Journal of Bone and Joint Infection最新文献

Background: Periprosthetic joint infections (PJIs) are a devastating complication following oncologic endoprosthetic reconstruction (EPR). Despite significant efforts to characterize the microbiologic profile of PJI in traditional joint arthroplasty, data are lacking in orthopedic oncology. Our study analyzed the causative microorganisms and time to positivity (TTP) of PJI in oncologic EPR and conventional joint arthroplasty (C-TJA). Methods: We retrospectively compared sample cultures for lower-extremity oncologic EPR and C-TJA patients diagnosed with PJI between 2000 and 2022. All positive microorganisms were assessed, along with clinical and culture method data. Comparisons utilized the Mann-Whitney $U$  test. Results: We included 70 oncologic EPR and 153 C-TJA patients diagnosed with PJIs. Staphylococcus epidermidis (16.8 % vs. 10.6 %, $p=0.01$ ), Enterococcus spp. (12.6 % vs. 4 %, $p<0.001$ ), and Peptostreptococcus spp. (5.3 % vs. 1.3 %, $p<0.001$ ) were common and more frequently isolated in oncologic EPR than C-TJA PJI. Conversely, Staphylococcus aureus predominated in samples from C-TJA patients (31.7 % vs. 15.1 %, $p<0.001$ ). Differences in endoprosthetic microorganism prevalence were observed between primary versus metastatic bone disease and bone versus soft tissue sarcoma. TTP was highly variable among microorganisms and was significantly faster ( $p<0.05$ ) for bone and soft tissue vs. synovial fluid (3 d vs. 4 d) and for broth and solid media vs. broth only (2.5 d vs. 4.5 d). Conclusion: The microorganism profile in oncologic EPR PJI was distinct from C-TJA PJI. The oncologic EPR population highlighted variability in the prevalence of Gram-negative rods and slower TTP for broth-only cultures. Further investigation of the mechanisms behind these differences will allow care teams to provide prompt, individualized, and targeted antimicrobial therapy.

Background: Prosthetic joint infection (PJI) is an uncommon but serious complication of joint arthroplasty, associated with significant morbidity and healthcare costs. Anaerobic organisms are an under-recognized cause of PJI, either as sole pathogens or within polymicrobial infections, and data on their clinical impact are limited. This study compared clinical presentation and outcomes of anaerobic vs. aerobic PJIs. Methods: This is a retrospective review of 284 patients who met Musculoskeletal Infection Society (MSIS) criteria for PJI from 2014 to 2020 at the University of Iowa Hospitals and Clinics (UIHC). A total of 38 had anaerobic PJI; 268 had aerobic PJI. Statistical analyses were performed using Pearson's ${\chi }^2$ , a Fisher exact test, and a $t$ test. Results: Anaerobic PJIs represented 13.4 % of PJIs in our institution. Compared to aerobic cases, anaerobic PJIs had longer symptom duration (19.4 vs. 10.9 weeks, $p=0.005$ ), more sinus tracts (23.7 % vs. 6.1 %, $p<0.001$ ), fewer fevers (13.2 % vs. 31.3 %, $p=0.022$ ), more radiographic abnormalities (44.7 % vs. 29.3 %, $p=0.024$ ), and lower ESR and CRP (ESR: 49.0 vs. 67.4 mm h^-1; CRP: 6.6 vs. 12.3 mg dL^-1; both $p=0.003$ ). Shoulder PJIs were more often anaerobic (39.5 % vs. 4.9 %, $p<0.001$ ). Anaerobic PJIs were more likely to be treated with two-stage exchange (65.8 %), while aerobic cases more often underwent debridement and implant retention (44.7 %). Recurrence rates were similar. Conclusion: Anaerobic PJIs tend to present with features such as shoulder involvement, prolonged or chronic symptoms, sinus tract formation, and radiographic signs of infection, whereas aerobic PJIs are more commonly linked to acute presentations. For this reason, both aerobic and anaerobic cultures should be performed routinely to optimize diagnostic yield.

The absence of a standardized definition for postoperative spinal infections (PSIs) hinders both diagnosis and research. Using a meta-epidemiological approach, we analyzed 101 studies, with most relying on predefined criteria but with a minority creating their own definition (mainly clinical). Establishing a universal definition is crucial to enhancing PSI management and facilitating research.

Awaiting final microbiology results can delay discharge in musculoskeletal (MSK) infections. We developed a novel process based on electronic medical records reviewing post-discharge results. Among 1662 encounters, 35.6 % had $\ge$ 1 intervention, often therapy modification. Multidisciplinary review by an orthopaedic infectious diseases team improved antimicrobial optimization through timely action on culture results after discharge.

