Diagnostic accuracy of various modalities relative to open bone biopsy for detection of long bone posttraumatic osteomyelitis

Fracture-related infection blood-based biomarkers: Diagnostic strategies

Fracture-related infections are significant postoperative complications that carry substantial patient burden and additional healthcare costs. Despite their impact on outcome, early diagnosis of these infections remains challenging due to current available tests lacking acceptable diagnostic parameters. This review compiles existing information on blood-based biomarkers that have been evaluated as early diagnostic tools and highlights the challenges in their reliability. To begin to overcome these challenges new avenues of biomarker discovery utilizing "omics" technologies and novel analytical methods are being investigated in recent years. It appears that, despite their complexity, these newer approaches may be the future in biomarker discovery for fracture-related infection diagnosis.

Femoral Shaft Fracture Developed Late-Onset Infection in 27 Years after Intramedullary Nailing: A Case Report

Postoperative late-onset infections more than 1 year after intramedullary nail surgery for femoral shaft fractures are very rare. We show an extremely rare case of developed late-onset infection 27 years after surgery, report on risk factors for late-onset infection, and infer why the infection occurred.

Application of metagenomic next-generation sequencing in the detection of pathogens in spinal infections

BACKGROUND CONTEXT

The precise diagnosis and treatment of spinal infections (SI) remains challenging for spine surgeons. Identifying the pathogens of SI through metagenomic next-generation sequencing (mNGS) may be a key approach to addressing this challenge.

PURPOSE

To evaluate the accuracy and applicability of mNGS in determining the etiology of SI.

STUDY DESIGN

Diagnostic test study.

PATIENT SAMPLE

Twenty-five patients who had a clinical suspicion of SI and underwent mNGS testing.

OUTCOME MEASURES

The specificity, sensitivity, and time cost of mNGS and bacterial culture were compared. Clinical outcomes were assessed using the numeric rating scale (NRS) score, Oswestry Disability Index (ODI), and the Japanese Orthopedic Association (JOA) score. Demographic data and laboratory results (blood cell count (WBC), erythrocyte sedimentation rate (ESR), neutrophil percentage (NEUT%), and C-reactive protein level (CRP) were also evaluated.

METHODS

In this retrospective study, samples were obtained from 25 eligible patients via surgery or CT-guided puncture and subjected to histopathological examination, bacterial culture, and mNGS. The sensitivity and specificity of the bacterial cultures and mNGS were calculated with respect to the histopathological results as a reference. Postoperative antibiotics or antituberculosis drugs were administered on the basis of mNGS results, combined with clinical manifestations, imaging examination, and histopathology. The changes of clinical outcomes and laboratory results after treatment were observed.

RESULTS

Of the 25 patients, 21 had a positive pathology, of which 10 showed a tuberculous pathology, and the remaining 11 showed a nontuberculous inflammatory pathology. The sensitivity of mNGS was higher than that of the bacterial culture. However, the difference in specificity between bacterial culture and mNGS was not significant. Moreover, the time needed to perform mNGS was significantly lower than that of bacterial culture and pathology. All patients were followed up for more than three months, and CRP and NEUT% significantly decreased by three months after treatment. There was no significant difference in WBC and ESR. The ODI, NRS and JOA scores were significantly improved after treatment.

CONCLUSION

Metagenomic next-generation sequencing technology can play an important role in the detection of pathogens in SI and should be further investigated and applied in future studies.

Surgical management of chronic osteomyelitis: Organisms, recurrence and treatment outcome

PURPOSE

The study aimed to identify the risk factors of recurrence in chronic osteomyelitis (COM) and to document the microbiological patterns pre- and intra-operatively and at recurrence, if any.

METHODS

We performed retrospective review on COM patients treated with surgical debridement and a six-week course of antibiotics. The patients with symptoms of osteomyelitis for at least six weeks, present or past episodes of discharging sinus, documentation of bone sequestration in operative notes or preoperative images were included in the study. Patients with symptoms of osteomyelitis < 6 weeks, lack of history of discharging sinus or lack of evidence of sequestration in preoperative images or intraoperative notes were excluded. Logistic regression models were used to assess the impact of risk factors of recurrence. Cohen-Kappa scores were derived to see the concordance between pre-operative and intra-operative isolates and at recurrence.

