Journal of Bone and Joint Infection最新文献

Introduction: Diabetic foot osteomyelitis (DFO) is a severe complication of diabetic foot ulcers, leading to high morbidity, mortality, and major limb amputation risk. While limb-sparing surgery is well established, optimal wound closure and intraosseous antibiotic strategies remain under-explored and under-reported. This study evaluates a single-stage limb-sparing surgical approach incorporating primary closure and local intraosseous antibiotic therapy. Methods: This retrospective study included 97 DFO patients (2017-2024) treated using the CLOSE-UP (Conservative surgery, Local antibiotics, Oral versus intravenous antibiotics - OVIVA, Samples, Effective limb preservation, and closUre Primary) protocol, developed to standardize DFO surgery. The one-stage procedure involved bone sampling, local debridement or minor amputation (distal to the tarsometatarsal joint), antibiotic-loaded calcium sulfate-hydroxyapatite biocomposite application, and primary wound closure. Postoperatively, patients followed the OVIVA antimicrobial protocol: 1 week of intravenous (IV) therapy and 5 weeks of oral (empiric penicillin-cloxacillin) therapy. The primary outcome was treatment failure within 1 year, with a minimum follow-up of 12 months. Results: Clinical failure occurred in 13 patients (13.4 %), with only 4 patients (4.1 %) requiring major amputation. Peripheral arterial disease was present in 24 patients (24.7 %) and was the only variable significantly associated with clinical failure (odds ratios: 10.21; $P<0.01$ ). The 1-year and 3-year mortality rates were 14.4 % and 35.9 %, respectively. Conclusions: The CLOSE-UP protocol demonstrated favourable outcomes. Given the high risk of mortality and limb loss in DFO, this structured approach has the potential to improve mobility, shorten rehabilitation, lower costs, and enhance quality of life. Further research, particularly randomized controlled trials, should focus on optimizing wound closure to improve long-term limb preservation and survival.

We present a 31-year-old immunocompromised woman with shoulder septic arthritis and an infraspinatus abscess presenting with paralysis secondary to axillary neuropathy after an intra-articular injection. At 12 months, mobility and normal functioning were restored. This first reported adult case highlights the need for high suspicion of septic arthritis in immunocompromised patients and emphasizes effective management strategies.

Introduction: One-stage revisions seem to have similar reinfection rates compared to two-stage revisions for the treatment of periprosthetic joint infections based on retrospective cohort studies with a large variety of indications and treatment protocols. This study aimed to compare outcomes between comparable groups of one-stage and two-stage revision patients. Materials and methods: We performed a retrospective cohort study, where equal numbers of one-stage and two-stage patients (knee: $n=24$ ; hip: $n=40$ ) were randomly included with the same inclusion and exclusion criteria. Patient characteristics and infection-related outcomes at latest follow-up were obtained via chart review. Functional outcomes (knee: Knee Society Score (KSS), range of motion (ROM), and visual analogue scale (VAS) pain and satisfaction; hip: Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score-Physical Function Shortform (HOOS-PS), VAS pain and satisfaction, and European Quality of Life 5 Dimensions 3 Level version (EQ5D-3L)) preoperatively (hip only) and at 1-year follow-up were extracted from a revision database. Outcomes were compared between one- and two-stage groups and for knee and hip cases separately. Results: One- and two-stage groups were comparable for baseline characteristics. Reinfection occurred for both the knee and hip cohorts in one one-stage patient and one two-stage patient ( $P=1.00$ for both cohorts). More adverse events, of which two were spacer-related, were observed in two-stage hip patients ( $n=7$ ) compared to in one-stage patients ( $n=2$ ) ( $P=0.13$ ). Functional outcomes did not differ between one- and two-stage patients for both knee and hip cohorts. Conclusions: This study showed no differences in terms of reinfection rates and functional outcomes between comparable groups of one- and two-stage septic knee and hip revision patients. A trend towards more adverse events in two-stage hip patients was seen, which was partly due to spacer complications.

