Bone and joint infection (BJI) represents a major complication in orthopaedic and trauma surgery, with incidence rates of 24/100,000 inhabitants for periprosthetic joint infection (PJI),1 17/100,000 inhabitants for osteomyelitis,2 and 11/100,000 inhabitants for fracture-related infection (FRI) in Germany.3 Steadily increasing primary arthroplasty procedures and numbers of fractures will further boost implant-associated infections.4 The choice of treatment is usually complex, depending on multiple factors such as soft-tissue and implant condition, duration of infection, the underlying pathogen, and the patient’s morbidity.5-7 Surgical strategies range from debridement of necrotic bone and implant retention in the case of stable implants and acute infection, to implant exchange in a one-stage, two-stage, or even multi-stage surgical treatment when infection is chronic or implants are loosened. Patients are faced with immobility up to amputation of the affected limb, pain, prolonged stay in hospital, the administration of local and systemic antibiotics with common side effects, and, consequently, reduced quality of life.8,9 Although classification systems and treatment algorithms have been developed,5,10 the uncertainty of surgeons regarding BJI treatment decision-making has been highlighted in a recent qualitative analysis.11 As the adequate treatment of BJI requires the consideration of multiple factors, case discussions between experts of different disciplines could enhance BJI management and research. Therefore, in order to achieve the best outcome for the patient, interdisciplinary approaches and early involvement of multidisciplinary teams are deemed important.12,13 Analogous to oncology, where interdisciplinary tumour boards have become an evidence-based gold standard in cancer therapy,14,15 collaborative approaches for the management of BJI should be supported.10 In addition, such interdisciplinary management complements the efforts of antibiotic stewardship programmes, and will play a key role in reducing the development of antimicrobial resistance.16 Going further, the establishment of a nationwide system with improved communication between centres specialized in treating BJI can also be beneficial as shown, for instance, in France.17
Ferguson et al18 recently investigated the impact of a multidisciplinary bone infection unit undertaking osteomyelitis surgery with a single-stage protocol on clinical outcomes and healthcare use. In comparison to national outcomes in England, the authors reported reduced hospital stays, lower reoperation rates for infection recurrence, improved survival, lower amputation rates, and lower overall healthcare use, advocating the establishment of centrally funded multidisciplinary bone infection units. A similar approach with valuable clinical experiences is reported by Carlson et al,19 with a collaboration between infectious disease clinicians and orthopaedic arthroplasty surgeons to optimize PJI treatment, which they termed “arthroplasty infection service”. Finally, Ntalos et al20 compared treatment outcomes of spondylodiscitis patients, whose treatment strategy was either established by a single discipline approach or by a weekly multidisciplinary infection conference consisting of orthopaedic surgeons, medical microbiologists, infectious disease specialists, and pathologists. The latter cohort showed reduced days of total antibiotic treatment, and the treatment plan differed between the groups. The same working group further demonstrated that patients treated for PJI of the hip had shorter in-hospital stay, reduced numbers of surgeries, and fewer antibiotics when discussed in a multidisciplinary setting.21 In addition, Bauer et al22 analyzed files of patients treated for bone and joint infection before and after the implementation of a multidisciplinary staff meeting, reporting optimized adaptation of antibiotic therapy. Furthermore, Kotsougiani-Fischer et al23 reported their experiences of multidisciplinary team meetings for patients with severe limb defects, concluding that such meetings represent a valid tool to tailor individualized treatment plans avoiding limb amputation.
In conclusion, based on findings in the literature, interdisciplinary approaches should be implemented as a standard of patient care in trauma surgery to further improve clinical outcomes in the treatment of BJI, as is already common practice in oncology.