RESULTS

Totally, 147 COM patients (115 males and 32 females, mean age (33 ± 19) years) were included in this study. Recurrence was noted in 28 patients (19.0%). Polymicrobial growth and extended spectrum beta-lactamase producing Enterobacteriaceae increased the chance of recurrence. Cierny-Mader stage-1, hematogenous aetiology and negative intraoperative culture reduced the chance of recurrence. Concordance between pre-operative and intra-operative cultures was 59.85% (Kappa score 0.526, p < 0.001) and between index surgery and at recurrence was 23.81% (Kappa score 0.155, p < 0.001). Lack of knowledge of causative organism preoperatively did not affect outcome. At mean follow-up (42 ± 15) months, all patients were apparently infection free for at least one year.

CONCLUSION

Polymicrobial growth and multi-drug resistant organisms increase the risk of recurrence in COM. Patients' age, gender, diabetes mellitus, previous failed treatment, duration of symptoms, haemoglobin, white cell count, C-reactive protein and erythrocyte sedimentation rate at presentation did not have any impact on the recurrence of infection. Preoperative isolation of organism is of questionable value. Recurrences of infections do occur and are more of re-infections than relapses. Diligent isolation of organism must be attempted even in re-debridements. Even patients with recurrences do well with appropriate debridement and antibiotic therapy.

The effectiveness of antibiotic cement-coated nails in post-traumatic femoral and tibial osteomyelitis - comparative analysis of custom-made versus commercially available nails

Background: The first objective of this retrospective study was to assess infection control rates in patients with chronic post-traumatic osteomyelitis (CPTO) of the femur or tibia treated with antibiotic cement-coated nails. The second objective was to compare the efficacy of custom-made nails versus commercially available antibiotic-coated nails in terms of infection control and need for reoperation. Methods: We reviewed a consecutive series of CPTO patients treated with antibiotic-coated nails who had a minimum follow-up of 24 months. We recorded the characteristics of the initial injury, the type of nail used, cement–nail debonding, infecting microorganisms, operating time, infection control, need for reoperation, and failure rate. We performed a comparative analysis between nails manufactured in the operating room (i.e., custom-made) and those commercially available. Results: Thirty patients were included. The affected bones were the femur (n=15) and the tibia (n=15). Twenty-one of the 30 initial injuries were open fractures. Staphylococcus aureus was the most frequently isolated microorganism (50 %). Sixteen patients were treated with custom-made nails and 14 with commercially available antibiotic-coated nails. At the time of extraction, four out of five custom-made antibiotic-coated nails experienced cement–bone debonding. Commercial nails were associated with shorter operating times (p<0.0001). The overall infection control rate was 96.66 %. Eight (26.66 %) patients needed reoperation. There was one failure (3.33 %) in the group treated with custom-made antibiotic-coated nails. We did not find significant differences between nail types in terms of reoperation, infection control, and failure rate. Conclusions: The use of antibiotic cement-coated nails proved useful in CPTO treatment. Commercially available nails had significantly shorter operating times and did not present cement–bone debonding during removal. Our results seem to indicate that both nail types are similar in terms of infection control and reoperation rates.

Rapid histological imaging of bone without microtome sectioning using nonlinear microscopy

