Background:Methods:≤ 90 d) treated between January 2022 and January 2025 with complete microbiological- and antimicrobial-susceptibility data. Microbiological isolates, susceptibility profiles, anatomical location, and the type of index procedure were analysed. Empirical coverage was assessed for cefazolin, vancomycin–ceftriaxone (SWAB-recommended), and vancomycin–ciprofloxacin, both overall and stratified by anatomical site. Results:Staphylococcus aureusEnterobacterS. aureus, cefazolin monotherapy covered only 49 % of infections due to resistance in S. epidermidisEnterobacterConclusion:
Fracture-related infections are among the most serious complications following osteosynthesis. They jeopardize fracture healing, prolong treatment duration, and can lead to loss of function or even amputation. Despite established standards, avoidable errors continue to occur in clinical practice. Fracture-related infections not only compromise healing but also significantly reduce life expectancy, and increase morbidity and mortality. The standardization of procedures is essential to improve outcomes and ensure consistent high-quality care. This article describes 20 common errors in the prevention, diagnosis, and treatment of fracture-related infection. For each error, the clinical consequences and practical recommendations are provided. The aim is to improve treatment quality and patient safety by identifying and avoiding typical decision-making pitfalls. Consistent standardization of surgical and microbiological procedures, interdisciplinary collaboration, and structured follow-up care are essential prerequisites for successful infection management.
Aim: Lavage aspiration following a dry tap remains a debated technique in the work-up for periprosthetic joint infection (PJI) of the hip and knee. This systematic review critically appraises the available evidence, with a particular focus on the diagnostic yield of lavage aspiration in detecting PJIs that would otherwise be missed. Methods: A comprehensive literature search was conducted in accordance with PRISMA guidelines across PubMed, Embase, MEDLINE, and Cochrane databases. Results: Eleven studies met the inclusion criteria, all level IV case series. Across 1965 patients, 2199 aspirations were performed. Overall, 798 procedures (36 %) resulted in a dry tap. Lavage aspiration was attempted in 698 of these cases, with 691 successful attempts. Among dry taps, 154 PJIs were ultimately identified, corresponding to a PJI prevalence of 19 %. Lavage aspiration contributed to a correct diagnosis in 22 % of successful procedures. Pooled culture sensitivity and specificity following saline lavage were 66 % and 89 %, respectively. The diagnostic performance of polymorphonuclear neutrophils (PMNs) >80 % was similar between saline lavage and normal aspiration. Although no safety concerns were reported, the potential introduction of pathogens and the risk of false-positive results remain concerns that are not fully mitigated by the available evidence. Conclusion: One in three aspirations result in a dry tap. Lavage aspiration provides analysable fluid in nearly all cases and appears to enable the diagnosis of PJI in roughly one out of five patients in whom standard aspiration fails. However, more robust evidence is needed before it can be recommended as a universal technique.
Despite advances in musculoskeletal trauma care, segmental bone loss remains a major clinical challenge. A substantial proportion of these cases are associated with fracture-related infection (FRI), which fundamentally alters the biological environment and reconstructive strategy. In this context, FRI should be considered in any patient with a segmental bone defect, and thorough surgical debridement with acquisition of multiple deep-tissue cultures represents an essential first step in management. The presence of infection reduces the likelihood of bone consolidation and eradication of disease, emphasizing the need for strict adherence to established FRI treatment principles. Depending on the extent of bone loss, host factors, and available expertise, patients may be eligible for a range of reconstructive options. Bone transport is one of these surgical methods and involves the gradual translocation of bone segments to reconstruct defects in long bones. Based on the principles of distraction osteogenesis (DO), controlled mechanical distraction promotes predictable bone regeneration according to Ilizarov's principles. Traditionally, DO has relied on circular external fixators. Recent developments involving integrated fixation, such as bone transport over a nail, have reduced morbidity and enabled faster reconstruction. Although these techniques carry a risk of contaminating the intramedullary canal, exclusive long-term use of external fixators is not harmless. Further innovations, such as motorized telescopic intramedullary nails, have led to the gradual replacement of external fixation, making the procedure less burdensome for patients. Advances in surgical skills and technology have enabled the treatment of more complex cases, making a specialized, multidisciplinary approach essential in modern clinical care.
