Introduction. Identification of the causative pathogen in musculoskeletal infection is critical as it directs further treatment. Fracture-related infection is often associated with ‘no growth’ in standard culture. We investigated the efficiency of two alternate methods to identify the causative pathogen, namely extended bacterial culture and 16Sr RNA gene sequence analysis with next generation sequencing (NGS) in ‘culture negative’ fracture related infections. Method. Patients were diagnosed as having fracture related infection based on the MSIS criteria (n=120). All patients had samples taken for culture and sensitivity. All samples which were culture negative by standard culture methods formed the study group. These samples were subjected to further extended culture in both aerobic and anaerobic medium for 14 days to improve recovery of pathogens. Further, DNA isolated from implants from a sub-group of these culture negative patients were subjected to 16SrRNA gene amplification followed by Sanger sequencing. Subsequent sequencing analysis was performed using the Illumina NGS platform which identified and detected the most abundant genera/species present in those samples more precisely. Result. 57 culture negative samples formed the study group. Eight samples (14%) converted to positivity after 14 days of culture. Bacteroides fragilis was the commonest yield. 14 samples underwent 16SrRNA gene amplification followed by Sanger sequencing. Acinetobacter baumannii, Enterococcus faecalis, Pseudomonas aeruginosa were identified as common pathogens. Next generation sequencing (n=12) not only identified common pathogens like as Staphylococcus, Acinetobacter baumannii, but also many uncultivable species. Conclusion. Positive results from extended bacterial culture are about 15%. The delay in definite identification of pathogens in extended culture may be critical in certain clinical situations. Molecular methods are quicker and have additional yield in culture negative infections. The exact role of all microorganisms identified by molecular methods in the pathogenesis of infection is unknown

Summary Statement. Using the latest Next Generation Sequencing technologies, we have investigated miRNA expression profiles in human trabecular bone from total hip replacement (THR) revision surgery where wear particle associated osteolysis was evident. Introduction. A major problem in orthopaedic surgery is aseptic loosening of prosthetic implants caused by wear particle associated osteolysis. Wear debris is known to impact on a variety of cellular responses and genes in multiple pathways associated with the development of the periprosthetic osteolysis. MicroRNAs (miRNAs) act as negative regulators of gene expression and the importance of miRNAs in joint pathologies has only recently been addressed. However, miRNA profiles in osteolytic bone are largely unknown. Using the latest Next Generation Sequencing technologies, we have investigated miRNA expression profiles in human trabecular bone sourced from bone discarded during total hip replacement (THR) revision surgery where wear particle associated osteolysis was evident. Patients and Methods. Three groups of gender and age-matched patients (n=9 per group) were recruited for this study including patients undergoing revision surgery, primary THR patients and healthy subjects. Total RNAs were prepared from trabecular bone specimens. The cDNA libraries were constructed using a TruSeq Small RNA Sample Preparation kit, and then sequenced on an Illumina HiSeq2000 sequencer. All good quality tags were aligned against the reference sequences containing human chromosomal sequences and 18s and 28s rRNA sequences were analysed using Bowtie software. We used miRBase v19 to identify the start positions of all mature miRNA and the edgeR package to analyse differential expression. Osteogenesis pathway-related gene expression was also investigated using RT-qPCR Array assay. Results. We observed a significant difference in expressed miRNAs between revision and primary THR groups, including upexpressed miR127, miR-409, miR-211 and miR-146a. Importantly, the miR-127 (3.1 fold, p=0.005) and miR-146a (3.5 fold, p=0.001) were not only upexpressed in the revision group vs primary group, but also upexpressed in the revision group vs the healthy group. Thus, miR-127 and miR-146a may have potential as both biomarkers to predict osteolysis and as therapeutic targets. The miR-127 and miR-146a are critical in bone diseases because some of their target genes play an important role in osteogenesis. We have thus studied osteogenic genes and confirmed that SMAD4, RUNX2, FGFR1, TGFβ1, COL1A1 and WNT4 were downregulated. Our data also revealed that miR-93 and miR-204a were downexpressed (−3.7 fold, p=0.023; −2.5, p=0.003 respectively) and t IL-6 and IL-6R, which had been reported as miR-204 target genes, were upexpressed. Discussion and Conclusion. Our results showed that upexpressed miR-127, miR-146a, miR-204a and miR-93 in trabecular bone from revision THR may be the key negative regulators in either osteogenic genes involved in osteogenic differentiation of bone formation or inflammatory genes involved in osteoclastogenesis. Aberrant miRNA expressions identified in the revision THR group may also suggest the existence of genetic risk factors favouring the development of osteolysis in certain specific subgroups of patients. An in-depth understanding of the roles of these regulatory miRNAs in the skeleton warrants further investigation