Aim. This is the first study to directly compare the clinical outcome of debridement, antimicrobials and implant retention (DAIR) with stabilization using new internal fixation after debridement, for patients with Fracture-related Infection (FRI). Method. Consecutive patients with FRI Consensus confirmed FRI had single-stage surgery with tissue sampling, debridement, stabilization, antimicrobial therapy and skin closure. All cases had FRIs which were unhealed at surgery. When existing implants were stable, the implant was retained but loose implants or fractures with poor reduction had implant removal and refixation with new implants. All patients had the same empiric and definitive antibiotics, the same diagnostic criteria and outcome assessment at least one year after surgery. Failure was defined as infection recurrence, reoperation or lack of fracture consolidation at one year. Results. Seventy-one patients were studied (40 DAIRs and 31 new implants, including 10 exchange nails). The two groups were well matched for age, duration of infection, BACH complexity, microbiology, bone involved and need for flap coverage. Ten patients (13.7%) died before the endpoint. Mortality was similar in both groups (DAIR 14.1% vs New Metalware 12.9%; p=0.801) but DAIR of IM nails had a higher mortality at 40% (p=0.011). Sixty-one patients were followed-up for a mean of 3.32 years (1.04-9.43). Infection was eradicated in 23/34 (67.6%) DAIR patients and 24/27 (88.9%) with new metalware (p=0.049). Overall rates of infection-free union were similar in both groups (58.8% vs 77.8%; p=0.117). DAIR of plates had significantly fewer infection-free unions compared to removal and implantation of new plates (DAIR 57.1% vs NM 91.7%; p=0.033). Conclusion. Implantation of new metalware had better eradication of infection and a strong trend towards better union rates. Treating FRI with retained or new metalware had a substantial mortality (13.7%). Choosing DAIR did not reduce this mortality and these patients more often required further surgery to treat residual infection and secure union

Aim. Decubitus ulcers are found in approximately 4.7% of hospitalized patients, with a higher prevalence (up to 30%) among those with spinal cord injuries. These ulcers are often associated with hip septic arthritis and/or osteomyelitis involving the femur. Girdlestone resection arthroplasty is a surgical technique used to remove affected proximal femur and acetabular tissues, resulting in a substantial defect. The vastus lateralis flap has been employed as an effective option for managing this dead space. The aim of this study was to evaluate the long-term outcomes of this procedure in a consecutive series of patients. Method. A retrospective single-center study was conducted from October 2012 to December 2022, involving 7 patients with spinal cord injuries affected by chronic severe septic hip arthritis and/or femoral head septic necrosis as a consequence of decubitus ulcers over trochanter area. All patients underwent treatment using a multidisciplinary approach by the same surgical team (orthopedic and plastic surgeons) along with infectious disease specialists. The treatment consisted of a one-stage procedure combining Girdlestone resection arthroplasty with unilateral vastus lateralis flap reconstruction, alongside targeted antibiotic therapy. Complications and postoperative outcomes were assessed and recorded. The mean follow-up period was 8 years (range 2-12). Results. Of the 7 patients, 5 were male and 2 were female, with a mean age of 50.3 years at the time of surgery. Minor wound dehiscence occurred in 28.6% of the flap sites, and 2 patients required additional revisional procedures—one for hematoma and the other for bleeding. There were no instances of flap failure, and complete wound healing was achieved in an average of 32 days (range 20-41), with the ability to load over the hip area. No cases of infection recurrence or relapse were observed. Conclusions. An aggressive surgical approach is strongly recommended for managing chronic hip septic arthritis or proximal femur osteomyelitis in patients with spinal cord injuries. A single-stage procedure combining Girdlestone resection arthroplasty with immediate vastus lateralis muscle flap reconstruction proves to be an effective strategy for dead space management and localized antibiotic delivery through the vastus muscle, giving reliable soft tissue coverage around the proximal femur to avoid the recurrence of pressure ulcers. The implementation of a standardized multidisciplinary protocol contributes significantly to the success of reconstruction efforts