Aim: The aim of this study was to investigate the diagnostic performance of a novel rapid multiplex polymerase chain reaction (mPCR) in adults with suspected acute native joint infection. Methods: This retrospective single-centre study included 143 patients with suspected acute native joint infection from February 2023 to May 2024. A septic arthritis was classified based on institutional criteria. The agreement between mPCR and conventional culture of synovial fluid (SF) was assessed by calculating the Cohen's $\kappa$ coefficient. The diagnostic performance of mPCR was calculated, and the area under the curve (AUC) was compared with conventional culture of synovial fluid by using the $z$ test. Results: When considering only microorganisms targeted by mPCR, this method detected 13 novel microorganisms in 13 cases compared to conventional culture, resulting in an overall agreement of 91 %, a positive agreement of 100 %, a negative agreement of 88 %, and a Cohen's $\kappa$  coefficient of 0.780. Of these 13 cases, 9 were classified as septic, with 6 ( $n=6/9$ , 67 %) on antibiotics prior to aspiration. When considering all microorganisms (including off-panel microorganisms), the overall percentage agreement between mPCR and conventional culture was 89 %, with a Cohen's $\kappa$  coefficient of 0.735, indicating substantial agreement. Sensitivity, specificity, PPV, NPV, LR $+$ , LR $-$ , accuracy, and AUC of mPCR were 45 %, 89 %, 90 %, 44 %, 4.21, 0.62, 59 %, and 0.671, and those of conventional culture were 40 %, 100 %, 100 %, 45 %, 0.60, 59 %, and 0.698. No difference in performance was observed between both methods ( $p=0.183$ ). The combination of both techniques showed a sensitivity, specificity, PPV, NPV, LR $+$ , LR $-$ , accuracy, and AUC of 48 %, 89 %, 90 %, 46 %, 4.5, 0.58, 62 %, and 0.686. Conclusion: Given its comparable diagnostic performance and faster turnaround time relative to conventional synovial fluid culture, this novel mPCR can be recommended as a valuable adjunct in the diagnosis of septic arthritis in adults, particularly in patients with prior antimicrobial treatment.

Background: Native vertebral osteomyelitis and infective endocarditis (NVO $+$ IE) are increasingly recognized as overlapping entities, sharing common risk factors (e.g., advanced age, immunosuppression) and similar pathogen profiles, most commonly Staphylococcus aureus and streptococci. Concurrent infection presents unique diagnostic and therapeutic challenges, leading to uncertainty regarding clinical outcomes and mortality. Therefore, we aimed to systematically evaluate the combined mortality associated with concomitant NVO $+$ IE and to summarize the available clinical characteristics from published studies. Methods: A systematic review was conducted following the PRISMA framework. The databases searched included MEDLINE, Embase, Cochrane Library, and Scopus from 1970 to October 2023. Studies were included if they involved at least 10 adult patients diagnosed with NVO and IE and provided mortality data. Two reviewers independently screened the references, extracted the data, and evaluated the methodological quality using a dedicated tool. A random-effects meta-analysis was performed to aggregate in-hospital, 1-month, 1-year, and 3-year mortality rates. Results: A total of 16 studies (12 retrospective, 3 prospective, 1 mixed) were included, involving 641 patients (mean age 67.1 years) with NVO $+$ IE. In-hospital mortality was 14.0 % (95 % CI: 10.0 %-20.0 %). At 1 month, mortality was 9.0 % (95 % CI: 5.0 %-17.0 %), rising to 18.0 % (95 % CI: 13.0 %-24.0 %) by 1 year and 16.0 % (95 % CI: 3.0 %-50.0 %) by 3 years. Significant between-study heterogeneity was observed ( $I^2$  range: 3 %-70 %). Common co-morbidities included diabetes mellitus (23.7 %), chronic renal failure (15.0 %), and immunosuppression (15.0 %). Streptococci (31.5 %), S. aureus (25.2 %), and enterococci (17.7 %) were the primary pathogens. Cardiac valve surgery and spinal surgery were reported in 47.5 % and 29.9 % of patients, respectively. A subgroup analysis on 1-month mortality showed that S. aureus predominance was associated with a significantly higher mortality compared to streptococci. Certainty in the estimates was low due to imprecision and methodological limitations. Conclusions: Concomitant NVO $+$ IE is associated with substantial mortality, especially for S. aureus, underscoring the need for earlier diagnosis, coordinated multidisciplinary management, and standardized treatment protocols. Future prospective, high-quality studies are needed to clarify optimal strategies for diagnostic workup and surgical intervention for this complex clinical scenario.

