The role of diathermy in orthopaedic surgical practice has increased since its introduction. It is widely used for underlying tissue dissection, cutting, and haemostasis. Previous studies have compared electrosurgical and scalpel incisions in terms of wound infection, wound-related pain, and blood loss. There are well documented hazards associated with diathermy use including burns injury, electrocution, hypoxic stress, inhalation of diathermy plume, and gene mutation. No single study to date has focused on the potential for diathermy tips to cause wound contamination and infection. We sought to identify whether diathermy tips could be possible sources of infection in orthopaedic procedures.

To determine the prevalence of bacterial contamination of diathermy tips during orthopaedic surgery and to assess any correlation with surgical site infections.

From July 2013 to September 2013, the diathermy tips from 86 consecutive orthopaedic procedures using diathermy were cultured using direct and enriched media. None of the diathermy tips were used for the skin incision. All patients underwent an orthopaedic procedure for a non-infected condition. For each procedure an unused control diathermy tip was placed on the instrument table at the beginning of the procedure and processed similarly. All patients were followed for any postoperative complications.

108 diathermy tips from 86 orthopaedic procedures were cultured. None of the tips cultured directly on blood agar demonstrated bacterial growth. Following enrichment culture, 6 (5.6%) of the procedure diathermy tips and 1 (0.92%) of the control tips demonstrated bacterial growth. Coagulase-negative staphylococci (83.3%) and proprionibacterium (16.7%) were cultured from the tips. 1 of the patients who had bacterial growth from the diathermy tip developed a superficial surgical site infection.

Surgical site infections contribute substantially to orthopaedic surgical morbidity and mortality each year. The prevention of these infections encompasses careful operative technique, preoperative antibiotics, and a number of important measures to minimize the risk of bacterial contamination posed by operative staff, the operating theatre environment, and the patient's endogenous skin flora. Identifying potential bacterial sources is an important component of surgery. The two bacteria cultured in our study (coagulase-negative staphylococci and proprionibacterium) are both well known major culprits in orthopaedic infections, responsible for up to 70% of early and late peri-prosthetic infections. Our study suggests diathermy tips and the tissue coagulated by its use may not be as sterile as previously thought. There may be benefit in changing the diathermy tips during orthopaedic procedures as they may represent a possible source of bacterial contamination.

Septic arthritis is a therapeutic emergency with a high mortality rate (about 11%)(1). Inadequate treatment can cause permanent joint damage. Management of the septic arthritis includes prompt antibiotic treatment as well as joint-decompression and removal of purulent material(2). It is still discussed controversially and there is little evidence which surgical concept is preferable: arthroscopy with lavage and debridement or open arthrotomy with synovectomy(3,4). The aim of the study was to compare efficacy of arthroscopy and arthrotomy in patients with septic gonarthritis.

We evaluated 70 consecutive patients who underwent arthroscopy or arthrotomy at our clinic, because of a bacterial monarthritis of the knee between 2002 and 2010. Our primary outcome was the early recurrence of infection (> 3 months after surgery), which made a second surgery necessary. We compared patients who suffered reinfection and those who did not, in regard to the surgery type as well as potential confounders like comorbidity (measured by Charlson comorbidity index), age, body mass index (BMI), Gächter's -, Kellgren and Lawrence - and Outerbridge classification, duration of symptoms and inflammatory parameters. Furthermore we evaluated differences of the confounders between the surgery groups.

From the 70 patients 41 were treated arthroscopic and 29 with arthrotomy. In total eight patients (11.4%) had to undergo a second surgery because of early reinfection. The rate was significantly higher in patients treated with arthrotomy (n=6; 20.7%) compared to those treated with arthroscopy (n=2; 4.9%) (p=0.041). Whereas we found no significant influence of potential confounders between the reinfection group and the group where primary eradication was achieved. Patients who underwent arthrotomy were significantly older, had more comorbidities (both p<0.001) and higher grades of osteoarthritis according to Kellgren and Lawrence classification (p=0.023). In order to adjust the study population towards confounders we performed a subgroup analysis on patients of the second and third age percentile. When we repeated our analysis we still found a significant higher reinfection rate in the arthrotomy group (p=0.036). At the same time there were no differences in prevalence of confounders, neither between the two surgery groups, nor between the reinfection and the primary eradication group.

Patients with bacterial monarthritis of the knee who were treated with arthroscopy had a significantly lower reinfection rate than those treated with arthrotomy. As arthroscopy is the less invasive and more sufficient method it should be considered the routine treatment according to our data.

Treatment of open fractures is complex and controversial.

The purpose of the present study is to add evidence to the management of open tibial fractures, where tissue loss necessitates cover with a free flap. We identified factors that increase the risk of complications. We questioned whether early flap coverage improved the clinical outcome and whether we could improve our antibiotic treatment of open fractures. From 2002 to 2013 we treated 56 patients with an open tibial fracture covered with a free flap. We reviewed patient records and databases for type of trauma, smoking, time to tissue cover, infection, amputations, flap loss and union of fracture. We identified factors thatincrease the risk of complications. We analyzed the organisms cultured from open fractures to propose the optimal antibiotic prophylaxis.

Follow-up was minimum one year. Primary outcome was infection, bacterial sensitivity pattern, amputation, flap failure and union of the fracture.

When soft tissue cover was delayed beyond 7 days, infection rate increased from 27% to 60% (p<0.04). High-energy trauma patients had a higher risk of amputation, infection, flap failure and non-union. Smokers had a higher risk of non-union and flap failure. The bacteria found were often resistant to Cefuroxime, aminoglycosides or amoxicillin, but sensitive to Vancomycin or Meropenem.

Flap cover within one week is essential to avoid infection. High-energy trauma and smoking are important predictors of complications. We suggest antibiotic prophylaxis with Vancomycin and Meropenem until the wound is covered in these complex injuries.

The authors wish to thank Christian E Forrestal for secretarial assistance, spreadsheets and figures, MD Maria Petersen for academic feedback and typography.

Table: Culture results. Depicts the organisms isolated from the wounds, their number N and the number of bacteria that were fully susceptible to antibiotics according to the culture results in falling order on day 2–30 from the trauma. Most organisms were resistant to Cefuroxime. A blank space denotes that the organism was not tested against this antibiotic. A “0” denotes that the organism was not fully sensitive to the antibiotic.

Almost any kind of bacteria can be involved in prosthetic joint infections (PJI).

In 2014 we collected data on 3 patients presenting with hip or knee pain and radiological signs of prosthetic joint mobilization without any other clinical or biochemical suspect of infection.

Interestingly, in all cases we isolated bacteria very rarely involved in human infections: Cupriavidus pauculus, Ralstonia paucula and Neisseria flavescens. Both Cupriavidus pauculus and Ralstonia paucula are Gram negative environmental bacteria which can contaminate water (tap, pool and mineral) and have been isolated from a variety of human clinical sources including blood, wounds, sputum, urine, eye, throat and peritoneal fluid, as non pathogenic flora. In such two patients we were able to cure the infection with quinolones (both strains were sensible). Neisseria species are Gram-negative bacteria included among the proteobacteria. Neisseria flavescens is often found in the upper respiratory tract and oropharynx of humans, rarely associated with infectious process (necrotizing pneumonia and empyema). In this last patient we successfully used piperacillin-tazobactam i.v. during hospitalization and shifted to amoxicillin-clavulanate per os at discharge.

In conclusion, any bacteria can induce PJI: in some cases pre-operative blood tests are normal and therefore useless. We need new tests to overcome this diagnostic problem (such as alpha-defensin) and we must check on rare bacteria prolonging incubation to a more extended period of time (as in Propionebacterium acnes or Mycobacterium spp) and/or sending samples to specialized laboratories.

We thank all the medical and nurse staff of Prosthetic Joint Replacement Unit of Orthopaedic Center, Humanitas Research Hospital

The aim of this study was to compare the clinical and radiographic results of a interlocking nail with a releasing antibiotic core of PMMA with a standard interlocking nail for the treatment of open fractures of the tibia.

Prospective, controlled trial, randomized by surgeon preference, including 30 patients with open fractures of the tibia. Patients were divided into two groups according to the treatment method: Group I (STD), consisting of 14 patients treated by delayed interlocking standard nailing, after an antibiotic treatment and bed rest. Group II (SAFE) comprising 16 patients treated with a interlocking intramedullary nail with a core of PMMA cement with antibiotics, 5 of which had a temporary stabilization with an external fixator. Antibiotics chosen to impregnate the SAFE nail in cases without prior bacteriology were vancomycin (2gr) and flucloxacillin (2gr)

There were no statistically significant differences between groups with respect to demographic data (age, gender), type of fracture and degree of exposure (p>0,05). The mean follow-up was 2.4 years (5 months to 4 years) for the STD group and 2.1 years (4 months to 3 years) for the SAFE group. 15 of the 30 patients had positive bacteriology, including 13 cases with aggressive agents predominating Enterobacter, Enterococcus, Pseudomonas and MSSA groups.

The infection rate after nailing was 43% (6/14 patients) for the STD group and 6% (1/16 cases) to the SAFE group, a statistically significant difference (p=0.02)

The mean time to union was 7.5 months (3 months to 1.5 years) for the STD group and 4.5 months (2 months to 8.5 months) for the SAFE group, a statistically significant difference (p=0.02). The complication rate was 64% (9/14) in the STD group and 25% (4/16) for the SAFE, including a infection rate of 43% in the STD group and 6% in the SAFE group, a statistically significant difference (p=0.03).

We observed that the open fractures of the tibia treated with SAFE nails presented a statistically significant lower rate of infection, faster consolidation and fewer complications compared with treatment with deferred standard nails. Compared to similar devices available on the market, it has the advantage of allowing selection of the type and dose of antibiotics, it allows fixation with screws of intermediate bone segments, it shorten the period of hospitalization and treatment time, reducing the costs associated with the treatment of this pathology

The goal of this paper is to compare the results and complication namely infection rates, of the techniques of Standard Ilizarov lengthening, lengthening over nail (LON) and lengthening then nailing (LTN) utilizing a standard nail (STD) and a special nail with a core of cement releasing antibiotics (SAFE).

In a first study done between 1993 and 2008, we have compared 25 patients treated with lengthening with a Ilizarov frame (LIF) with 26 patients where a standard nail was used to do a lengthening over nail technique (LON).

From 2009 and 2012 we have utilized the SAFE nail in 17 patients to perform lengthening over nail (SAFE-LON) and lengthening then nailing (SAFE-LTN) techniques. 7 patients had a pseudarthrosis, 5 a malconsolidation with shortening and or axial deviation and 5 a bone loss after infection of total knee replacements.

We used a lengthening over nail in 4 cases, a lengthening and axial correction then nailing in three, acute compression and proximal lengthening then nailing in five patients and knee arthrodesis and femoral or tibial lengthening then nailing in another 5 cases. We have used a Ilizarov frame in all cases.

We found that with LON technique, the external fixation time was 3 times lower, promoting the recovery of full range of knee mobility in half the time, comparatively with LIF technique, with statistically very significant differences.

We found a rate of 30% of intercurrences on the LON group and 24% in the Ilizarov, difference that was not statistically significant. 3 patients got bone infection after LON technique, a rate of 11.5%. Late consolidation and fracture of regenerate appeared only in the Ilizarov technique group, whereas in the LON technique we had 3 cases of premature consolidation of the regenerate.

In the SAFE-LON and SAFE-LTN techniques utilizing the SAFE nail with antibiotics, we found a decrease of the overall intercurrence rate from 30% to 12% and namely, bone infection was cured or didn't appeared after nailing with this new device in all cases.

LON and LTN techniques are somehow more demanding, but much more comfortable for the patient, which need to carry the frame for less time, It permits an earlier return to activity, about half the time, it controls better delayed regenerate and its fracture does not increase complication rate and costs of treatment and prevents infection when converting from external to internal fixation.

There is an apparent need for easily accessible research data on Periprosthetic hip joint infections (PJI)(1). Administrative discharge registers could be a valuable single-sources for this purpose, and studies originating from such registers have been published(2–4). However, the quality of routinely collected data for administrative purposes may be questionable for use in epidemiological research. The aim of this study was to estimate the positive predictive value of the International Classification of Disease 10th revision (ICD-10) periprosthetic hip joint infection diagnose code T84.5.

The study was performed as a cross-sectional study on data extracted from the Danish National Patient Register. Patients with a registration of performed surgical treatment for hip PJI were identified via the ICD-10 code T84.5 (Infection and inflammatory reaction due to internal joint prosthesis) in association with hip-joint associated surgical procedure codes. Medical records of the identified patients (n=283) were verified for the existence of a periprosthetic hip joint infection. Positive predictive values with 95% confidence intervals (95% CI) were calculated.

A T84.5 diagnosis code irrespective of the associated surgical procedure code had a positive predictive value of 85 % (95% CI: 80–89). Stratified to T84.5 in combination with an infection-specific surgical procedure code the positive predictive value increased to 86% (95% CI: 80–91), and in combination with a noninfection-specific surgical procedure code decreased to 82% (95% CI: 72–89).

This study is the first to evaluate the only discharge diagnose code of prosthesis-related infection in an administrative discharge register. It is apparent, that codes in administrative discharge registers are prone to misclassification on an administrative level, either by wrongful coding by the physician or administrative personal in the registration process. Misclassification must be expected and taken into consideration when using single-source administrative discharge registers for epidemiological research on periprosthetic hip joint infection. We believe that the periprosthetic hip joint infection diagnose code can be of use in single-source register based studies, but preferably should be used in combination with alternate data sources to ensure higher validity(5)

This study is funded in part by the Lundbeck foundation Centre for Fast-track Hip and Knee Surgery, Denmark.

To evaluate the proportion of microbial associations causing PJI, diversity of their strains and impact on treatment failure after the removal of the hip implant and insertion of a spacer.

Spectrum of pathogens in 189 cases of PJI was studied retrospectively. Strains were isolated from the joint aspirates, tissue samples and removed orthopedic devices. The cohort comprised 144 cases of PJI after primary THA and 45 cases after the hip replacement revision surgery. All patients underwent first stage of two-stage revision procedure which involves the removal of a hip implant, debridement of infected periprosthetic tissues and subsequent insertion of a bone cement spacer. There were 92 males and 97 females (median age of 57 yrs). Statistical analysis of the results was performed with GraphPad Prism 6.0 (California, USA).

Microbial associations were detected in 28.6% (n=54) of PJI cases. Gram-positive bacteria prevailed in both groups with mono- and polymicrobial etiology. There were 52.5% of S. aureus isolates in monomicrobial group and 25% isolates in polymicrobial group (p=0.0002). This also included 8.4 and 20.6% isolates of MRSA, respectively (p<0.0001). CNS were detected in 20.1% of mono- and 27.9% of polymicrobial infection isolates, including about 40% of MRSE in both groups. Gram-negative pathogens accounted for 25.7% of isolates in polymicrobial group and 14.1% in monomicrobial group (p=0.022). Non-fermenting bacteria prevailed among Gram-negative strains presented in associations. Acinetobacter sp. and P. aeruginosa were identified in 7.4% (p=0.043) and 5.1% (p=0.56) of polymicrobial isolates. The percentage of treatment failure after the removal of the hip implant and insertion of a spacer was considerably higher (p<0.0001) in patients with polymicrobial than monomicrobial infection: 72.2 vs 25.2%, respectively. The proportion of isolates in microbial associations involving Gram-negative pathogens was 61.5% in patients with infection recurrence and 26.7% in patients with a successful outcome of the surgery (p=0.033).

Microbial associations were found in 28.6% of PJI cases after hip arthroplasty. They posed a significant risk for treatment failure after removal of the hip implant and insertion of a spacer. The multidrug-resistant strains (MRSA, Acinetobacter sp. and P. aeruginosa) were often isolated in microbial associations. Our results suggest that further study of the risk factors for polymicrobial infection is necessary in patients with PJI. Identification of a patient group at high risk for developing polymicrobial PJI will allow prescription of empiric antimicrobial therapy in time, taking into account possible multi-resistant pathogens.

Evaluation of the surgical approach and treatment outcomes in patients with chronic osteomyelitis of the tibia classified as anatomic type 3 and 4, physiologic class B (Cierny-Mader).

Analysis of surgical treatment of 68 patients (average age of 45.6 years) with chronic osteomyelitis of the tibia covered the period from June 1, 2013 till January 1, 2015. There were 49 males (72%). The first (I) group included 39 patients with type 3 chronic osteomyelitis of the tibia, the second (II) group – 29 patients with type 4 osteomyelitis. The follow-up was for 1–18 months. Duration of the surgery, intraoperative blood loss, causes of osteomyelitis and the frequency of infection recurrence were evaluated.

In the group I, 33.3% of patients underwent debridement of the infected site and replacement of the bone defect with an antibiotic-laden cement spacer. In 28.2% of cases, a biodegradable antibiotic delivery system was used for the replacement. 23.1% of cases involved muscle flap coverage of the bone and tissue defect, while 15.4% – treatment with external fixation. In the group II, the proportion of cases treated with external fixation was 58.6%. It was higher than in group I (p<0.01). 27.6% of patients in this group had their defects replaced with an antibiotic-laden cement spacer, whereas 10.3% had muscle flap coverage. One patient had amputation of the tibia.

Duration of the surgery and blood loss in group II was 2.4 and 1.7 times higher than in group I. The frequency of infection recurrence in both groups was comparable (about 13%). The average time of its manifestation was 20.8 days in group II and 41.6 days in group I. Infection recurrence after muscle flap coverage was not observed. S.aureus was the most common pathogen in both groups (50–60%). Microbial associations were isolated in 28.3 and 38% of cases in groups I and II, respectively. 33.3% of patients experienced infection caused by P.аeruginosa.

Differences in the blood loss and duration of the surgery were due to the larger volume of the affected tissues in type 4 chronic osteomyelitis of the tibia. High frequency of infection recurrence was observed in patients with microbial associations and P.aeruginosa. The surgical treatment of choice for these patients might be muscle flap coverage. It is necessary to consider the type of a pathogen for systemic and local antimicrobial therapy.

We herein report a case of isolated hip pain in a four year old boy. The importance of this project is the unusual history, presentation, ultrasound, MRI and blood culture results and treatment, which lead to the diagnosis of adductor pyomyositis with a rare organism (Streptococcus Mitis) in a temperate country.

The patient presented with a one day history of malaise, fever, left groin pain and inability to weight bear on the left leg. There was no history of any predisposing infections or recent travel. A working diagnosis of transient synovitis / septic arthritis of the hip was made on clinical examination.

Plain radiograph and ultrasound of the hip was normal with no effusion. Two consecutive blood cultures suggested Streptococcus Mitis bacteriaemia and MRI scan confirmed pyomyositis of the left hip adductors that was too small to drain. Streptococcus Mitis is a normal commensal organism of the oral cavity however it can lead to opportunistic infections particularly endocarditis. Echocardiogram revealed no cardiac complications, in particular no endocarditic vegetation.

Patient was treated with intravenous benzylpenicillin for a week followed by oral phenoxymethylpenicillin for a week. As it was a soft tissue infection, a short course of antibiotics was sufficient and he made a complete recovery. Adductor pyomyositis must be considered as a differential diagnosis in a child with unusual presentation of hip pain. When an ultrasound is normal, MRI scan is warranted to confirm diagnosis. Septic screen should include blood cultures. The commonest organisms are the Staphylococcus family. However if Streptococcus Mitis is isolated, cardiac sources of infection resulting in septic emboli must be investigated. Repeated MRI scans are required particularly if the patient does not respond to medical management

The purpose of this study was to evaluate the accuracy of the sonication fluid cultures (SFC) for the diagnosis of prosthetic joint infection and compare it with frozen section and periprosthetic tissue cultures.

108 patients underwent revision or explantation procedure for any reason. Frozen sections of intraoperative specimen were analized and multiple periprosthetic samples (at least 5) were collected and cultured. All explanted prosthesis components were subject to sonication and cultured. All cultures were incubated for 14 days.

PJI was diagnosed in 52 patients (48%). Sonication achieved the highest sensivity with 95% and specificity of 98%. Frozen section showed low sensivity (44%) and specificity (80%) and periprosthetic tissue cultures showed sensivity of 75% and specificity of 98%.

Sonication fluid culture is a cheap, easy, accurate and sensitive diagnostic method and helps to detect about 30% more PJI compared to frozen section and 16% more compared to periprosthetic tissue cultures. It also detect about 25% more pathogens than periprosthetic tissue cultures

Joint replacement is a highly effective intervention to treat osteoarthritis of the hip, relieving pain and improving mobility and quality of life.(1) Periprosthetic joint infection (PJI) is a devastating complication after arthroplasty. Debridement, antibiotics and implant retention are treatment of first choice in case of early infection after total hip arthroplasty (THA).(2) In case of persisting infection, one- or two-stage revision needs to be performed.(3) The use of different kinds of spacers has been widely debated in the past years.(4)

The aim of this study was to determine which type of spacer should be used during the interval of two-stage revision of an infected THA.