Aim. Determine therapeutic and prognostic value of three different prosthetic joint infections (PJI) staging systems – JS-Bach, McPherson and PJI-TNM. Method. Retrospective analysis of patients who received surgery for PJI between 2011 and 2022 at one single institution, including DAIR, 1-stage revision and 2-stage revision. We applied three staging systems - JS-Bach, McPherson, PJI-TNM – and categorize the results into A (less severe), B (intermediate) and C (most severe). Demographic data and comorbidities, anatomic location, type of treatment, recurrency of infection, final outcome and antibiogram were analyzed. Results. 186 patients were included, 112 (60%) were woman. Median age was 70 years old. 51% were submitted to DAIR, 10% to 1-stage revision and 39% to 2-stage revision. Recurrence of infection was found on 27% of patients after initial treatment. 10% died with complication related to PJI. Final status at last follow-up showed 96% of cases were ultimately free of infection at last follow-up. JS-BACH was associated with recurrence. All three staging systems were associated with final outcome. Conclusions. Despite all existing knowledge around risk factors for treatment failure of PJI, there is still a lack of a generally accepted classification system to accurately predict patient outcome. JS-BACH, McPherson and PJI-TNM are three different proposed classifications developed to predict clinical outcomes. To the best of our knowledge there are no studies directly comparing their performance. We retrospectively evaluated our cohort and found that all three correlated with final patient outcome but JS-BACH was the only who significantly correlated with infection recurrence after initial treatment

Aim. To report outcomes of soft tissue reconstruction using free tissue transfer for the treatment of tibial osteomyelitis as part of a single-stage, ortho-plastic procedure. Method. Patients who underwent ortho-plastic reconstructive surgery to excise tibial osteomyelitis in combination with free tissue transfer in one stage were included. Patients underwent surgery between 2015 and 2024 in a single specialist centre within the UK. Baseline patient information, demographics, and infection information was recorded. Adverse outcomes were defined as (i) flap salvage required, (ii) flap failure and (iii) recurrence of infection. Patient reported quality of life was measured using the EuroQol EQ-5D-5L index score. Pre-operative QoL was compared to QoL at 1 year with a control group of 53 similar patients who underwent surgical treatment for tibial osteomyelitis without a free flap (local flap or primary closure). Results. Ninety-three patients were eligible for inclusion, with a mean age of 52 years (range 18–90). 77/93 (82.8%) had a free muscle flap with the remainder (17.2%) receiving a fasciocutaneous flap. The donor tissue was defined as 57 gracilis, 6 latissimus dorsi, 14 hemi-latissimus dorsi, and 16 anterolateral thigh. The recipient area of the tibia was distal 1/3 in 52 cases, middle 1/3 in 27 cases and proximal 1/3 in 12 cases. The average flap ischaemic time was 70 minutes (range 28 to 125). Seven patients (7.5%) required urgent flap salvage at a median time of 1.0 day (range 0.5 – 4.0). Of these, 4 (4.3%) went on to have total flap failure, of which 2 patients underwent below knee amputation subsequently. Flap failure was due to either arterial (n=2) or venous (n=2) anastomotic thrombus. There were 3 (3.2%) episodes of confirmed infection recurrence within the first year after the index procedure. EQ-index scores at 1-year post-operatively were significantly improved when compared to pre-operative scores (p=0.008). At 1-year post-operatively, EQ-index scores in patients who underwent free flap was similar compared to local flaps (p=0.410) and in those who underwent primary closure for tibial osteomyelitis (p=0.070). Conclusions. Microsurgical single stage surgery can achieve high flap survival rate (95.7%). Free flaps fail early due to anastomotic thrombus with no late failures seen. Free tissue transfer does not appear to give inferior QoL compared to matched patients with local flaps or direct closure in tibial osteomyelitis

Aims

We aimed to determine the concentrations of synovial vancomycin and meropenem in patients treated by single-stage revision combined with intra-articular infusion following periprosthetic joint infection (PJI), thereby validating this drug delivery approach.

