Aims. Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections. Methods. Between January 2019 and December 2022, 106 patients with bone and joint infections were treated by five surgeons in five hospitals. Surgical debridement and calcium sulphate bead insertion was performed for local elution of antibiotics in high concentration. In all, 100 patients were available for follow-up at regular intervals. Choice of antibiotic was tailor made for each patient in consultation with microbiologist based on the organism grown on culture and the sensitivity. In majority of our cases, we used a combination of vancomycin and culture sensitive heat stable antibiotic after a thorough debridement of the site. Primary wound closure was achieved in 99 patients and a split skin graft closure was done in one patient. Mean follow-up was 20 months (12 to 30). Results. Overall, six out of 106 patients (5.6%) presented with sepsis and poorly controlled comorbid conditions, and died in the hospital within few days of index surgery. Out of the remaining 100 patients, control of infection was achieved in 95 patients (95%). Persistence of infection was noted in five (5%) patients. Out of these 95 patients that had good control of infection, four patients (4.2%) with gap nonunion needed Masquelet procedure to achieve union. Conclusion. Our multicentre experience confirmed that surgical debridement along with calcium sulphate bead insertion was effective in treating bone and joint infections without any side effects and complications. Cite this article: Bone Jt Open 2023;4(7):516–522

Introduction. Rapid identification of bacteria from extemporaneous samples would greatly help management of prosthesis joint infection. The aim of the present retrospective study was to evaluate a new molecular assay (GeneXpert MRSA-SA SSTI (Cepheid)) for detecting Staphylococcus aureus (SA) and methicillin resistance directly from bone and joint samples in less an hour (58 minutes). Material et method. Retrospective study using 91 frozen samples (76 patients) of joints (n=24), bone biopsies (n=42) and tissue biopsies (n=25):. -. SA positive samples: n=72 (methicillin susceptible SA (MSSA), n=63; methicillin resistant MRSA, n=9). -. SA positive samples: n=19. The results were compared with routine results (culture in solid and liquid medium, identification and susceptibility test) from each participating lab. Results. The 72 SA positive samples gave:. -. 68 concordant positive results comprising:. . 9 MRSA positive samples,. . 56 MSSA positive samples,. . 3 MSSA positive samples, positive for SA but with inconclusive results for methicillin resistance. -. 4 negative discordant results for MSSA positive samples. The 19 SA negative samples gave:. . 16 concordant negative results. . 3 SASM positive results for negative culture of samples obtained from patients with other MSSA positive deep or superficial samples, suggesting a higher sensitivity for the GeneXpert test than culture in these cases. Sensitivity and specificty for bone and joint samples:. Se=68/72=94.4%. Sp=16/16=100%. Conclusion. The GeneXpert MRSA-SA SSTI assay provides 58-minute detection of MSSA and MRSA directly from bone and joint samples. Sensitivity and specificity were excellent in this preliminary study. This test may enable real-time peroperative diagnosis of Staphylococcus aureus, which could be very useful in the field of revision surgery. Further prospective studies should be done to accurately determine the PPV, NPV, and clinical and pharmaco-economic impact of this test in the setting of prosthesis joint infection

Gram staining is used as an initial indicator of synovial joint infection but has widely varied false negative rates in the literature. Clinical decisions are often made on the basis of gram stain results, such as whether a patient requires urgent surgery, and therefore it is important to understand the tests efficacy.

A retrospective review of synovial fluid aspirates in NHS Tayside for the years 2017 and 2018 was performed from the departmental microbiology database. Aspirates of large joints were included (hip, knee, shoulder, wrist, elbow, ankle). Any joints with prosthesis were excluded, including fixation metalwork. Any abscess overlying a joint that was not proven to penetrate the joint was also excluded. Initial gram stain results and formal culture results were reviewed. Final culture results were considered to be the gold standard to compare gram stain results to.

2167 samples were reviewed. Of these 1552 were excluded base on inclusion criteria. Of the remaining 615, 120 (19.5%) were culture positive. There were 33 positive gram stain results, 1 false positive and 32 true positive results. The sensitivity was 26.67% with a specificity of 99.80% (p=0.0001). The negative predictive value is 84.88% (CI 83.44% – 86.21%).

