Journal of Bone and Joint Infection最新文献

Introduction: With the increasing number of primary total hip arthroplasties (THAs), the incidence of associated complications has risen, with periprosthetic joint infection (PJI) being among the most severe. The influence of surgical approach on infection risk remains debated; however, its effect on the microbiological profile of PJIs is not well examined. This study aimed to evaluate whether the primary surgical approach affects the spectrum of microorganisms involved in acute postoperative periprosthetic hip joint infections in a retrospective single-center cohort. Methods: A total of 76 patients who underwent revision surgery for PJI following THA between January 2013 and June 2024 were retrospectively reviewed. After applying exclusion criteria, patients were categorized based on the initial surgical approach: lateral vs. direct anterior/anterolateral. The microbiological spectrum was compared between groups using Fisher's exact test. Demographic characteristics and their associations with surgical approach and pathogen type were also analyzed. Results: No significant differences were found in the microbiological spectrum between surgical approaches. Similarly, there was no significant correlation between surgical approach and the occurrence of Gram-positive or Gram-negative organisms. Body mass index (BMI) was not associated with variations in pathogen distribution, suggesting that obesity does not influence the microbiological profile of PJI. Discussion: These findings suggest that the microbiological characteristics of acute postoperative PJI are independent of the primary surgical approach. Minimally invasive anterior techniques do not appear to carry an increased microbiological risk. Additionally, BMI does not influence the microbial spectrum of infection. Level of evidence: this is a retrospectively registered cohort study with a Level III level of evidence.

Introduction: Chronic osteomyelitis (COM) is a serious musculoskeletal infection that affects a patient's quality of life and long-term survival. In this study, we assessed overall, regional, and patient-level characteristics of bacterial COM in a large, multicenter database in the United States. Methods: We used ICD-10 codes to identify incident bacterial COM in the TriNetX database between 1 January 2016 and 31 December 2022. We calculated COM incidence per 1000 adult patients with the associated 95 % confidence intervals. We used the Cochran-Armitage test to assess incidence trends across the study period. Results: A total of 93 324 adult patients were identified. Overall, a steady COM incidence was observed over time, with some indication of lower rates starting in 2020. The incidence was about 2-fold higher in males than females. As expected, lower-extremity COM was most common overall and among males. Although lower-extremity COM and vertebral COM had comparable incidence among females, vertebral COM became slightly more common than lower-extremity COM among females during the study period. Conclusions: To our knowledge, this study provides the largest available, multicenter estimate of COM incidence in the United States. Although the incidence of COM was generally steady over time, a slight reduction was noted during the pandemic (2020 and later). This finding may reflect important differences in ascertainment or competing risks during that period.

Aim: As part of a multi-society effort to derive a unified consensus definition of periprosthetic joint infection (PJI), a systematic review of serum inflammatory marker diagnostic performance for hip, knee, and shoulder PJI was performed. Methods: PubMed (MEDLINE) and EMBASE were searched for studies reporting the diagnostic performance of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC), fibrinogen, interleukin-6 (IL-6), or D-dimer for PJI. From these, each markers' pooled sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and area under the summary receiver operating characteristic curve (AUSROC) were calculated using a random-effects model. Results: A total of 89 studies reported all diagnostic performance measures for at least one marker. CRP (84 studies, 22 351 patients) demonstrated a pooled sensitivity, specificity, PPV, NPV, and AUSROC of 79.4 % (95 %CI: 78.5-80.3), 77.7 % (77.1-78.3), 67.0 % (63.3-70.7), 86.6 % (84.5-88.7), and 0.872 (SE 0.01), respectively. Corresponding performance estimates for fibrinogen (14 studies, 3433 patients) were 70.9 % (68.3-73.3), 85.9 % (84.3-87.3), 77.2 % (71.8-82.6), 82.1 % (77.1-87.2), and 0.889 (0.02), respectively, and those for IL-6 (20 studies, 2318 patients) were 76.3 % (73.4-79.0), 85.8 % (83.8-87.6), 74.5 % (69.0-80.0), 86.0 % (80.6-91.3), and 0.900 (0.01), respectively. ESR, D-dimer, and WBC did not offer greater predictive values than these markers. Conclusion: Although serum CRP, fibrinogen, and IL-6 demonstrated the best performance among all analysed parameters, their diagnostic accuracy remains insufficient to reliably confirm or exclude PJI. Elevated serum markers should be re-evaluated as a diagnostic criterion in future PJI definitions. Level of evidence: The level of evidence was Level III.