Introduction: Peri-prosthetic joint infection (PJI) is a significant complication of arthroplasty, lacking a single gold standard diagnostic test. Synovial fluid white blood cell (WBC) count and polymorphonuclear neutrophil (PMN) proportion are widely used diagnostic tools, but their optimal cutoffs remain unclear, particularly for chronic PJI. Material and methods: This systematic review and meta-analysis included 74 studies published between 2000 and 2024. Data on diagnostic performance (sensitivity, specificity, and diagnostic odds ratios - DORs) of WBC count and PMN proportions were analysed. Sub-group analyses and heterogeneity assessments were performed, and optimal cutoffs for diagnostic accuracy were identified. Results: The meta-analysis revealed a WBC count summary DOR of 58.38 (95 % CI - confidence interval: 48.48-70.32) with an area under the curve (AUC) of the summarized receiver operating characteristic curve of 0.952. The PMN proportion showed a DOR of 43.17 (95 % CI: 35.31-52.79) and an AUC of 0.941. Optimal diagnostic thresholds for chronic PJI were WBC count $>$ 2600 cells per microlitre and PMN $>$ 70 %. Rule-in thresholds (specificity $>95$ %) were WBC count $\ge$ 3000 cells per microlitre and PMN $\ge$ 75 %, while rule-out thresholds (sensitivity $>$ 95 %) were WBC count $\le$ 1500 cells per microlitre and PMN $\le$ 65 %. Confounding conditions such as fractures, inflammatory arthritis, and metal-related reactions reduced test accuracy. Conclusions: Synovial fluid analysis remains a critical diagnostic tool for chronic PJI. Thresholds of WBC count $<$ 1500 and $>3000$  cells per microlitre and PMN $<$ 65 % and $>75$ % provide reliable negative and positive predictive values. A standardized diagnostic framework is essential for addressing remaining controversies and ensuring consistent interpretation across clinical settings.

Background. Post-osteomyelitis bone defects represent a challenging clinical situation. This retrospective cohort study was designed to evaluate the long-term outcome of the use of non-vascularized bone grafts in the management of such defects in children. Methods. Twenty-three children (mean age 7 years, range 2-13 years) were studied. All of the defects were segmental (mean defect length 6 cm, range 3-12 cm), involving the tibia, femur, humerus and radius. Fifteen children presented with an active infection and were managed with a staged protocol. The first stage included sequestrectomy or debridement of the site. The second stage, i.e. the graft procedure, was performed after 12 weeks on average. The mean follow-up was 9.2 years (range 7-15 years). Results. Bone union was primarily achieved in 14 children (61 %). Complications were experienced in the remaining nine children. Conservative and surgical treatment led to bone union in all patients within 5 years of the index procedure. Recurrence of infection was observed in two patients (8.7 %). All of the children were able to use the limb at the final follow-up; only three required the use of a brace. Conclusions. Autogenous non-vascularized bone graft may be considered a valid option in the treatment of bone defects secondary to osteomyelitis in children.

Background and aim: Complex bone and joint infections (BJIs), including prosthetic joint infections (PJIs) and infections associated with osteosynthetic materials, present significant treatment challenges that often require surgical intervention and prolonged antibiotic therapy. In France, the incidence of PJIs in knee and hip arthroplasties ranges from 0.79 % to 2.4 %, with staphylococci being the primary pathogens involved. Recent studies have suggested that oral antibiotic therapy may be as effective as intravenous therapy and that 12 weeks of antibiotic treatment are needed. Tetracyclines, particularly doxycycline and minocycline, are of interest because of their broad-spectrum activities, good oral bioavailability, and potential efficacy in treating BJIs. We aimed to provide a literature review on the role of oral tetracyclines in the management of BJIs. Method: We performed a systematic review of the literature identified via an electronic search of PubMed and ScienceDirect. Results: A total of 648 articles were screened, and 31 studies were included. Pharmacological studies demonstrated that the bone to blood penetration ratio ranged from 0.06 to 0.75. Less than 20 % of strains implicated in BJIs exhibited resistance to oral tetracyclines. Four studies demonstrated potential inhibition of strain growth. Eight studies that included 62 patients reported curative treatment, with a success rate ranging from 82 % to 100 % for PJIs regardless of the surgical management. For suppressive therapy, 10 studies that included 201 patients reported success rates ranging from 57 % to 100 %. The rate of adverse effects ranged from 0 % to 14 % for curative treatment and from 0 % to 57 % for suppressive treatment, leading to treatment discontinuation in less than 20 % of cases. Conclusion: This review highlights that the number of studies supporting the use of oral tetracyclines for the treatment of BJIs is limited. More robust pharmacological and clinical studies are needed to confirm the safety and efficacy profiles of oral tetracyclines for the treatment of BJIs.