Mycobacterium abscessusM. abscessus) is a rapidly growing nontuberculous mycobacterium (NTM). We present the case of a 57-year-old female on immunosuppressive therapy for polymyalgia rheumatica (PMR) who developed disseminated M. abscessus
Introduction: Septic arthritis (SA) is an orthopaedic emergency; delayed treatment endangers joint function and survival. Unlike periprosthetic infections, diagnostic criteria for native joints are poorly standardized. This study aimed to (1) evaluate diagnostic parameters including synovial white blood cell (sWBC) count, neutrophil percentage, serum C-reactive protein (CRP), and leukocyte count and (2) assess a new evaluation score combining these parameters. Methods: In a retrospective cohort study, cases of knee and shoulder SA treated at a German university hospital (2013–2022) were analysed. Parameters included synovial fluid analysis (sWBC, neutrophils), blood samples (CRP, leukocytes), and intraoperative cultures. Cut-offs for sWBC and neutrophils were determined using receiver-operating characteristic (ROC) analysis and the Youden index, comparing SA patients with non-infected controls. A new evaluation score for SA (Septic Arthritis Evaluation Score, SAES) was created: 2 points each for sWBC and neutrophils and 1 point each for CRP and leukocytes. Results: Complete data were available for 45 patients (71.4 % male, mean age 64.3 years). Knees were affected in 73.7 %, and shoulders were affected in 26.3 %. Median values were as follows: leukocytes – 11/nl, CRP – 158 mg L−1, sWBC – 42 910/µL, and neutrophils – 93.6 %. ROC analysis identified an optimal sWBC cut-off of 35 650/µL (sensitivity of 64.4 %, specificity of 87.8 %). The SAES showed higher discriminatory performance; with a threshold ≥ 3 points, sensitivity was 95.6 %, and specificity was 70.7 %. Conclusions: In this retrospective cohort, commonly used laboratory parameters for native joint SA showed limited discriminatory ability when applied individually. A newly developed composite score combining synovial and serum markers demonstrated higher sensitivity within this dataset. Prospective validation in larger cohorts is required before clinical application.
Fracture-related infection (FRI) is a serious complication in orthopaedic trauma that can lead to delayed union, nonunion, and poor clinical outcomes. A better understanding of the host immune response may provide valuable insights into the pathophysiology of FRI and may help identify genomic elements that contribute to the infection. This observational study compared immune responses between patients with FRI and non-infected controls using bone/tissue biopsies and sonication fluid, and it explored the possibility of detecting bacterial and biofilm genes using transcriptome profiling with hybridization technology (nCounter®CXCL1, CXCL2, CCL4/L1/L2) signalling, with higher levels compared to tissue biopsies. Transcriptomic analysis identified bacterial transcripts in cases where conventional culture was negative, revealing potential cases of low-bacterial-load infections causing culture-negativity. Transcriptome profiling exposed distinct immune activation patterns in FRI and enabled the detection of pathogens missed by conventional culture. These findings call for larger, prospective studies to further explore the clinical utility of transcriptomics in understanding and managing FRI.
Rapid and accurate pathogen detection is essential for effective management of periprosthetic joint infections (PJIs), yet conventional culturing (CC) often yields false-negative results and requires prolonged incubation times. In the present study we compared the performance of CC to that of two alternative approaches, i.e., culturing in synthetic synovial fluid (SSF2) and isothermal microcalorimetry (IMC).A total of 79 synovial fluid (SF) samples from patients with suspected PJI were included; for these samples, CC data were available. Samples were incubated in SSF2 (aerobically and anaerobically, for 10 d), and isolates were identified by matrix-assisted laser desorption/ionization mass spectrometry (MALDI-TOF MS). With IMC we determined the time to detect microbial activity in the samples (in two different media; brain heart infusion (BHI) broth and fluid thioglycolate medium (FTM)).Culturing in SSF2 yielded the highest positivity rate (53.2 %), followed by IMC and CC (34.2 % and 32.9 %, respectively). More than one-third of all positive samples were detected only after culturing in SSF2 (39.3 %), and this approach also revealed the greatest microbial diversity. IMC enabled rapid detection of microbial activity in a sample, with median detection times of 15.9 h in BHI and 15.6 h in FTM.Our results demonstrate that culturing of SF samples in SSF2 increased the diagnostic yield and that IMC reduced the time to identify clinical samples that contain viable microorganisms. This highlights the potential of these approaches; however further optimization is warranted to integrate them in diagnostic PJI workflows.