A search term with Boolean operators was constructed. We extracted all information regarding study and patient characteristics and baseline clinical and laboratory findings. Data regarding type of spacer and antibiotics used, timing of second stage surgery, tissue culture results, postoperative regimen, functional outcome and patient satisfaction were extracted.

A total of twenty-six studies met our inclusion criteria and were included for data analysis. Ten studies described various preformed spacers, six studies described functional spacers and eleven studies described custom made spacers. See Table 1 for results.

Research should focus on finding the preferred type of treatment and type of spacer to combine a high success rate of infection treatment with a good functional and patient reported outcome. There is a need for a prospective study evaluating patient satisfaction and functional outcome after two-stage revision THA comparing various spacers. Secondly, research should focus on the optimal timing of the second stage procedure.

Functional spacers achieve a comparable rate of infection eradication in the treatment of periprosthetic hip joint infections as compared to preformed spacers. There is insufficient evidence concerning rehabilitation and functional outcome after two-stage revisionTHA to advocate or discourage the use of either kind of interval spacer.

The incidence of rupture of an Achilles tendon constitutes 0,01–0,02%. The infection of the Achilles tendon after operativ repair is a very rare but severe complication. In this study we examined the functional outcome after radical debridement of the Achilles tendon.

From 2009 to 2014 we treated 26 patients (22 male, 4 female) with an infection oft he Achilles tendon. In 24 cases the infection was caused after suture of the tendon, in 2 cases the infection was caused by an open injury. The average age was 46,8 (21 to 75). The number of operations the patient had to undergo before admitted to our hospital was 23, in average (with an range from 0 to 9 operations). We performed a radical debridement and the insertion of a local antibiotic carrier. In all cases an at least subtotal resection of the Achilles tendon was necessary. In 10 cases we found Staphylococcus aureus, in 4 cases atleast 2 different types of bacteria. In 2 cases we detected E.coli, in 1 case Enterococcus faecalis and 1 case Bacteroides fragiles. In 6 cases we didn´t succeed in identifying a bacteria despite of a hisological report describing a severe infection.

In all cases we achieved a long-lasting stop of the infection. We succeed in 22 cases with just one operation. In 2 cases we had to perform several surgeries(3 Operations and 7 operations) due to extended soft tissue damage of the lower leg and the necessity of a free flap. 22 patients are mobilized in normal shoes, 2 in orthopedic shoes. Because of the building of scartissue we didn´t find a serious impairment of the function despite a subtotal resection of the tendon. The plantar flexion was possible against resistance with reduced strength. Further operative measure such as replacement with other tendons were not required.

In order o obtain a durable stop of the infection it is decisive to operate radical. All infected tissue has to be removed. Even a subtotal resection of the Achilles tendon leads to0 a satisfactory functional outcome.

The objective of this study was to compare the elution characteristics, antimicrobial activity and mechanical properties of antibiotic-loaded bone cement (ALBC) loaded with powdered antibiotic, powdered antibiotic with inert filler (xylitol), or liquid antibiotic, particularly focusing on vancomycin and amphotericin B.

Cement specimens loaded with 2 g of vancomycin or amphotericin B powder (powder group), 2 g of antibiotic powder and 2 g of xylitol (xylitol group) or 12 ml of antibiotic solution containing 2 g of antibiotic (liquid group) were tested.

Vancomycin elution was enhanced by 234% in the liquid group and by 12% in the xylitol group compared with the powder group. Amphotericin B elution was enhanced by 265% in the liquid group and by 65% in the xylitol group compared with the powder group. Based on the disk-diffusion assay, the eluate samples of vancomycin-loaded ALBC of the liquid group exhibited a significantly larger inhibitory zone than samples of the powder or the xylitol group. Regarding the ALBCs loaded with amphotericin B, only the eluate samples of the liquid group exhibited a clear inhibitory zone, which was not observed in either the xylitol or the powder groups. The ultimate compressive strength was significantly reduced in specimens containing liquid antibiotics.

Adding vancomycin or amphotericin B antibiotic powder in distilled water before mixing with bone cement can significantly improve the efficiency of antibiotic release than can loading ALBC with the same dose of antibiotic powder. This simple and effective method for preparation of ALBCs can significantly improve the efficiency of antibiotic release in ALBCs.

We thank H.Y. Hsu for performing the bioassay.

This study aimed to determine the optimal formulation of antibiotic-loaded bone cement (ALBC) for periprosthetic joint infection (PJI) using both in vitro and in vivo models incorporating various combinations of gram-positive and gram-negative antibiotics.

The in vitro antibiotic release characteristics and antibacterial capacities of ALBCs loaded with either 4 g of vancomycin or teicoplanin and 4 g of ceftazidime, imipenem, or aztreonam were measured against methicillin-susceptible S. aureus, methicillin-resistant S. aureus, coagulase-negative staphylococci, Pseudomonas aeruginosa and Escherichia coli. ALBC spacers with superior in vitro antibacterial capacity were then implanted into ten patients (five females and five males between 29 and 75 years of age) diagnosed with chronic hip/knee PJIs and antibacterial activities within joint fluid were measured. The average duration of ALBC spacer implantation was 80 days (range, 36–155 days). Antibiotic concentrations and antibacterial activities of joint fluid at the site of infection were measured during the initial period as well as several months following spacer implantation.

Cement samples loaded with vancomycin/ceftazidime or teicoplanin/ceftazidime exhibited equal or longer antibacterial duration against test bacteria as compared with other ALBCs. Joint fluid samples exhibited antibacterial activity against the test microorganisms including ATCC strains and clinically isolated strains. There were no adverse systemic effects, infection at second stage re-implantation, or recurrent infection at final follow-up.

Vancomycin/ceftazidime ALBC provided broad antibacterial capacity both in vitro and in vivo and was shown to be an effective and safe therapeutic measure in the treatment of hip/knee PJIs.

We thank H.Y. Hsu for performing bioassay.

Fresh-frozen allograft bone is frequently used in orthopaedic surgery. We investigated the incidence of allograft-related infection and analysed the outcomes of recipients of bacterial culture-positive allografts from our single-institute bone bank during bone transplantation.

The fresh-frozen allografts were harvested in a strict sterile environment during total joint arthroplasty surgery and immediately stored in a freezer at −78° to −68° C after packing. Between January 2007 and December 2012, 2024 patients received 2083 allografts with a minimum of 12 months of follow-up.

The overall allograft-associated infection rate was 1.2% (24/2024). Swab cultures of 2083 allografts taken before implantation revealed 21 (1.0%) positive findings. The 21 recipients were given various antibiotics at the individual orthopaedic surgeon's discretion. At the latest follow-up, none of these 21 recipients displayed clinical signs of infection following treatment.

Based on these findings, we conclude that an incidental positive culture finding for allografts does not correlate with subsequent surgical site infection. Additional prolonged post-operative antibiotic therapy may not be necessary for recipients of fresh-frozen bone allograft with positive culture findings.

Chang Gung Medical Foundation

The best surgical modality for treating chronic periprosthetic shoulder infections has not been established, with a lack of randomised comparative studies. This systematic review compares the infection eradication rate and functional outcomes after single- or two-stage shoulder exchange arthroplasty, to permanent spacer implant or resection arthroplasty.

Full-text papers and those with an abstract in English published from January 2000 to June 2014, identified through international databases, were reviewed. Those reporting the success rate of infection eradication after a single-stage exchange, two-stage exchange, resection arthroplasty or permanent spacer implant were included, with a minimum follow-up of 6 months and sample size of 5 patients.

Eight original articles reporting the results after resection arthroplasty (n = 83), 6 on single-stage exchange (n = 75), 13 on two-stage exchange (n = 142) and 8 papers on permanent spacer (n = 68) were included.

The average infection eradication rate was 86.7% at a mean follow-up of 39.8 months (SD 20.8) after resection arthroplasty, 94.7% at 46.8 months (SD 17.6) after a single-stage exchange, 90.8% at 37.9 months (SD 12.8) after two-stage exchange, and 95.6% at 31.0 months (SD 9.8) following a permanent spacer implant. The difference was not statistically significant.

Regarding functional outcome, patients treated with single-stage exchange had statistically significant better postoperative Constant scores (mean 51, SD 13) than patients undergoing a two-stage exchange (mean 44, SD 9), resection arthroplasty (mean 32, SD 7) or a permanent spacer implant (mean 31, SD 9) (p=0.029). However, when considering studies comparing pre- and post-operative Constant scores, the difference was not statistically significant.

This systematic review failed to demonstrate a clear difference in infection eradication and functional improvement between all four treatment modalities for established periprosthetic shoulder infection. The relatively low number of patients and the methodological limitations of the studies available point out the need for well designed multi-center trials to further assess the best treatment option of peri-prosthetic shoulder infection.

The segmental bone transport allows the reconstruction of large scale bone defects resulting after a redical debridement due to an infection or after trauma. We use the Ilizarov fixator for the segmental transport. The part of the bone that has to be moved through the defect is pulled by a lateral and a medial towing rope. To determine continuously the forces of tension in the wires and to detect early complications of the bone transport we implanted in each wire a load cell with a resistance strain gauge. The knowledge of the resulting forces leads to the development of an automatic forced controlled bone transport.

Since 09/2004 we have measured the forces of tension in the wires in 77 patients undergoing a segmental bone transport due to a long-extending osteomyelitis. The average age was 47,2 (6 to 68). In 12 patients we had to treat a bone defect of the thigh (average size of the defect 12,5 cm), in 55 patients 56 large scale bone defects of the lower leg (average size of the defect: 8,6 cm ranging from 6,0 to 20,0 cm). We implanted a load cell with a resistance strain gauge in the lateral and medial towing rope. This way we could, after converting the measured values from analog to digital, the impacting forces.

In all patients we were able to meausure continuously rising forces of tension. Lwe noticed forces which didn´t change much. At the end the bone transport we again found rising forces of tension. We noticed higher forces in the lateral wires, on femur and on tibia. Due to the measurement of the acting forces we were abel to perform a bone transport without close X-ray-monitoring. Complications such as premature ossification of the new building bone were identified and treated in an early stage.at

We developed a theoretical model drawing into consideration the interfering forces caused by the regenerating bone, the soft tissue, the friction of the wire, adherend soft tissue and geometry otf the wire. The forces calculated using this model were similar to the acting forces we found when measuring the forces of the bone transport. We now record the data on memory cards. A control of the data is possible over long-distance. We now started a model of an automatic bone transport controlled by the the acting forces. Our aim is to perform such an automatic bone transport in patients.

We present the case of a previously well 18 year old female who presented with an acute onset swollen painful right ankle with an overlying non-blanching purpuric rash. There were no associated systemic features. Ankle joint aspirate grew Neisseria Meningitides. She was treated with intravenous third generation cephalosporin's and surgical washout of the joint with improvement. Primary meningococcal arthritis (PMA) is rare and mostly associated with the knee joint. Presentation of meningococcal disease in this manner is easily missed or misdiagnosed as gonococcal disease or overlying cellulitis.

Primary meningococcal arthritis is a rare form of septic arthritis. It can be misdiagnosed as an overlying cellulitis or as a gonococcal rash. Physicians should be aware of the possibility of this microorganism presenting as a septic arthritis, and understand the importance of joint aspiration at the centre of diagnosis.

Post operative prosthetic joint infection (PJI) is the most common cause of failure of total joint arthroplasty, requiring revision surgery, but a gold standard for the diagnosis and the treatment of PIJ is still lacking [1].

SuPAR, the soluble urokinase plasminogen activation receptor, has been recently described as a powerful diagnostic and prognostic tool, able not only to detect sepsis but also to discriminate different grade of sepsis severity [2,3]

This study aimed to examine the diagnostic value of SuPAR in post operative PJI, in order to explore the possible application of this new biomarker in the early diagnosis of PJI.

The level of SuPAR have been measured in PJI patients and controls (patients undergoing prosthesis revision without infection), and correlated with pro and anti inflammatory markers (CRP C-reactive protein, IL-6, IL-1 TNFα, IL-10, IL-12, IL-8, IL1ra and the chemokine CCL2).

Statistical analysis of Receiver Operating Characteristic (ROC) curves and Area Under the Curve (AUC) was performed

As described in Figure 1, serum SuPAR displayed a strongly significative increase in PJI patients compared to not infected controls, and a significative positive correlation with C-reactive protein, IL-6, IL-1 and TNFα and the chemokine CCL2.

SuPAR displayed a very good AUC, significantly higher than CRP and IL-6 AUC

This study clearly show that the measure of Serum level of SuPAR provide a extremely important benefit because it is a precise indicator of bacterial infection, and the addition of SuPAR serum level measurement to classical inflammatory markers can strongly improve the diagnosis of prosthesis joint infection

The authors acknowledge ViroGates, Denmark for providing suPARNOSTIC Standard Kit.

The authors would also acknowledge the Italian Ministero dell’ Istruzione, Università e Ricerca (MIUR) and Italian Ministero della Salute for providing funds for this research project.

Local infiltration analgesia (LIA) is promoted as an effective treatment modality for pain control after total knee arthroplasty (TKA) (1). A mixture of drugs is used to provide a multimodal analgesic effect. Previous studies reported that the use of these drugs is safe. After we carefully implemented a LIA study protocol in our practice, concerns raised about patient safety with probably higher infection rates. This forced us to perform an interim analysis after the first 58 cases.

58 patients underwent a unilateral TKA with a standardised LIA protocol (2), which consisted of a mixture of ropivacaine, epinephrine, and triamcinolone acetonide. Complications, knee function and patient satisfaction scores were prospectively recorded during regular outpatient control.

Four patients (6.9%) presented with signs of periprosthetic joint infection (PJI) within two months after surgery. Baseline characteristics were similar between the infected and non infected group. All infections were treated with debridement and retention, and antimicrobial treatment was started. One patient who suffered an infection died during followup. At two years followup all implants could be retained. Knee function and KSS score were acceptable for the patients who suffered PJI.

There is no consensus on the combination of drugs used for LIA. The application of corticosteroids in LIA is reported to be safe (3), but arguable results about the injection of local corticosteroids around knee arthroplasty surgery in the past have raised suspicion in literature (4). Combined with our unacceptable high rate of PJI, we believe that the current body of evidence, with small heterogeneous series, does not support the safe use of corticosteroids in LIA.

Two-stage revision surgery is the current gold standard for treating prosthetic joint infections (PJI). Between the first and the second stage gentamicin-loaded (G) spacers are widely used but the rate of gentamicin resistant staphylococci is increasing. The potential benefit of vancomycin + gentamicin-loaded (V/G) spacers has not yet been evaluated. The aim of our study was to compare the microbiological eradication and infection control rates in PJI treated with G- or V/G-spacers.

147 PJIs treated in our institution were retrospectively reviewed. From 2003 to 2009 G-spacers (Tecres®) were used (group G) and from 2010 to 2013 V/G-spacers (Group V/G). Gender, age, body mass index (BMI), co-morbidities, ASA score, type of infection, microorganisms isolated in the first and second stages, time between stages, infection outcome at last visit were collected. The 2 main outcome variables were microbiological eradication in the second stage (≤1 positive culture out of 6) and infection control after the second stage. Univariate and multivariate analysis were performed using SPSS®.

There were 83 patients in group G and 63 in group V/G. The mean (SD) age was 71.5 (10.3) years and 54% were female. Groups were similar in gender, age, BMI, ASA score, time with spacer, microorganism isolated in the first stage, or type of infection (acute or chronic) (p>0.05). The presence of ≥2 positive cultures in the second stage was significantly higher in group G (23.2%) than in group V/G (6.7%, P<0.05). Logistic regression model identified polymicrobial infections (OR: 4.26, CI95%: 1.44–12.64) and the use of G-spacers (OR: 5.88, CI95%: 1.60–21.74) as independent predictors of failure in microbiological eradication. The global rate of infection control was 75% after a mean (SD) follow-up of 56 (32) months. Infection control was higher in chronic than acute PJI (83.6% vs 59.6%, P<0.05), when cultures during second stage were negative (81.5%) vs positive (61%, P<0.05), and there was a trend towards a higher control rate when V/G-spacers (82%) vs G-spacers (69.5%) were used (P=0.09). Multivariate analysis identified chronic PJI (OR: 5.43, CI95%: 2.20–13.51) and, at the limit of significance, the use of V/G spacers (OR: 2.36, CI95%: 0.97–5.71) as predictors of infection control.

Vancomycin loaded spacers were significantly associated with a higher microbiological eradication and there was a trend towards a higher infection control than gentamicin loaded spacers.

Open debridement, irrigation with implant retention and antibiotic treatment (DAIR) is an accepted approach for early prosthetic joint infections (PJI). Our aim was to design a score to predict patients with a higher risk of failure.

From 1999 to 2014 early (<90 days) PJIs without signs of loosening of the prosthesis were treated with DAIR and were prospectively collected and retrospectively reviewed. The primary end-point was early failure defined as: 1) the need of an unscheduled surgery, 2) death-related infection within the first 60 days after debridement or 3) the need for suppressive antibiotic treatment. A score was built-up according to the logistic regression coefficients of variables available before debridement.

A total of 222 patients met the inclusion criteria. The most frequently isolated microorganisms were coagulase-negative staphylococci (95 cases, 42.8%) and Staphylococcus aureus (81 cases, 36.5%). Fifty-two (23.4%) cases failed. Independent predictors of failure were: chronic renal failure (OR:5.92, 95%CI:1.47–23.85), liver cirrhosis (OR:4.46, 95%CI:1.15–17.24), revision surgery (OR:4.34, 95%CI:1.34–14.04) or femoral neck fracture (OR:4.39, 95%CI:1.16–16.62) compared to primary arthroplasty, CRP >11.5 mg/dL (OR:12.308, 95%CI:4.56–33.19), cemented prosthesis (OR:8.71, 95%CI:1.95–38.97) and when all intraoperative cultures were positive (OR:6.30, 95%CI:1.84–21.53). Furthermore, CRP showed a direct relationship with the percentage of positive cultures (Linear equation, R2=0,046, P=0.002) and an inverse association with the time between the debridement and failure (Logarithmic equation, R2=0.179, P=0.003). A score for predicting the risk of failure was done using pre-operative factors (KLIC-score, figure 1) and it ranged between 0–9.5 points. Patients with a score ≤2, >2–3.5, 4–5, >5–6.5 and ≥7 had a failure rate of 4.5%, 19.4%, 55%, 71.4% and 100%, respectively.

The KLIC-score was highly predictive of early failure after debridement. In the future, it would be necessary to validate our score using cohorts from other institutions.

Early prosthetic joint infections (PJI) are managed with debridement, implant retention and antibiotics (DAIR). Our aim was to evaluate risk factors for failure after stopping antibiotic treatment.

From 1999 to 2013 early PJIs managed with DAIR were prospectively collected and retrospectively reviewed. The main variables potentially associated with outcome were gathered and the minimum follow-up was 2 years. Primary endpoint was implant removal or the need of reintroducing antibiotic treatment due to failure.

A total of 143 patients met the inclusion criteria. The failure rate after a median (IQR) duration of oral antibiotic treatment of 69 (45–95) days was 11.8%. In 92 cases PJI was due to gram-positive (GP) microorganisms, in 21 due to gram-negatives (GN) and 30 had a polymicrobial infection. In GP infections, combination of rifampin with linezolid, cotrimoxazole or clindamycin was associated with a higher failure rate (27.8%, P=0.026) in comparison to patients receiving a combination of rifampin with levofloxacin, ciprofloxacin or amoxicillin (8.3%) or monotherapy with linezolid or cotrimoxazole (0%) (Figure 1). Among patients with a GN infection, the use of fluoroquinolones was associated with a lower failure rate (7.1% vs 37.5%, P=0.044). Duration of antibiotic treatment was not associated with failure.

The only factor associated with failure was the oral antibiotic selection, but not the duration of treatment. Linezolid, cotrimoxazole and clindamycin but not levofloxacin serum concentrations are reduced by rifampin; a fact that could explain our findings. Further studies monitoring serum concentration could help to improve the efficacy of these antibiotics when combining with rifampin.

Osteomyelitis is usually related to trauma, surgery, immunocompromised patients, IV drug abuse, poor vascular supply, diabetes, sickle cell disease or peripheral neuropathy. We report an unusual case of femur osteomyelitis without any of these risk factors.