The main complications after complex talar fractures, especially with respect to open injuries, are avascular necrosis (AVN) and fracture-related infection (FRI) Their treatment is a source of discussion, and reconstruction options are scarce. A descriptive longitudinal study of three cases with a two-stage tibiocalcaneal (TC) arthrodesis (talectomy followed by a retrograde nailing and two tantalum spacers) is presented. Information on infection relapse and fusion of the arthrodesis was collected, along with demographic, radiological, and functional variables (such as Manchester-Oxford Foot Questionnaire, MOXFQ, values; EuroQol index values; and visual analogue scale for pain, VAS-pain, values) After a minimum of 3 years, no infection relapse or pseudoarthrosis was observed. Leg alignment was comparable to the contralateral side. Functional and pain tests showed optimal values: MOXFQ index of 16.6, mean EuroQol index of 0.782, and mean VAS-pain of 19. For a salvage procedure in FRI $+$ AVN of the talus, this two-stage TC arthrodesis is a safe procedure in terms of infection and provides good functional outcomes.

Background: The preferred imaging modality in diabetes-related foot osteomyelitis is magnetic resonance imaging; however the test characteristics of magnetic resonance imaging have not been well evaluated in histologically confirmed disease. Although there is reasonably strong evidence of the effectiveness of medical therapy in the treatment of diabetes-related foot osteomyelitis, there is limited evidence in histologically confirmed cases. Methods: A retrospective review of episodes in which diabetes-related foot osteomyelitis was suspected was performed among patients who had both magnetic resonance imaging and bone histology. Magnetic resonance images were reviewed by a musculoskeletal trained radiologist using guideline criteria. Cases were subsequently followed for need for amputation at 1 year. Results: Among 84 episodes, the sensitivity of magnetic resonance imaging in histologically confirmed diabetes-related foot osteomyelitis was 96 %, specificity 38.2 %, positive predictive value 69.6 %, negative predictive value 86.7 %, positive likelihood ratio 1.15, and negative likelihood ratio 0.1. Of 15 cases in which the histology specimen revealed osteomyelitis from a diagnostic biopsy, 10 responded to medical management without the need for an amputation. Conclusions: Magnetic resonance imaging is useful excluding diabetes-related foot osteomyelitis but is of limited diagnostic value in confirming its presence. Most cases of histologically confirmed diabetes-related foot osteomyelitis responded to medical management without the need for amputation.

Introduction: Debridement, antibiotics, and implant retention (DAIR) is recommended for early acute postoperative and late acute periprosthetic joint infections (PJIs). The KLIC and CRIME-80 scores have been proposed to predict DAIR outcomes. Nevertheless, their clinical utility remains uncertain. This study aimed to evaluate their predictive value for DAIR failure in our cohort, both at primary indication and when repeat DAIR was considered necessary. Methods: We retrospectively reviewed all patients who underwent DAIR for total hip or knee PJI between 2010 and 2021, with at least 1 year of follow-up. Failure was defined as persistent infection, need for implant removal, amputation, or infection-related death. Results: A total of 102 patients were included, with a mean follow-up of 48.9 months. The overall failure rate was 35.3 %. Failure rates did not differ significantly between patients who underwent a single DAIR and those who required repeat procedures (32.5 % vs. 45.5 %, $p=$  0.26). No significant correlations were found between KLIC or CRIME-80 scores and failure rates, either at the initial indication for DAIR ( $p=$  0.54 and $p=$  0.93, respectively) or in repeat DAIR procedures ( $p=$  0.44 and $p=$  0.50, respectively). Conclusions: In our cohort, the KLIC and CRIME-80 scores were not predictive of DAIR failure, either at initial treatment or when repeat DAIR was required. These scores offered limited prognostic value and did not support clinical decision-making. Prospective studies are needed to validate and improve predictive tools for DAIR outcomes.

In 2023, members of the Musculoskeletal Infection Society (MSIS) and the European Bone and Joint Infection Society (EBJIS) participated in a survey assessing their approaches to prevention, diagnosis, and management of orthopedic infections. The survey revealed notable differences between the two societies in several key areas, including requirements for smoking cessation prior to elective surgery, use of pre-operative skin and nasal antiseptics, application of local antibiotics in non-infected cases, preferred definitions of periprosthetic joint infection (PJI), use of alpha-defensin testing in pre-operative diagnosis, application of sonication of explanted implants, number of tissue samples obtained for microbiological and histological analysis, use of sequence-based diagnostics, and duration of antibiotic therapy. These findings demonstrate substantial variability in clinical practice among international experts in the field, highlighting the need for further research and consensus to harmonize strategies in orthopedic infection care.