Background: Although malnutrition is globally associated with incremental morbidity, mortality, and cost, there has been a fundamental lack of consensus on diagnostic criteria for application in clinical settings. The study aims were (i) to identify the role of malnutrition as an independent risk factor for complications in the total joint arthroplasty (TJA) context; and (ii) to analyse the impact of malnutrition on treatment success, specifically in terms of patient-reported quality of life. Methods: The study retrospectively analysed 1070 patients undergoing total hip or knee arthroplasty between January 2019 and July 2022. Before the surgery, patients' nutritional status were assessed through Nutritional Risk Screening 2002 (NRS-2002) and controlling nutritional status (CONUT) scores. Patients were classified in two different groups: patients with NRS ≥ 3 were included in the Malnutrition group, and patients with NRS < 3 in the Control group. Results: A total number of 682 patients was included in the study. Mean age was 70.1 ± 9.6, 53 % women ratio, BMI 28.1 ± 4.8 kg m−2. A univariate regression, adjusted for age and sex, was performed. Both NRS-2002 and the CONUT score were significant risk factors in infectious complications and in EQ5 domains of quality-of-life assessment (p<0.05). Conclusions: Malnutrition, as identified by both the NRS-2002 and CONUT scores, emerges as an independent risk factor, contributing to worse post-operative outcomes and increased complications, thereby decreasing the potential benefits of TJAs. Pre-operative nutritional assessment and targeted intervention to address malnutrition can play a crucial role in improving clinical outcomes, quality of life, and complication rates.
Background: Septic arthritis (SA) and prosthetic joint infection (PJI) are severe musculoskeletal emergencies associated with rapid joint destruction, functional disability, and high mortality. Accurate microbiological diagnosis remains challenging, particularly in PJIs where biofilm formation reduces culture sensitivity. Local epidemiological data are essential to optimize empirical therapy and stewardship strategies. This study aimed to determine the distribution of microorganisms isolated from synovial fluid cultures and to evaluate antimicrobial resistance trends, with a direct comparison between native SA and PJI over a 5-year period. Methods: We retrospectively analyzed 3171 synovial fluid specimens collected between January 2020 and December 2024 at a tertiary referral hospital. Microorganisms were identified by MALDI-TOF MS, and antimicrobial susceptibility was tested with VITEK-2 according to EUCAST criteria. Resistance trends were assessed for major pathogens. Results: Overall, 651 samples (20.5 %) yielded growth, with significantly higher positivity in blood culture bottles than sterile containers (29.6 % vs. 16.1 %, p<0.001). PJIs accounted for 47.8 % of positive cultures. The most frequent pathogens were Staphylococcus aureusPseudomonas aeruginosap=0.017) and E. faecalisp=0.009) were significantly more common in PJIs. Methicillin resistance increased among S. aureus→ 30.8 %) and remained high among CoNS (51 %–85 %). Extended-spectrum β-lactamase (ESBL) prevalence rose in K. pneumoniae→ 42.1 %) and remained high in E. coliConclusions: Staphylococci remain the dominant pathogens in joint infections, with CoNS and E. faecalis
Introduction: This study evaluated early treatment outcomes and the management of complications in patients with periprosthetic joint infection (PJI) of the hip and knee treated at a specialized centre using an algorithm-guided multidisciplinary team (MDT) approach. Methods: This prospective cohort includes all consecutive patients treated for acute or chronic PJI between December 2019 and December 2022, with a minimum 1-year follow-up. PJI was defined according to the criteria of the European Bone and Joint Infection Society (EBJIS). Surgical decisions were based on a published treatment algorithm. The primary outcome was treatment success at 1 year after the last PJI surgery. Results: 106 patients were included according to prespecified criteria, with a median age of 74 years (IQR 66–82) and follow-up of 24 months (IQR 15–28). 79 patients (75 %) were referred from other institutions. 44 patients (42 %) were treated with debridement, antibiotics, and implant retention (DAIR); 17 (16 %) were treated with one-stage revision; and 45 (42 %) were treated with two-stage revision. 9 patients (8 %) needed plastic surgery for soft tissue reconstruction. The 1-year infection-free survival (Delphi-based consensus criteria) was 69 % (95 % CI: 60 %–78 %). Within 1 year, 14 (13.2 %) septic and 12 (11.3 %) aseptic failures occurred after a median of 0.5 months (IQR 0.4–1) and were successfully treated in most patients. 12 patients (11 %) died after a median of 0.8 months (IQR 0.3–2.8). Conclusion: Our results demonstrate the value of an algorithm-driven MDT approach as an effective strategy for managing complex PJI patients and PJI-surgery-related complications in a specialized referral centre for bone and joint infections.