Tissue preparation for histologic evaluation of bone is particularly lengthy, limiting its use in intraoperative or intraprocedural histological evaluation. Nonlinear microscopy (NLM) is an optical sectioning microscopy method that can visualize pathology in freshly excised tissue without requiring physical microtome sectioning. This study describes a rapid protocol for NLM imaging of bone and associated cartilage. NLM imaging was performed on 71 specimens of normal bone as well as arthritic, malignant and inflammatory bone tissue from 40 patients who underwent joint replacement, amputation, bone marrow biopsy or autopsy. Specimens ranged in size from core needle biopsies to transections of entire femoral heads. Specimens were stained with acridine orange and sulforhodamine 101, nuclear and cytoplasmic/stromal fluorescent dyes, for 5 min, then rinsed for 30 s. NLM fluorescent images were displayed using colors analogous to hematoxylin and eosin (H&E) to facilitate interpretation. Pathologists examined NLM images of the specimens in real time by rapidly translating the specimen to areas of interest, similar to a standard transmission light microscope. By adjusting the NLM focus depth, images from a few-μm-thick layer could be obtained down to ~100 μm below the tissue surface, analogous to serial sectioning. Following real-time NLM imaging, the tissue was processed for conventional paraffin histology, and H&E slides were compared to recorded NLM images. Similarities and differences between NLM and paraffin H&E were assessed. NLM enabled visualization of normal bone architecture, including the lamellar matrix and osteocytes of trabecular bone, articular cartilage, as well as pathological bone features such osteoarthritis, osteomyelitis, and malignancy with an appearance resembling the paraffin H&E. Differences such as changes in cell border sharpness, cellular and nucleolar size, and color patterns were noted, suggesting that training is required for accurate evaluation of bone pathology with NLM. Irregular surface contours and debris generated by gross tissue preparation of bone can make some regions difficult to evaluate with NLM, but the ability to perform rapid three-dimensional translation and sub-surface imaging reduced these problems. NLM is a promising technique for rapid evaluation of bone pathology. Further studies assessing diagnostic performance are warranted.

Comparative study of culture, next-generation sequencing, and immunoassay for identification of pathogen in diabetic foot ulcer

Treatment of deep musculoskeletal infection (MSKI) begins with accurate identification of the offending pathogen, surgical excision/debridement, and a course of culture-directed antibiotics. Despite this, the incidence of recurrent infection continues to rise. A major contributor to this is inaccurate or negative initial cultures. Accurate identification of the main pathogen is paramount to treatment success. This is especially important in treating diabetic foot infections (DFIs) with limb salvage efforts. This study seeks to utilize standard culture, next-generation sequencing (NGS), and immunoassay for newly synthesized antibodies (NSA) to Staphylococcus aureus and Streptococcus agalactiae for diagnosis. This is a level II prospective observational study approved by our IRB. Thirty patients > 18 years of age who presented with a DFI and underwent surgical debridement or amputation by a single academic orthopedic surgeon from October 2018 to September 2019 were enrolled. Intraoperative samples were obtained from the base of the wound and sent for culture, NGS, and a peripheral blood sample was obtained at the time of diagnosis. NGS and culture were highly correlated for S. aureus (κ = 0.86) and S. agalactiae (κ = 1.0), NSA immunoassay and culture demonstrated a fair correlation for S. aureus (κ = 0.18) and S. agalactiae (κ = 0.67), and NGS and NSA immunoassay demonstrated fair correlation for S. aureus (κ = 0.1667) and S. agalactiae (κ = 0.67). Our study demonstrates a high concordance between culture and NGS in identifying the dominant pathogen in DFU. NGS may be a useful adjunct in DFI diagnosis.

Reconstruction of Septic Tibial Bone Defects With the Masquelet Technique and External Ring Fixation-A Low Healing Rate and High Complication and Revision Rates

OBJECTIVES

To evaluate the results of a series of septic tibial bone defects treated with the Masquelet technique and external ring fixation as a standardized treatment procedure.

DESIGN

Retrospective study.

SETTING

Level one trauma center.

PATIENTS/PARTICIPANTS

All patients 18 years of age or older with septic diaphyseal bone defects of the tibia who underwent induced membrane treatment with ring fixation at our institution between June 1, 2012, and November 31, 2017.

INTERVENTION

Staged management as described by Masquelet using an external ring fixator for definitive fixation.

MAIN OUTCOME MEASUREMENTS

Bony healing at the last follow-up and the time to healing in months. Functional results were assessed according to the scoring system of the Association for the Study and Application of Methods of Ilizarov. The secondary outcome measures were treatment failure and complications.

RESULTS

Thirty-one patients were treated, with a mean follow-up period of 33 months (range, 13-69 months). Overall, among 14 patients assessed as having achieved bone healing, an average of 3.7 surgical revisions were required. The mean healing time was 15.5 months (range, 6-49 months). According to the Association for the Study and Application of Methods of Ilizarov criteria, 7 patients were rated as "excellent" and 6 patients were rated as "good"; one patient showed "poor" functional results. A total of 17 cases of treatment failure and 36 complications were detected.

