Journal of Bone and Joint Infection最新文献

Aims: It remains unclear if postoperative antibiotic (AB) treatment is advantageous in presumed aseptic revision arthroplasties of the hip (rTHA) and knee (rTKA) with unexpected positive intraoperative cultures (UPIC). The aim of this study is to evaluate if there is a difference in the re-revision rate in patients with UPIC when treated with postoperative AB or when postoperative AB is withheld. Methods: In this retrospective matched cohort study we compared the re-revision rates in rTHA and rTKA with (AB group: 45 rTHA, 25 rTKA) and without (non-AB group: 45 rTHA, 25 rTKA) AB treatment in patients with UPIC. Baseline covariates for matching were the microorganism (likely or not likely to be a contaminant), patient demographics, joint, revision type, surgical site infection score, American Society of Anesthesiologists classification, serum C-reactive protein (CRP). Results: After a median follow-up of 4.1 (inter-quartile range, IQR: 2.9-5.5) years after rTHA and rTKA, the re-revision rate between the AB group and the non-AB group was 14.3 % versus 15.7 % (P=0.81). In the AB group, 4.3 % (3/70) of patients underwent revision due to septic complications compared to 5.7 % (4/70) in the non-AB group (P=0.69). None of the patients were diagnosed with a confirmed periprosthetic joint infection (PJI) according to the PJI diagnostic criteria of European Bone and Joint Infection Society (EBJIS). In 22/70 (31.4 %) of the patients in the AB group and in 15/70 (21.4 %) of the patients in the non-AB group, a diagnosis of "infection likely" was made according to the EBJIS criteria (P=0.18). All UPICs with low virulent microorganisms were considered to be contamination (coagulase-negative Staphylococci; Corynebacterium; anaerobic Gram-positive bacilli and cocci, e.g., Finegoldia magna, Cutibacterium acnes). Conclusion: Postoperative AB treatment did not result in a decreased re-revision rate in patients with UPIC in presumed aseptic rTHA and rTKA. Patients diagnosed with pathogens classified as a likely contaminant can be safely ignored.

Introduction: In native septic arthritis, synovial glucose is a well-established diagnostic marker. However, its diagnostic utility in periprosthetic joint infection (PJI) remains unexplored. Given the diagnostic challenges of acute postoperative PJI, we hypothesized that synovial glucose could serve as a valuable biomarker and aimed to evaluate its diagnostic accuracy. Material and methods:  This is a retrospective diagnostic study in acute postoperative PJI in total knee arthroplasty (TKA). We reviewed all TKA surgeries performed in the past 10 years and cross-checked those patients that consulted to our emergency room during the first 90 d after TKA surgery for knee-related symptoms. We calculated the serum-to-synovial-glucose ratio for each patient (serum-to-synovial-glucose ratio = [(serological glucose - synovial glucose) / serological glucose]), and we formed the receiver operating characteristic (ROC) curves for synovial glucose, serum-to-synovial-glucose ratio, serum C-reactive protein (CRP), synovial white blood cell (s-WBC) count, and polymorphonuclear cell percentage (PMN%); then we extracted the optimal cutoff values. Results: The optimal cutoffs for diagnosing acute postoperative PJI were < 44 mg dL^-1 for synovial glucose and > 0.69 for serum-to-synovial-glucose ratio. The area under the curve (AUC) values were 0.861 and 0.889, respectively. ROC curves for serum CRP, s-WBC count, and PMN% showed AUC values of 0.69, 0.714, and 0.66, respectively. The combined ROC curve analysis for serum CRP, s-WBC count, and PMN% showed an AUC of 0.722. When adding synovial glucose, the AUC was 0.859 and with serum-to-synovial-glucose ratio we achieved an AUC of 0.876. Conclusion: Synovial glucose and serum-to-synovial-glucose ratio demonstrated good diagnostic potential for acute postoperative PJI following TKA. These biomarkers exhibited superior accuracy compared to the combination of serum CRP, s-WBC count, and PMN%.