Hip resurfacing arthroplasty (HRA) is being offered as a viable alternative to total hip arthroplasty (THA). For very young patients (under 30 years old), THA achieves fair results but with high revision and complication rates. This retrospective study was designed to evaluate the results of HRA performed in patients under 30 years old with a long follow-up. During the inclusion period (2007–2021), we collected in a single operator database, all HRA performed in patients under 30 with a minimum follow up of 2 years. 103 HRA in 93 patients (77 male / 16 females; a mean age at operation 27.7 years (18 to 29.9)) were included. The two mean preoperative diagnoses were osteoarthritis in 54 HRA (52.5%) and DDH or hip dislocation in 19.4% (20 cases). No patient was lost to follow-up and 3 patients (5 HRA) deceased. There were 2 revisions (one for femoral aseptic loosening and one infection recurrence (pediatric osteoarthritis)). No dislocation and adverse wear-related failures were found. At a mean follow-up of 10.4 years (2–17.4), mean UCLA activity and Oxford Hip score improved respectively from 5.4 (1 to 7) and 39.9 (25–55) pre-operatively to 7.9 (3 to 10) and 15.8 (12–34) post-operatively (p<0.001). Mean Harris hip score increased from 41.6 (22–63) to 91.8 (72–100) (p<0.001). There were no radiological cases exhibiting lysis while two cases displayed limited partial radiolucency around the femoral stem. Kaplan-Meier survival analysis, with the endpoint revision for any reason, showed a 10.8-year survival rate of 98% (95% expected with NICE guidelines). This cohort of HRA performed under 30 is the longest follow-up ever reported in the literature. Despite a challenging cohort of patients, HRA exceeds the stricter NICE survivorship criteria. HRA remains an effective treatment with excellent functional outcomes and a very low rate of complications

The August 2024 Foot & Ankle Roundup³⁶⁰ looks at: ESWT versus surgery for fifth metatarsal stress fractures; Minimally invasive surgery versus open fusion for hallux rigidus; Diabetes and infection risk in total ankle arthroplasty; Is proximal medial gastrocnemius recession useful for managing chronic plantar fasciitis?; Fuse the great toe in the young!; Conservative surgery for diabetic foot osteomyelitis; Mental health and outcome following foot and ankle surgery.

Aims

The number of revision arthroplasties being performed in the elderly is expected to rise, including revision for infection. The primary aim of this study was to measure the treatment success rate for octogenarians undergoing revision total hip arthroplasty (THA) for periprosthetic joint infection (PJI) compared to a younger cohort. Secondary outcomes were complications and mortality.

Aims

Although low-intensity pulsed ultrasound (LIPUS) combined with disinfectants has been shown to effectively eliminate portions of biofilm in vitro, its efficacy in vivo remains uncertain. Our objective was to assess the antibiofilm potential and safety of LIPUS combined with 0.35% povidone-iodine (PI) in a rat debridement, antibiotics, and implant retention (DAIR) model of periprosthetic joint infection (PJI).

Aims

This study aimed to investigate the clinical characteristics and outcomes associated with culture-negative limb osteomyelitis patients.

Aims

To explore the clinical efficacy of using two different types of articulating spacers in two-stage revision for chronic knee periprosthetic joint infection (kPJI).

Aims. The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes. Methods. Between May 2012 and December 2020, 203 patients with infected segmental bone defects treated with the IMT were enrolled. The digital medical records of these patients were retrospectively analyzed. Factors associated with unfavourable outcomes were identified through logistic regression analysis. Results. Among the 203 enrolled patients, infection recurred in 27 patients (13.3%) after bone grafting. The union rate was 75.9% (154 patients) after second-stage surgery without additional procedures, and final union was achieved in 173 patients (85.2%) after second-stage surgery with or without additional procedures. The mean healing time was 9.3 months (3 to 37). Multivariate logistic regression analysis of 203 patients showed that the number (≥ two) of debridements (first stage) was an independent risk factor for infection recurrence and nonunion. Larger defect sizes were associated with higher odds of nonunion. After excluding 27 patients with infection recurrence, multivariate analysis of the remaining 176 patients suggested that intramedullary nail plus plate internal fixation, smoking, and an allograft-to-autograft ratio exceeding 1:3 adversely affected healing time. Conclusion. The IMT is an effective method to achieve infection eradication and union in the management of infected segmental bone defects. Our study identified several risk factors associated with unfavourable outcomes. Some of these factors are modifiable, and the risk of adverse outcomes can be reduced by adopting targeted interventions or strategies. Surgeons can fully inform patients with non-modifiable risk factors preoperatively, and may even use other methods for bone defect reconstruction. Cite this article: Bone Joint J 2024;106-B(6):613–622