Introduction: Pseudomonas aeruginosaP. aeruginosaMethods: We retrospectively analyzed culture-positive revision total hip and knee arthroplasties (rTHA and rTKA) from 2008 to 2023. Cases were evaluated according to the International Consensus Meeting (ICM) 2018 and European Bone and Joint Infection Society (EBJIS) criteria 2021. The success rate was calculated according to Tier classification. Results: Among 1640 revision procedures performed on 1286 patients, 195 revisions in 160 patients were positive for GN microorganisms, including 50 P. aeruginosaProteus mirabilisConclusion: In our patient cohort, Pseudomonas aeruginosaPseudomonas aeruginosa
Antibiotic therapy holds an integral role in the prevention and treatment of fracture-related infection (FRI). Because local concentrations after systemic administration are limited by the potential for side effects, the local application of antibiotics serves as a valuable adjunct. One concern with the local administration of high amounts of aminoglycosides and vancomycin is the absorption into the systemic circulation, leading to detrimental effects on renal function. In this study, serum antibiotic concentration and renal function were measured in patients treated for open fractures or FRI using local antibiotics at 6, 24 and 48 h postoperatively. Afterwards, laboratory analyses were continued daily until the concentration dropped beneath the lower limit of quantification (LLOQ) (0.22 mg L−1−1−1). The highest measured antibiotic level was 1.0 mg L−1, well below the generally accepted toxic trough level of 2.0 mg L−1. Although the total quantity of antibiotics delivered via beads was less than that provided by an antibiotic spacer, the use of beads more frequently yielded measurements exceeding the established threshold. None of the vancomycin measurements surpassed the LLOQ. The results of this study suggest that the current clinical use of locally applied antibiotics in orthopaedic trauma surgery is safe in the context of nephrotoxicity. The type of antibiotic carrier might affect local release and subsequent systemic absorption, which must be considered.
Introduction: We aimed to identify and explore the psychological and physical strains that caregivers of patients suffering from a periprosthetic joint infection (PJI) experience. Methods: Twenty-four qualitative semi-structured interviews with people giving care to patients suffering from a PJI were conducted by a single trained interviewer. The interviews were used to identify physical and emotional challenges that caregivers were confronted with. Results: The psychological and physical strains caregivers reported were wide-ranging and included suffering from stress and anxieties, and feelings of hopelessness and helplessness while having to function all the time to the point where, subjectively, caregivers felt as if they gave themselves up. Caregivers were suffering from mental and physical exhaustion as mainly family members and close ones provided the caregiving. Oftentimes an elaborate team effort approach was needed to lighten the caregiving burden. Conclusions: This study shows that caregivers are willing to go above and beyond for their loved ones, while exhausting and exceeding their individual resources. Caregivers of PJI patients deal with major issues. Specifically, we identified (1) conflicts regarding the hospital stay, (2) novel personal challenges, (3) nursing, (4) emotional and psychological consequences, and (5) effects on the relationship. Our research shows that there is a profound need for support during and after hospitalisation, and caring for a PJI patient seems surprisingly similar to caring for a cancer patient. We recommend including the caregivers of PJI patients, and how to better support them, into the PJI treatment guidelines.
Lyme periprosthetic joint infection (PJI) is rare, with only 8 cases reported in the literature. In this paper, we describe 2 cases and review the prior 8 cases to better characterize its diagnosis and management. All 10 cases presented with culture-negative PJI in Lyme-endemic regions and were confirmed to have Lyme PJI via a positive Borrelia-targeted polymerase chain reaction (PCR) run on joint specimens. Treatment strategies varied: 5 underwent debridement, antibiotics, and implant retention (DAIR); 1 had exchange arthroplasty; and 4 were managed non-operatively. Antimicrobial treatment also varied considerably. All patients achieved clinical cure. Lyme disease should be considered a potential cause of culture-negative PJI occurring in endemic regions. Because Borrelia-targeted PCR is not routinely included in standard PJI diagnostic workup, diagnosis may be delayed; therefore, clinicians should consider ordering this test when Lyme PJI is part of the differential.