CONCLUSIONS

The combination of the Masquelet technique and external fixation yielded a low healing rate and was associated with a significant number of cases of treatment failure.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical Outcomes of Foot Infections in Patients Without Diabetes

The aim of this study was to report clinical outcomes of moderate and severe foot infections in patients without diabetes. Medical records of 88 nondiabetic patients with foot infections treated at a safety net hospital were retrospectively reviewed. Patients were grouped by the presence of soft-tissue infection (STI) or osteomyelitis (OM). The diagnosis of OM was determined by positive bone culture or histopathology. STIs were defined by negative bone biopsy or negative imaging with magnetic resonance imaging or computed tomography/dual-modality radiolabeled white blood cell single-photon emission computed tomography. Patient outcomes were recorded ≤1 year after admission. Eighty-eight nondiabetic patients admitted to our institution for moderate or severe foot infections were included, 45 OM and 43 STI. No differences were noted in patient characteristics except that OM patients had a higher prevalence of neuropathy (66.7% versus 39.5%, p = .02). OM patients required surgery more often (97.8% versus 67.4%, p < .01), a greater number of surgeries (2.0 ± 1.2 versus 1.4 ± 1.3, p = .02), and more amputations (75.6% versus 11.6%, p < .01) than STI patients. OM patients had a higher proportion of wounds that healed (82.2% versus 62.8%, p = .04). There were no significant differences in reinfection (35.6% versus 25.6%, p = .36), foot-related readmission to hospital (35.6% versus 23.3%, p = .25), or total duration of antibiotics (13.9 ± 10.2 versus 13.5 ± 12.9, p = .87) between OM and STI patients. In conclusion, OM patients required more surgeries and amputations than patients with STIs; however, they had similar rates of reinfection and readmission within a year after the index hospitalization.

Can CRP Levels Predict Infection in Presumptive Aseptic Long Bone Non-Unions? A Prospective Cohort Study

Nonunion remains a major complication of the management of long bone fractures. The primary aim of the present study was to investigate whether raised levels of C-reactive protein (CRP) and white blood cell count (WBC), in the absence of clinical signs, are correlated with positive intraoperative tissue cultures in presumptive aseptic long-bone nonunions. Infection was classified as positive if any significant growth of microorganisms was observed from bone/tissue samples sent from the theater at the time of revision surgery. Preoperatively all patients were investigated with full blood count, white blood count differential as well as C-reactive protein (CRP). A total of 105 consecutive patients (59 males) were included in the study, with an average age of 46.76 years (range 16-92 years) at the time of nonunion diagnosis. The vast majority were femoral (56) and tibial (37) nonunions. The median time from the index surgical procedure to the time of nonunion diagnosis was 10 months (range 9 months to 10 years). Positive cultures revealed a mixed growth of microorganisms, with coagulase-negative Staphylococcus (56.4%) being the most prevalent microorganism, followed by Staphylococcusaureus (20.5%). Pseudomonas, Methicillin-Resistant Staphylococcus aureus (MRSA), coliforms and micrococcus were present in the remainder of the cases (23.1%). Overall, the risk of infection with normal CRP levels (<10 mg/L) was 21/80 = 0.26. Elevated CRP levels (≥10 mg/L) increased the risk of infection to 0.72. The relative risk given a positive CRP test was RR = 0.72/0.26 = 2.74. Overall, the WBC count was found to be an unreliable marker to predict infection. Solid union was achieved in all cases after an average of 6.5 months (3-24 months) from revision surgery. In patients with presumed aseptic long bone nonunion and normal CRP levels, the risk of underlying low-grade indolent infection can be as high as 26%. Patients should be made aware of this finding, which can complicate their treatment course and outcomes.

Concordance of bone and non-bone specimens in microbiological diagnosis of osteomyelitis: A systematic review and meta-analysis

BACKGROUND

The diagnosis of osteomyelitis is invasive and expensive as the current standard technique is the bone biopsy. Our aim was to compare the degree of agreement and concordance between standard bone biopsy and other non-bone techniques.