A 31 years old male, light smoker, presented at the Emergency Room for pain in the left thigh for about a month, without any previous event. He had 2 previous visits to the hospital with similar diffuse complaints interpreted as irradiated low back pain. He was pale, feverish but no signs of local inflamation. His left knee ROM was 30°-15°-0°. He had no neurologic deficits. Blood tests showed high WBC count and PCR (400mg/L). After contrasted CT showing an 1,2×6×2,5cm abcess the patient was taken to the OR for irrigation and debridment.

The day after the patient did a MRI that showed extended femur osteomyelitis and adjacent myositis (images). He underwent new surgery for a more extensive irrigation and debridment, femur medular canal included, from where a large pus quantity erupted.

The hemocultures and bone biopsys, revealed a Multissensible Strep. Alfa-hemolitic (S. anginosus) and appropriate antibiotherapy was implemented (Amoxicillin/Clavulanate). He slowed improve till 11th day when he showed rise of PCR and a new MRI showed the same inflammatory process. He underwent new surgery but no pus was visible. He gradually improved, started hyperbaric oxygen therapy and was discharged on the 28th day after the first surgery, continuing antibiotherapy at home for a total of 8 weeks.

Transthoracic Ecography was normal, as well Brucella, HIV, and other serologies.

Three weeks later, the patient again presented to the ER with fever and rise of inflammatory markers in blood, consistent with recurrence of the infection. The patient was taken to the OR for surgical debdridment and irrigation, but this time the cultures showed a multissensible Gemella haemolysans, possible contamination during the hyperbaric oxygen therapy sessions.

This is the case of a healthy young adult with an idiopathic femur osteomyelitis, initially misinterpreted for irradiated low back pain, that recurred after the first medical and surgical successful treatment, with an unusual agent.

Osteomyelitis caused by resistant bacterial strains can be dealt with antimicrobial agents which have a different mode of action compared to antibiotics. A very promising appears to be antimicrobial peptides (AMPs). We found and verified in vitro experiments that one of the most effective and least toxic antimicrobial peptides are contained in the wild bee venom.

The aim of this study was to verify the efficacy of topically applied, synthetically prepared antimicrobial peptide (Hal 2/27) with carrier, originally isolated from the venom of the wild bee in experiments on laboratory rats.

It was used 18 rats, which were indicated osteomyelitis of the left femurs. After a week of six rats were injected calcium phosphate carrier with AMP Hal 2/27, six rats received only a carrier without AMP and six other rats remained without further intervention. After a week, rats were sacrificed and X-ray was performed in all rats limbs.

Rats who received carrier with AMP Hal 2/27 had less X-ray evidence of osteomyelitis of femurs compared to rats after administration of the carrier without AMP.

Topical application of a new synthetic antimicrobial peptides isolated from wild bee venom (Hal 2/27) using local carriers seems to be a promising way to treat and prevent infectious complications in orthopedics and traumatology.

Internal grant of University Hospital Motol, Advanced Therapies, NO: 9777 and Internal grant of University Hospital Motol, NO 6010

In France, 5% of men and 7% of women aged more than 60 years have a joint prosthesis (JP). The incidence of H-PJI following BSI remains unknown (1–2). The aim of this study was to determine prospectively the clinical characteristics of patients with JP and the incidence of H-PJI following a BSI.

A prospective observational multicentric study was performed in two French General Hospitals, from December 2012 to April 2015. Each patient with JP, in whom a BSI was diagnosed, was evaluated prospectively by an ID specialist. Data regarding clinical and microbiological characteristics were collected. A follow-up by phone call was performed monthly during 6 months to determine the incidence of H-PJI following BSI.

During the study period, 97 patients of mean age ± SD of 82.1 ± 10.4 years were identified, with a predominance of women (n=61). Nineteen patients (20%) had neoplasia, and 32 diabetes mellitus (33%). Most patients had one (n=61; 63%) or two JP (n=29; 30%); with a predominance of hip arthroplasty (n=77; 79%). Predominant pathogens were E. coli (n=41; 42%), S. aureus (n=23; 23%) and S. pneumoniae (n=8; 8%).

At the onset of BSI, the JP was concomitantly infected in 10 (10.3%) patients (including 8 S. aureus, 1 E. coli and 1 P. mirabilis), thus 87 were studied for the incidence of H-PJI following BSI of another source. Among these 87 patients, no H-PJI was detected, with a complete 6-month follow-up available for 29 patients (34%), incomplete follow-up for 26 patients (30%), loss of follow-up for 3 patients (3%), and death occurring in 29 patients (34%). The comparison between the patients with no H-PJI detected (« No Event Group ») and the deceased patients (« Death Group ») showed that patients of the « No Event Group » had a lower rate of neoplasia (14% vs 34%; P=0.025).

Our preliminary results show that patients with JP in whom a BSI occurred were old, and had a high mortality rate. In our study, the incidence of secondary H-PJI appears to be low, since no event was detected during the follow-up. The incidence of H-PJI may have been underestimated due to the high mortality rate.

We would like to thank Dron Hospital and Bethune Hospital medical teams.

The authors declare that there are no conflicts of interest.

There is currently no consensus on the use of suppressive antibiotic therapy (SAT) in prosthetic joint infections (PJI) (1). We describe herein the experience of a French Reference Centre for Complex Osteo-Articular Infections on use of oral cyclines (doxycline and minocycline) for SAT.

A retrospective analysis was performed on consecutive patients with PJI who received oral cyclines (doxycycline or minocycline) for SAT between January 2006 and June 2014. All patients had surgical management, followed by systemic antibiotic treatment and SAT instauration thereafter. Remission was defined as an asymptomatic patient with a functioning prosthesis.

Seventy-nine patients with a mean age of 63.8 ± 16.8 years were included. Sixteen patients (20%) had neoplasia, 9 (11%) diabetes mellitus, 10 (13%) rheumatoid arthritis, and 6 patients (8%) were receiving corticosteroids or chemotherapy.

There were 37 knee (47%), 36 hip (46%), 4 elbow (5%), and 2 shoulder (3%) infections, with a mean delay from implantation of 7.37 ± 6.94 months (range 1–27). Surgical management consisted in debridement and implant retention for 60 patients (76%), or in implant exchange for 19 patients (24%).

Main pathogens were coagulase-negative staphylococci (37%) and Staphylococcus aureus (41%); 23 patients had polymicrobial infection (29%).

The most frequent initial antibiotic regimens debuted before SAT were rifampicin combinations (70%). Mean duration of curative antibiotic therapy was 103 ± 75 days.

Indications of SAT were (i) patients unsuitable for or refusing further surgery (n=23), suboptimal (ii) surgery (n=26) or (iii) curative antibiotic therapy (n=11), (iv) complex orthopaedic surgery (n=11), and (v) immunosuppressive status (n=8). Seventy-three patients received doxycycline and 6 patients received minocycline as SAT (n=48). Mean SAT duration was 625± 536 days (range 30–2900), with a mean follow-up of 765 ± 572 days.

Adverse events were reported in 13 patients (16%), leading to SAT discontinuation in 5 (6%).

During follow-up, 59 patients were considered in remission (75%), and 20 failed including 13 relapses (16%) and 7 reinfections (9%). Among failure patients, 10 pathogens resistant to doxy/minocycline were identified, including 5 with acquisition of cycline resistance.

In our study, SAT with cyclines is associated to a 75% remission rate, with an acceptable tolerability.

Further studies are warranted to determine ideal regimens and optimal duration of SAT.

We would like to thank Dron Hospital and Lille University Hospital medical teams.

The authors declare that there are no conflicts of interest.

Of the 6075 patients enrolled in EU-CORE registry, 206 patients had orthopaedic device-related infections. Significant underlying diseases were reported in 71% patients, most frequently cardiovascular disease (38%). The common sites of infection were knee (40%) and hip (33%). Among the 170 patients with available culture results, 135 (79%) were positive. Coagulase-negative staphylococci (CoNS, 44%) and Staphylococcus aureus (43%, of those 47% were methicillin resistant) were the most commonly isolated pathogens. Daptomycin was used empirically in 48% patients and as second-line therapy in 67% patients. During daptomycin therapy, 67% patients had undergone surgery (debridement, 61%; removal of foreign device, 39%; incision and drainage, 9%). Over half of the inpatients (54%) received concomitant antibiotics. Daptomycin was most frequently prescribed at a dose of 6 mg/kg/day (48%), with a median duration of therapy of 16 (range, 1–176) days. The overall clinical success rate was 85%, and was similar whether daptomycin was administered as first- or second-line therapy. The success rates achieved for infections caused by S. aureus and CoNS were 86% and 83%, respectively. Among the 79 patients who entered the long-term follow-up, 85% had a sustained response. Adverse events (AEs) and serious AEs possibly related to daptomycin were reported in 4.4% and 1.9% patients, respectively.

Results from this real-world clinical experience showed that daptomycin is an effective and well-tolerated treatment option for orthopaedic device-related infections with a high success rate up to 2 years of follow-up.

Since its approval by the FDA two decades ago, Negative Pressure Wound Therapy (NPWT) has become a valuable asset in the management of open fractures with significant soft tissue damage as those seen in high velocity gunshot injuries. These lesions are often associated with grossly contaminated wounds and require a prompt and effective approach. Wound dehiscence and surgical site infection are two of the most common post-operative complications, with poor results when treated with standard gauze dresses. NPTW comes as a legitimate resource promoting secondary intention healing through increased granulation and improved tissue perfusion, as well as continuous local wound drainage preventing bacterial growth and further infection. Recent evidence-based guidelines are still limited for use of NPWT in the treatment of Gustilo-Anderson type IIIB open fractures and there are few cases in literature reporting the management of upper extremity injuries. We present and discuss a successful case of a type IIIB open humeral fracture wound treated with NPWT.

A 38-years-old male was admitted to the Emergency Room with a type IIIB open humeral fracture as a result of a gunshot with extensive soft tissue damage. IV antibiotic therapy was promptly started followed by surgical stabilization by intramedullary nailing with primary wound closure. The patient presented an early surgical site infection with wound dehiscence requiring secondary debridement with poor subsequent healing and deficient soft tissue coverage. After ineffective 28 days of standard gauze dresses we started NPWT.

NPTW was applied using foam coverage over the dehiscence area with visible results after 13 days and complete granulation of the skin defect by the 28th day. The wound healed completely after 14 weeks of NPWT. The fracture evolved into a painless pseudarthrosis revealing an excellent functional recovery and an acceptable aesthetic result.

NPTW is a valuable, effective, and well tolerated resource in the treatment of open fractures with extensive soft tissue damage such as Gustilo-Anderson type IIIB fractures. It should be considered not just as a salvage procedure but as well as a primary option especially in grossly contaminated wounds.

No benefits in any form have been received from a commercial party.

Staphylococcus aureus is a leading cause of implant-associated infections (IAI). The aim of this study was to identify bacterial and/or clinical features involved in the pathogenesis of S. aureus IAI.

57 IAI S. aureus and 31 nasal carriage (NC) S. aureus isolates were studied. S. aureus genetic background was obtained by microarray analysis. Multi-Locus Sequence Typing was performed to determine clonal complexes (CC). The ability of S. aureus isolates to produce biofilm was investigated by resazurin and crystal violet methods. Clinical data were retrospectively collected from the patient's medical records.

Fifty-five IAI patients were included. Two of them had two different S. aureus IAI episodes. The median age was 73 years (range: 21–96 years) with 29 women (52.7%). The main diagnosis for arthroplasty was arthrosis (38%). Implants were hip prosthesis (n=35), knee prosthesis (n=18) and osteosynthesis (n=4). Infectious and nasal carriage isolates belonged respectively to 18 and 13 different sequence types (STs) without significant difference. Among IAI isolates, five strains were methicillin resistant. IAI isolates were classified as strong (14%), moderate (42.1%) and weak (43.9%) biofilm producers. For NC isolates, distribution was 12.9%, 25.8% and 61.3% for strong, moderate and weak, respectively. Staphylokinase gene was associated with the occurrence of S. aureus IAI (p<0.001). Patients’ ABO blood group phenotype was associated with IAI S. aureus genetic background (sasG, slpB, lukD and set12/ssl8) (p≤0.01). In vitro, CC8 S. aureus strains produce more biofilm than others (p≤0.0001). Two alleles of bbp gene were significantly associated with CC8 S. aureus strains (p≤0.0001). No specific CC involved in IAI compared to NC S. aureus isolates was revealed.

Our results suggested that occurrence of IAI may depend on patients’ ABO blood group and staphylokinase gene detection. We also observed a strong biofilm producer phenotype in CC8 S. aureus. Further studies are needed to prove whether one bbp gene variant is correlated to this phenotype.

This study was supported by a grant number WS1106649 from Pfizer, France and by the French “Ministère de l'Enseignement Supérieur et de la Recherche”.

Several risk factors can and should be addressed during first stage or spacer implantation surgery in order to minimize complications. Technical aspects as well as practical tips and pearls to overcome common nuisances such as spacer instability or femoral and acetabular bone loss will be discussed and shown with pictures.

Total joint arthroplasty (TJA) is one of the most successful procedures in orthopaedics and excellent results are expected in virtually all cases. Periprosthetic joint infection (PJI) though unusual, is one of the most frequent and challenging complications after TJA. It is the third most common cause of revision in total hip replacement, responsible for up to 15% of all cases.

In the past few years several improvements have been made in the management of an infected total hip prosthesis. Nevertheless it remains a challenging problem for the orthopaedic surgeon. Although numerous studies report favourable outcomes after one-stage revision surgery, two-stage has traditionally been considered as the gold standard for management of chronic infection. Two-stage exchange consists of debridement, resection of infected implants and usually temporary placement of an antibiotic-impregnated cement spacer before reimplantation of a new prosthesis.

Spacers can be classified as static or articulating. The goals of using an articulating antibiotic loaded cement spacer are two-fold: to enhance the clearance of infection by local antibiotic therapy and dead-space management while maintaining joint function during treatment thus improving the functional outcome at reimplantation. Still, hip spacer implantation is not innocuous and there are several possible complications.

Going forward, one must consider not just eradicating infection but also the importance of restoring function. In this regard using a mobile spacer adds an element of physiologic motion that both increases patient comfort between stages and facilitates re-implantation surgery. Conversely, mechanical complications are one of the major consequences of this preference. Be that as it may there are ways to minimize these problems. It is the surgeon responsibility to optimize mechanical circumstances as much as possible.

I would like to thank Dr. Ricardo Sousa for his help with this work

Autologous bone grafting for bone defect reconstruction is associated with complications including donor site morbidity, infection risk, pain and surgical time. Therefore, bone graft substitutes provide an alternative for distinct indications and different characteristics with regard to their mechanical properties and resorption rates. In order to fill the loss of bone substance and to control the infection, we tried the efficacy of Cerament™G, a new absorbable composite of Calcium Sulphate and Hydroxyapatite with Gentamicin.

We present 3 male patients aged between 45 and 68 years affected by post-traumatic severe septic non union of femur, tibia and foot. The first patient with femur fracture was involved in a car accident (mixed flora Acinetobacter Baumanii, MRSA and Klebsiella pneumoniae carbapenemase (KPC)-producing), the second patient with femur and foot fracture falled by height in a work accident (MRSA) and the third one had a chronic tibial osteomyelitis several years after a road accident (Pseudomonas Aeruginosa). All 3 patients had undergone previous surgery. The first patient had several operations including multiple bone resection and debridement with external fixator, occlusion of superficial femoral artery with arterial bypass and finally debridement with implantation of Cerament™ G with external fixator and long term antibiotic therapy. The other 2 patients were subjected to resection of tissue septic with debridement, implantation of Cerament™ G and soft tissue closure and systemic antibiotics. Clinical and radiographic outcome were assessed at final follow-up (mean 8 months; range 8–18)

The follow-up was 8–18 months with examining clinical, radiographic, CT scan and laboratory tests. The patients had self-limiting fluid leakage. There was no recurrence of infection during the follow-up period. Bone ingrowth occurred in all cases with limb shortening.

Cerament™ G gives good elution of antibiotic and allows bone ingrowth. The implantation of Cerament™ G was associated with good clinical outcomes and satisfactory bone consolidation.

We acknowledge Antonella Esposito for septic nursing assistance

Stored red blood cells (RBCs) undergo a variety of changes that impair their post-transfusion viability, but the detrimental effect of such lesion at the clinical level is a matter of debate (1) and there is no data about the incidence of postoperative infection, a complication frequently associated with transfusion of stored RBCs (2).

We reviewed 9906 patients who underwent a primary or revision arthroplasty between January 2000 and December 2012. Of these, 1153 (11.6%) received transfusion during surgery or within the first 6h after surgery (early transfusion, ET) and 920 (9.3%) received transfusion only between 24 and 96 hours after surgery (late transfusion, LT). Primary end-point was prosthetic joint infection (PJI) within the first year. Demographics, joint, type of surgery, duration of surgery, number and length of storage of transfused RBCs were collected. Ethical Committee approved the study.

The median age was 74.9 (IQR:68.3–80.1) years and 1546 (74.6%) were female. There were 914 (44.1%) hip and 1117 (53.9%) knee arthroplasties and 428 (20.6%) were revision surgeries. The median duration of surgery was 105 (IQR:80–145) minutes. A total of 100 (4.8%) patients had a PJI. Figure 1 shows the PJI rate according to the number of RBC units transfused and the proportion of such units that had been stored for more than 14 days, both in the ET-group (Fig. 1A) and the LT-group (Fig. 1B). In the ET-group, the fact that >50% of transfused RBCs had been stored >14 days was an independent predictor of PJI (OR:2.50, 95%CI:1.44–4.33, Hosmer-Lemeshow test P=0.972).

Stored RBC occlude the microcirculation (1), thereby precluding a good oxygenation of the surgical wound and the arrival of leukocytes and prophylactic antibiotics. Both factors are involved in the progression from wound bacterial contamination to wound infection and are particularly operative in the few hours following surgery (5). It is biologically plausible that transfusion of old RBC in this early, critical period results in more wound infections as compared to RBCs transfused later.

The Danish Hip Arthroplasty Register (DHR) is a national database on total hip arthroplasties (THAs) with a high completeness and validity of registration for primary procedures. The aim was to validate the registration in DHR for revisions due to Prosthetic Joint Infection (PJI).

We identified a cohort of patients in the DHR who underwent primary THA from January 1, 2005 to December 31, 2012 and we followed these patients until first-time revision, death, emigration or December 31, 2012. The PJI diagnosis registered was tested against a gold standard encompassing information from microbiology, prescription, and clinical biochemistry registries in combination with clinical findings retrieved from medical records. We estimated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) with 95% confidence interval (CI) for PJI in DHR alone and in DHR combined with microbiology registries.

Out of 37,828 primary THAs, 1,382 were registered with any revision, 232 of which were due to PJI. For PJI revisions in DHR, the sensitivity was 67.0% (CI: 61.0 – 72.6), specificity 95.2% (CI: 93.8 – 96.4), PPV 77.2% (CI: 71.2 – 82.4), and NPV 92.3% (CI 90.7 – 93.8).

Combining DHR with microbiology registries led to a notable increased in the sensitivity for PJI revision to 90.3% (CI: 86.1 – 93.5) and likewise for specificity 99.6% (CI: 99.1 – 99.9), PPV 98.4% (CI: 95.9 – 99.6) and NPV 98.5% (CI: 97.6 – 99.1).

Only two thirds of PJI revisions were captured in DHR and the PPV was moderate. However, combining DHR with microbiology registries improved the accuracy remarkably.

The study was supported by Region of Southern Denmark and Lillebaelt Hospitals.

The aim of the study is to determine reimbursement cost of treating periprosthetic joint infection (PJI) in Poland, the rate of THR and TKA septisc revisions in the years 2009–2013, the type of revision, comparison of the costs of septic and aseptic revisions.

Data published on the website of the National Health Fund (NHF) were analysed on revision arthroplasty for aseptic and septic recisions in the years 2009–2013. To calculate the cost of revision NHF report for 2013 was analysed giving the average cost of the group of septic and aseptic revision.

According to NHF „point system”, in therapy of PJI three types of revisions can by choosen: partial revision (305 points), one-stage revision (490 points), and two-stage revision with spacer (728 points for two stages). In the years 2009–2013 a total of 260030 THR and TKA were performer, including 23027 revisions. There were 4221 septic revisions: 1677 hips and 1430 knees. In 2013 septic revisions stated 1.38% (556 of 40152) of all hip and 2.56% (325 of 12654) of all knee replacements. Septic revisions constituted 14.67% of all hip revisions and 30.23% of all knee revisions. The average refund of the NHF for a minor revision for PJI in 2013 was 3889 Euro and the average cost for hospital was 4127 Euro. The average refund of the NHF for a one-stege revision (for any reason) in 2013 was 6124 Euro, and the average cost for hospital was 6339 Euro. The average refund of the NHF for a two-stage revision (for two stages) in 2013 was 10013 Euro, and the average cost for hospital was 10466 Euro for two hospital stays. Data revealed that in 2013 all 921 revisions performed for PJI were reimbursed as „minor revisions” for 3889 Euro. In 2013 the difference between the average cost incurred by the hospital and the refund of the NHF for septic revision was at least 238 Euro and for the entire year undervalued refund for treatment of 921 infected prostheses was at least 219198 Euros.

