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Brodell JD, Haws B, Shroff JB, Karnyski ST, Hoffman S, Soin SP, Humphrey CA, Gorczyca JT, Ketz JP. Primary Closure of External Fixator Pin Sites Is Safe After Orthopaedic Trauma Surgery. J Orthop Trauma 2024; 38:e288-e294. [PMID: 39007665 DOI: 10.1097/bot.0000000000002823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVES To determine if rates of pin site infection and surgical site infection among patients managed with primary closure after external fixator removal were similar to those allowed to heal secondarily. METHODS DESIGN Retrospective cohort. SETTING Urban/Suburban Academic Level I Trauma Center. PATIENT SELECTION CRITERIA Patients who had received a lower extremity external fixator for provisional management before definitive fixation of lower extremity fractures were included with pin site wounds closed primarily or allowed to heal by secondary intention. OUTCOME MEASURES AND COMPARISONS The rate of pin tract infection and surgical site infection following primary closure of external fixator pin sites relative to patients whose pin sites were allowed to heal through secondary intention. RESULTS In total, 256 patients were evaluated: 143 patients (406 pin sites) in the primary closure group and 113 patients (340 in sites) in the secondary closure group. The average age was 49 ± 16 years. Sixty-five percent of included patients were male. There was no difference in pin tract infections between cohorts (primary = 0.5%, secondary = 1.5%, P = 0.26). External fixator duration in the primary closure group was 11.5 ± 8.4 days and 13.0 ± 8.1 days in the secondary closure group (P = 0.15). There was a greater rate of surgical site infections in the secondary intention cohort (15.9% vs. 7.7%, P = 0.047). CONCLUSIONS There was no difference in pin site infection rate after primary pin site closure relative to patients who were allowed to heal through secondary intention. Furthermore, there was a lower rate of surgical site infection after primary closure. These results challenge the dogma of secondary closure for ex fix pin sites, suggesting that debridement and primary closure is a safe option for management of external fixator pin sites and may impart benefit in decreasing infection risk. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- James D Brodell
- Department of Orthopaedics and Physical Performance, University of Rochester Medical Center, Rochester, NY
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Li C, Nie L, Sun Z, Ding X, Luo Q, Shen C. 3DFRINet: A Framework for the Detection and Diagnosis of Fracture Related Infection in Low Extremities Based on 18F-FDG PET/CT 3D Images. Comput Med Imaging Graph 2024; 115:102394. [PMID: 38714019 DOI: 10.1016/j.compmedimag.2024.102394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 04/11/2024] [Accepted: 04/28/2024] [Indexed: 05/09/2024]
Abstract
Fracture related infection (FRI) is one of the most devastating complications after fracture surgery in the lower extremities, which can lead to extremely high morbidity and medical costs. Therefore, early comprehensive evaluation and accurate diagnosis of patients are critical for appropriate treatment, prevention of complications, and good prognosis. 18Fluoro-deoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is one of the most commonly used medical imaging modalities for diagnosing FRI. With the development of deep learning, more neural networks have been proposed and become powerful computer-aided diagnosis tools in medical imaging. Therefore, a fully automated two-stage framework for FRI detection and diagnosis, 3DFRINet (Three Dimension FRI Network), is proposed for 18F-FDG PET/CT 3D imaging. The first stage can effectively extract and fuse the features of both modalities to accurately locate the lesion by the dual-branch design and attention module. The second stage reduces the dimensionality of the image by using the maximum intensity projection, which retains the effective features while reducing the computational effort and achieving excellent diagnostic performance. The diagnostic performance of lesions reached 91.55% accuracy, 0.9331 AUC, and 0.9250 F1 score. 3DFRINet has an advantage over six nuclear medicine experts in each classification metric. The statistical analysis shows that 3DFRINet is equivalent or superior to the primary nuclear medicine physicians and comparable to the senior nuclear medicine physicians. In conclusion, this study first proposed a method based on 18F-FDG PET/CT three-dimensional imaging for FRI location and diagnosis. This method shows superior lesion detection rate and diagnostic efficiency and therefore has good prospects for clinical application.
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Affiliation(s)
- Chengfan Li
- School of Computer Engineering and Science, Shanghai University, Shanghai 200444, China
| | - Liangbing Nie
- School of Computer Engineering and Science, Shanghai University, Shanghai 200444, China.
| | - Zhenkui Sun
- Department of Nuclear Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China; Bone nonunion & bone infection MDT, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China
| | - Xuehai Ding
- School of Computer Engineering and Science, Shanghai University, Shanghai 200444, China.
| | - Quanyong Luo
- Department of Nuclear Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China; Bone nonunion & bone infection MDT, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China.
| | - Chentian Shen
- Department of Nuclear Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China; Bone nonunion & bone infection MDT, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China.