METHODS

We performed an electronic search through 12 electronic databases to retrieve relevant studeis. Our criteria included any original article that reported the degree of agreement and/or the concordance between bone biopsy and other non-bone techniques in diagnosing osteomyelitis. We published our protocol in PROSPERO with a registration number, CRD42017080336.

RESULTS

There were 29 studies included in the qualitative analysis, of which 15 studies were included in the meta-analysis. Samples from sinus tract had the highest concordance with bone biopsy samples, while swab samples were the least concordant with bone biopsy samples. Additionally, Staphylococcus aureus was the most common bacteria isolated and the most concordant from samples, compared to other types of causative agents. Sinus tract had a significantly very high degree of agreement with bone samples. S. aureus had the highest degree of agreement in bone smaples.

CONCLUSION

Diagnosis of osteomyelitis using sinus tract swab is close in results' accuracy to bone biopsy. S. aureus was the most common extracted organism found in these samples and had the highest degree of agreement.

Performance of a rapid two-sequence screening protocol for osteomyelitis of the foot

OBJECTIVE

Compare a two sequence protocol to a standard protocol in the detection of pedal osteomyelitis (OM) and abscesses and to identify patients that benefit from a full protocol.

MATERIALS AND METHODS

One hundred thirty-two foot MRIs ordered to assess for OM were enrolled, and the following items were extracted from the clinical reports: use of IV contrast, the presence of OM, reactive osteitis, and a soft tissue abscess. Using only one T1 nonfat-suppressed and one fluid sensitive fat-suppressed sequences, two experienced musculoskeletal radiologists reviewed each case for the presence of OM, reactive osteitis, or an abscess. A Kappa test was calculated to assess for interobserver agreement, and diagnostic performance was determined. The McNemar test was used to assess for the effect of contrast.

RESULTS

Agreement between both observers and the clinical report on the presence of osteomyelitis was substantial ( k = 0.63 and 0.72, p < 0.001), while the agreement for abscess was fair (k = 0.29 and 0.38, p < 0.001). For osteomyelitis, both observers showed good accuracy (0.85 and 0.86). When screening bone for a normal versus abnormal case, this method was highly sensitive (0.97-0.98), but was less sensitive for abscess (0.63-0.75). Fifty-one percent of exams used contrast, and it did impact the diagnosis of abscess for one observer.

CONCLUSION

This rapid protocol is accurate in making the diagnosis of OM, and its high sensitivity makes it useful to screen for patients that would benefit from a full protocol.

Value of antigranulocyte scintigraphy with Tc-99m-sulesomab in diagnosing combat-related infections of the musculoskeletal system

AIM

Combat-related extremity injuries are regularly associated with long-term complications such as chronic infection, especially osteomyelitis. Clinical examination and laboratory parameters do not usually allow reliable diagnosis. In contrast, imaging techniques enable constructive assertions to be made about the location and extent of an infection of the peripheral musculoskeletal system. The aim of this study was therefore to determine the diagnostic reliability of three-phase bone scanning and antigranulocyte scintigraphy using Tc-99m-sulesomab (Leukoscan) in the diagnostic clarification of infections associated with combat-related extremity injuries.

METHODS

Twenty-seven male patients (mean age 33.9 years) with suspected combat-associated infections of the extremities were included in this retrospective analysis. All patients underwent three-phase bone scanning using Tc-99m-HDP followed by antigranulocyte scintigraphy with Tc-99m-sulesomab. In 26 of the 27 patients, a CT scan of affected limb was obtained, where the secondary fusion with single photon emission CT data set was possible. The diagnostic reliability of imaging techniques was validated against microbiological samples obtained during surgery and used as gold standard.

RESULTS

Three-phase bone scanning yielded a positive result in all patients, with 18 scans classified as true positive (TP) and nine scans as false positive (FP). This produced a sensitivity of 100%, a specificity of 0% and a positive predictive value (PPV) of 67%. Antigranulocyte scintigraphy recognised 13 patients as TP, 1 patient as FP, 8 patients as true negative (TN) and 5 patients as false negative (FN), which gave a sensitivity of 72%, a specificity of 88%, a PPV of 93%, a negative predictive value (NPV) of 62% and an accuracy of 78%. CT recognised in 7 cases a TP result, in 3 cases an FP, in 5 cases a TN and in 11 cases an FN result. This produced a sensitivity of 39%, a specificity of 63%, a PPV of 70%, an NPV of 31% and an accuracy of 46%.