The reimbursement for revision due to infection encourages surgeons to perform two-stage septic revision instead of debridement or one-step, because two-step treatment in the final bill is better paid.

Infected nonunion of the femur or tibia diaphysis requires resection of infected bone, stabilization of bone and reconstruction of bone defect. External fixation of the femur is poorly tolerated by patients. In 2004 authors introduced in therapy for infected nonunions of tibia and femur diaphysis coating of IMN with a layer of antibiotic loaded acrylic cement (ALAC) containing 5% of culture specific antibiotic.

Seven patients with infected nonunion of the diaphysis of femur (2) and tibia (2) were treated, aged 20–63 years, followed for 2–9 years (average 5,5 years). All have been infected with S. aureus (MSSA: 2 and MRSA: 4) or Staph. epidermidis (1) and in one case with MRSA and Pseudomonas aeruginosa. All patients underwent 3 to 6 operations before authors IMN application. Custom-made IMN coated with acrylic cement (Palamed) loaded fabrically with gentamycin with admixture of 5% of culture-specific antibiotic: vancomycin (7 cases) and meropeneme (1 case) was used for bone stabilization. Static interlocking of IMN was applied in 4 cases and dynamic in 2 cases. In 1 case the femur was stabilized with IMN without interlocking screws. In 2 cases IMN was used for fixation of nonunion at docking site after bone transport. In 3 cases ALAC was used as temporary defect filling and dead space management. In one case after removal of IMN coated with ALAC, a new custom made Gamma nail and tubular bone allograft ranging 11 cm was used for defect reconstruction.

Infection healing was achieved in all 7 cases, bone union was achieved in 4 from 7 cases. In 1 case of segmental diaphyseal defect ranging over 12 cm infection was healed, but bone defect was not reconstructed. This patient is waiting for total femoral replacement. In another case of segmental defect of 11 cm infection is healed, but allograft substitution and remodeling by host bone is poor. In the 3rd case of lacking bone healing, the 63 year old patients was noncooperative and not willing to walk in walker with weight bearing. This patient refused further treatment.

Custom-made intramedullary nail coated with a layer of acrylic cement loaded with 5% of culture specific antibiotic can provide local infection control, offer comfortable bone stabilization, and replace standard IM nail in therapy for difficult to treat infected diaphyseal nonunion of femur or tibia.

Staphylococcus aureus gene locus sdr is encoding proteins responsible for adhesion to bone tissue and therefore for the invasiveness of this bacteria. The aim of the study was to determine possible mechanism of activation of this gene and its role in bone infections.

S. aureus strain 838/05 was isolated from the bone adjacent to infected joint prostheses. The strain contains all sdrC,D, and E genes. It was grown in liquid TSB medium (Bio Merieux) with gentle aeration or on Columbia agar plates containing 5% sheep blood (Bio Merieux). The presence of putative promoters and transcriptional organization of the sdr region was detected using BPROM and FGENESB algorithms (www.softberry.com) based on region 611262bp-623152bp (GeneBank number CP000730.1) of the Staphylococcus aureus subsp. aureus USA300_TCH1516 complete genome sequence. In order to determine interaction of S. aureus with human blood, 50 ml of bacteria grown in TSB medium to ML growth phase were collected and washed twice with sterile PBS to remove the medium and re-suspended in 50ml of sterile PBS. 10 ml of cells were mixed with ∼100ml of mixed fresh human blood collected from healthy volunteers. Immediately after mixing blood with bacteria, 30 ml of the sample (Time 0) were mixed with two volumes of RNA Protect reagent (Qiagen), centrifuged to sediment cells, and frozen at −800C. Additional samples were collected after 30 and 90 minutes of incubation of bacteria with blood. Samples collected after 30 and 90 minutes were treated the same as samples collected at the beginning of the experiment. RNA was isolated, and cDNA was generated. The expression level of the sdr genes was calibrated to the gyrA level and then normalized to the expression level at time 0 using the ΔΔCT method.

Results and conclusions. The study confirms separation of the Sdr region into three transcriptional units and suggests its dissimilar functions, based on differential reaction of the sdrD transcript to environmental conditions and blood.

SdrE has been previously proposed to play role in bone infections; our results indicate that sdrD can play a role in the interactions between the pathogen and human immune system.

Antibiotic-loaded bone cements are used to decrease occurrence of bone infections in cemented arthroplasties and actually being considered as a more cost-effective procedure when compared to cementless implants [1]. However, considering the challenge of treating device-associated infections there is a reduced number of formulations in the market. Response from the industry to medical need is still slow considering the rapid change in the infecting microbial profile and the emergence of multiresistant strains [2]. In this context, the aim of the work is to evaluate the role of lactose (L), as a porogen, on the antibiotic release from bone cement (BC). Levofloxacin (Lev) and minocycline (M) were the selected antibiotics to be individually loaded into BC due to their low cost and potential application in bone infections [3,4].

Two types of matrices were prepared: 1) Loaded with 2.5% of antibiotics (controls) and 2) Loaded with 10% lactose and 2.5% antibiotic. In vitro drug release and microbiological tests against representative strains causative of bone infections were assessed.

Lactose significantly increased the release of both antibiotics. Complete minocycline release after one-week was observed (Fig.1A). Also, lactose increased 3.5-fold the levofloxacin released from BC (Fig.1B).

Furthermore, microbiological studies showed that no interaction was observed between lactose and antibiotic as no decrease in drugs antimicrobial activity was observed (Table 1).

Considering the results, L-BC matrix appears to be a valuable alternative to available formulations. Future work will include testing other antibiotics as well as mixtures of drugs.

Fundação para a Ciência e Tecnologia (Portuguese government) for financial support: EXCL/CTM-NAN/0166/2012 and strategic project PEst-OE/SAU/UI4013/2011.

Pressure ulcers are a common and recurrent clinical condition in paraplegic patients, requiring specialized equipment and care, as well as surgical interventions in order to treat them. This is especially true whenever and infection is declared, which will delay or impair ulcer epitelization. These surgical interventions require a good use of various myocutaneos flaps to cover all defects. Problem arises whenever there is not enough flap tissue to cover the entire ulcer, or when multiple surgeries to correct previous ulcers have already been performed.

Our goal is to describe the use of a last resort surgical technique for covering infected pressure ulcers.

This is a retrospective and descriptive case report based on data from clinical records, patient observation and analysis of complementary exams.

We present the case of a 30-years-old man, paraplegic for 10 years due to motor vehicle accident with spinal cord injury. Since the accident, and although he used adapted equipment and pressure relief mattresses and wheelchair cushions, he developed recurrent, infected ulcers in the perineal and sacral area, being operated on for multiple times by the Plastic and Reconstructive Surgery (PRS) department, for surgical debridement and ulcer coverage with tensor faciae latae and hamstrings myocutaneous flaps.

Despite all treatment, patient developed a stage IV perineal ulcer, which ranged from his left great trochanter to the right buttock, and a simultaneous stage IV sacral ulcer. Both ulcers were infected with meticilin-resistent Staphylococcus aureus (MRSA), sensitive to vancomycin. The patient's left hip joint was also infected (due to a direct trajectory to the perineal ulcer) and subluxated (due to absence of soft tissue support).

A multidisciplinary team assembled and decision was made to disarticulate the patient's left hip, debride and irrigate extensively the surgical site, and use a double gastrocnemius myocutaneous fillet flap in-continuity, in a surgical collaboration between the Orthopaedics and PRS department. This should provide satisfactory soft tissue ulcer coverage as well as facilitate antibiotics penetrance and infection eradication.

Surgery went without complications and the patient healed uneventfully. He resumed unrestricted positioning for sitting and wheelchair mobilization. Now, at two years follow-up, the patient still has no recurrence of either the ulcer or the infection.

This surgical technique provided robust soft tissue coverage for the ulcers, as well as an important aid for infection control. It proved to be a viable option in a paraplegic patient, when more traditional flap techniques can no longer be used and with a recurrent infection.

Revision surgery and surgery in previously operated areas are associated with an increased infection risk. In such situations, aggressive surgical debridement may be necessary to control and eradicate the infection. Full thickness defects resulting from such debridement present as a challenge. In most cases, an association of various methods, both surgical and non-surgical, is necessary.

Our goal is to describe the use of vaccum dressings as an effective way to deal with extensive and infected dorsolumbar surgical defects, while avoiding the use of myocutaneous flaps.

This is a retrospective and descriptive case report based on data from clinical records, patient observation and analysis of complementary exams.

We present the case of a 57-years-old obese woman with prior history of double approach with posterior instrumentation and spine arthrodesis (D3 to L4) due to severe dorsolumbar adolescent idiopathic scoliosis. She presented to our consult 42 years after surgery, complaining of lower back pain. Clinical observation and imaging exams demonstrated degenerative disc disease in L5-S1 and L5 anterolisthesis. There was also distal instrumentation breakage (right L4 pedicular screw and contralateral rod) with pseudarthrosis suspicion.

Distal instrumentation was removed and no pseudarthrosis was found. Therefore, posterior instrumentation and arthrodesis was performed, from L4 to S1. Surgery went without complications.

One week after surgery, patient developed fever and inflammatory signs at the surgical incision, with purulent oozing. Escherichia coli and Proteus mirabilis were identified as the causative agents.

Decision was made to remove both lumbar and distal dorsal instrumentation and perform aggressive debridement and lavage, with debridement surgery being repeated twice. Finally, a full thickness defect with approximately 20cm long and 6cm wide resulted from the debridement.

A vacuum dressing was then applied, for 5 weeks, with progressive decrease in clinical and analytical inflammatory parameters and wound closure.

Four months after the initial surgery, patient was discharged with complete defect closure and reepithelialization.

This dressing technique provided a sound solution for defect resolution, as well as an important aid for infection control. It proved to be a viable option in an extensive defect, when surgical flap techniques and traditional dressing techniques could not provide a complete solution.

Following arthroscopic arthrolysis for frozen shoulder, steroid injections may become necessary to improve ongoing pain and facilitate stretching exercises. The aim of this study was to evaluate the rate of steroid injections needed post-arthroscopic arthrolysis of frozen shoulder.

Case series review carried out in a District General Hospital in UK. 30 consecutive patients who had arthroscopic arthrolysis under the care of the senior author were included. Patients’ records were analysed to identify the number of steroid injections administered post-operatively.

11 males and 19 females were examined, aged 46–83 years old (mean 56.1). 7 patients were diabetic. 10 patients (33.3%) received steroid injections post-operatively, with 8 of them receiving the injection within the first 6 post-operative months. The average post-operative time of steroid injection was 9.8 months. There was no association between diabetes and administration of a post-operative steroid injection P>0.01.

Following arthroscopic arthrolysis a substantial proportion of patients may require one or more steroid injections to help pain and facilitate stretching exercises and physiotherapy. This study showed that 1 in 3 frozen shoulders treated with arthroscopic arthrolysis may need a subsequent steroid injection in the first year post surgery. Patients should be counselled preoperatively with regards to that, and be warned that arthroscopic arthrolysis is only the first step in the treatment pathway leading to recovery.

Blackpool Victoria Hospital Orthopaedic Department

In Denmark the most common postoperative pathogen is S. aureus (1), sensitive to dicloxacillin. These bacteria can cause a postoperative infection despite using prophylactic antibiotics. Whether the tissue concentration reached is above the minimal inhibitory concentration (MIC) for the pathogens is unknown, and if lower than expected could result in a postoperative infection. Thus a trial was conducted, measuring the actual tissue concentration of dicloxacillin in human muscle and adipose tissue and compared these to the plasma concentration.

MIC for dicloxacillin against S. aureus was determined using the broth macrodilution method. Six healthy male volunteers aging 25 to 27 years (body-mass-index; 20–28), were recruited. A CMA63 (Mdialysis, Stockholm, Sweden) catheter was placed in the subcutaneous tissue of the abdomen and in the rectus muscle of the thigh and the volunteers given 2 g dicloxacillin intravenously over 5 minutes. In 10 min intervals for the following 6 hours, samples from blood and Microdialysis fluid (flowrate 5 ml/min) were collected. Recovery was determined in vitro. Plasma was isolated from blood samples. The unbound dicloxacillin was isolated from plasma using filter plates (AcroPrep 30K Omega, Pall Corporation, US) centrifuged for 30 minutes at 1000 × g and 37°C. All samples were analyzed with High Performance Liquid Chromatography.

MIC was determined to be 0.125 µg/ml. Average recovery was 73,7 % Maximum concentrations were reached in muscle tissue after a median of 0.5 hours and adipose tissue after 0.8 hours. The geometric mean ration (GMR) of AUC0-6h for adipose tissue compared to plasma was 0.32 [0.15–0.71]. GMR of AUC0-6h for muscle tissue compared to plasma and adipose tissue compared to muscle showed no statistically significant differences. The tissue concentrations were above MIC for 3.4 hours for adipose tissue and 4.1 hours for muscle tissue.

The administration of prophylactic dicloxacillin should be given at least 30 minutes prior to incision to ensure maximum tissue concentrations at the onset of surgery. A second dose should be given after 3.4 hours in case of long surgery time. Since the dicloxacillin concentration reached in the adipose tissue is lower than in plasma, it should be investigated whether this difference is more prominent in adipose patients or patients with impaired peripheral circulation, since these patients are at a greater risk of postoperative infections.

Surgical treatment of distal tibia fractures is usually associated with extensive soft tissue compromise and high complication rates (infection, delayed or non-union, ankle stiffness and osteoarthritis). Wound infection is one of the most common complication (deep infection rates up to 15%) and can develop into an infected non-union.

In 1973, Papineau described a staged technique for treating infected non-union of long bones, consisting of (1) surgical debridement of necrotic tissue, temporary splinting, specific antibiotic treatment, postoperative wet-to-dry wound dressing changes; (2) packing of the bone defect with cortico-cancellous autograft; (3) closure of the soft-tissue wound by a flap or secondary intent.

The authors aim to report a clinical case of a successful treatment of a distal tibia infected non-union with the Papineau technique and negative-pressure wound therapy.

Woman, 56 years-old, referred to Orthopaedic consultation on October 2013 for wound dehiscence and infection with a methicillin-resistant Staphylococcus aureus, one month after open reduction and internal fixation of an open distal tibia fracture.

On November 2013 she underwent surgical debridement, removal of osteosynthesis material, osteotaxis with external fixator, negative-pressure wound therapy and antibiotic treatment with intravenous vancomycin 1g 12/12h (1st stage of Papineau procedure)

On December, she underwent autologous iliac crest cancellous bone grafting and wound care, daily irrigated with saline solution (2nd stage).

On February 2014, she underwent a partial thickness skin graft for wound closure (3rd stage).

On April, the external fixator was removed and there was still no evidence of union. She had pain, disuse osteoporosis, ankle and midfoot stiffness, and was sent to physical therapy.

On April 2015, she can full weight bear with mild pain, the soft tissue envelope is in good condition, the fracture has united and she has an Ankle AOFAS Score of 83.

The Papineau technique has been used for the management of infected non-unions with bony defects, with high success rates. Complete necrotic tissue debridement and targeted antibiotics are fundamental for obtaining a viable and healthy tissue, able to receive the bone graft. Negative-pressure wound therapy is important in reducing the bacterial load, improving the microcirculation and enhancing the granulation tissue.

In the present case, the combination of the two techniques probably acted together in achieving successful eradication of the infection, reconstruction of the bone defect and soft tissue closure.

To reveal if patient reported knee-related pain, function, quality of life, general health and satisfaction at one year after primary total knee arthroplasty (TKA) is different between patients not being subject to revision surgery and those having had early treatment with open debridement and exchange of the tibial insert for postoperative PJI.

The Swedish Knee Arthroplasty Register was used to identify 50 patients in the region of Skane that had a primary TKA during the years 2008 – 2012 and within 6 months were revised with open debridement and exchange of the tibial insert due to suspected or verified PJI. Only patients without further revisions were included. Patient reported outcome measurements (PROM) were obtained preoperatively and 1 year postoperatively and included knee related pain, function, quality of life using the Knee injury and Osteoarthritis Outcome Score (KOOS), general health using the EQ-VAS as well as satisfaction with the surgery. The scores were compared to those reported by 3,913 patients having a TKA during the same time but not revised during the first year. Welch's t-test and the Chi2-test were used in statistical analysis.

Compared to the controls the infected patients were older (mean age 72 vs 69 years, p = 0.04) and were more morbid (ASA 3; 14/50 patients vs 14%, p = 0.02). The preoperative PROM data were similar. Complete 1 year PROM data was available for 31 of the patients. Those patients reported somewhat worse outcome one year postoperatively than the controls with statistically and clinically significant differences in general health (mean 61 vs 76, p=0.002), KOOS ADL (mean 65 vs 76, p=0.03) and knee related quality of life (mean 51 vs 63, p=0.02) with large variations on individual level. Just over half of the patients (17/29) treated for PJI were very satisfied or satisfied with the surgery compared to 79% of the controls.

Patients treated with open debridement and exchange of the tibial insert due to early PJI after primary TKA reported less beneficial postoperative outcome than those without revision surgery during the first postoperative year but with large individual variations.

To study in resolution of triggering 12 months after injection with either a soluble methylprednisolone acetate or dexamethasone for idiopathic trigger finger.

Twenty-eight patients were enrolled in a prospective randomized controlled trial comparing methylprednisolone acetate and dexamethasone injection for idiopathic trigger finger. Twenty-seven patients completed the 6-week follow-up (11 methylprednisolone acetate arm, 16 dexamethasone arm) and thirteen patients completed the 3-month follow-up (4 methylprednisolone acetate arm, 9 dexamethasone arm). Outcome measures included resolution of triggering, recurrence rate of trigger finger, satisfaction on a visual analog scale, tender, snapping, locking, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and tip to palm distance (mm.) at 2, 6, 12 and 24 weeks follow-up. Eight patients were repeated a second injection (3 methylprednisolone acetate arm, 5 dexamethasone arm) at 6-week follow-up. To preserve autonomy, patients were permitted operative treatment any time. The analysis was according to intention to treat principles.

Six weeks after injection. Absence of triggering was documented in 6 of 11 patients in the methylprednisolone cohort and in 6 of 16 patients in the dexamethasone cohort. The rate 3-month after injection were 2 of 4 patients in the methylprednisolone cohort and in 8 of 9 patients in the dexamethasone cohort. There were no significant difference between recurrence rate of trigger finger, satisfaction on a visual analog scale, tender, snapping, locking, the Disabilities of the Arm, Shoulder and Hand (DASH) scores and tip to palm distance (mm.) at 2, 6, 12 and 24 weeks follow-up.

Although there were no differences 3months after injection, our data suggest that in the dexamethasone cohort was better in resolution of triggering than the methylprednisolone cohort at 12-week follow-up.

Treatment of osteomyelitis is a challenge for every surgeon, but even more so in low and middle income countries, because of delay in presentation, lack of resources and troublesome follow-up. We present a series of fifteen patients, treated for osteomyelitis in 2014 in a rural Ghanean hospital with one-year follow up. All bony defects were filled using Bonalive®.

Fifteen consecutive patients with osteomyelitis were included in this study and treated with Bonalive® in March 2014. The group consisted of twelve men and three women (age 10–46y, mean 26y). All patients consented and the study was approved by the hospital's ethical committee. Imaging was performed preoperatively, immediate postoperatively and at various occasions thereafter with final X-rays taken at follow-up in April 2015. All were treated by extensive debridement of the osteomyelitic bone, sequestrectomy, saucerisation and filling of the defect with Bonalive® granules (1,0–2,0 mm in size). Primary closure of the wound was possible in all cases. Fistulae were curetted, not closed. Peroperatively, multiple culture specimens were taken and all patients received a course of intravenous antibiotics for a week, continued orally thereafter for another week. Patients were regularly followed up postoperatively and final review took place in April 2015.

Of all fifteen treated patients, only seven were seen back in April 2015, more than one year postoperatively. The osteomyelitis was located in the femur in seven patients, tibia in seven and the humerus in two. Microbiology showed growth of St. aureus in six patients, Proteus species in six, St. epidermidis in two and pseudomonas in one. Of the seven patients presenting at one year follow-up, all had relief of symptoms for at least three months. Two were completely symptom free, the other five still had one or more draining fistulae. Initial X-rays showed good filling of all osteomyelitic defects with the bioglas granules.