These results show that gram stain tests of native joints have a low sensitivity and poor negative predictive value. This is reflected in the current literature with prosthetic joints. Based on this study caution should be used when interpreting a negative gram stain result with appropriate safety netting and follow up required alongside clinical assessment.

Introduction. Microbiological diagnosis of bone and joint infections (BJIs) currently relies on standard cultures which are time consuming and lack sensitivity. Various molecular approaches have been described and allowed improvement of BJI diagnosis. This study evaluated for the first time the performance of a DNA microarray-based assay (Prove-it™ Sepsis assay, PISA) for the rapid (<6 hours) detection and identification of 50 different species involved in BJI directly from clinical samples. Material and methods. We retrospectively selected 130 bone and joint samples (67 synovial fluids and 63 bone biopsies) including 114 positive and 16 negative samples. The microbiological diagnosis had been previously established either by culture(C+, n=53) or by PCR16S and sequencing when culture was negative (C-/PCR+). The positive samples were selected to match the species targeted on the DNA microarray. DNA extraction was performed before proceeding to PISA amplification and hybridization on every selected sample. Results. Among the 16 negative samples, one was detected positive with S. epidermidis by PISA, result that was secondarily confirmed using specific PCR. Among the 114 positive samples, 62.3% were positive using PISA with highly concordant identification compared to culture and PCR16S/sequencing results. Forty-three samples (37.7%) remained negative, illustrating a defect of sensitivity. However, PISA accurately detected methicillin resistance not only among the 16 C+/PISA+ Staphylococcus species (n=5) but also among the 28 C-/PCR16S+ Staphylococcus species (n=12) offering crucial rapid information to adapt the treatment of staphylococcal BJIs. Seven polymicrobial samples were also identified without extensive experiments. Discussion – Conclusion. Even if the sensitivity deserves to be improved by optimizing DNA extraction and investigating on human DNA interference, these preliminary promising results highlight that this new and simple microarray method could be in the future an alternative to conventional PCR16S for the diagnosis of BJI

Aims. Monocyte-lymphocyte ratio (MLR) or neutrophil-lymphocyte ratio (NLR) are useful for diagnosing periprosthetic joint infection (PJI), but their diagnostic values are unclear for screening fixation-related infection (FRI) in patients for whom conversion total hip arthroplasty (THA) is planned after failed internal fixation for femoral neck fracture. Methods. We retrospectively included 340 patients who underwent conversion THA after internal fixation for femoral neck fracture from January 2008 to September 2020. Those patients constituted two groups: noninfected patients and patients diagnosed with FRI according to the 2013 International Consensus Meeting Criteria. Receiver operating characteristic (ROC) curves were used to determine maximum sensitivity and specificity of these two preoperative ratios. The diagnostic performance of the two ratios combined with preoperative CRP or ESR was also evaluated. Results. The numbers of patients with and without FRI were 19 (5.6%) and 321 (94.4%), respectively. Areas under the ROC curve for diagnosing FRI were 0.763 for MLR, 0.686 for NLR, 0.905 for CRP, and 0.769 for ESR. Based on the Youden index, the optimal predictive cutoffs were 0.25 for MLR and 2.38 for NLR. Sensitivity and specificity were 78.9% and 71.0% for MLR, and 78.9% and 56.4% for NLR, respectively. The combination of CRP with MLR showed a sensitivity of 84.2% and specificity of 94.6%, while the corresponding values for the combination of CRP with NLR were 89.5% and 91.5%, respectively. Conclusion. The presence of preoperative FRI among patients undergoing conversion THA after internal fixation for femoral neck fracture should be determined. The combination of preoperative CRP with NLR is sensitive tool for screening FRI in those patients. Cite this article: Bone Joint J 2021;103-B(9):1534–1540

Aims. Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited. Methods. Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year. Results. A total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection. Conclusion. Deep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures. Cite this article: Bone Jt Open 2021;2(11):958–965

Aims

Fracture-related infections (FRIs) are a devastating complication of fracture management. However, the impact of FRIs on mental health remains understudied. The aim of this study was a longitudinal evaluation of patients’ psychological state, and expectations for recovery comparing patients with recurrent FRI to those with primary FRI.

Aims

For displaced femoral neck fractures (FNFs) in geriatric patients, there remains uncertainty regarding the effect of total hip arthroplasty (THA) compared with hemiarthroplasty (HA) in the guidelines. We aimed to compare 90-day surgical readmission, in-hospital complications, and charges between THA and HA in these patients.