Introduction. Knee arthrodesis is a useful limb salvage technique to maintain function in patients with complex and infected total knee arthroplasties (TKA). There are a number of commonly used external fixators, but no consensus on which of these are optimal. The aim of this study was to synthesise the current literature to guide clinical decision making and improve patient outcomes. We systematically review the literature to compare outcomes of external fixators in arthrodesis following infected TKA. Materials & Methods. A systematic review of the literature of primary research articles investigating the use of external fixators for knee arthrodesis after an infected TKA was conducted. Relevant articles were identified with a search strategy on online databases (EMBASE and Medline) and reviewed by two independent reviewers. Clinical outcome measures were independently extracted by two reviewers which included union rate, infection eradication rate, complication rate, time to fusion, and time in frame. Results. Circular frames were more likely to result in union compared to biplanar (OR 1.40 p=0.456) and monoplanar frames (OR 2.28 p=0.018). Infection recurrence was least likely in those treated by circular frames when compared to monoplanar (OR 0.12 p=0.005) and biplanar external fixators (0.41 P=0.331). Complication rates were highest in the circular fixator group, followed by the monoplanar fixator group and biplanar fixator group at 34%, 31% and 11% respectively. Conclusions. Analysis of the available literature suggests higher union and infection eradication rates with circular frames over the other two fixation methods despite a higher complication rate. There is a paucity in the literature and therefore, no firm conclusions can be drawn. Further research investigating the variations and biomechanical properties between different external fixation methods for knee arthrodesis is necessary. Further clarity in reporting and pooled data would be useful for future analysis

Cite this article: Bone Joint Res 2024;13(3):124–126.

The December 2023 Trauma Roundup³⁶⁰ looks at: Distal femoral arthroplasty: medical risks under the spotlight; Quads repair: tunnels or anchors?; Complex trade-offs in treating severe tibial fractures: limb salvage versus primary amputation; Middle-sized posterior malleolus fractures – to fix?; Bone transport through induced membrane: a randomized controlled trial; Displaced geriatric femoral neck fractures; Risk factors for reoperation to promote union in 1,111 distal femur fractures; New versus old – reliability of the OTA/AO classification for trochanteric hip fractures; Risk factors for fracture-related infection after ankle fracture surgery.

Aim. Debridement, antibiotics, and implant retention (DAIR) is a viable treatment option for acute periprosthetic joint infections (PJI). The landmark DATIPO trial of Bernard et al. concluded that six weeks is not non-inferior to 12-week antibiotic therapy for DAIR. However, it is unknown if suppressive antibiotic treatment (SAT) would improve patient outcomes. Therefore, our study aims to evaluate the utility of SAT after 12 weeks of therapy. Method. We performed a retrospective study of patients with acute hip or knee PJI managed with DAIR at five institutions; in the U.S. (n=1), Netherlands (n=3), and Spain (n=1) from 2005–2020. We analyzed the effect of SAT using a Cox model among patients after 12 weeks of antibiotic treatment. The primary covariate of interest was whether the patient was on antibiotics after week 12, which was coded as a time-varying covariate. We decided a-priori to control for the clinically important risk factors such as age, sex, type of infection, modular exchange, joint, and presence of bacteremia and Staphylococcus aureus. We excluded patients who died, had treatment failure, or were lost to follow-up before 12 weeks. We defined treatment failure as infection recurrence (same or different organism), unexpected reoperation, or death due to infection. Results. There were 504 patients included in the study. The majority were female (58%, n=292), with a mean age of 70 years ago (SD 11). Hips and knees were equally proportioned. Primary arthroplasties represented 69% of the total cohort (n=349). Treatment failure was 11.9% in the total cohort (n=60). There was no statistically significant association between SAT after 12 weeks and treatment failure (HR 1.25, p=0.45, 95% CI 0.70–2.24). This finding was consistent across different subgroups, including hip or knee joints, early or late acute infections, cohort, and a subgroup of knee joints after 180 days. Conclusions. SAT after 12 weeks of antibiotic treatment for acute PJI managed with DAIR does not appear to improve patient outcomes