Treatment of osteomyelitis remains a challenge in low and middle income countries. First, there is almost always a delay in presentation and most cases have become chronic by the time they are treated. Secondly, some sequesters were missed and therefore not removed at surgery, due to the lack of good initial x-ray films. Thirdly, there is often no access to microbiological diagnostics. At last, a lot of patients are lost to follow-up.

In our opinion, the Bonalive® product delivered it's claims, but the overall circumstances in which we treated these patients were importantly responsible for the overall suboptimal outcome.

Methicillin– resistant Staphylococcus aureus (MRSA) infected gap non –union of long bones fractures is a challenge to manage. Treatment options are limited such a Ilizarov bone transport, vascularized bone free transfer etc. These techniques have complications and require expertise. We present a rare case with MRSA infected nonunion and bone defect 5cm of ulna which was managed with the induced membrane formation.

A 33-years old male presented to outpatient department, 2 months after internal fixation on both left bone forearm fractures (Gustillo I). There was pus discharge from the operative site of ulna. Culture results: MRSA, C-Reactive Protein (CRP): 2,58 (0–5), Erythrocyte Sedimentation Rate (ESR): 42 (0–20). Intravenous (iv) Teicoplanin and Rifampicin were administrated and after one month no topic symptoms and CRP- ESR were normal. One month later he had again actively draining sinus (CRP: 1,47 ESR:22). The implant (ulna) was removed and a gap 5 cm was created at the fracture site (necrotic-infected bone debrided), which was filled by cemented spacer (Tobramycin and vancomycin). An external fixator was applied to ulna. Radius was not involved. Post op. iv the same antibiotics for 4 weeks. At the end of 8 weeks, the spacer was removed and the gap was filled with autologous cancellous bone graft (iliac crest).

After 5 months the patient was reviewed. No any clinical and functional problems. Radiographics and CT-images were showed osseous consolidation.

This technique (called as ‘Masquelet’) gives promising result in the management of infected long bone defects in upper extremity.

Patient safety is a major concern worldwide, but particularly high rates of adverse events are reported in the surgery setting. Orthopaedic and Traumatology is the speciality most frequently involved in claims in Catalonia. The objective of the study is to perform a descriptive study of the claims regarding infection in Orthopaedic and Traumatology in Catalonia.

We performed a retrospective study of the claims regarding infection in Orthopaedic and Traumatology from the prospective claims database of the Service of Professional Liability of The Catalonian Council of Official Colleges of Physicians. The time frame of data collection was from 2003 to 2013. We analyzed both the clinical and legal characteristics of the cases.

During the 10-year period, 638 registered claims were related to the practice of Orthopaedic and Traumatology, and 74 (11,6%) were due to infection. The most frequent surgical procedure involved were arthroplasty (knee, hip or shoulder) (14, 18,9%), traumatic wounds and cellulitis (12, 16,2%), spine procedures (10, 13,5%) and arthroscopy (7, 9,4%). The most frequent anatomical site involved were foot and ankle (17, 22,9%), spine (15, 20,3%), knee (14, 18,9%), wrist and hand (11, 14,8%). The 68,92% of claims was solved by the courts and 29,73% by an “out-of-court” procedure. The average compensation in cases considered to have professional liability was 145.045€.

Orthopaedic and Traumatology seem to be a specialty with a high risk for claims, and infection is one of the most important causes. The study of the claims can lead to improvements in prophylaxis, diagnosis and treatment of infection in Orthopaedic and Traumatology.

The objective was to compare susceptibility testing of all coagulase negative species (CNS) found in periprosthetic joint infections (PJI).

We conducted a multicentre retrospective study in a same area from 2011 to 2014, including 215 CNS strains.

Diagnosis of PJI was based on clinical, radiological and biological criteria. Microbiological criterion was at least 2 per-operative deep positive cultures with the same species of CNS. Identification and susceptibility testing were performed on automated Vitek2 (Biomérieux, France).

PJI localizations were 54% knees, 39% hips, 7% other sites.

CNS found in our study were by dicreasing order:

S. epidermidis (SE) 60%, S. capitis 11%, S. lugdunensis (SL) 10%, S. caprae 5%, S. warneri (SW) 4%, S. hominis (SHo) 3%, S. haemolyticus (SHa) 3%. Fifty two percent of CNS strains were meticillin (oxacillin) resistant and 31%, 33%, 41%, 20% were also resistant to clindamycin (CLI), trimethoprim-sulfamethoxazole (SXT), ofloxacin (OFX), rifampicin (RMP) respectively. Regarding CNS species, meticillin resistance was detected for 70% SE, 71% SHo and 71% SHa. SE was the most resistant species, with 34% of the strains resistant to CLI, SXT, OFX and RMP simultaneously. Half of SE and SHa were resistant to the reference treatment levofloxacin+rifampicin. Thirteen percent of CNS were resistant to teicoplanin and only 1% to vancomycin.

Susceptibility testing profiles are presented in table field.

In our study, S. epidermidis was the main species found in PJI. Emerging species like S. lugdunensis or S. caprae were found, with more susceptible antibiotic profiles. The most active antibiotics in vitro were daptomycin, linezolid, vancomycin and teicoplanin.

A common step to revision surgery for infected total knee replacement (TKR) is a thorough debridement. Whilst surgical and mechanical debridement are established as the gold standard, we investigate a novel adjuvant chemical debridement using an Acetic Acid (AA) soak that seeks to create a hostile environment for organisms, further degradation of biofilm and death of the bacteria.

We report the first orthopaedic in vivo series using AA soak as an intra-operative chemical debridement agent for treating infected TKR's. We also investigate the in vitro efficacy of AA against bacteria isolated from infected TKR's.

A prospective single surgeon consecutive series of patients with infected TKR were treated according to a standard debridement protocol. Patients in the series received sequential debridement of surgical, mechanical and finally chemical debridement with a 10 minute 3% AA soak.

In parallel, we isolated, cultured and identified bacteria from infected TKR's and assessed the in vitro efficacy of AA. Susceptibility testing was performed with AA solutions of different concentrations as well as with a control of a gentamicin sulphate disc. The effect of AA on the pH of tryptone soya was also monitored in an attempt to understand its potential mechanism of action.

Physiological responses during the AA soak were unremarkable. Intraoperatively, there were no tachycardic or arrythmic responses, any increase in respiratory rate or changes in blood pressure. This was also the case when the tourniquet was released. In addition, during the post-operative period no increase in analgesic requirements or wound complications was noted. Wound and soft tissue healing was excellent and there have not been any early recurrent infections at mean of 18 months follow up.

In vitro, zones of inhibition were formed on less than 40% of the organisms, demonstrating that AA was not directly bactericidal against the majority of the clinical isolates. However, when cultured in a bacterial suspension, AA completely inhibited the growth of the isolates at concentrations as low as 0.19%v/v.

This study has shown that the use of 3% AA soak, as part of a debridement protocol, is safe. Whilst the exact mechanism of action of acetic acid is yet to be determined, we have demonstrated that concentrations as low as 0.19%v/v in solution in vitro is sufficient to completely inhibit bacterial growth from infected TKR's.

A resorbable, antibiotic-eluting bone void filler (AEBVF) was developed to address device-related infections. The AEBVF provides two functions: osteoconductive matrix for bone restoration, and local antibiotic delivery to treat device-related infections. In vitro evaluations of this AEBVF demonstrated antimicrobial activity to 7 weeks against Staphylococcus aureus (S. aureus).1 Subsequent rabbit studies demonstrated bactericidal capacity2 of the AEBVF against 105 CFU S. aureus and osteoconductivity.1 We hypothesized that the AEBVF would restore bone volume while eliminating 105 CFU S. aureus in a pilot sheep femoral condyle defect model.

Four groups (n=2/group) were utilized to assess osteoconductivity (Group A-commercial ProOsteon & B-AEBVF) and antimicrobial activity (Group C-ProOsteon with 105 CFU S. aureus & D-AEBVF with 105 CFU S. aureus). AEBVF devices comprised degradable polymers (PCL, PEG, PLGA), ProOsteon (Biomet, USA), CaCl2, and tobramycin.3 Devices (1.5cc ProOsteon or 6 AEBVF croutons) were implanted into rectangular defects in the medial face of each sheep femoral condyle. Defects were evaluated using backscatter electron microscopy, mineral apposition rate (MAR) analysis, and light microscopy with Sanderson's Rapid Bone Stain (SRBS).

All animals in Groups A, B, and D survived to the 12-week endpoint. In contrast, Group C animals were euthanized 11 days post-op. MAR and SRBS demonstrated comparable bone remodeling and defect restoration after 12 weeks in Groups A, B, and D. Notably, implant volumes of Groups A and D were greatly diminished (0.16±0.1%; 0.35%) after 12 weeks, compared to Group A (13.23±3.2%) and Time “0” (16.8%).

These data show the AEBVF device's ability to: eliminate 105 CFU S. aureus, promote bone remodeling comparable to known bone void filler, and degrade at rates that do not interfere with bone remodeling.

Aim of this work was to evaluate the efficacy of a new antibiotic bone substitute (CERAMENTTM|G) in the treatment of osteomyelitis (OM) in diabetic foot.

From June 2013 to April 2015 we used a new Calcium Sulphate Hemihydrate + Hydroxyapatite + Gentamicin Sulfate (CSH + HA + GS) compound to fill resected bone voids following surgical intervention in cases of diabetic foot OM. The uniqueness of this product is that it induces native bone growth, while the synthetic bone disappears and antibiotic is released into the surrounding tissues, maintaining high gentamicin concentrations for some weeks.

In 20 patients, with or without Charcot neuroarthropathy and post-lesional osteomyelitis, after removal of infected bone we applied 10 to 20 ml CSH + HA + GS, filling the residual spaces and aiming to stabilize the remaining bone fragments. When needed, these arthrodeses were stabilized by external-internal hybrid fixators. X-ray evaluations and, when indicated, MRI evaluations were performed before and after surgical intervention, and 3 months post-op. Revascularization with percutaneous angioplasty was performed when needed.

20 patients affected by OM were treated, 4 of them having 1st metatarsal head involvement, 4 having heel involvement, 12 tarsal and hindfoot involvement. After surgical intervention all of them were treated with standard medication and pressure relief.

The three 1st metatarsal OM cases healed, both in regards to infection and lesions. One of the patients is still ongoing. One of the patients with heel OM presented with a worsening of the infection and was treated by major amputation, another one presented with good soft tissue growth and, two months from the intervention, and in the absence of clinical signs of OM relapse, was treated with a sural fasciocutaneous pedicled flap; of the remaining two patients one heald and the other is still ongoing; 11 of the 12 patients who had midfoot or hindfoot partial resections healed, one patient is still ongoing. The healed patients are all wearing suitable shoes.

The use of a new CSH + HA + GS bone substitute has shown to be efficacious in inducing OM healing and preserving foot structures in diabetic feet.

Spondylodiscitis rarely coexists with endocarditis (around 5% of patients with endocarditis). Furthermore, viridans streptococci are not common pathogens of spondylodiscitis and finally the combination of spondylodiscitis and right – sided endocarditis due to viridans streptococci is rare. We present a case of right-sided native valve endocarditis due to Streptococcus mutans presenting as cervical and lumbar spondylodiscitis in a patient with obstructive cardiomyopathy.

A 52 year – old man with a history of hypertrophic obstructive cardiomyopathy was admitted with fever and back pain of ten days duration, followed by torticollis. He had undergone dental therapy some weeks before symptom appearance, due to bad oral hygiene, without receiving any chemoprophylaxis. Magnetic resonance imaging revealed L4-L5 and C4-C5 spondylodiscitides. Four blood cultures drawn were all positive for Streptococcus mutans, while fine needle aspiration of the lumbar lesion was unsuccessful. Transesophageal echocardiogram revealed tricuspid and possible pulmonary valve vegetations.

The patient was treated with ceftriaxone plus gentamicin for 2 weeks and then ceftriaxone only, for a total of 3 months. He had an uneventful recovery and was referred for cardiosurgical consultation.

Physicians managing cases of spondylodiscitides should bear in mind to rule out endocarditis, especially in cases with underlying cardiopathy. The possibility of coexistence is even greater when there is sustained bacteremia and the pathogen isolated from blood cultures is a common pathogen for endocarditis.

The aim of the present study was to assess the antibiofilm activity of daptomycin- and vancomycin-loaded poly(methyl methacrylate) (PMMA) and PMMA-Eudragit RL100 (EUD) microparticles against mature biofilms of polysaccharide intercellular adhesin-positive S. epidermidis.

The effect of plain, daptomycin- and vancomycin-loaded PMMA and PMMA-EUD microparticles on S. epidermidis biofilms was assessed by isothermal microcalorimetry (IMC) and fluorescence in situ hybridization (FISH). Biofilms were grown for 48h onto poly-urethane pieces of fixed dimensions. Each sample was washed with PBS in order to remove planktonic bacteria and incubated for 24h with different concentrations of acrylic microparticles (20–1.25 mg/mL). The minimal biofilm inhibitory concentration (MBIC) of the antibiotic-loaded particles was defined as the lowest concentration of particles that was able to prevent heat flow associated to the recovery of the biofilms. After incubation with the microparticles, sessile cocci were hybridized with the pan-bacterial EUB338-FITC and the staphylococci-specific STAPHY-FICT probes and stained with DAPI. Biofilm structure and metabolic state were characterized by fluorescence microscopy.

According to the IMC results, plain PMMA-particles showed no effect on S. epidermidis biofilms, whereas PMMA-EUD-microparticles negatively influenced the recovery of the biofilm probably due to the highly positive charge of these particles. The MBIC of daptomycin-loaded PMMA-microparticles was 20 mg/mL, whereas vancomycin-loaded PMMA microparticles were not able to inhibit biofilm recovery. Adding EUD to the formulation reduced the MBIC of daptomycin-loaded microparticles to 1.25 mg/mL, corresponding to a 16-fold reduction. Regarding the vancomycin-loaded microparticles, EUD caused a further decrease of their antibiofilm activity. The FISH micrographs corroborated the IMC results and provided additional insights on the antibiofilm effect of these carriers. According to FISH, daptomycin-loaded PMMA-EUD microparticles were responsible for the most pronounced reduction in biofilm mass. In addition, FISH showed that both PMMA and PMMA-EUD microparticles were able to attach to the biofilms.

Adding EUD to the formulations proved to be a powerful strategy to improve daptomycin-loaded microparticles antibiofilm activity. In addition, the combination of IMC and FISH was essential in order to fully assess the effect of polymeric microparticles on sessile S. epidermidis. Although the present study enabled gaining further insights on this subject, the nature of these interactions remains unclear. However, this may be a crucial aspect for the enhancement of antibiofilm activity of antibiotic-loaded polymeric microcarriers against mature biofilms.

This work was supported by the Portuguese government (Fundação para a Ciência e a Tecnologia) and FEDER (grant SFRH/BD/69260/2010 and research project EXCL/CTM-NAN/0166/2012) and strategic project PEst-OE/SAU/UI4013/2011.

Daptomycin has a unique mechanism of action against Gram-positive bacteria. Daptomycin is only bactericidal in the presence of calcium ions. [1]

Kanellakopoulou et al [2] investigated elution of daptomycin from calcium sulfate. The results indicated above MIC elution concentrations out to 28 days. Experience reports that the ability for calcium sulfate to set hard when combined with daptomycin can be problematic.[3] This study aimed to investigate the combination of daptomycin with a synthetic recrystallised form of calcium sulfate and investigate zone of inhibition (ZOI) testing against susceptible organisms.

6mm hemispherical beads, were prepared using a commercially available calcium sulfate hemihydrate powder (CSH) – CaSO4 ·1/2H2O. [4] In order to combine daptomycin [5] with the CSH and enable it to set hard, 7mls of saline solution was added to 20g CSH powder and mixed for 80 seconds to initiate the setting reaction. Then 1g of daptomycin powder was added and mixed for a further 30 seconds. The resultant paste was applied to a bead mat and allowed to set.

Tryptone soya agar plates were seeded with 0.2ml of a 10e6 – 10e8 cfu/ml suspension of the relevant organism. The plates were incubated at 33 °C ± 2 °C for 30 minutes. The plates were then removed from the incubator and the beads placed on the surface. The plates were then incubated at 33 °C ± 2 °C for 24 hours before examination for the absence of growth as seen by a clear zone around the test sample.

Triplicate samples were tested against Staphylococcus epidermidis, Staphylococcus aureus, MRSA, VRE Enterococcus faecium and Propionibacterium acnes.

Repeat tests were carried out for beads that had been stored at 37 °C for 21 days to simulate in-vivo conditions.

Setting times for the CSH/daptomycin beads were approximately 20 minutes. ZOIs indicating efficacy were seen for all samples both ‘fresh’ and ‘incubated’ with MRSA and Propionibacterium acnes having the largest ZOIs at 31–33mm.

A mixing protocol was established to enable set beads to be formed with daptomycin loaded calcium sulfate. As assessed by ZOI testing, the eluted antibiotic maintained efficacy against susceptible pathogens. Results obtained in-vitro may not be indicative of in-vivo performance.

Daptomycin is a novel lipopetide antibiotic against gram-positive organisms, including multi-resistant strains. It effectively penetrates bone and has bactericidal activity within biofilms. In adults it has been demonstrated active against Staphylococcus Aureus Methicillin Sensible (MSSA) and Resistant (MRSA) bacteremia. The main side effect is a transitory myopathy that appears to be dose and frequency related. There are limited dates on daptomycin in pediatric patients.

We reviewed the medical records of four children (3 males and 1 female), with a median age of 11.2 years (range 7–13 years), who received daptomycin therapy for a complicated osteomyelitis. Osteomyelitis was clinically suspected and confirmed by magnetic resonance imaging at left ankle, left tibia, left calcaneum, lumbar column.

The pathogen isolated was a MSSA in all four cases. All patients received prior antibiotic treatment. Therapy was swiched to Daptomycin for first line treatment failure (in three cases) and for an adverse reaction to first line treatment (in one case). Daptomycin was prescribed at the mean dosage of 9 mg/kg/day (range 8–10 mg/kg/day) for a median time of 15 days. After 4 days therapy, all patients clinically and laboratory improved with resolution of fever and pain and decreased inflammatory indexes. No patient underwent surgery. After a median of 20 days of hospitalization, patients were discharged with oral antibiotic therapy. They received follow-up clinical evaluation for 8 months (range 6–10 months) with no sequelae.

With the limits of a small population and of a retrospective and unblended study, daptomycin therapy may be useful in complicated osteomyelitis and allowed the avoidance of surgery. The good outcome of the patients was probably due to daptomycin bactericidal activity against bacteria and to its ability to penetrate into bone and synovial fluid. Daptomycin therapy has been well tolerated in all patients, even if administered at a higher dose. No side effect was reported during therapy and at a 30 days follow-up evaluation.

Prosthetic joint infections (PJI) caused by Streptococcus species are relatively common.

The aim of our study was to assess outcome after treatment for early and late PJI with Streptococcus species after a follow-up of two years.

For this study we retrospectively included all patients with primary or revision total knee arthroplasty (TKA) or total hip (THA) arthroplasty, a minimum of two periprosthetic tissue cultures positive for Streptococcus species and a minimum follow-up of one year. According to international guidelines patients were classified as having early or late PJI. All patients with an early PJI were treated according to a standard treatment protocol, i.e. debridement and retention of the prosthesis, followed by adequate antibiotic therapy. Patients with late PJI underwent a debridement followed by adequate antibiotic therapy or joint revision. Patients’ hospital records were reviewed and we evaluated the status of the original prosthesis after an infection.

Forty cases were included; 24 early and 16 late PJI. For early PJI, open debridement was performed in all patients, after a mean of 19 (range: 9 – 80) days. At final follow-up 21 prostheses (88%) were still in situ and without clinical signs of infection. Eight cases (41%) of late PJI were successfully treated with debridement and retention. Nine patients (59%) underwent a one- or two-stage revision. At final follow-up 16 patients (100%) with late PJI had a prosthesis in situ. Streptococcus dysgalactiae species accounted for more than 50% of the early infections, followed by Streptococcus agalactiae with 30%.

In case of PJI with Streptococcus species open debridement and retention of the prosthesis should be performed followed by adequate and long-term antibiotic treatment. As expected, the retention rate for early PJI is much higher than that for late PJI.

Evaluation of the effectiveness of biodegradable bone substitute with high doses of antibiotics in cavitary osteomyelitis and infected nonunions.

The authors evaluated 8 cases, 5 of them related to osteomyelitis with bone sequestration and other 3 regarding infected nonunions. All of them had in common the persistence of infection after antibiotic therapy.