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

Aims

This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements.

Aims

The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

Antimicrobial resistance (AMR) is projected to result in 10 million deaths every year globally by 2050. Without urgent action, routine orthopaedic operations could become high risk and musculoskeletal infections incurable in a “post-antibiotic era.” However, current methods of studying AMR processes including bacterial biofilm formation are 2D in nature, and therefore unable to recapitulate the 3D processes within in vivo infection. Within this study, 3D printing was applied for the first time alongside a custom-developed bioink to bioprint 3D bacterial biofilm constructs from clinically relevant species including Staphylococcus aureus (MSSA), Methicillin-resistant staphylococcus aureus (MRSA), Escherichia coli and Pseudomonas aeruginosa. Bacterial viability and biofilm formation in bioprinted constructs was excellent, with confocal laser scanning microscopy (CSLM) used to demonstrate biofilm production and maturation over 28 days. Bioprinted 3D MRSA and MSSA biofilm constructs had greater resistance to antimicrobials than corresponding two-dimensional (2D) cultures. Thicker 3D E.coli biofilms had greater resistance to tetracycline than thinner constructs over 7 days of treatment. Raman spectroscopy was also adapted in a novel approach to non-invasively diagnose 3D bioprinted biofilm constructs located within a joint replacement model. In conclusion, mature bacterial biofilm constructs were reproducibly 3D bioprinted for the first time using clinically relevant bacteria. This methodology allows the study of antimicrobial biofilm penetration in 3D, and potentially aids future antimicrobial research, replicating joint infection more closely than current 2D culture models. Furthermore, by deploying Raman spectroscopy in a novel fashion, it was possible to diagnose 3D bioprinted biofilm infections within a joint replacement model

Aims

It is imperative to understand the risks of operating on urgent cases during the COVID-19 (SARS-Cov-2 virus) pandemic for clinical decision-making and medical resource planning. The primary aim was to determine the mortality risk and associated variables when operating on urgent cases during the COVID-19 pandemic. The secondary objective was to assess differences in the outcome of patients treated between sites treating COVID-19 and a separate surgical site.

Objectives. Deep bone and joint infections (DBJI) are directly intertwined with health, demographic change towards an elderly population, and wellbeing. The elderly human population is more prone to acquire infections, and the consequences such as pain, reduced quality of life, morbidity, absence from work and premature retirement due to disability place significant burdens on already strained healthcare systems and societal budgets. DBJIs are less responsive to systemic antibiotics because of poor vascular perfusion in necrotic bone, large bone defects and persistent biofilm-based infection. Emerging bacterial resistance poses a major threat and new innovative treatment modalities are urgently needed to curb its current trajectory. Materials and Methods. We present a new biphasic ceramic bone substitute consisting of hydroxyapatite and calcium sulphate for local antibiotic delivery in combination with bone regeneration. Gentamicin release was measured in four setups: 1) in vitro elution in Ringer’s solution; 2) local elution in patients treated for trochanteric hip fractures or uncemented hip revisions; 3) local elution in patients treated with a bone tumour resection; and 4) local elution in patients treated surgically for chronic corticomedullary osteomyelitis. Results. The release pattern in vitro was comparable with the obtained release in the patient studies. No recurrence was detected in the osteomyelitis group at latest follow-up (minimum 1.5 years). Conclusions. This new biphasic bone substitute containing antibiotics provides safe prevention of bone infections in a range of clinical situations. The in vitro test method predicts the in vivo performance and makes it a reliable tool in the development of future antibiotic-eluting bone-regenerating materials. Cite this article: M. Stravinskas, P. Horstmann, J. Ferguson, W. Hettwer, M. Nilsson, S. Tarasevicius, M. M. Petersen, M. A. McNally, L. Lidgren. Pharmacokinetics of gentamicin eluted from a regenerating bone graft substitute: In vitro and clinical release studies. Bone Joint Res 2016;5:427–435. DOI: 10.1302/2046-3758.59.BJR-2016-0108.R1

