value for patients with possible prosthetic joint infection (PJI). Methods: We retrospectively identified adult patients treated surgically for hip and knee PJI who underwent both preoperative aspiration and intraoperative sampling. Synovial and intraoperative culture results were analyzed. Cultures were defined as concordant if they yielded the same organism(s) or if both were negative. Cultures were considered to be discordant if different organisms were isolated or if one had growth and the other was sterile. Demographic, clinical, and laboratory variables between groups were compared. Results: Among 75 patients, 54 (72 %) had concordant results, and 21 (28 %) had discordant results. In the discordant group, 7 of 21 patients (33 %) had negative synovial cultures with positive intraoperative cultures. Among culture-positive concordant patients, staphylococci and streptococci were the most common isolates, with 20 % gram negatives. True culture-negative PJI was uncommon (n=1). Preoperative antibiotic exposure was frequent (>50 %) in both groups. Conclusion: In a cohort of hip and knee PJI patients treated surgically, preoperative synovial aspiration cultures were concordant with intraoperative cultures in 72 % of cases, but negative synovial aspirations did not reliably exclude infection. Given the observed discordance, our findings support the obtainment of preoperative synovial aspiration and the collection of multiple intraoperative specimens at the time of surgery.
Introduction: Clinical criteria are included in all current periprosthetic joint infection (PJI) definitions, with sinus tract and purulence among the most unequivocal indicators of infection. However, evidence regarding their diagnostic accuracy remains limited. This study evaluated their diagnostic performance, associated microbial profile, and clinical outcomes. Methods: This retrospective study included 463 revision hip and knee arthroplasties between 2015 and 2023. A total of 245 (52.9 %) were classified as infected according to the 2021 European Bone and Joint Infection Society (EBJIS) definition. Receiver-operating-characteristic (ROC) curves and their areas under the curve (AUCs) were used for diagnostic accuracy calculations. Follow-up analysis was conducted using the Kaplan–Meier survival estimator. Results: Sensitivities for sinus tract and purulence were 12.7 % (95 % CI: 8.8–17.5) and 35.1 % (29.1–41.4), with specificities of 100 % (98.3–100) for both. AUCs were 0.546 (0.521–0.571) and 0.695 (0.653–0.737). The highest prevalence of sinus tract was observed in Candida albicansCutibacterium acnesStreptococcusStaphylococcus aureusp=0.011) and showed a trend for purulence (p=0.068). Conclusion: A sinus tract can be considered a confirmatory criterion for PJI due to its excellent specificity. Although highly specific, purulence remains subjective, with limited sensitivity, and should, if considered, be regarded only as a suggestive criterion. Both parameters were associated with lower survival rates and a consistent trend towards treatment failure.
Periprosthetic joint infection is a major cause of morbidity and economic cost after total joint arthroplasty, with Staphylococcus aureusS. aureus. Molecular epidemiology investigations have found concordance between nasal organisms and infecting strains, implying that many postoperative infections arise endogenously. Over the last decade, various clinical trials, institutional protocols, and meta-analyses have evaluated the efficacy of nasal screening and decolonization of Staph aureus. Recent evidence suggests that the success of infection prevention procedures is dependent on the reliability and consistency of decolonization rather than screening alone. This narrative review summarizes current evidence on nasal decolonization in total joint arthroplasty, including epidemiological data, methods of screening, and accessible therapy choices to suggest practical and reproducible infection control measures.