All infections were confirmed by microbiological studies. In all cases the surgeons conducted a thorough surgical debridement and filling of bone defects with Herafill®. Later a tight clinical, analytical and imagiological control was performed.

Five of the cases were a success with simultaneous healing of the bone loss and treatment of the infection. These corresponded to the cases of cavitary osteomyelitis. In the remaining 3 cases, despite infection eradication, union was not achieved and additional surgical procedures were required for definitive treatment of nonunion.

In the treatment of bone infection, use of high doses of antibiotics at the site is a consensus as it allows eradication of the infection with lower systemic effects. With the emergence of biodegradable bone substitutes, the need for a new surgical intervention for their removal can be avoided. Properties of calcium sulfate and calcium carbonate stimulate osteogenesis at the site, allowing their absorption and replacement by bone matrix. These properties make them ideal to usage in cases of cavitary bone defects.

Our experience supports the idea that the use of high doses of antibiotics locally permits remission of the infection. However, when this is implemented through a bone substitute, it is possible to achieve osteogenesis in bony cavities. Nevertheless, when applied to infected nonunions, their role seems to be limited to the eradication of the infection.

A multimodality approach is needed for management of infected joint replacement prostheses and infected skeletal metalwork. We present our results in six patients managed surgically with standard techniques, with the addition of a local antibiotic delivery system using absorbable Calcium Sulphate beads.

A retrospective study was undertaken of 6 patients with established musculoskeletal infection in relation to existing metalwork. Two patients had infection in the hip replacement prosthesis, three had infected prosthetic knee joints and one had infection in a femoral locking plate. All were treated with extensive debridement, revision / retention of implants, parenteral antibiotics and local antibiotics.

Patients were followed up in clinic for resolution of inflammatory markers and subsidence of signs of infection. Control of infection was achieved in five patients at average 19 months followup. One patient had persistent infection and has undergone further surgery.

In this preliminary study, we found local antibiotic delivery using absorbable calcium sulphate beads to be an effective adjuvant to standard debridement, parenteral antibiotics and revision of implants.

A Prosthetic Joint infection (PJI) is an orthopedic disaster. There is a direct correlation between persistent wound drainage (>72 hours) and the development of a PJI. It is unknown if early wound drainage (<12 hours) is correlated with PJI.

We included 753 consecutive patients treated with a Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA) operated between December 2012 and December 2013. All patients were treated according to our local fast track joint surgery protocol. We retrospectively analyzed the prospectively collected data on wound drainage and PJI.

The diagnosis PJI was established according to the definition by the International Consensus Group on Prosthetic Joint Infections. Per PJI-case, two control-cases were matched on type of surgery (THA or TKA) and day of surgery. Analysed variables were co-morbidities, medication, use of drains, haematoma, wound drainage and dressing changes. Statistical analysis was done using Kaplan Meier logistic regression with statistic significance set at p<0.005.

In 753 included patients, 25 PJI-cases were identified and 50 controls were matched. Cases had significant more wound drainage (88% vs 36% P=0.001)) and wound dressing changes (56% vs 18% P=0.006) in the direct postoperative phase (<12 uur postoperative). Cases had more haematoma (44% vs 10% P=0.005). We found no association between PJI and co-morbidity, medication and use of drains.

We found that wound drainage directly postoperative (<12hr) correlated with PJI. We believe that direct post operative drainage is of crucial importance in the development of PJI and inhibition of drainage offers opportunities for prevention of PJI. The use of tranexamic acid, suction drains and critical evaluation of guidelines for preventing thrombo embolic events all offer reducing the risk on wound drainage and the development of PJI.

Septic arthritis is a medical emergency that can lead to significant morbidity and mortality arising from irreversible joint destruction and overwhelming sepsis. The purpose of this prospective study is to present epidemiological, clinical and laboratory findings in adult patients with septic arthritis.

Adult patients treated for septic arthritis at the Department of Infectious Diseases, University Medical Centre Ljubljana, Slovenia, from January 2012 to December 2014, qualified for the present report. The following data were analyzed: age, sex, underlying diseases, previous joint procedure, microbiological diagnostic examinations, causative agents, complications and therapy.

During the study period of three years 94 episodes of septic arthritis were diagnosed. There were 49 (52.1%) females and 45 (47.9%) males, aged 64.5 (18 to 97) years. At the first visit elevated concentration of C-reactive protein was found in 93 (98.9%) patients. The most common affected joint was knee (48.9%), followed by shoulder (20.2%), wrist (12.8%), ankle (7.4%) and others. In 8 (8.5%) patients more than one joint was affected. Risk factors were found in 63 (67%) of study patients. The underlying joint disease (e.g. osteoarthritis, rheumatoid arthritis, gout) was found in 50.8% patients, following by malignancy and immunosuppressive therapy in 28.6%, diabetes mellitus in 14.9%, recent trauma in 12.8%, and prior joint procedure in 9.6% patients.

In 65/94 (69.1%) patients the causative pathogen was demonstrated by blood culture in 35.6%, by synovial fluid culture in 48.8%, and by both methods in 13.8% patients. In patients with proven aetiology Staphylococcus aureus was the most frequent (44.6%) isolated pathogen (only one methicillin resistant), followed by gram-negative bacteria in 30.8%, and Streptococcus spp. in 23.1% patients. In 4/65 (6.2%) patients more than one pathogen was isolated. The patients were treated with antibiotics according to isolated pathogen. In 17 (70.8%) out of 24 patients with complications synovectomia was performed, and adjacent osteomyelitis was found in 9 (37.5%) patients.

Our results show that the foremost risk factor in adult patients with septic arthritis is pre-existing joint disease, knee is the principal target of infection, and the most common isolated pathogen is S. aureus. It was established that prompt recognition, early appropriate antimicrobial and surgical treatment in these patients are critical to ensuring a good prognosis.

For which patients is bone-defect-reconstruction with the Masquelet-technique suitable?

Between 11/2011 and 1/2015 we treated 27 Patients (4 female/ 23 male) with bone-defects up to 150mm after septic complications with the Masquelet-technique.

Reason of the bone defects were infected-non-unions of lower extremity, chronic osteomyelitis, infected knee-arthrodesis, chronic upper-ancle-empyema and infect-defect-non-union of the humerus. On average the patients were 47,5 (18–74) years old. The mean bone-defect-size was 62,6 mm (25–150). 26 of the 27 patients came from other hospitals, where they had up to 20 (mean 4,9) operations caused by the infection. The time before transfer to our hospital was on average 177days (6–720). 25 patients receaved flaps because of soft tissue-defects (7 free flaps, 18 local flaps).

13 patients suffered a polytrauma.

In 5 cases the femur, in 3 cases a knee-arthrodesis, in 18 cases the tibia and in 1 case the humerus was affected by infection resulting in bone defects.

Indication for the Masquelet-technique was low-/incompliance in 10 cases due to higher grade of traumatic brain injury and polytrauma and difficult soft-tissue conditions, in 6 times after problems with segment-transport and in 1 case as dead space management.

Positiv microbial detection succeeded in 19 patients at the first operation although most of the patients underwent long term antibiotic therapy. Mainly we found problematic bacteria. At the time of defect reconstruction with spongious graft we found persistant bacteria in 4 cases.

The first operation aimed treating the infection with radical sequestrectomy, removal of foreign bodies and filling the defect with an antibiotic loaded cementspacer as well as external fixation. 6–8 weeks later we removed the spacer and filled the defect with autologous bonegraft. In 2 cases we needed 2 bone grafts to fill the defect. In 9 cases we removed the fixateur and stabilized the defect with an internal anglestable plate.

All patients were examined clinically and radiologically every 4–6 weeks in our outpatient-department for osteitis until full weight bearing and later every 3months

In 22 of 27 cases the infection was clinically treated successfully. 5 patients are allowed for full weight bearing (all with secondary internal plates). No patient underwent amputation.

There were 4 recurrences of infection, 9 instabilities needing internal stabilization and further bonegraft.

For patients with low-/incompliance for various reasons and for those with difficult soft tissue conditions following flaps the Masquelet technique is a valuable alternative to the normal autologious spongegraft and to the segmenttransport. Internal fixation seems necessary.

Implementation of new diagnostic methods (i.e. MALDI-TOF MS) has made it possible to identify coagulase-negative staphylococci (CoNS) to species level in routine practice. Further knowledge about clinical and microbiological characteristics of prosthetic joint infections (PJIs) caused by different CoNS may both facilitate interpretation of microbiological findings and improve clinical algorithms.

The aim of this study was clinical and microbiological characterization of PJIs caused by Staphylococcus capitis.

Patients with PJIs caused by S. capitis (growth in ≥2 perioperative tissue samples, n=19, identified by MALDI-TOF MS) from three centres between 2005–2014 were included. Medical records were examined (n=16). Further characterization of S. capitis was performed; rep-PCR (Diversilab, BioMerieux), standard antibiotic susceptibility testing, GRD Etest and macromethod Etest for detection of heteroresistant subpopulations and microtitre plate assay for detection of biofilm production.

Multi-drug resistant (MDR) S. capitis (R≥3 antibiotic groups) was detected in 5/19(26%) of isolates, 1/19(5%) were ciprofloxacin resistant and no isolates was rifampin resistant. Biofilm formation was present in 14/19(74%). The dendrograms created by rep-PCR showed two distinct clusters, including one that contained isolates from all centres, as well as the reference isolates. Furthermore, three additional clusters were identified, all of these mainly obtained from single centres. In two of these, MDR was highly prevalent. In one of these clusters, 4 of the 8 strictly monomicrobial infections were found.

All of the PJIs were defined as either early postinterventional (10/16) or chronic (6/16). No late haematogenous infection was found. The highest CRP values were reported in monomicrobial infections. Wound healing disturbances was noted in 8/10 early postinterventional infections. Fever was absent in chronic infections, sinus tracts rare (1/6), while pain was a common symptom (5/6).

S. capitis has the potential to cause PJIs, both by itself as well as part of a polymicrobial infection. The antibiotic susceptibility patterns were more favourable than has previously been reported in S. epidermidis isolated from PJIs(1). Clinical data suggests that PJIs caused by S. capitis were acquired perioperatively or in the early postoperative phase. The clustering found by rep-PCR together with data showing high prevalence of S. capitis in the air of operation rooms during prosthetic joint surgery(2) implicates that nosocomial spread might be present. Epidemiological surveillance may be of value in order to ensure early detection of nosocomial transmission.

Grants were received from the research committees of Värmland County Council and Örebro University, Sweden.

We wanted to study the risk of systemic toxic effect of gentamycin/vancomycin loaded spacers, and to investigate whether there is any difference in the elution of gentamycin and vancomycin to the joint fluid between theatre- made and in factory ready-made spacers

The study consists of 28 patients.

In group one, 14 patients were given a in factory ready-made spacer containing gentamycin 1,1g – 3,2g and vancomycin 1,1g – 3,2g depending of the size of the spacer.

In group two, 14 patients were given spacers made in the operating theatre. from PMMA containing 0,5 g gentamycin in each 40 g batch. 4 g vancomycin were added to each batch of 40 g PMMA.

The concentration of gentamycin and vancomycin was measured from drainfluid and in serum day 1 and 2 after the operation

Group one Group two Significance

Vancomycin drain day 1 10,3 (2,0–23.3) 88,5 (11,7–242,9) p<0,001

Vancomycin drain day 2 6,3 (2,0–17,5) 55,2 (7,5–161,0) p<0,001

Vancomycin serum day 1 2,0 (2,0–2,0) 1,8 (0,7–2.0) ns

Vancomycin serum day 2 2,0 (1,6–2,2) 1,9 (1,0–2,0) ns

Gentamycin drain day 1 23,4 (0,5–68,0) 44,3 (11,0–117,5) p=0,05

Gentamycin drain day 2 8,7 (0,8–16,1) 18,0 (6,8–45,3) p<0,005

Gentamycin serum day 1 0,2 (0,2–0,2) 0,3 (0,2–1,3) ns

Gentamycin serum day 2 0,2 (0,0–0,2) 0,3 (0,2–1,1) ns

In theatre-made spacers had a significant higher concentration of both gentamycin and vancomycin in the joint fluid. Even with very high consentrations of gentamycin and vancomycin in the joint fluid the concentrations in serum were far below the toxic limit and no toxic reactions were observed

Gentamycin and vancomycin added to the hip spacers only to a very small degree passes to the circulation system.

In theatre-made spacers have a significantly higher elution of gentamycin and vancomycin than in factory ready-made spacers. If a high initial concentration of gentamycin and vancomycin in joint fluid is desired. in theatre-made spacers should be considered.

Honey has been used as a topical antiseptic for at least 5,000 years. SurgiHoney is a CE licensed sterile product, which has been proven to be non-toxic and effective when used topically in the treatment of chronically infected wounds. The key difference from other medical grade honey is the broad spectrum antimicrobial characteristics with activity against Gram +ve, Gram –ve and multi-resistant organisms. Its novel role against the bacterial bioburden and biofilm associated with periprosthetic infections around total knee arthroplasties (TKA's) is therefore considered.

SurgiHoney was used as an implant coating immediately prior to wound closure after implantation of salvage endoprosthesis for multiply revised, infected TKA's undergoing staged reconstruction.

We report a consecutive series of multi-revised, infected revision TKA's where SurgiHoney was used as an active antimicrobial coating. We discuss its intra-operative application and early clinical outcomes.

The use of Surgihoney as a novel anti-microbial is established in the management of complex wound infections. This is the first reported use of SurgiHoney as a deep, implant coating in the salvage of prosthetic joint infection.

We conducted a randomized controlled trial (RCT) to investigate if iodine impregnated incision drapes (IIID) increases bacterial recolonization rates compared to no drape use under conditions of simulated total knee arthroplasty (TKA) surgery.

Background: To prevent surgical site infection (SSI), one of the important issues is managing the patient´s own skin flora. Many prophylactic initiatives have been suggested, including the use of IIID. IIID has been debated for many years and was deemed ineffective in preventing SSI in a recent systematic review [1], while some evidence suggests a potential increase in postoperative infection risk, as a result of IIID use [2].

IIID is sparsely investigated in orthopaedic surgery. An increase in the number of viable bacteria in the surgical field of an arthroplasty operation has a potential to increase the risk of SSI in an otherwise elective and clean procedure [3].

20 patients scheduled for TKA were recruited. Each patient had one knee randomized for draping with IIID [4] while the contralateral knee was left bare, thus the patients acted as their own controls. Operating theater settings with laminar airflow and standard perioperative procedures were simulated. Sampling was performed with the cup-scrup technique [5] using appropriate neutralizers. Samples were collected from the skin of each knee prior to disinfection and on 2 occasions after skin-preparation, 75 minutes apart. Bacterial quantities were estimated by spread plating with 48-hour aerobic incubation. Outcome was measured as colony forming units per square centimeter of skin. We used Wilcoxon signed-rank test for comparative analysis within and between knees.

Following skin-disinfection we found no significant difference in bacterial quantities between the intervention and the control knee (p = 0.388). Neither did we see any difference in bacterial quantities between the two groups after 75 minutes of simulated surgery (p = 0.367). When analyzed within the intervention and control group, bacterial quantities had not significantly increased at the end of surgery when compared to baseline, thus no recolonization was detected (p = 0.665 and 0.609, respectively).

Iodine impregnated incision drapes did not increase bacterial recolonization rates in simulated TKA surgery. Thus, the results of this RCT study does not support the hypothesis that iodine impregnated incision drapes promotes bacterial recolonization and postoperative infection risk.

To prevent nosocomial transmission (NT) of multiresistent germs (MRG) the German Robert Koch Institute (RKI) recommends to isolate patients with MRG.

At a so-called normal ward isolating patients is a challenging and stressful procedure for both patients and hospital staff.

The present study proposes the hypothesis that, compared to normal wards, an isolation ward reduces the nosocomial infection rate.

After an isolation ward with twelve beds has been established in 2005, patients with MRG on the wards of the department for spinal cord injury as well as on the isolation ward were monitored using a prospective screening and meeting the requirements of the RKI. Apart from detecting transmitter of MRG the NT of these bacteria was identified and registered between 2006 and 2013.

The total length of a patients stay in the hospital, the number of isolation days and the rate of NTs were documented. The quotient of MRG load per ward and the number of NTs per ward were compared.

In the investigation period of eight years 262175 patient days, 33416 isolation days and 33 transmissions were registered.

On the spinal cord injury ward 223167 of the patient days, 1120 of the isolation days and 29 of the NTs were documented. On the isolation ward 39008 of the patient days and 32296 of the isolation days with four of the transmissions were registered.

The mean load of MRG resulted from the quotient of the number of days with MRG per 100 patient days.

The effective nosocomial frequency of transmission resulted from the quotient of the mean load of MRG to the number of transmissions.

As a result, the frequency of transmission on the isolation ward was significantly lower (p=0,001) in comparison to the spinal cord injury ward.

The presented results suggest that, despite multiple higher loads of MRG, constructional measures combined with contact isolation facilitate a reduction of NT rates of MRG.

The reservation must be made, however, that in case of known MRG the screening was performed under isolation conditions, with unkown MRG without meeting requirements of isolation.

The present comparison of NT rates on an isolation ward and a normal spinal cord injury ward emphasizes the importance and function of an isolation ward through constructional (physical) separation and pooling of professional competency for successful management of MRG in healthcare facilities.

Listeria monocytogenes is usually thought of as a bacterial pathogen that causes invasive disease including meningitis and bacteraemia in susceptible hosts. It remains a rare cause of bone and joint infection; there is therefore potential for clinical and laboratory delay in diagnosis and for uncertainty over optimal management. We describe our experience of two such cases of L. monocytogenes prosthetic joint infection to highlight key features in clinical presentation and management.

Two case reports of L. monocytogenes prosthetic joint infection are described with reference to previous published cases.

A 57 year old woman presented with a 10 day history of severe pain and swelling around a left knee prosthesis which had been implanted as bilateral total knee replacements three years previously. She had a background of rheumatoid arthritis, controlled with prednisolone, methotrexate and ritixumab. Cultures from the left knee isolated L. monocytogenes. The patient was commenced on IV amoxicillin and after 4 weeks underwent 1st stage revision including radical debridement and removal of prosthesis. During the procedure an antibiotic-impregnated spacer (gentamycin/clindamycin with additional vancomycin added in house) was inserted. Antibiotic therapy with intravenous amoxicillin was continued for 2 weeks post-procedure and on discharge the patient was converted to oral amoxicillin for a further 8 weeks. The patient went on to have a 2nd stage revision, making a good recovery.

An 85 year old woman presented with an 18 month history of discomfort and recurrent abscesses along the wound line of a left hip prosthesis, implanted over 20 years ago. She had a background of osteoarthritis and bullous phemphigoid, previously on steroid treatment. Fluid from the abscess was aspirated and isolated L. monocytogenes. Due to patient preference and frailty, radical revision was not thought a viable management option. Chronic suppressive therapy with oral amoxicillin was therefore instigated; one year on the infection remains well controlled and discomfort in the left hip has improved.

L. monocytogenes has previously been infrequently implicated as a pathogen in prosthetic joint infection; however, there are reports of increasing numbers of cases particularly amongst immunosuppressed individuals. With an expanding at-risk population(1), its importance as a cause of prosthetic joint infection is set to rise in the future. Optimal management has not been well studied; it is likely that the best option combines antimicrobial therapy and prosthetic removal if possible.

Open tibial fractures have a high infection risk making treatment difficult and expensive. Delayed skin closure (beyond 7 days) has been shown to increase the infection rate in several studies (1).

We aim to calculate the cost of infection as a complication of open tibial fractures and to determine the effect of delayed skin closure on this cost.

We retrospectively reviewed all records of patients treated with a free flap in our institution for an open tibial fracture from 2002 to 2013.

We calculated direct costs of treatment by the DRG-values (2014 figures), based on length of stay (LOS), diagnosis, orthopaedic and plastic surgical procedures and the corresponding reimbursement.

The primary goal was to establish the extra cost incurred by an infection, compared to treating an uninfected open tibial fracture. The cost efficiency saving of early soft tissue cover was also investigated.

We analysed 45 injuries in 44 patients. All patients were treated with debridement, stabilization, prophylactic antibiotics and free flap cover. Infection increased the mean total LOS in hospital from 28.0 to 63.8 days. The presence of an infection increased the cost of treatment from a mean of €49.301 for uninfected fractures compared to a mean of €67.958 for infected fractures.

Achieving skin cover within 7 days of injury decreased the infection rate from 60% to 27% (total series rate 48%). The provision of early soft tissue cover (before 7 days) for all patients would have saved an average of €18.658 per patient.