CONCLUSIONS

Three-phase bone scanning did not deliver any diagnostic benefit, since no result was able to differentiate unequivocally between infection-related and reactive changes. Antigranulocyte scintigraphy using Tc-99m-sulesomab represented a highly suitable technique for diagnostically clarifying combat-related infections of the extremities. It is superior to CT in sensitivity, specificity, PPV, NPV and accuracy.

Post-traumatic osteomyelitis in Middle East war-wounded civilians: resistance to first-line antibiotics in selected bacteria over the decade 2006-2016

BACKGROUND

War-wounded civilians in Middle East countries are at risk of post-traumatic osteomyelitis (PTO). We aimed to describe and compare the bacterial etiology and proportion of first-line antibiotics resistant bacteria (FLAR) among PTO cases in civilians from Syria, Iraq and Yemen admitted to the reconstructive surgical program of Médecins Sans Frontières (MSF) in Amman, Jordan, and to identify risk factors for developing PTO with FLAR bacteria.

METHODS

We retrospectively analyzed the laboratory database of the MSF program. Inclusion criteria were: patients from Iraq, Yemen or Syria, admitted to the Amman MSF program between October 2006 and December 2016, with at least one bone biopsy sample culture result. Only bone samples taken during first orthopedic surgery were included in the analysis. To assess factors associated with FLAR infection, logistic regression was used to estimate odds ratio (ORs) and 95% confidence intervals (CI).

RESULTS

558 (76.7%) among 727 patients included had ≥1 positive culture results. 318 were from Iraq, 140 from Syria and 100 from Yemen. Median time since injury was 19 months [IQR 8-40]. Among the 732 different bacterial isolates, we identified 228 Enterobacteriaceae (31.5%), 193 Staphylococcus aureus (26.3%), 99 Pseudomonas aeruginosa (13.5%), and 21 Acinetobacter baumanii (2.8%). Three hundred and sixty four isolates were FLAR: 86.2% of Enterobacteriaceae, 53.4% of Pseudomonas aeruginosa, 60.5% of S. aureus and 45% of Acinetobacter baumannii. There was no difference in bacterial etiology or proportion of FLAR according to the country of origin. In multivariate analysis, a FLAR infection was associated with an infection of the lower extremity, with a time since the injury ≤12 months compared with time > 30 months and with more than 3 previous surgeries.

CONCLUSIONS

Enterobacteriaceae were frequently involved in PTO in war wounded civilians from Iraq, Yemen and Syria between 2006 and 2016. Proportion of FLAR was high, particularly among Enterobacteriaceae, regardless of country of origin.

Accuracy of Tissue and Sonication Fluid Sampling for the Diagnosis of Fracture-Related Infection: A Systematic Review and Critical Appraisal

Introduction: Intraoperatively obtained peri-implant tissue cultures remain the standard for diagnosis of fracture-related infection (FRI), although culture-negative cases may complicate treatment decisions. This paper reviews the evidence on sonication fluid and tissue sampling for the diagnosis of FRI.

Methods: A comprehensive search in Pubmed, Embase and Web-of-Science was carried out on April 5, 2018, to identify diagnostic validation studies regarding sonication fluid and tissue sampling for FRI.

Results: Out of 2624 studies, nine fulfilled the predefined inclusion criteria. Five studies focused on sonication fluid culture, two on PCR and two on histopathology. One additional histopathology study was found after screening of reference lists. There is limited evidence that sonication fluid culture may be a useful adjunct to conventional tissue culture, but no strong evidence that it is superior or can replace tissue culture. Regarding molecular techniques and histopathology the evidence is even less clear. Overall, studies had variable 'gold standard' criteria for comparison and poorly reported culture methods.

Conclusions: Scientific evidence on sonication fluid and tissue sampling, including culture, molecular techniques and histopathology for the diagnosis of FRI is scarce. It is imperative that laboratory protocols become standardized and uniform diagnostic criteria, as recently published in a consensus definition, be implemented.