Introduction: Endoprosthetic replacement (EPR) is the preferred limb salvage method for musculoskeletal tumours involving bone; however, infection rates range from 8 % to 12 %. We investigated the impact of antibiotic prophylaxis at primary implantation on the development of prosthetic joint infection (PJI). Methods: We conducted a retrospective analysis of patients who underwent primary EPRs between 2010 and 2021. Prosthetic joint infections were identified and classified according to criteria from the European Bone and Joint Infection Society (EBJIS). The follow-up period extended until an infection was identified, subsequent surgery for non-infectious reasons occurred or the last known follow-up was conducted. For all primary procedures, we collected details of postoperative complications at the surgical site, including superficial wound infections, delayed wound healing and wound dehiscence. PJIs were divided into two groups. The first group included patients with an uncomplicated postoperative course, while the second comprised those with either postoperative wound problems or infections from an identifiable source. Results: Out of 1064 patients, 73 (6.9 %) developed PJI within a median follow-up of 25.6 months (IQR 8.8-52.7). A total of 26 % of PJIs were attributed to primary implantation, while 74 % of PJIs were due to secondary causes, with 47 % having wound complications and 27 % presenting acutely. The microbiological profiles between groups differed significantly, with infections from skin flora related to primary implantation and a high proportion of other bacteria (Gram-negatives and enterococci) linked to secondary infections. Conclusions: Skin flora are likely responsible for infections related to the primary procedure, and antibiotic prophylaxis should be optimised accordingly. Additional measures are needed to prevent secondary infections.

Background: Elbow native joint septic arthritis (NJSA) is a rare condition, constituting 6 %-9 % of all native septic arthritis cases. It is associated with elevated mortality and morbidity. This study aims to clarify the characteristics, management, and outcomes of elbow NJSA. Methods: We retrospectively analyzed adults diagnosed with elbow NJSA who underwent surgical intervention at Mayo Clinic facilities from January 2012 to December 2021. Diagnosis relied on clinical presentation, synovial fluid white blood cell (WBC) count, and aspiration or operative cultures. Results: Among 557 patients with NJSA during the study time frame, 19 (3.4 %) were found to have elbow NJSA. The median age of these patients was 64 years. Joint aspirations were conducted in 16 cases (84.2 %). The median synovial fluid WBC count was 43 139 cells mm^-3. Crystals were observed in three patients (15.8 %). Synovial fluid and operative tissue samples revealed 12.5 % and 20 % positive Gram stains, mostly indicating Gram-positive cocci clusters. Open arthrotomy (72.2 %) was the predominant surgical approach, and three patients (16.7 %) required reoperation within 90 d. The median antimicrobial therapy duration was 30 d (interquartile range: 22-44 d). Non-tuberculosis mycobacterium (NTM) was detected in two patients, with a treatment duration of 274 and 374 d, respectively. Complications included joint contracture and joint resection. Conclusions: Elbow NJSA is an infrequent condition associated with significant complications, such as the necessity for reoperation. Although the synovial fluid WBC count, crystals, and Gram stain positivity were less helpful for diagnosis in this study, positive Gram stain and culture results from operative tissue specimens demonstrated greater effectiveness in diagnosing elbow NJSA.

Introduction: This study aimed to evaluate infection-free survival and outcomes after two-stage revision surgery for hip periprosthetic joint infection (PJI) performed in a specialised arthroplasty unit over 20 years. Methods: We retrospectively identified 158 hips (154 patients) treated with two-stage revision surgery for hip PJI between 2001 and 2021. We analysed their data and presented their infection-free survival, re-operation rate, mortality, risk factors and complications. Results: The mean follow-up time was 9 (2 to 21.7) years. A total of 22 hips (13.9 %) were re-infected. The infection-free survival was 94.4 % at 2 years, 89.3 % at 5 years, 84.2 % at 10 years, and 82.6 % at 15 and 20 years. The re-operation rate for aseptic causes was 12 %, and the most common cause of re-operation was dislocation (7 %). The cumulative survival for re-operation for aseptic causes was 93.6 % at 2 years, 89.7 % at 5 years, 88.8 % at 10 years, and 82.8 % at 15 and 20 years. The cumulative survival for all-cause re-revision was 88.8 % at 2 years, 80.8 % at 5 years, 74.9 % at 10 years, and 68 % at 15 and 20 years. The mean Western Ontario and McMaster Universities Arthritis Index (WOMAC) hip score significantly improved from 68.3 at the pre-operative stage to 35.9 at 2.1 (2 to 3.3) years, 35.3 at 5.3 (5 to 8.4) years, 38.3 at 11.3 (10-15) years and 43.8 at 18.7 (16.5 to 21.7) years ( $p<0.01$ ). Duration of antibiotics and gram-negative infection were the only predictive risk factors for re-infection. Conclusion: Our results of the two-stage revision protocol for hip PJI were satisfactory and comparable with the best reported outcomes.

