Journal of Bone and Joint Infection最新文献

Introduction: Debridement, antibiotics and implant retention (DAIR) procedures are effective treatments for acute postoperative or acute hematogenous periprosthetic joint infections. However, literature reporting on the effectiveness of DAIR procedures performed after a one- or two-stage revision because of a prosthetic joint infection (PJI) (PJI-related revision arthroplasty) is scarce. The aim of this study is to retrospectively evaluate the infection control after 1 year of a DAIR procedure in the case of an early postoperative infection either after primary arthroplasty or after PJI-related revision arthroplasty. Materials and methods: All patients treated with a DAIR procedure within 3 months after onset of PJI between 2009 and 2017 were retrospectively included. Data were collected on patient and infection characteristics. All infections were confirmed by applying the Musculoskeletal Infection Society (MSIS) 2014 criteria. The primary outcome was successful control of infection at 1 year after a DAIR procedure, which was defined as the absence of clinical signs, such as pain, swelling, and erythema; radiological signs, such as protheses loosening; or laboratory signs, such as C-reactive protein (CRP) ( $<10$ ) with no use of antibiotic therapy. Results: Sixty-seven patients were treated with a DAIR procedure (41 hips and 26 knees). Successful infection control rates of a DAIR procedure after primary arthroplasty ( $n=51$ ) and after prior PJI-related revision arthroplasty ( $n=16$ ) were 69 % and 56 %, respectively ( $p=0.38$ ). The successful infection control rates of a DAIR procedure after an early acute infection ( $n=35$ ) and after a hematogenous infection ( $n=16$ ) following primary arthroplasty were both 69 % ( $p=1.00$ ). Conclusion: In this limited study population, no statistically significant difference is found in infection control after 1 year between DAIR procedures after primary arthroplasty and PJI-related revision arthroplasty.

Introduction: The goals of osteomyelitis therapy are successful control of infection and reconstruction of the bone. The gold standard for filling defects is the autologous bone graft. Bioactive glass S53P4 is an inorganic bone substitute. We compared the outcome of using bioactive glass (BAG) versus autologous bone graft (AB) in patients with infected non-union. Methods: Patients with chronic osteomyelitis and infected non-union who received either bioactive glass or autologous bone grafts between 2013 and 2017 were analyzed retrospectively. The primary endpoint was successful control of infection during follow-up. Secondary endpoints were bone healing, functional outcome, and occurrence of complications. Results: Eighty-three patients were analyzed (BAG $n=51$ , AB $n=32$ ). Twenty-one patients experienced reinfection (BAG $n=15$ , 29 %; AB $n=6$ , 19 %). Seventy-eight patients achieved full weight bearing (BAG $n=47$ , 92 %; AB $n=31$ , 97 %). Sixty-four patients had complete bone healing at the end of the follow-up period (BAG $n=39$ , 77 %; AB $n=25$ , 78 %). There were no significant differences between the groups with respect to the primary or secondary endpoints. Patients with multidrug-resistant pathogens had a significantly higher rate of incomplete bone healing ( $p=0$ .033) and a 3-fold higher risk of complications in both groups. Conclusions: Bioactive glass appears to be a suitable bone substitute not only for successful control of infection and defect filling but also for bone healing in cases of infected non-union. In our study, bioactive glass was neither superior nor inferior to autologous bone graft with regard to the primary and secondary endpoints. Further studies with larger numbers of patients are required.

Introduction: The gastrocnemius myofascial flap is used to manage soft-tissue defects over the anterior aspect of the knee in the context of a patient presenting with a sinus and periprosthetic joint infection (PJI) or extensor mechanism failure. The aim of this study was twofold: firstly, to evaluate the outcomes of gastrocnemius flaps performed by appropriately trained orthopaedic surgeons in the context of PJI and, secondly, to evaluate the infection-free survival of this patient group. Patients and methods: We retrospectively reviewed 30 patients who underwent gastrocnemius flap reconstruction during staged revision total knee arthroplasty for prosthetic joint infection (PJI). All flaps were performed by an orthopaedic surgeon with orthoplastics training. Patients had a mean age of 68.9 years (range 50-84) and were followed up for a mean of 50.4 months (range 2-128 months). A total of 29 patients (97 %) were categorized into Musculoskeletal Infection Society (MSIS) local extremity grade 3 (greater than two compromising factors), and 52 % of PJIs were polymicrobial. The primary outcome measure was flap failure, and the secondary outcome measure was recurrent infection. Results: Flap survival was 100 % with no failures or early returns to theatre for flap problems such as necrosis or haematoma. Overall infection-free survival during the study period was 48 % (13 of 27 infected cases). Using limb salvage as the outcome, 77 % (23 of 30 patients) retained the limb. Infection recurrence occurred in 48 % (10 patients) in the type B3 cohort and 67 % (4 patients) in the type C3 cohort ( $p=0.65$ ). Conclusions: The surgical technique for a gastrocnemius myofascial flap is reliable and reproducible when performed by appropriately trained orthopaedic surgeons, even in high-risk groups. However, the risks of recurrent infection and amputation remain high within our series due to poor host and extremity factors.