Treatment of infection following intramedullary nailing of tibial shaft fractures-results of the ORS/ISFR expert group survey

OBJECTIVE

The lack of universally accepted treatment principles and protocols to manage infected intramedullary (IM) nails following tibial fractures continues to challenge us, eliciting a demand for clear guidelines. Our response to this problem was to create an ORS/ISFR taskforce to identify potential solutions and trends based on published evidence and practices globally.

MATERIALS AND METHODS

A questionnaire of reported treatment methods was created based on a published meta-analysis on the topic. Treatment methods were divided in two groups: A (retained nail) and B (nail removed). Experts scored the questionnaire items on a scale of 1-4 twice, before and after revealing the success rates for each stage of infection. Inter- and intra-observer variability analysis among experts' personal scores and between experts' scores was performed. An agreement mean and correlation degree between experts' scores was calculated. Finally, a success rate report between groups was performed.

RESULTS

Experts underestimated success rate of an individual treatment method compared to published data. The mean difference between experts' scores and published results was + 26.3 ± 46 percentage points. Inter-observer agreement mean was poor (< 0.2) for both rounds. Intra-observer agreement mean across different treatment methods showed a wide variability (18.3 to 64.8%). Experts agree more with published results for nail removal on stage 2 and 3 infections.

CONCLUSIONS

Experts' and published data strongly agree to retain the implant for stage 1 infections. A more aggressive approach (nail removal) favoured for infection stages 2 and 3. However, literature supports both treatment strategies.

EVIDENCE

Clinical Question.

Epidemiology of Trauma-Related Infections among a Combat Casualty Cohort after Initial Hospitalization: The Trauma Infectious Disease Outcomes Study

BACKGROUND

The Trauma Infectious Disease Outcomes Study (TIDOS) cohort follows military personnel with deployment-related injuries in order to evaluate short- and long-term infectious complications. High rates of infectious complications have been observed in more than 30% of injured patients during initial hospitalization. We present data on infectious complications related to combat trauma after the initial period of hospitalization.

PATIENTS AND METHODS

Data related to patient care for military personnel injured during combat operations between June 2009 and May 2012 were collected. Follow-up data were captured from interviews with enrolled participants and review of electronic medical records.

RESULTS

Among 1,006 patients enrolled in the TIDOS cohort with follow-up data, 357 (35%) were diagnosed with one or more infection during their initial hospitalization, of whom 160 (45%) developed a trauma-related infection during follow-up (4.2 infections per 10,000 person-days). Patients with three or more infections during the initial hospitalization had a significantly higher rate of infections during the follow-up period compared with those with only one inpatient infection (incidence rate: 6.6 versus 3.1 per 10,000 days; p < 0.0001). There were 657 enrollees who did not have an infection during initial hospitalization, of whom 158 (24%) developed one during follow-up (incidence rate: 1.6 per 10,000 days). Overall, 318 (32%) enrolled patients developed an infection after hospital discharge (562 unique infections) with skin and soft-tissue infections being predominant (66%) followed by osteomyelitis (16%). Sustaining an amputation or open fracture, having an inpatient infection, and use of anti-pseudomonal penicillin (≥7 d) were independently associated with risk of an extremity wound infection during follow-up, whereas shorter hospitalization (15-30 d) was associated with a reduced risk.

CONCLUSIONS

Combat-injured patients have a high burden of infectious complications that continue long after the initial period of hospitalization with soft-tissue and osteomyelitis being predominant. Further research on the long-term impact and outcomes of combat-associated infection is needed.

Present role and future perspectives of interventional radiology in the treatment of painful bone lesions

Interventional radiology has experienced an exponential growth in the last years. Nowadays it is possible to treat painful benign lesions or metastases with optimal results in terms of pain management and disease control. Among the benign lesions, osteoid osteoma is the most frequently treated with minimal invasive techniques and the results are excellent. Another lesion, traditionally treated with surgery (osteoblastoma) represent today another field of application. In the oncological field, metastases are, numerically, the most diffuse indications for treatment. Research carried out during the last decades has provided the interventional radiologist with a great variety of techniques of ablation and devices for monitoring the sensitive structures close to the target lesion. New ablation techniques and monitoring devices contribute to the achievement of significantly increasing rates of effectiveness and safety of interventional radiology procedures.