Aim. Prosthetic joint infection (PJI) due to Candida spp. is a severe complication of arthroplasty but is little reported. This study describes Candida PJI epidemiology, management, and outcome. Method. We performed a retrospective, observational multinational study with support of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). Patients diagnosed with PJI due to Candida spp. between 1990 and 2021 were included. Demographic, clinical, laboratory, imaging, medical/surgical treatment, and outcome data were collected within a standardized database. Treatment failure was defined either as a Candida infection recurrence, superinfection, or death due to infection. Results. Data from 151 patients across 18 centers were analyzed. Mean age was 69.5 ± 13.1yo, 78 (51.7%) patients were male, and 21 (13.9%) were immunosuppressed. Site of infection included hip (55.0%), knee (41.7%), shoulder (2.6%), and femur (0.7%). Twenty-five (16.6%) patients were febrile, and 58 (38.4%) had fistula. Mean number of previous surgeries on the same anatomical site was 3.3±2.3. Surgeries were DAIR (33.8%), one-stage exchange (19.9%), two-stage exchange (39.1%), and implant removal (6.0%). Candida species identified were C. albicans (60.3%), C. parapsilosis (26.5%), C. glabrata (7.3%), and C. tropicalis (5.3%). Co-infection with bacteria was found in 69 (45.7%) cases. Fluconazole (62.9%) and caspofungin (14.6%) were the main antifungal agents prescribed for 148.6 ± 167.5 days. Favorable outcome was found in 54/144 (37.5%) cases. Failure was associated with the number of previous surgeries (OR 1.249, 95%CI 1.061–1.469; p-value=0.007), while treatment by fluconazole was associated with cure (OR 0.336, 95%CI 0.160–0.707; p-value=0.004). Conclusions. This study provides epidemiologic and outcome data on Candida PJIs. Although poor overall, the prognosis did not seem associated with immunosuppression, type of surgery, fungal species or treatment duration

Aim. Pin site infection (PSI) is a common complication of external fixators. PSI usually presents as a superficial infection which is treated conservatively. This study investigated those rare cases of PSI requiring surgery due to persistent osteomyelitis (OM), after pin removal. Method. In this retrospective cohort study we identified patients who required surgery for an OM after PSI (Checketts-Otterburn Classification Grade 6) between 2011 and 2021. We investigated patient demographics, aetiology of the OM, pathogen and histology, treatment strategies and complications. Infection was confirmed using the 2018 FRI Consensus Definition. Successful outcome was defined as an infection-free interval of at least 24 months following surgery, which was defined as minimum follow-up. Results. Twenty-seven patients were treated due to a pin site infection with an osteomyelitis (22 tibias, 2 humeri, 2 calcanei, 1 radius). 85% identified as male and the median age was 53.9 years. Eighteen infections followed external fixation of fractures, with 4 cases after Ilizarov deformity correction, 2 cases followed ankle fusion and 3 after traction pin insertion. Fifteen patients were classified as BACH Uncomplicated and 12 were BACH Complex. The median follow-up was 3.99 years (2.00–8.05 years). Staphylococci were the most common pathogens (16 MSSA, 2 MRSA, 2 CNS). Polymicrobial infections were present in 5 cases (19%). All surgery was performed in a single stage following the same protocol at one institution. This included deep sampling, debridement, implantation of local antibiotics, culture-specific systemic antibiotics and soft tissue closure. Seven patients required flap coverage (6 local, 1 free flap), which was performed in the same operation. 25 (93%) patients had a successful outcome after one surgery. Two had recurrence of infection which was successfully treated by repeat of the protocol. One patient suffered a fracture through the operated site after a fall. This healed without infection recurrence. Wound leakage after local antibiotic treatment was seen in 3/27 (11%) of cases. All resolved without treatment. After a minimum of 2 years follow up, all patients were infection free at the site of the former osteomyelitis. Conclusions. OM after PSI is uncommon but has major implications for the patient as 7 out of 27 patients needed flap coverage. This reinforces the need for careful pin placement and pin site care to prevent deep infection. These infections require appropriate surgery, not just curettage. All patients in our cohort were infection-free after a minimum follow-up of 2 years suggesting that this protocol is effective