Chronic bone infections often present with complex bone and soft tissue loss. Management is difficult and commonly delivered in multiple stages over many months. This study investigated the feasibility and clinical outcomes of reconstruction in one stage. Fifty-seven consecutive patients with chronic osteomyelitis ( $n=27$ ) or infected non-union ( $n=30$ ) were treated with simultaneous debridement, Ilizarov method and free muscle flap transfer. 41 patients (71.9 %) had systemic co-morbidities (Cierny-Mader group Bs hosts). Infection was confirmed with strict criteria. 48 patients (84.2 %) had segmental defects. The primary outcome was eradication of infection at final follow-up. Secondary outcomes included bone union, flap survival and complications or re-operation related to the reconstruction. Infection was eradicated in $55/57$ cases (96.5 %) at a mean follow-up of 36 months (range 12-146). No flap failures occurred during distraction but 6 required early anastomotic revision and 3 were not salvageable (flap failure rate 5.3 %). Bony union was achieved in $52/57$ (91.2 %) with the initial surgery alone. After treatment of the five un-united docking sites, all cases achieved bony union at final follow-up. Simultaneous reconstruction with Ilizarov method and free tissue transfer is safe but requires careful planning and logistic considerations. The outcomes from this study are equivalent or better than those reported after staged surgery.

Introduction: Guidelines and consensus statements do not support routine preoperative testing for asymptomatic bacteriuria (ASB) prior to elective arthroplasty. Despite this, urine testing remains commonplace in orthopaedic practice. This mixed methods stepwise quality improvement project aimed to develop and implement a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty within a single centre. Methods: Step 1 - description of current practice in preoperative urine testing prior to arthroplasty within a single centre; Step 2 - examination of the association between preoperative urine culture and pathogens causing prosthetic joint infection (PJI); Step 3 - co-design of a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty; Step 4 - implementation of a sustainable guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty. Results: Retrospective chart review showed inconsistency in mid-stream urine (MSU) testing prior to elective arthroplasty (49 % preoperative MSU sent) and in antimicrobial prescribing for urinary tract infection (UTI) and ASB. No association was observed between organisms isolated from urine and joint aspirate in confirmed cases of PJI. Co-design of a guideline and decision support tool supported through an implementation strategy resulted in rapid uptake and adherence. Sustainability was demonstrated at 6 months. Conclusion: In this stepwise study, implementation science methodology was used to challenge outdated clinical practice, achieving a sustained reduction in unnecessary preoperative urine testing for ASB prior to elective arthroplasty.

We report on a patient with septic arthritis of the knee with Pantoea agglomerans after a penetrating black locust thorn injury. Antibiotics alone or in combination with an arthroscopy may be insufficient for achieving source control. Accurate medical history and open debridement with a search for a thorn fragment are key to successful treatment.

We present the first reported case of prosthetic joint infection caused by Trueperella pyogenes. This animal pathogen rarely causes human infection. Our patient was successfully treated with single-stage exchange and 12 weeks of rifampicin and moxifloxacin.

The benefit of suppressive antibiotic treatment in inoperable patients with a chronic periprosthetic joint infection and a sinus tract is unknown. Some physicians prefer to just let the sinus drain, while others prefer antibiotic treatment. In this viewpoint article we discuss the advantages and disadvantages of suppressive antibiotic treatment in this particular patient group.

Actinomyces viscosus is an oral bacterium that is rarely virulent in humans, with most case presentations involving dental and maxillofacial infections. We describe the first reported case of A. viscosus vertebral osteomyelitis in a patient who had a significant response to penicillin after minimal response to cephalosporin therapy.

Neisseria meningitidis is a rare cause of prosthetic joint infection (PJI), with only three cases previously reported. Here we report three further cases, all of which were successfully treated with implant retention and short-course antibiotics ( $<6$  weeks).