The development of an infection after a severe open tibial fracture greatly increases the cost of treatment. Early soft tissue cover is one aspect of care which has been shown to improve clinical outcomes. This study confirms that it will also reduce the cost of treating these complex fractures – underscoring the need for rapid referral and an ortho-plastic setup to handle them.

We have only calculated the direct costs of treatment. Infected fractures will also consume extra costs in rehabilitation and absenteeism from later infection recurrence and non-union. Therefore, our estimate of the potential saving is likely to be conservative.

In acute haematogenous multifocal osteomyelitis, infectious foci occur in several bones simultaneously due to haematogenous bacterial spread.

Acute haematogenous multifocal osteomyelitis should be distinguished from chronic recurrent multifocal osteomyelitis (CRMO).

We reviewed the medical records of three male adolescents of 15 years (range 13–16 years) with acute multifocal haematogenous osteomyelitis. All patients were athletes (soccer player, water polo player, practicing rowing).

The mean duration of painful symptoms before seeking medical attention was 3 days. Osteomyelitis was confirmed by magnetic resonance imaging (MRI) and bone three phase scintigraphy. The lesions were at level of spine plus left femur in the first case, bilateral tibia and lumbosacral column in the second one, right foot plus left femur were interested in the third case. Two of the patients exhibited a spinal osteomyelitis, which is described as a common spinal affection in athletes.

Blood cultures (in all patients) and culture of abscess drainage (in one case) were positive for Staphylococcus aureus (MSSA). Inflammatory indices were increased in all patients (mean values: WBC 15.130/mmc, CRP 19 mg/dl, and ESR 63,6 mm/h).

Intravenous antibiotic therapy was prescribed for 19 days (range 13–33 days), followed by oral antibiotic therapy for a median of 18 days. After a median of 11 days, all patients clinically improved with resolution of fever and reduction of pain. Patients were discharged with oral antibiotic therapy after a median of 22 days hospitalization, and underwent a 16 months follow up. No patient reported sequelae.

Differential diagnosis among multifocal acute osteomyelitis, septic arthritis, CRMO, juvenile idiopathic arthritis and/or reactive arthritis may be difficult.

Previous studies reported that athletes are more at risk for osteomyelitis, but, to our knowledge, no case series of acute haematogenous multifocal infectious have been reported in competitive athletes. Staphylococcal outbreaks have been reported in sport players, as position, artificial grass abrasion, and body shaving are the main portal of bacterial entry.

In conclusion, a diagnosis of acute multifocal osteomyelitis must be considered in a patient with fever and pain of several bones. A prompt hospitalization and an appropriate therapy reduce the morbidities and can help to avoid surgery.

Debridement, antibiotics and implant retention (DAIR) is a surgical option in the treatment of prosthetic joint infection (PJI). It is thought to be most appropriate in the treatment of early (≤6 weeks post-op) PJI. Most studies to-date reporting on DAIRs in hip PJI have been underpowered by reporting on small cohorts (n= <45), or report on registry data with associated biases and limitations. In our, tertiary referral, bone infection unit we consider DAIR to be a suitable option in all cases of PJI with a soundly fixed prosthesis, with early or late presentation, especially in patients who are too elderly or infirm to undergo major surgery.

Aim: To define the 10-year outcome following DAIR in hip PJI and identify factors that influence it.

We retrospectively reviewed all DAIRs performed in our unit between 1997 and 2013 for hip PJI. Only infected cases confirmed by histological and microbiological criteria were included. Data recorded included patient demographics and medical history, type of surgery performed (DAIR or DAIR + exchange of modular components), organism identified and type/duration of antibiotic treatment. Outcome measures included complications, mortality rate, implant survivorship and functional outcome.

121 DAIRs were identified with mean age of 71 years (range: 33–97). 67% followed an index procedure of 1° arthroplasty. 53% included exchange of modular components. 60% of DAIRs were for early onset PJI. Isolated staphylococcus was present in 50% of cases and 25% had polymicrobial infection. At follow-up (mean:7 years, range: 0.3 – 18), 83 patients were alive; 5- and 10- year mortality rates were 15% and 35% respectively. 45% had a complication (persistence of infection: 27%, dislocation: 10%) and 40% required further surgery. Twenty hips have been revised to-date (17%). Performing a DAIR and not exchanging the modular components was associated with an almost 3× risk (risk ratio: 2.9) of subsequent implant failure (p=0.04). 10-yr implant survivorship was 80% (95%CI: 70 – 90%). Improved 10-year implant survivorship was associated with DAIR performed for early PJI (85% Vs 68%, p=0.04). Functional outcome will be discussed.

DAIR is a particularly valuable option in the treatment of hip PJI, especially in the early post-operative period. Whenever possible, exchange of modular implants should be undertaken, however DAIRs are associated with increased morbidity even in early PJI. Factors that predict success of DAIR in late PJI need to be identified.

Diagnosis of chronic prosthetic joint infection (PJI) is often challenging. Painful prosthesis is frequently due to an infection but to diagnose it is somethimes difficult. All recent guidelines stress the central role of joint punction in diagnosis of PJI if the infection is not demonstrated. However which test on synovial fluid must be carried out is not so clearly defined. Total white blood cell count and differential leukocite count are usually considered useful in diagnosis but cut offs reported by different studies are quite different. Moreover this test needs a relatively large amount of fluid and blood contamination of it largely affects the result. What's more the synovial fluid WBC count may be unreliable in the setting of a metal-on-metal bearing or corrosion reaction.

Routine cultures should be maintained between 5 and 14 days, their sensitivity appears low in chronic infection even if witholding antimicrobial therapy before the collection of the fluid can increase the likelihood of recovery an organism.

Synovial leukocyte esterase can be performed as a rapid office or intraoperative point of care test using urinalysis strips. It is cheap and easy to perform, but the presence of blood in the sample can affect the result and it needs centrifugation.

Recently a new test has been proposed to detect alfa-defensine in synovial fluid. It shows a high sensitivity and an exellent specificity.

We performed 25 joint punctions on 25 patients with suspected PJI (enrollment is going on). Synovial fluid collected was tested for: leukocite esterase, WBC count and differential, colture in blood colture bottle for anerobe and aerobes (BacT/ALERT Biomerieux, inc) and detection of alfa-defensine level (Synovasure – Zimmer)

In patients who underwent surgery at least 5 samples of periprotesic tissue were collected for microbiologic analysis and the removed implant was sonicated according with the methodic. Furthermore samples for frozen section were sent and a histologic examination was made according to the Moriewitz – Kerr classification. The MSIS criteria was utilized to classify the case as infected or not.

Prosthetic joint infections (PJI) occur in 0.8–1.9 % of arthroplasties, but the absolute number is increasing because of the frequency of procedures. Two stage exchange is the most effective strategy, but failures are often described. Culture of perioperative tissues during removal of arthroplasty is a standard procedure but culture during second step is equally important to define a success or a failure.

We retrospectively reviewed PJI treated with two stage-exchange from January 2011 and December 2012 at “Ospedale S. Maria Misericordia”, Albenga-Italy. The procedure calls for bacterial culture not only during first step but also during reimplantation. Antibiotic treatment is prolonged after reimplantation until the cultures availability. A failure was defined by persistence of infection for positive culture or reocurrence of infection during a follow up of at least 2 years in patients with negative cultures. Three positive cultures yielding phenotypically identical organisms, or a single specimen of a virulent microorganism (e.g. Staphylococcus aureus) were required to rule out false positive for contaminants. Patients with persistence of infection were treated for 3 months with antibiotics.

86 patients underwent the two stage treatment: 45 hip and 41 knee prosthesis. The average ESR before arthroplasty removal was 59 mm/ 1st h (range 5–120), the average CRP was 3.9 mg/dl (range 0.3 – 34). Coagulase-negative staphylococci were isolated in 31 cases, Staphylococcus aureus in 19, Streptococcus spp in 8 and enterococci in 4. Gram-negatives were isolated in 4 patients and polymicrobial infection in 6 patients. In 14 patients (16%) no pathogen was identified.

A positive culture during reimplantation was documented in 11 (13%) cases: 8 coagulase-negative staphylococci, 2 Staphylococcus aureus, 1 Candida sp. All patients received 3 months of therapy after surgery and 6 of them were free of infection at 2 years of follow up after the end of treatment. Among the 75 patients with negative cultures, a relapse was documented in 2 (3%), after 5 and 24 months, respectively. These cases were treated with arthrodesis and 6 weeks antibiotic treatment, with resolution of infection but poor functional results. Overall the success rate of our strategy was 92% (79/86).

In patients treated with two-stage exchange, the combination of cultures at reimplantation and antibiotic suppressive treatment for 3 months in presence of positive cultures, are associated with a high rate of success. Only a prolonged follow up can rule out a relapse and agree with a true resolution of infection.

Squamous Cell Carcinoma (SCC) is a rare complication of chronic osteomyelitis (OM), arising in a sinus tract (Marjolin's Ulcer). We routinely send samples for histological analysis for all longstanding sinus tracts in patients with chronic osteomyelitis. We reviewed the clinical features and outcomes of patients with SCC arising from chronic osteomyellitis.

A retrospective study was performed of patients with osteomyelitis between January 2004 and December 2014 in a single tertiary referral centre. Clinical notes, microbiology and histo-pathological records were reviewed for patients who had squamous cell carcinoma associated with OM.

We treated 9 patients with chronic osteomyelitis related squamous cell carcinoma. The mean age at time of diagnosis was 51 years (range 41–81 years) with 4 females and 5 males. The mean duration of osteomyelitis was 16.5 years (3–30 years) before diagnosis of SCC. SCC arose in osteomyelitis of the ischium in 5 patients, sacrum in 1 patient, femur in 1 patient and tibia in 2 patients. Osteomyelitis was due to pressure ulceration in 7 patients and post-traumatic infection in 2 patients. The histology showed well differentiated SCC in 4 cases and moderately differentiated SCC in 2 cases with invasion. Two patients had SCC with involvement of bone. One patient had metastatic SCC to bowel. All patients had polymicrobial or Gram-negative cultures from microbiology samples.

Four patients (57%) in our series died as result of their cancer despite wide resection. The mean survival after diagnosis of SCC was 1.3 years and mean age at time of death was 44.7 years. Two of these patients had ischial disease and were treated with hip disarticulation, hemi-pelvectomy and iliac node clearance.

Five patients remain disease free at a mean of 3.4 years (range 0.1 – 7yrs) after excision surgery. One patient in this group underwent a through-hip amputation, one underwent an above knee amputation and one underwent excision of ischium and surrounding sinuses. Of note, all these patients had clear staging scans at time of diagnosis.

This case series demonstrates the consequences of an uncommon complication of osteomyelitis. In our series only 3 patients underwent biopsy for suspected SCC due to clinical appearances. The other cases were all identified incidentally after routine histological sampling, demonstrating the importance of this practice.

Propionibacterium acnes is an emerging pathogen especially in orthopedic implant infection. Aim of this study was to investigate P. acnes phylogeny and to screen for virulence factors among a large collection of clinical isolates involved in spine material infections, arthroplasty infections and acne lesions.

88 P. acnes clinical isolates were collected between January 2003 and December 2014 at Nantes University Hospital (France). Fifty-eight isolates came from spine infections, 14 from prosthetic infections (knee, hip or shoulder), 14 from acne lesions and two reference strains (ATCC11827 and ATCC6919). Implant associated infections were confirmed using Infectious Diseases Society of America criteria for bone and joint infections. Phylotypes and Multi-Locus Sequence Typing (MLST) was carried out on all isolates as described by Lomholt et al. All isolates were tested by established PCR-based assays for 21 putative virulence factor genes characteristic of P. acnes.

MLST analysis revealed an association between clonal complexes (CCs) and origin of P. acnes isolates (p = 0,027). Regarding CCs distribution between different origins, CC36 and phylotype II P. acnes isolates are more frequently observed in prosthetic joint infections. On the other hand, CC18 (IA) and CC28 (IB) P. acnes isolates are more frequently involved in spine infections and acne lesions.

Among all virulence factors screened, hyaluronate lyase gene was only present in CC36 and phylotype II P acnes isolates. Other virulence factors were present in all isolates, whatever their origin or CC.

Regarding molecular typing results, P. acnes involved in spine infections seem to have a skin origin (same CC as isolates from acne lesion). Interestingly, the origin of prosthetic joint infection isolates seems different and they all carry one more virulence factor.

Hyaluronate lyase (Hyl) is a major surface protein of P. acnes with potential antigenetically variable properties that might be essential for P. acnes virulence. Increased tissue permeability caused by the action of hyaluronidase on the extracellular matrix appears to play a role in wound infections, pneumonia, and other sepsis such as bacteremia and meningitis. It could be also take a prominent part in P. acnes prosthetic joint infection pathogenesis.

Chronic osteomyelitis is a challenging clinical problem. Aggressive debridement, bony fixation, obliteration of dead space and vascularised soft tissue coverage with appropriate antimicrobial therapy are essential to successful management of this condition. The gracilis muscle flap is the workhorse flap in our unit for reconstruction of limb osteomyelitis.

We describe the experience and use of this flap in our unit over a 3 year period.

Clinical records were reviewed from a prospectively-maintained Oxford Free Flap Database and patient notes. All patients who received a free gracilis flap reconstruction as part of the treatment of osteomyelitis between 2011 and 2014 were included in the study.

40 patients received free gracilis flaps; 38/40 for lower limb and 2/40 for upper limb osteomyelitis. Two were myocutaneous flaps, and the remainder were muscle only. The return to theatre rate was 12.5% with a total flap loss rate of 5%. Other flap-specific complications include partial flap loss (2.5%), flap site haematoma (2.5%), donor site haematoma (2.5%) and seroma (2.5%). General complications included pulmonary embolism (2.5%) and death from sepsis (2.5%).

All but 2 patients were treated successfully and remain disease free following their initial surgery, with a mean follow up of 12.4 months (range 1–23 months).

We have found that the free gracilis muscle flap is effective in the successful treatment of osteomyelitis, with a low complication rate.

Infection after total knee replacement, which is a serious and expensive complication, often represent a diagnostic and therapeutic problem. The current incidence of infection after the primary procedure is 1 to 3%, depending on the published series. A correct and timely diagnosis, classification between early and delayed infection, and which microorganisms are involved, are crucial steps in defining prevention and treatment strategies.

Determination of the annual and three years incidence of infection after primary total knee replacement; evaluation of the microorganisms involved and its resistance patterns; assessment of treatment – surgical approach and selection of antibiotics.

Collection of clinical and laboratorial data of all patients who underwent primary total knee arthroplasty between 2011 and 2013 in our hospital; definition of periprosthesic infection cases following the Musculoskeletal Infection Society (MSIS) criteria.

During the study period, 526 primary knee replacements were performed in 521 patients; with 41 patients having bilateral replacements. The mean follow-up period was 30 months; 5 patients had no follow up and 1 died in the post operatory.

We reported 9 prosthetic infections, of which 2 did not reached the MSIS criteria, but were also considered based on high clinical suspicion. The majority of the cases (6) were delayed infections. The calculated 3 year incidence of infection after primary knee replacement was 1,6%, with annual rates of 3,0% (2011), 1,7% (2012) and 0,9% (2013). The microorganisms isolated were as follows: Staphylococcus aureus and coagulase-negative staphylococci, resistant to penicillin; Streptococcus agalactiae and one isolate of Serratia marcescens, both showing multiple antibiotic resistances.

Only one case was treated with surgical debridement and conservation of prosthesis, in the other 8 cases a two-stage implant revision procedure was performed. The antibiotics selected were vancomycin, fluoroquinolones and association of gentamicin and clindamycin.

Our local infection rates are in line with the published series from reference surgical centers. The annual incidence is decreasing, probably because the majority of our infection cases are delayed (recent years, shorter follow up period) and our preventive measures are improving. The microorganisms identified are also in agreement with published data, and our antibiotic resistance pattern is a valuable information to consider in a first empirical approach.

Treatment options suitable to each case, and antibiotic protocols need to be improved in our local practice. Preventive measures in delayed infections are still under debate, and represent another future challenge.

To report a case and a review of the literature about TKA infection caused by P. multocida.

We report the case of a 65 year old woman, with history of a left TKA for primary osteoarthritis. Six months after surgery, the patient presented with fever and a wound in her right leg, two days after being bitten by her cat. She was treated with flucloxacilin. One week later, she returned complaining about pain and stifness in her left knee. She presented fever, swelling, erythema, warmness and pain of the left knee. Complete blood count revealed leukocytosis with neutrophilia. Erythrocyte Sedimentation Rate and C-Reactive Protein were elevated. The knee joint was aspirated and a large amount of purulent fluid was obtained and sent to gram stain and culture. The X-ray of the knee was normal

Gram stain showed a large number of leucocytes and gram-negative coccobacilli. The patient began ceftriaxone, empirically. The culture grew Pasteurella multocida sensitive to ceftriaxone, therefore the treatment was maintained during hospitalization period. The patient showed a gradual improvement over the time and inflammatory markers remained negative since the first week of treatment. After three weeks of intravenous antibiotic treatment, the patient was discharged with oral ciprofloxacin. After a three year follow-up, she remained asymptomatic. ESR and CRP remained negative in every measure and no alterations on knee radiography were detected.

P. multocida is a facultative anaerobic Gram-negative coccobacillus, commensal in the nasopharyngeal tract of domestic pets. Prosthetic joint infection caused by P. multocida is rare and we found reports of 22 TKA and 5 THA infections caused by this organism. Although all options of treatment contemplate intravenous antibiotherapy, it can be combined with different operative techniques. Of the 27 patients, only two were successfully treated without the need of a surgical intervention. We have chosen a conservative approach based on several factors: the patient had no risk factors; the prosthesis was not loose; the existence of one case described of a successfully treatment with antibiotherapy alone (the second case we refer above was only published recently); a good early and maintained response to antibiotic treatment. We advocate that in selected patients, with no risk factors, with a sensitive organism, we should try conservative treatment first. However, if infection signs are severe, we should proceed to surgical debridement and sinovectomy and if the radiography shows any signs of loosening of the implant, it should be removed.

This retrospective study evaluates the outcome of patients with a late infection of a cemented total hip arthroplasty (THA) treated with two-stage revision with retention of the original well-fixed femoral cement mantle.

Operation reports of all two stage revision performed in our clinic between 2009 and 2013 were reviewed (249 patients). Patients in which femoral cement mantle was retained during surgery were included (10 patients). The average age at the first stage revision procedure was 61.5 years (range 38–80). The mean follow-up period was 26 months (range 5 to 54 months). Clinical, laboratory, and radiological outcomes were evaluated.

Successful treatment of periprosthetic joint infection (PJI) was achieved in six out of 10 patients; four patients showed no signs of infection during follow-up. Two of these patients received three months of antibiotic treatment after second stage, because of positive cultures at second stage. The other two successfully treated patients showed recurrence of PJI one week after second stage. Debridement with retention of prosthesis (DAIR) was performed. Newly cultured microorganisms were successfully treated with 3 months of antibiotics.

The other four patients were considered to be failures; in three patients, the femoral cement mantle was removed after the first stage due to recurrent infection. The other failure showed a recurrent PJI after second stage. Despite DAIR and three months of antibiotic treatment, this patient is treated with suppressive antibiotics until latest follow-up.

Based on this study, results in managing an infected THA with cement-within-cement revision are disappointing. Therefore, more research is required to determine which patients are appropriate for cement-within-cement revision.

Surgical site infections after total hip arthroplasty result in decreased quality of life, increased morbidity and increased health care cost. We hypothesized that the implementation of a bundle of care for total hip arthroplasty decreases the amount of surgical site infections.

In this retrospective cohort study we investigated the implementation of this bundle in a University Medical Centre and its effect on perioperative surgical site infections after total hip arthroplasty and on incidence of hypothermia.

In 2009 the bundle of care consisting of four elements was implemented in total hip arthroplasty in our hospital; (I) perioperative normothermia, (II) hair removal before surgery, (III) the use of preoperative antibiotic prophylaxis and (IV) discipline on the operation room measured by door movements. For this study we used data from January 2010 – October 2013. We measured all parameters prospectively including surgical site infections within 6 weeks postoperatively.

In the study period a total of 585 patients received a primary total hip arthroplasty. Bundle compliance improved significantly in 3.5 years from 71.7% in 2010 to 91.6% in 2013. Postoperative hypothermia decreased from 10.5% to 8.4% (non-significant) and SSI rate from 0.9% to 0.0% (non-significant).

Implementation of this bundle of care is possible in an academic tertiary referral center. A relatively cheap solution can increase patient safety in a surgical environment. Introduction of a bundle of care resulted in a non-significant reduction of hypothermia and rate of surgical site infections in total hip arthroplasty.