It has been shown that the outcome of a DAIR (debridement, antimicrobial therapy, and implant retention) procedure depends on multiple factors (e.g. infection type, host factors, clinical presentation, condition of surrounding soft tissue, causing pathogen, surgical technique, antimicrobial therapy); therefore, adequate patient selection is key for DAIR success. In this position paper, we discuss the most relevant factors influencing the outcome and define indications, contraindications, and risk factors for a DAIR procedure based on the most robust and most recently published data. Furthermore, we discuss the surgical technique in combination with systemic antimicrobial therapy in patients undergoing a DAIR procedure. This position paper may help reduce reinfection rates as well as the physical, psychological, and economic burden associated with periprosthetic joint infection (PJI). We believe that a reasonable outcome can be achieved with careful patient selection, a dedicated multidisciplinary team, and an appropriate surgical technique and antimicrobial therapy.

This is a summary of our position paper on debridement, antimicrobial therapy, and implant retention (DAIR) procedures as curative treatment strategy for acute periprosthetic hip and knee infections. It includes the defined indications as well as the contraindications for DAIR procedures when eradication/cure is intended, based on the currently available literature. Risk factors which need to be considered during the decision-making process are described. Additionally, we give an overview of important surgical and medical considerations in the management of acute PJI patients treated with DAIR.

Dalbavancin is a lipoglycopeptide with a half-life of 14 d, significantly reducing the need for daily antibiotic dosing. Although dalbavancin is approved for acute bacterial skin and skin structure infections, its off-label use in complex musculoskeletal infection (MSKI) is increasing. Evidence on its effectiveness for MSKI, especially in facilitating early discharge for patients unsuitable for oral or OPAT (outpatient parenteral antimicrobial therapy) treatments, is limited. This multi-centre observational study aims to evaluate dalbavancin's role in facilitating discharge and improving clinical outcomes in MSKI. Method: this study included adult patients treated with dalbavancin between January 2017 and December 2022 across five hospitals in the UK and France. Data on patient demographics, clinical characteristics, microbiology and treatment outcomes were collected using a standardised form. The study also compared treatment costs between dalbavancin and hypothetical alternatives involving either inpatient care or OPAT. Clinical success was defined as the absence of definite failure based on the OVIVA (oral versus intravenous antibiotics) trial criteria. Results: a total of 39 patients were included, with a median age of 51 years (interquartile range (IQR) 40-72). Prosthetic joint infections (38 %) and septic arthritis (31 %) were the most common indications for dalbavancin use. The primary pathogens identified were Staphylococcus aureus (51 %) and coagulase-negative staphylococci (44 %). Dalbavancin was primarily chosen due to poor adherence or lack of OPAT options in 77 % of cases and for convenience in 23 %. In the necessity group, the use of dalbavancin resulted in a median cost saving of GBP 8894 per patient, and 31 inpatient days were avoided. Of the 32 patients (82 %) assigned a definite outcome, 72 % achieved clinical success. No significant adverse drug reactions were reported. Conclusion: this study fills an important evidence gap by demonstrating that dalbavancin is a viable and cost-effective option for MSKI patients that are unsuitable for oral or OPAT treatments. Dalbavancin facilitates early discharge, reduces hospital stays and achieves comparable clinical outcomes to conventional therapies.

Background: Periprosthetic joint infections (PJIs) pose a significant challenge in orthopedic surgery, and emerging evidence suggests that the gut microbiome may play a crucial role in their development and management. Despite the rarity of these infections, the continuous increase in prosthetic joint arthroplasties has made understanding how to prevent them more pressing. A stronger comprehension of the disruption of the gut microbiome and how this can lead to more of these infections and other pre-surgical risks may be crucial in preventing them. Objective: This article aims to provide a stronger understanding of the topic through the analysis of different pieces of already existing literature to help draw new conclusions and raise potential questions that need answering. Methods: A comprehensive search strategy without filters was employed, and multiple papers were thoroughly analyzed, understood, and compiled into this paper. Conclusions: Despite the limitations of some of the analyzed studies and finite evidence, this paper suggests that there could be a connection between periprosthetic joint infections and a compromised gut microbiome. However, further research is required to draw a definitive conclusion.