Background: This systematic review aimed to evaluate the current evidence regarding the clinical outcome of single- and two-stage revision procedures for long-bone fracture-related infection (FRI). The review focused on unhealed fractures without critical-sized bone defects, treated with internal fixation. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. A systematic search was carried out in PubMed, Embase via Elsevier, and Web of Science Core collection. Results: Out of 21 126 articles initially identified, 35 studies, including 985 patients, were eligible for the final analysis. A total of 27 studies assessed single-stage revisions, 5 examined two-stage procedures, and 3 included both approaches. The mean bone-healing rate was 80 % for single-stage approaches and 77 % for two-stage approaches. The mean infection eradication rate for single-stage revisions was 87 %, whereas two-stage revisions demonstrated a mean infection eradication rate of 81 %. Only five studies included patients ( $n=$ 34) diagnosed with an FRI within 6 months after the primary fracture fixation. Conclusion: For patients with unhealed long-bone FRIs without critical-sized bone defects, the current literature is of poor quality, heterogeneous, and lacks strong evidence to recommend either a single-stage or two-stage approach with internal fixation. For both protocols, the rate of revision surgery remains high. Furthermore, high-quality studies focusing on two-stage procedures, especially for the treatment of FRIs occurring within 6 months after initial fracture fixation, are almost non-existent. The identification of positive cultures during single-stage procedures for presumed aseptic fracture non-unions might be linked to poorer clinical outcomes.

Periprosthetic joint infection (PJI) after tumor resection and megaprosthetic reconstruction of bone defects is a common complication. The purpose of this study was to evaluate the prevalence of these infections, assess their microbiological profile, and identify perioperative risk factors for these complications. A single-center retrospective cohort study was conducted including 273 patients, who had undergone musculoskeletal tumor resection and megaprosthetic reconstruction. The medical records of these patients were screened for several parameters, including development of postoperative PJI. All reviewed parameters were compared between patients who developed infections and those who did not. Infection developed in 36 patients, indicating an incidence of 13.2 % (95 % confidence interval (CI): 9.4 %-17.8 %). The most common isolated pathogens in patients with PJI included coagulase-negative staphylococci ( $n=20$ ; 56 %), followed by Staphylococcus aureus ( $n=9$ ; 25 %). Multivariable logistic regression analysis indicated that development of PJI was associated with diabetes (odds ratio (OR): 7.64; 95 % confidence interval (CI): 1.36-42.7; $p=0.020$ ), a lower albumin level (OR: 0.10; 95 % CI: 0.02-0.49; $p=0.005$ ), and a prolonged duration of surgery (OR: 4.30; 95 % CI: 1.08-17.1; $p=0.038$ ). Our results indicate that certain parameters such as diabetes, low albumin levels, and prolonged duration of surgery are associated with a higher risk of infection.

Objectives: The novel local antibiotic-eluting depot technology CarboCell G/C has shown great promise in terms of efficacy in an osteomyelitis pig model. The present study aimed to investigate the initial release kinetics of gentamicin and clindamycin from CarboCell G/C in trabecular bone after a thin-needle intraosseous injection. Methods: In the tibial metaphysis of four pigs (both hind legs, $n=8$ ), microdialysis catheters were placed 5 and 10 mm from an intraosseous injected CarboCell G/C depot of 1.5 mL comprising gentamicin (25 mg) and clindamycin (95 mg). Sampling was performed for 12 consecutive hours to evaluate gentamicin and clindamycin concentrations in trabecular bone and subcutaneous tissue adjacent to the knee joint. Plasma samples were taken to determine systemic spillover. Results: Across trabecular bone locations, the mean peak drug concentrations ranged from 471-524 $\mu$ g mL^-1 for gentamicin and from 681-788 $\mu$ g mL^-1 for clindamycin. The mean concentrations at 12 h ranged from 126-321 $\mu$ g mL^-1 for gentamicin and from 255-594 $\mu$ g mL^-1 for clindamycin. Low concentrations of both drugs were found in subcutaneous tissue adjacent to the knee joint ( $<1$ $\mu$ g mL^-1) and plasma ( $<0.2$ $\mu$ g mL^-1). Conclusions: CarboCell G/C can maintain high local concentrations of gentamicin and clindamycin for at least 12 h after intraosseous injection with negligible systemic spillover. The data bolster the potential benefit of improved local antibiotic delivery systems with flexible administration in target tissues for future therapeutic strategies addressing orthopaedic infections.