Background: Prior studies have indicated that administration of prolonged courses of oral antibiotics after Stage 2 reimplantation surgery for periprosthetic joint infection (PJI) results in a lower rate of recurrent PJI. However, there is concern that this antibiotic usage results in an increased risk of antibiotic resistance in any subsequent PJI that does occur. Methods: We retrospectively reviewed patients who underwent Stage 2 reimplantation surgery for PJI within the national Veterans Affairs hospital system of the United States. We compared those who received at least 2 weeks of oral antibiotics after Stage 2 reimplantation to those who did not. The primary outcome was the proportion of organisms resistant to four classes of antibiotics (tetracyclines, fluoroquinolones, oral beta-lactams, and sulfonamides) in recurrent PJI. Secondary outcomes included recurrent PJI and death. Results: Of the 605 patients who underwent Stage 2 reimplantation for PJI, 154 patients received at least 14 d of antibiotics after surgery and 451 patients did not. Bacteria causing recurrent PJI in patients who received prolonged antibiotics were more likely to be resistant to tetracyclines and trimethoprim-sulfamethoxazole but not oral beta-lactams or fluoroquinolones. There was no difference in risk of recurrent PJI or death between the two groups. Conclusions: Prolonged oral antibiotic treatment after Stage 2 reimplantation increases the risk of antibiotic resistance to some antibiotics in subsequent PJI. We recommend further research to identify the best choice of antibiotic and duration after Stage 2 reimplantation, to maximize benefits while minimizing risks.

In 2018, the Centrum fOr translational Medicine on Bone and joint INfEctions (COMBINE) was created to facilitate collaboration among Danish scientists and researchers dedicated to bone and joint infection research. The COMBINE approach was developed to ensure successful collaboration, and this publication aims to share this successful approach.

We report a case of post-traumatic Metamycoplasma hominis fracture-related infection of the right femur in a young male with no identified immunodeficiency. Treatment required multiple washouts and femoral nail revision, combined with 10 weeks of treatment with doxycycline and clindamycin.

Background: Antibiotic-laden polymethyl methacrylate (PMMA)-coated intramedullary nails (IMNs) are an effective treatment for osteomyelitis, but they pose multiple disadvantages. Antibiotic-loaded resorbable calcium sulfate (ARCS) paste is an alternative option to deliver a local antibiotic depot around IMNs, but such use has been minimally investigated. This study aimed to define the immediate covering and filling characteristics of ARCS around IMNs by using anatomic bone models. Method: Five tibia models (foam with cortical shell) were prepared by reaming a uniform 13 mm cylindrical path. Three 40 cc kits of ARCS (STIMULAN, Biocomposites Ltd, Keele, UK) were mixed with 3 g vancomycin and 1.2 g tobramycin powder and injected into the intramedullary canal while wet, completely filling the canal. A 10 mm $\times$ 345 mm tibial IMN was immediately inserted without interlocking screws and allowed to completely cure for 2 h. The models were then longitudinally cut without disrupting the dry ARCS covering on the nail. The ARCS was removed from the nail at five equidistant locations along the nail. The thickness of the ARCS was measured with a caliper. A repeated-measures ANOVA test was used to compare the mean width of each segment for each model. Results: In all five trials, the tibial canal volume surrounding the nail remained completely filled. The ARCS paste was confluent along the length of the IMN. There were no gaps or air pockets between the paste and reamed model bone. There was no statistically significant difference among the five samples at each location ( $p=0.913$ ) or among the five locations along the bone ( $p=0.210$ ). Conclusion: In a model setting, ARCS fully fills the intramedullary canal of a tibia and covers an IMN uniformly. Study of the in vivo material properties of ARCS may further elucidate the bone penetration as well as the clinical utility of this antibiotic depot technique.

Orthopedic-device-related infections (ODRIs) are challenging clinical complications that are often exacerbated by antibiotic resistance and biofilm formation. This review explores the efficacy of naturally occurring antimicrobials - including agents sourced from bacteria, fungi, viruses, animals, plants and minerals - against pathogens common in ODRIs. The limitations of traditional antibiotic agents are presented, and innovative naturally occurring antimicrobials, such as bacteriophage therapy and antimicrobial peptides, are evaluated with respect to their interaction with conventional antibiotics and antibiofilm efficacy. The integration of these natural agents into clinical practice could revolutionize ODRI treatment strategies, offering effective alternatives to conventional antibiotics and mitigating resistance development. However, the translation of these compounds from research into the clinic may require the substantial investment of intellectual and financial resources.