Peri-prosthetic wound infections can complicate total knee arthroplasty (TKA) in 1–1.5% of cases and may require the input of a combined orthopaedic and plastic surgery team. Failure of optimal management can result in periprosthetic joint infection, arthrodesis or in severe cases limb amputation. A retrospective 11-year review of TKA patients was undertaken in a single unit. Data was collected on a proforma and patient demographics were identified by case note analysis. Incidence of periprosthetic wound infections was recorded. A protocol to standardise treatment was subsequently developed following multidisciplinary input. 56 patients over 11 years developed periprosthetic wound infection. 33 patients were available for analysis. The male:female ratio 1:0.7 with a mean age of 70 years (range: 32–88 years). 5 (15%) developed superficial infections, 4 (12%) patients developed cellulitis requiring antibiotics, 14 (42%) with superficial wound dehiscence and 2 (6%) required washout of the prosthesis with long-term antibiotic therapy. 4 (12%) were managed without plastics involvement, one leading to arthrodesis and 4 (12%) had plastic surgical input, with one leading to arthrodesis. The mean time before plastic surgical review after initial suspicion of infection was 13 weeks. The management of periprosthetic wound infections following TKA are variable and can require a multidiscplinary ortho-plastic approach. Early plastic surgical involvement in specific cases may improve outcome. Our proposed management protocol would facilitate in standardising the management of these complex patients

Aims

Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture.

Background. Sterile Surgical Helmet System (SSHS) are used routinely in hip and knee arthroplasty in order to decrease the risk of infection. It protects surgeon from splash and also prevents contamination of surgical field from reverse splash by virtue of its perceived sterility. A prospective study was conducted to confirm if SSHS remain sterile throughout the procedure in Hip (THA) and Knee (TKA) Arthroplasty. We also evaluated if type of theatre had any effect on degree of contamination. Material and Methods. Visor area of 40 SSHS was swabbed at half hourly interval until the end of the procedure. Two groups of 20 each were made on the basis of theatre used for performing surgery. Group 1 (Gp1) had surgery performed in laminar flow and Group 2 (Gp2) in non-laminar flow theatre. Swabs collected were processed to compare the time dependent contamination of the SSHS and identify the organisms responsible for contamination. Results. Overall 80% (70% laminar, 90% non-laminar) of masks were contaminated by end of the procedure. There was a statistically significant difference in degree of contamination after direct inoculation while there was no statistical difference after 24 hrs of incubation. Coagulase negative Staphylococcus was the most common bacteria grown in both the groups. Conclusion. SSHS lose their sterility peroperatively due to airborne contamination, mandating prompt change of gloves in case of active contact with them to avoid the bacterial transmission into surgical wound and catastrophic joint infection

Aims

This study aimed to investigate the role of quantitative histological analysis in the diagnosis of fracture-related infection (FRI).

We undertook a retrospective case-control study to assess the clinical variables associated with infections in open fractures. A total of 1492 open fractures were retrieved; these were Gustilo and Anderson grade I in 663 (44.4%), grade II in 370 (24.8%), grade III in 310 (20.8%) and unclassifiable in 149 (10.0%). The median duration of prophylaxis was three days (interquartile range (IQR) 1 to 3), and the median number of surgical interventions was two (1 to 9). We identified 54 infections (3.6%) occurring at a median of ten days (IQR 5 to 20) after trauma. Pathogens intrinsically resistant to the empirical antibiotic regimen used (enterococci, Enterobacter spp, Pseudomonas spp) were documented in 35 of 49 cases (71%). In multivariable regression analyses, grade III fractures and vascular injury or compartment syndrome were significantly associated with infection. Overall, compared with one day of antibiotic treatment, two to three days (odds ratio (OR) 0.6 (95% confidence interval (CI) 0.2 to 2.0)), four to five days (OR 1.2 (95% CI 0.3 to 4.9)), or > five days (OR 1.4 (95% CI 0.4 to 4.4)) did not show any significant differences in the infection risk. These results were similar when multivariable analysis was performed for grade III fractures only (OR 0.3 (95% CI 0.1 to 3.4); OR 0.6 (95% CI 0.2 to 2.1); and OR 1.7 (95% CI 0.5 to 6.2), respectively).

Infection in open fractures is related to the extent of tissue damage but not to the duration of prophylactic antibiotic therapy. Even for grade III fractures, a one-day course of prophylactic antibiotics might be as effective as prolonged prophylaxis.

Cite this article: Bone Joint J 2013;95-B:831–7.