Fracture-related infections (FRIs) and periprosthetic joint infections (PJIs) occur in nearly 2 % of patients with orthopaedic devices, contributing to significant morbidity and mortality. Effective microbiological diagnosis of these infections remains challenging, with the homogenisation of bone/tissue biopsies recognised as the most reliable pre-analytical procedure. This prospective study compared the inoculation of homogenised samples into a BacT/ALERT ^® VIRTUO ^® system using FA and FN PLUS blood culture bottles (BCBs) with inoculation into conventional Wilkins-Chalgren broth. Bone and tissue samples collected during surgery for suspected or confirmed FRIs or PJIs were homogenised with saline and glass beads. The resulting suspension was inoculated into BCBs (14 d incubation) or into Wilkins-Chalgren broth (10 d incubation). Among the 59 patients included, cultures remained negative in 19 cases, whereas both methods successfully identified all pathogens in 28 patients. Although sensitivity was similar between the two methods (85 % for BCB vs. 80 % for the conventional method; $p=0.77$ ), the BCB method demonstrated significantly higher specificity (93 % vs. 56 %; $p=0.0001$ ). The BCB method yielded much faster results, with 80 % of cultures turning positive within the first 2 d of incubation (median of 24.5 h). In contrast only 16 % of cultures processed with the conventional method were positive within the same time frame (median of 69.0 h; $p=0.03$ ). For Cutibacterium acnes, a minimum incubation period of 14 d was necessary with the BCB method to ensure accurate detection. This prospective study demonstrated an enhanced method for culturing bone and tissue biopsies from patients with FRIs or PJIs using the BacT/ALERT ^® VIRTUO ^® system, resulting in improved specificity and the significantly faster detection of pathogenic microorganisms.

This communication updates a previous report describing mixing formulas for antimicrobial agents into a synthetic, dissolvable calcium sulfate (CaSO₄) product to create small-sized beads (3-6 mm). Antimicrobial-loaded calcium sulfate (ALCS) beads are applied as surgeon-directed, point-of-care use in cases of periprosthetic joint infection (PJI), fracture-related infection (FRI), and other related bone site infections. This treatment technique has been utilized more frequently in the last decade to combat microbial musculoskeletal infections (MSIs). With the widening spectrum of identified microbes encountered in MSIs, we have provided additional antimicrobial formulas to be used singularly and in combination using our in vitro mixing lab protocol previously published. This communication reports 20 additional agents/combinations tested using our protocol to arrive at a standard mix formula or, when necessary, a modified mixing method. Most mixing formulas derived were for antimicrobials effective against fungi and mycobacterium species.

Background: Synovial pH, glucose, and lactate have been studied in native joint septic arthritis, but studies in periprosthetic joint infection (PJI) are limited. The purpose of this study is to evaluate the diagnostic utility of synovial pH, lactate, and glucose as potential diagnostic biomarkers for PJI. Materials and methods: Joint aspirations were performed in 100 consecutive patients (24 hips, 76 knees) with suspected PJI. In our cohort, 36 % were diagnosed with PJI, while 64 % were classified as uninfected based on the EBJIS criteria of 2021. Receiver operating characteristic (ROC) curves and Youden's index were employed to determine the optimal thresholds for synovial pH, lactate, and glucose. Results: The mean synovial pH was significantly lower in the PJI group compared to the uninfected group (7.23 vs. 7.49; $p=0.009$ ). The mean synovial lactate was significantly higher in the PJI group compared to the uninfected group (8.81 vs. 6.28; $p=0.008$ ). The mean synovial glucose was significantly lower in the PJI group compared to the uninfected group (41.4 vs. 62.1; $p=0.027$ ). The optimal thresholds for synovial pH, lactate, and glucose were 7.25, 8.45 mmol L^-1 and 18 mg dL^-1 with a sensitivity of 50 %, 50 %, and 30 % as well as a specificity of 81 %, 84 %, and 96 %, respectively. The combined use of all three biomarkers yielded a negative predictive value of 84 % for the diagnosis of PJI. Conclusion: Synovial pH, lactate, and glucose may serve as valuable adjunct parameters in the diagnosis of PJI with a high negative predictive value.