Aims. Achievement of accurate microbiological diagnosis prior to revision is key to reducing the high rates of persistent infection after revision knee surgery. The effect of change in the microorganism between the first- and second-stage revision of total knee arthroplasty for periprosthetic joint infection (PJI) on the success of management is not clear. Methods. A two-centre retrospective cohort study was conducted to review the outcome of patients who have undergone two-stage revision for treatment of knee arthroplasty PJI, focusing specifically on isolated micro-organisms at both the first- and second-stage procedure. Patient demographics, medical, and orthopaedic history data, including postoperative outcomes and subsequent treatment, were obtained from the electronic records and medical notes. Results. The study cohort consisted of 84 patients, of whom 59.5% (n = 50) had successful eradication of their infection at a mean follow-up of 4.7 years. For the 34 patients who had recurrence of infection, 58.8% (n = 20) had a change in isolated organism, compared to 18% (n = 9) in the infection eradication group (p < 0.001). When adjusting for confound, there was no association when the growth on the second stage was the same as the first (odd ratio (OR) 2.50, 95% confidence interval (CI) 0.49 to 12.50; p = 0.269); however, when a different organism was identified at the second stage, this was independently associated with failure of treatment (OR 8.40, 95% CI 2.91 to 24.39; p < 0.001). There were no other significant differences between the two cohorts with regard to patient demographics or type of organisms isolated. Conclusion. Change in the identified microorganism between first- and second-stage revision for PJI was associated with failure of management. Identification of this change in the microorganism prior to commencement of the second stage may help target antibiotic management and could improve the success of surgery in these patients. Cite this article: Bone Jt Open 2023;4(9):720–727

Aims. This study aimed to evaluate the effectiveness of the induced membrane technique for treating infected bone defects, and to explore the factors that might affect patient outcomes. Methods. A comprehensive search was performed in PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases between 1 January 2000 and 31 October 2021. Studies with a minimum sample size of five patients with infected bone defects treated with the induced membrane technique were included. Factors associated with nonunion, infection recurrence, and additional procedures were identified using logistic regression analysis on individual patient data. Results. After the screening, 44 studies were included with 1,079 patients and 1,083 segments of infected bone defects treated with the induced membrane technique. The mean defect size was 6.8 cm (0.5 to 30). After the index second stage procedure, 85% (797/942) of segments achieved union, and 92% (999/1,083) of segments achieved final healing. The multivariate analysis with data from 296 patients suggested that older age was associated with higher nonunion risk. Patients with external fixation in the second stage had a significantly higher risk of developing nonunion, increasing the need for additional procedures. The autografts harvested from the femur reamer-irrigator-aspirator increased nonunion, infection recurrence, and additional procedure rates. Conclusion. The induced membrane technique is an effective technique for treating infected bone defects. Internal fixation during the second stage might effectively promote bone healing and reduce additional procedures without increasing infection recurrence. Future studies should standardize individual patient data prospectively to facilitate research on the affected patient outcomes. Cite this article: Bone Joint Res 2023;12(9):546–558