Introduction: Biofilm formation is one of the key elements making orthopaedic device-related infections (ODRIs) difficult to eradicate. Aminoglycosides such as gentamicin are frequently applied via local carriers, and systemic rifampin is added for its anti-biofilm activity. However, robust in vitro evidence of their ability to eradicate mature biofilm is limited. This study assessed whether gentamicin, alone or in combination with rifampin, can eradicate established Staphylococcus aureusMethods: A clinical methicillin-susceptible S. aureus−1) for 28 d, (ii) intermittent 2 h exposures twice daily (at 15, 250 and 2000 mg L−1) for 28 d to reflect systemic twice-daily dosing and (iii) a 14 d burst release starting at 2000 mg L−1−1, approximating peri-implant concentrations from preclinical pharmacokinetic studies. Biofilm viability was quantified as colony-forming units (CFUs) from sonicated pegs, and selected surviving isolates underwent susceptibility testing. Results: Across all regimens, concentration- and time-dependent decreases in CFU counts were observed, but no regimen resulted in bacterial counts falling below the lower limit of detection (LLOD). The addition of rifampin did not result in the sustained enhancement of biofilm killing, and, in some regimens, resulted in higher CFU counts. Isolates recovered from culture-positive pegs remained largely susceptible to gentamicin, whereas rifampin resistance arose sporadically. Conclusion: High-dose gentamicin exposures failed to eradicate 5 d old S. aureus
Data on the implementation of international consensus guidelines for fracture-related infection (FRI) in low- and middle-income countries (LMICs) are scarce. This study assessed whether FRI diagnosis and management in an LMIC align with these recommendations. Methods:Results:± 15.4 years; 72.7 % male). In 34.3 % of cases, FRI occurred without prior surgery, limiting applicability of the Willenegger and Roth classification. Clinical confirmatory criteria were present in 97 % of cases. Microbiological standards were seldom achieved: none fulfilled sampling quantity, and only 46.6 % met sampling method recommendations. A microbiological confirmatory criterion was documented in 36 patients (21.3 %); histopathology was rarely performed (1.2 %), and nuclear imaging was not used. Most patients (81.1 %) were on antibiotics before admission or surgery. The most common treatment strategies were suppressive antibiotic therapy (44.4 %); one-stage (11.2 %) or two-stage (10.7 %) debridement, antibiotics, and implant exchange (DAIEX); and debridement, antibiotics, and implant retention (DAIR; 9.5 %). Overall, 62.7 % of treatments deviated from consensus guidelines. Conclusion:
Introduction: Periprosthetic joint infection (PJI) after hip revision surgery shows variable failure rates, with the impact of osteomyelitis in the surrounding bone on outcomes remaining unclear. This study aims to examine bone osteomyelitis prevalence and its impact on hip PJI revision outcomes. Material and methods: This retrospective study reviewed 75 cases of chronic hip PJI patients undergoing hip revisions performed at a single center between January 2019 and June 2023. Only cases with peri-implant bone samples submitted for histology evaluation were included. Bone samples were assessed for osteomyelitis using histological criteria. Risk factors, including demographic data, preoperative infections, and previous revisions, were analyzed. Statistical significance was determined using Chi-square and Kaplan–Meier survival analysis (p≤0.05). Results: A total of 52 cases of chronic hip PJI were included for final analysis. Up to 30.8 % of the cases (n=16) presented histological signs of osteomyelitis. The success rate among those 36 cases where no signs of osteomyelitis were observed was 88.9 %, whereas, in the 16 cases where it was present, the rate dropped to 37.5 %. Histological signs of osteomyelitis were significantly associated with a prior history of multiple surgeries and unsuccessful antibiotic treatments (p=0.01), the presence of a sinus tract (p=0.01), and the need for additional debridement with spacer exchange after the first stage of a two-stage revision (p=0.001). Conclusion: Patients with signs of osteomyelitis demonstrated a higher failure rate. Histological evaluation of periprosthetic bone should ideally be performed during the first stage of revision surgery to guide second-stage management and to improve outcomes.
Introduction: Fungal periprosthetic joint infection (PJI) has historically been reported in 1 %–2 % of cases, with CandidaCandida-associated PJI. Methods: Following a systematic literature search, we performed a quantitative sensitivity analysis using imputation with informative missingness odds ratios (IMORs). Reported CandidaResults: 23 studies met inclusion criteria, reporting a total of 28 253 PJI patients, of whom 590 had CandidaCandidaCandidaConclusion: The involvement of CandidaCandidaLevel of Evidence: Level III.
Synovial fluid specific gravity (SG) was evaluated as a rapid, inexpensive test for periprosthetic joint infection (PJI) diagnosis in revision arthroplasties. High diagnostic accuracy (area under the curve 0.89; threshold 1.007) with high specificity (100 %) and moderate sensitivity (65 %) was found, supporting its use as an adjunctive point-of-care (POC) tool for PJI.