In two-stage revision surgery of infected joint prosthesis, temporary bone cement spacers have been used for several years. By adding antibiotics to the cement, high local antibiotic concentrations that exceed the minimum inhibiting and bactericidal concentration of the respective pathogen during the first days after surgery, are achieved. Currently, aminoglycosides (e.g. gentamicin and tobramycin), as well as glycopetides (e.g vancomycin) are used as antibiotic agents and mixed into the acrylic cement. In order to increase the quantity of active antibiotic substances, we established a novel surgical technique of additional superficial vancomycin coating (SVC) of temporary bone cement spacer. The aim of this study was to analyze the safety of this method by measuring postoperative joint and serum vancomycin concentrations, as well as the creatinine levels.

We reviewed prospectively collected data on all patients, which were treated by explanting the prosthetic components, following temporary spacer implantation and SVC between 05/2013 and 04/2015 at the Department of Orthopedic Surgery, Medical University of Graz. In total 13 patients were treated by addition SVC during the study period. Before hardening, vancomycin powder (2 grams) was pressed manually onto the surface of the bone cement. Vancomycin levels were obtained from drains and blood samples on postoperative days 1 to 5. Forty-six blood serum samples and 52 drain fluid samples were available for further

On postoperative day one to five, a median serum vancomycin level of < 2.0 μg/mL was present (range <2.0 – 3.9). The highest median vancomycin level from the drain was documented on postoperative day 1 with a value of 388.0 μg/mL (range 44.4–1650.0), continually decreasing until postoperative day 4. After SVC, neither an anaphylactic reaction nor side effects such as a red man syndrome, fever and chills were observed. Furthermore, no patient complained about subjective hearing loss. No serum creatinine increase of 0.5 mg/dL from creatinine baseline value or a ≥50% increase from baseline was detected. After a median of 64 days (range 18–82), the temporary cement spacer was explanted followed by prosthesis implantation. During this time no reinfection occurred. One patient suffered from a dislocation of the spacer with a distal femur fracture and was therefore re-operated after 18 days.

Powdered vancomycin as an additional superficial coating of bone cement spacer results in much higher local antibiotic concentrations than in conventional spacers. The newly introduced method is feasible, safe and promising to enhance local inhibiting concentrations of vancomycin.

There is high morbidity and mortality associated with infection following orthopaedic procedures. In accordance to local guidelines, most hospitals follow a set protocol for surgical prophylaxis, which expects a compliance rate of 100%.

A new protocol was introduced to the orthopaedic department of a teaching hospital in August 2013, changing from a cephalosporin, with potential C. difficile risk, to teicoplanin and gentamicin, within 30 minutes of incision.

Our aim was to audit how well the protocol was followed across 3 different time periods.

Data was collected for 3 different time periods following the introduction of the new protocol (August-November 2013, April-May 2014 & November 2014) on the choice of antibiotic. Both elective and trauma cases were included. After each cycle, the data was presented to the orthopaedic surgical and anaesthetic departments to raise awareness and draw attention to the antibiotic prophylaxis posters in theatre.

The 1st audit cycle (n=30) indicated that there was 0% compliance with the current protocol and 100% compliance with the previous protocol. The 2nd audit cycle (n=27) indicated that 0% complied with the current protocol, 54% complied with the previous protocol and that there was a combination of both protocols being used in 46% of the patients. Finally the 3rd audit cycle (n=33) indicated a 100% compliance rate in terms of antibiotic choice. However, only 9% were given the appropriate dose according to body weight and within the appropriate time based on the documented evidence.

This audit demonstrates the value of auditing and then disseminating the findings to relevant departments to influence practice. Each audit cycle demonstrated a progressive uptake in compliance with the hospital trust's antibiotic prophylaxis policy. The last audit cycle highlighted discrepancy in dosage based on weights; a further intervention will be to provide ideal body weight (IBW) vs dose tables in all orthopaedic theatres to ensure the correct antibiotic dosage is given.

Surgical Site Infection (SSI) is one of the most frequent nosocomial infections and depends on many factors: patient, microorganism, antiseptic solution use, antibiotic prophylaxis, hand scrubbing, wound care or hospital stay lenght.

With the present paper the authors aim to study the SSI incidence after Total Knee (TKA) or Hip Arthroplasty (THA).

All patients who underwent primary TKA or THA between January 2011 and May 2012 at our institution were considered. Patients who died within 1 year after the procedure of unrelated causes were excluded. Data collected included ASA classification, type of procedure, total and post-operative hospital stay, type and duration of antibiotic prophylaxis.

Data were collected from the consultation at 1 month and 1 year post-operative, clinical registries and telephone interview. SSI was defined according to the Centers for Disease Control and Prevention criteria. Suspected cases of SSI included antibiotic administration longer than 5 days or absence of antibiotic prescription, hospital stay after the procedure longer than 9 days, patient referring infection symptoms, and clinical data reports of infection or re-intervention.

During the studied period and after exclusion of 5 cases, a total of 251 surgeries (104 TKA, 147 THA) were performed, of which 2 were urgent.

For both TKA and THA, the average total hospital stay was 9 days (8 days post-operative). The majority were American Society of Anesthesiologists (ASA) classification 2 and 3.

There were 4 SSI (1,60%), 2 TKA (1,92%) and 2 THA (1,36%), all of them after discharge. Their average total hospital stay was 10,5 days.

Antibiotic prophylaxis was used in 93% of the patients (97,4% a cephalosporin), with an average length of 5,7 days.

Recommended hospital stay after a TKA or THA is about 5 days. On HELICS-CIRURGIA 2006–2010 report it was 10 days, similar to ours. In infected patients, our total hospital stay was lower (10,5 vs 26).

Recommended duration of antibiotic prophylaxis is 24h. On HELICS-CIRURGIA more than 50% had it for more than 24h, which also happened with us; our antibiotic coverage was similar.

Comparing to HELICS-CIRURGIA, the predominance of ASA 2 and 3 classifications was similar, but the overall SSI rate was lower (1,6% vs 2,24%).

We conclude we must reduce hospital stay and antibiotic duration and keep the surveillance of SSI after TKA or THA.

Successfully treatment of acute shoulder arthroplasty infections strongly depends on the timing of treatment. The objective of this study is to determine the normalization curve of C-reactive protein (CRP) after shoulder arthroplasty

Prospective study including 63 patients undergoing shoulder arthroplasty (46 reverse shoulder arthroplasty (RSA) and 17 total shoulder (TSA)). Mean age 74.1 years old. 25 cuff deficient shoulders, 14 acute fractures, 19 primary gleno-humeral arthritis and 5 fracture sequel were included. Blood samples to determine CRP were obtained before surgery the day of surgery, 24 and 48 hours after surgery and then 6, 8 and 14 days after surgery (data of blood samples was determined based on a previous limited study). Co-morbidities that could interfere CRP were also recorded

Normal value of CRP before surgery (mean 1.28) slightly increases 24 hours after surgery (mean 3.92), reach maximum value at 48 hours after surgery (mean 6.91) and then slowly decreases to normalize at 14 days (6th day mean 3.80, 8th day 2.33 and 14th day 1.08). Normalization curve is not affected by age, diagnosis or type of arthroplasty

CRP after shoulder arthroplasty reaches maximum value at 48h and then slowly decreases to become normal at 14 days. Any deviation from this normalization curve may help in diagnosis and early treatment of acute shoulder arthroplasty infections

Infection of the musculoskeletal (MSK) system is a dreaded complication that seems to be on the rise. Many factors, such as resistant bacteria or poor host factors, may influence such rise. This increase leads to greater resource consumption, especially due to antibiotic (ATB) prescription. Strategies must be created to detect patients at risk and prevent such infections. Hospital administrators should be made aware of the costs and impact of MSK infections in order to understand the need to prevent such complications.

Therefore, our goal is to characterize the infected orthopaedic patient and evaluate the cost associated with ATB prescription in such cases.

This is a retrospective and descriptive study, based on patient record analysis of all patients treated at our department, from January 2013 to March 2015.

We identified 177 patients with a MSK infection and an isolated infectious agent.

There was no predominance of either sex. Approximately 50% of patients were aged between 66 and 85 years old.

Most frequent agents were MSSA (30,2%) and MRSA (21,8%), followed by Streptococcus species (8,9%) and Pseudomonas aeruginosas (7,1%). Although most patients were infected by a single agent, 18,6% had two or more causative agents isolated in cultures. Of those, 69,7% had either MSSA or MRSA as one of the isolated agents.

Most commonly affected area was the hip (39,5%), followed by the knee (23,2%) and ankle (21,5%). Nearly all patients had had prior surgery, with arthroplasty and osteosynthesis as the most common procedures (52,4% and 33,3%, respectively).

Infection related admission was responsible for a total of 6.116 hospital bed-days, with the majority of patients staying in hospital for up to 30 days (77,3%).

Total cost of hospital ATB administration was 61.365,61€, with approximately 346,7€ spent in each patient. This corresponds to 42,6% of the total cost of medication during hospital stay (144.146,1€ of total cost, with 814,4€ per patient).

The typical infected orthopaedic patient is aged 66 to 85 years old, was operated to his hip or knee, and either an arthroplasty or osteosynthesis was performed. Staphylococcus aureus remains the most common agent.

MSK infections have significant costs associated with their treatment, and clinical departments should periodically re-evaluate discharged patients in order to understand what groups are at risk of developing such a complication.

Only a correct identification of all these factors makes it possible to create a targeted preventive strategy, in order to reduce costs to the institution.

The aim of our project is to develop resorbable nanostructured composite layer with controlled elution of antibiotics for implants survival rate enhancement. The nanostructured layers are expected to be used especially in the case of known systemic or local (joint) inflammation. This layer can provide a bone tissue/implant (titanium alloy) bioactive interface improving the physiological healing process and eliminating the risk of bacterial orthopedic infections. The main aim of this study was to verify whether the local concentration of released vancomycin exceeded the minimum inhibitory concentration (MIC) for vancomycin-resistant Staphylococcus aureus (VRSA, >16 mg/l).

The layer is composed of collagen (type I, isolated form calf skin), hydroxyapatite nanoparticles and vancomycin hydrochloride (10 wt%). The stability of collagen was enhanced by EDC/NHS cross-linking. The in vitro release of vancomycin and crystalline degradation products from optimally cross-linked layers was investigated. An elution method and a high performance liquid chromatographic assay were employed to characterize the in vitro release rates of the vancomycin and its crystalline degradation antibacterial inactive products over a 21-day period.

During the whole experimental period, the level of released vancomycin was high above the MIC for VRSA. The maximum average concentration was obtained between day 4 and day 8 and it reached 265 mg/l. At the end of the experiment (day 21), an average concentration of 104 mg/l was detected.

Our study confirmed the prophylactic effects of studied vancomycin-loaded nanostructured layers

Prosthetic joint infection (PJI) is a severe complication of prosthetic joint implantation, with an estimated incidence of 2.18%. Most frequently used treatment strategy for PJI is a two-stage revision procedure. However there are specific patients with a new or persisting infection after primary or revision surgery where further surgical treatment is not attractive. This may be because of medical or local surgical conditions, or patient's refusal to undergo (further) surgical therapy. For these patients suppressive antibiotic therapy (SAT) may be an alternative treatment.

The aim of this study is to describe the clinical and radiological outcome of patients with a PJI of a hip arthroplasty, treated with SAT.

Twenty-four patients with a hip arthroplasty treated with suppressive antibiotic therapy for PJI between January 1, 2008 and December 31, 2013 were included. All patients had a proven prosthetic joint infection, either by ≥2 intraoperative cultures or joint aspiration. SAT was defined as treatment with antibiotic therapy for more than three months. Most used antibiotics were doxycycline in 15 patients and cotrimoxazole in six patients.

Patients were supposed to have a successful outcome when their prosthesis remained in situ and they had no relapse or new infection.

Suppressive antibiotic therapy was considered successful in 15 (62.5%) patients with a mean follow-up of 20.6 months. Two patients (8.3%) had to stop the antibiotic therapy due to adverse effects.

The mean duration of the SAT was 20.4 months (range 0.92–92.65 months).

Mean modified Oxford hip score of the successfully treated patients at the latest follow up was 35 (range 16–49) and mean Harris hip score 71 (range 40–93). The mean visual analogue scale (VAS) was 16 (range 0–70) in rest, 32 (range 0–85) during exercise and 65 (range 10–100) for satisfaction.

Of the 9 patients with an unsuccessful outcome, there was a radiological loosening of the cup in 4 patients. In the group of 15 patients that were considered successful, 2 patients had a radiological loosening of the cup and one patient loosening of the stem.

Suppressive antibiotic therapy can be an attractive alternative treatment in selected patients with a prosthetic joint infection of a hip arthroplasty who cannot or will not undergo (further) surgical therapy.

Further research with a larger number of patients is required. Also the optimal dosage and duration of suppressive antibiotic therapy and possible resistance to the antibiotic therapy is unknown.

The use of new megaprosthesis for massive bone loss is an option for the replacement of skeletal segments. There are several clinical scenarios that can be associated with this situation including severe trauma with multiple failed osteosynthesis with a non union or with a previous prosthetic replacement of a neighbouring joint; multiple revision of arthroplasty with or without infections or large resections of tumours. The aim of this work is to evaluate retrospectively both clinical and radiological outcomes and any complications in patients treated with megaprosthesis in SEPTIC BONE DEFECTS in our Hospital from February 2012 to January 2015.

From February 2012 to January 2014 a total of 20 patients were treated with mono-and bi-articular megaprosthesis subdivided as follows: 4 proximal femur, 11 distal femur, 3 total femur, 1 total humerus and 1 proximal humerus. Clinical and serial radiographic evaluations were performed at 6 weeks, 3, 6, 12, 18 and 24 months. Blood parameters with CRP and ESR were monitored for at least 2 months. The mean follow-up of patients was about 24.4 months (range 5 months to 31 months). The mean age of the patients was 53 years (range 37–80years). Of the patients 20, 9 were female and 11 were male. The aetiology was: 11 septic non unions, 3 infected TKA, 4 infected THR and 2 infected tumor prostheses.

We have evaluated retrospectively both clinical and radiological outcomes of 20 patients. They had large bone defects that threatened the viability of the limb. They were treated with megaprosthesis. Although the mean length of follow-up was only 24.4 months they showed encouraging clinical results, with good articulation of the segments, no somato-sensory or motor deficit and acceptable functional recovery. There were three cases of dislocation, one case with rifampicin toxicity, one case with acute prosthetic infection (case that needed debridement and one case with chronic oral antimicrobial.

Megaprosthesis provides a valuable opportunity to restore functionality to patients with highly disabling diseases. The number of complications is not depreciable.

Acute postoperative periprosthetic joint infection (PJI) is a serious complication after any hemiarthroplasty (HHA) implanted due to a proximal hip fracture. The growing number of chronic institutionalized geriatric patients (CIGP) colonized with multi-drug resistant bacteria (e.g.: MRSA), not covered by usual antibiotic prophylaxis, has been identified as a risk factor for PJI after HHA. We therefore sought to compare the HHA infection characteristics between non-institutionalized patients (NIP) with proximal hip fractures and CIGP. We investigate (1) the rate of compliance with a new proposed protocol, (2) the acute infection rate, 3) the microbiologic characteristics of the infection, and 4) the success of the new protocol.

We gathered clinical, operative and infection data on all patients who underwent HHA due to a proximal femoral fracture in our center, during a 3-year period. We focus in the cases of acute postoperative infection (Zimmerli´s criteria). The new proposed antibiotic prophylaxis is cefazolin except in CIGP in which co-trimoxazole is used.

During the study period a total of 385 HHA in 385 patients were performed. In all cases the HHA was performed after a proximal femoral fracture. Overall, 109 patients (28,2%) were CIGP. We found an acute postoperative PJI in 21 out 385 HHA procedures, that is, a global acute infection rate of 5.43%. Ten out 109 (9.17%) CIGP patients resulted infected compared to 11 out 278 (3.9%) non-institutionalized patients (p: 0.049). One or more causative microorganisms were identified in 20/21 (95%) of PJI. Globally the Gram-Negative bacilli group accounted for the majority of the infections (60%). Staphylococus aureus was isolated in 3 cases (8.6%) with only a single MRSA infection. The percentage of polymicrobial infections was 47% (10 out of 21). Co-trimoxazole was used in the prophylaxis in 80.1% of the CIGP. In the infected cases a non-effective drug against the microorganism was used in the prophylaxis in 17 (81%) of the acute infected HHA.

We confirm that institutionalized patients are more prone to acute infections after a HHA. Our current strategy of antibiotic prophylaxis has showed to be effective in preventing MRSA PJI in CIGP. However, we found an increased rate of infection due to gram-negative bacilli non-covered by the current antibiotic prophylaxis. According our data an extended antibiotic prophylaxis on gram-negative drug will be proposed to be implemented in CIGP scheduled to a HHA because a proximal femoral fracture.

Pyogenic spondylodiscitis is an uncommon but clinically relevant infection that represents 3 to 5% of all cases or osteomyelitis. In Europe, it has an estimated incidence of 0.4 to 2.4/100.000 people/year. Mortality is less than 5%, increasing with a delay in diagnosis greater than 2 month. Patients with renal failure have greater predisposition to infections, consequence of the chronic uremic state. Infection rates in Polytetrafluoroethylene (PTFE) hemodialysis grafts in end-stage renal disease (ESRD) range from 3 to 35%. We present a rare case of concurrent spondylodiscitis and PTFE graft infection in a patient with ESRD and recurrent urinary tract infections (RUTI).

The authors present a case of an 80-year-old man with past medical history significant for abdominal aortic aneurysm, bilateral ureter-hydronephrosis, Pseudomonas aeruginosa RUTI and ESRD. Three months after a dialysis PTFE graft hemoaccess was performed a Pseudomonas graft infection was diagnosed and the PTFE graft was removed. One week later, the patient was observed in the author's Department due to an insidious dorsal-lumbar mechanic back pain without neurologic deficits, with progressive deterioration over the past 6 months. A T12-L1 and L1-L2 spondylodiscitis with dural compression was diagnosed and vertebral instability was documented on MRI and TC, demanding surgical treatment. Instrumented fusion with a screw and rod construct was performed from T9 to L5, along with somatic L1 and L2 debridement, and T12-L1 interbody fusion with autograft. Microbiology results were positive for Pseudomonas aeruginosa. Antibotic therapy with ceftazidime (6 weeks) and ciprofloxacin (12 weeks) was performed. Symptomatic relieve was achieved and C-reactive protein and white blood cell count returned to normal values.

No complications were documented. Four months post-surgery, the patient was asymptomatic (Visual Analogue Scale=0), with no significant limitation in his daily life activity (Disability Rating Index=85) and the vertebral body height was sustained, with imagiological signs of spinal fusion.

ESRD patients are more susceptive to infections. Failure in early diagnosis and treatment may lead to disease progression and subsequent functional limitations, deformity and increase in mortality. An aggressive approach, despite delay on diagnosis, is the key factor for a worthy outcome.

Despite the good results, recrudescence of spondylodiscitis is known to occur even years after the original offense is treated.

Osteoarticular infections in paediatric population are primarily hematogenous in origin, although cases secondary to penetrating trauma, surgery or contiguous site are also reported.

Despite being rare, numerous studies report infection relapse rates around 5 %. Osteomyelitis complications in children include septic arthritis, osteonecrosis of the bone segment, impaired growth.

7 years old male patient presented with history of traffic injury in January 2004. He sustained closed diaphyseal fracture of the right femur initially treated by elastic osteosynthesis.

Four years after traffic injury he was diagnosed at our Institution of chronic femoral Osteomyelitis with positive cultures for methicillin sensible Staphylococcus aureus, requiring multiple surgical debridements and systemic antibiotic therapy.

Five years follow- up the patient developed valgus deformity of his right knee (mechanical axis 11° genu valgum) with limb length discrepancy of 15 mm, intermalleolar distance of 15 cm and bone edema in external compartment of the knee (MRI). At this time the patient did not present any recurrence of septic process with normalization of laboratory parameters (ESR and CRP) and clinically asymptomatic.

In February 2014, at the end of growth, a distal femoral varus osteotomy was used to treat valgus knee malalignment. Medial closing wedge osteotomy was performed satisfactorily using Tomofix® Osteotomy System (DePuySynthes).

18 months follow- up after varus osteotomy the patient progressed satisfactorily without pain and a normal function of his right knee. Correction limb length discrepancy was achieved (5 mm) with a normal alignment of his right limb (mechanical axis 3° genu valgum).

Although Osteomyelitis is not very frequent in children population, its treatment requires not only prolonged antibiotic therapy but also multiple surgical debridements.

We recommend monitoring over a long period of time children affected with Osteomyelitis in order to prevent and treat correctly impaired growth.