1. Walter N , Rupp M , Hinterberger T , Alt V . [Prosthetic infections and the increasing importance of psychological comorbidities: An epidemiological analysis for Germany from 2009 through 2019] . Orthopade . 2021 ; 50 ( 10 ): 859 – 865 . (Article in German) Google Scholar
2. Walter N , Baertl S , Alt V , Rupp M . What is the burden of osteomyelitis in Germany? An analysis of inpatient data from 2008 through 2018 . BMC Infect Dis . 2021 ; 21 ( 1 ): 550 . Google Scholar
3. Walter N , Rupp M , Lang S , Alt V . The epidemiology of fracture-related infections in Germany . Sci Rep . 2021 ; 11 ( 1 ): 10443 . Google Scholar
4. Rupp M , Lau E , Kurtz SM , Alt V . Projections of primary TKA and THA in Germany from 2016 through 2040 . Clin Orthop Relat Res . 2020 ; 478 ( 7 ): 1622 – 1633 . Google Scholar
5. Wimmer MD , Randau TM , Petersdorf S , et al. Evaluation of an interdisciplinary therapy algorithm in patients with prosthetic joint infections . Int Orthop . 2013 ; 37 ( 11 ): 2271 – 2278 . Google Scholar
6. Metsemakers WJ , Kuehl R , Moriarty TF , et al. Infection after fracture fixation: Current surgical and microbiological concepts . Injury . 2018 ; 49 ( 3 ): 511 – 522 . Google Scholar
7. Walter G , Kemmerer M , Kappler C , Hoffmann R . Treatment algorithms for chronic osteomyelitis . Dtsch Arztebl Int . 2012 ; 109 ( 14 ): 257 – 264 . Google Scholar
8. Walter N , Rupp M , Hierl K , et al. Long-term patient-related quality of life after knee periprosthetic joint infection . J Clin Med . 2021 ; 10 ( 5 ): 907 . Google Scholar
9. Walter N , Rupp M , Hierl K , et al. Long-term patient-related quality of life after fracture-related infections of the long bones . Bone Joint Res . 2021 ; 10 ( 5 ): 321 – 327 . Google Scholar
10. Alt V , Rupp M , Langer M , Baumann F , Trampuz A . Can the oncology classification system be used for prosthetic joint infection?: The PJI-TNM system . Bone Joint Res . 2020 ; 9 ( 2 ): 79 – 81 . Google Scholar
11. Moore AJ , Blom AW , Whitehouse MR , Gooberman-Hill R . Managing uncertainty - a qualitative study of surgeons’ decision-making for one-stage and two-stage revision surgery for prosthetic hip joint infection . BMC Musculoskelet Disord . 2017 ; 18 ( 1 ): 154 . Google Scholar
12. Vasoo S , Chan M , Sendi P , Berbari E . The value of Ortho-ID teams in treating bone and joint infections . J Bone Jt Infect . 2019 ; 4 ( 6 ): 295 – 299 . Google Scholar
13. Metsemakers WJ , Onsea J , Neutjens E , et al. Prevention of fracture-related infection: a multidisciplinary care package . Int Orthop . 2017 ; 41 ( 12 ): 2457 – 2469 . Google Scholar
14. El Saghir NS , Keating NL , Carlson RW , Khoury KE , Fallowfield L . Tumor boards: optimizing the structure and improving efficiency of multidisciplinary management of patients with cancer worldwide . Am Soc Clin Oncol Educ Book . 2014 ; e461 - 6 . Google Scholar
15. Taylor C , Munro AJ , Glynne-Jones R , et al. Multidisciplinary team working in cancer: what is the evidence? BMJ . 2010 ; 340 : c951 . Google Scholar
16. Pickens CI , Wunderink RG . Principles and Practice of Antibiotic Stewardship in the ICU . Chest . 2019 ; 156 ( 1 ): 163 – 171 . Google Scholar
17. Ferry T , Seng P , Mainard D , et al. The CRIOAc healthcare network in France: A nationwide Health Ministry program to improve the management of bone and joint infection . Orthop Traumatol Surg Res . 2019 ; 105 ( 1 ): 185 – 190 . Google Scholar
18. Ferguson J , Alexander M , Bruce S , O’Connell M , Beecroft S , McNally M . A retrospective cohort study comparing clinical outcomes and healthcare resource utilisation in patients undergoing surgery for osteomyelitis in England: a case for reorganising orthopaedic infection services . J Bone Jt Infect . 2021 ; 6 ( 5 ): 151 – 163 . Google Scholar
19. Carlson VR , Dekeyser GJ , Certain L , Pupaibool J , Gililland JM , Anderson LA . Clinical experience with a coordinated multidisciplinary approach to treating prosthetic joint infection . Arthroplast Today . 2020 ; 6 ( 3 ): 360 – 362 . Google Scholar
20. Ntalos D , Schoof B , Thiesen DM , et al. Implementation of a multidisciplinary infections conference improves the treatment of spondylodiscitis . Sci Rep . 2021 ; 11 ( 1 ): 9515 . Google Scholar
21. Ntalos D , Berger-Groch J , Rohde H , et al. Implementation of a multidisciplinary infections conference affects the treatment plan in prosthetic joint infections of the hip: a retrospective study . Arch Orthop Trauma Surg . 2019 ; 139 ( 4 ): 467 – 473 . Google Scholar
22. Bauer S , Bouldouyre M-A , Oufella A , et al. Impact of a multidisciplinary staff meeting on the quality of antibiotherapy prescription for bone and joint infections in orthopedic surgery . Med Mal Infect . 2012 ; 42 ( 12 ): 603 – 607 . Google Scholar
23. Kotsougiani-Fischer D , Fischer S , Warszawski J , et al. Multidisciplinary team meetings for patients with complex extremity defects: a retrospective analysis of treatment recommendations and prognostic factors for non-implementation . BMC Surg . 2021 ; 21 ( 1 ): 168 . Google Scholar
N. Walter: Conceptualization, Writing – original draft.
M. Rupp: Conceptualization, Writing – original draft, Project administration.
S. Baertl: Conceptualization, Writing – review & editing.
V. Alt: Conceptualization, Supervision, Writing – review & editing.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
ICMJE COI statement
The authors declare no competing interests.
We acknowledge the valuable work of all members of the Extremity board implemented at the University Medical Center Regensburg.