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Guan X, Wu S, Ouyang S, Ren S, Cui N, Wu X, Xiang D, Chen W, Yu B, Zhao P, Wang B. Remodeling Microenvironment for Implant-Associated Osteomyelitis by Dual Metal Peroxide. Adv Healthc Mater 2024; 13:e2303529. [PMID: 38430010 DOI: 10.1002/adhm.202303529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/02/2024] [Indexed: 03/03/2024]
Abstract
Implant-associated osteomyelitis (IAOM) is characterized by bone infection and destruction; current therapy of antibiotic treatment and surgical debridement often results in drug resistance and bone defect. It is challenging to develop an antibiotic-free bactericidal and osteogenic-enhanced strategy for IAOM. Herein, an IAOM-tailored antibacterial and osteoinductive composite of copper (Cu)-strontium (Sr) peroxide nanoparticles (CSp NPs), encapsulated in polyethylene glycol diacrylate (PEGDA) (CSp@PEGDA), is designed. The dual functional CSp NPs display hydrogen peroxide (H2O2) self-supplying and Fenton catalytic Cu2+ ions' release, generating plenty of hydroxyl radical (•OH) in a pH-responsive manner for bacterial killing, while the released Sr2+ promotes the in vitro osteogenicity regarding cell proliferation, alkaline phosphatase activity, extracellular matrix calcification, and osteo-associated genes expression. The integration of Cu2+ and Sr2+ in CSp NPs together with the coated PEGDA hydrogel ensures the stable and sustainable ion release during short- and long-term periods. Benefitted from the injectablity and photo-crosslink ability, CSp@PEGDA is able to thoroughly fill the infectious site and gelate in situ for bacterial elimination and bone regeneration, which is verified through in vivo evaluation using a clinical-simulating IAOM mouse model. These favorable abilities of CSp@PEGDA precisely meet the multiple therapeutic needs and pave a promising way for implant-associated osteomyelitis treatment.
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Affiliation(s)
- Xin Guan
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Siyuan Wu
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Sixue Ouyang
- School of Chemistry and Chemical Engineering, South China University of Technology, Guangzhou, 510640, China
| | - Shuchen Ren
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Naiqian Cui
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Xiaohu Wu
- Department of Orthopedics, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510515, China
| | - Dayong Xiang
- Division of Orthopaedic Trauma, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Wenting Chen
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Bin Yu
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Division of Orthopaedic Trauma, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Peng Zhao
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, 510515, China
| | - Bowei Wang
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
- Division of Orthopaedic Trauma, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
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Wang YJ, Zhao ZH, Lu SK, Wang GL, Ma SJ, Wang LH, Gao H, Ren J, An ZW, Fu CX, Zhang Y, Luo W, Zhang YF. Analysis of risk factors, pathogenic bacteria characteristics, and drug resistance of postoperative surgical site infection in adults with limb fractures. Chin J Traumatol 2024:S1008-1275(24)00059-2. [PMID: 38811319 DOI: 10.1016/j.cjtee.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 03/22/2024] [Accepted: 04/28/2024] [Indexed: 05/31/2024] Open
Abstract
PURPOSE We carried out the study aiming to explore and analyze the risk factors, the distribution of pathogenic bacteria, and their antibiotic-resistance characteristics influencing the occurrence of surgical site infection (SSI), to provide valuable assistance for reducing the incidence of SSI after traumatic fracture surgery. METHODS A retrospective case-control study enrolling 3978 participants from January 2015 to December 2019 receiving surgical treatment for traumatic fractures was conducted at Tangdu Hospital of Air Force Medical University. Baseline data, demographic characteristics, lifestyles, variables related to surgical treatment, and pathogen culture were harvested and analyzed. Univariate analyses and multivariate logistic regression analyses were used to reveal the independent risk factors of SSI. A bacterial distribution histogram and drug-sensitive heat map were drawn to describe the pathogenic characteristics. RESULTS Included 3978 patients 138 of them developed SSI with an incidence rate of 3.47% postoperatively. By logistic regression analysis, we found that variables such as gender (males) (odds ratio (OR) = 2.012, 95% confidence interval (CI): 1.235 - 3.278, p = 0.005), diabetes mellitus (OR = 5.848, 95% CI: 3.513 - 9.736, p < 0.001), hypoproteinemia (OR = 3.400, 95% CI: 1.280 - 9.031, p = 0.014), underlying disease (OR = 5.398, 95% CI: 2.343 - 12.438, p < 0.001), hormonotherapy (OR = 11.718, 95% CI: 6.269 - 21.903, p < 0.001), open fracture (OR = 29.377, 95% CI: 9.944 - 86.784, p < 0.001), and intraoperative transfusion (OR = 2.664, 95% CI: 1.572 - 4.515, p < 0.001) were independent risk factors for SSI, while, aged over 59 years (OR = 0.132, 95% CI: 0.059 - 0.296, p < 0.001), prophylactic antibiotics use (OR = 0.082, 95% CI: 0.042 - 0.164, p < 0.001) and vacuum sealing drainage use (OR = 0.036, 95% CI: 0.010 - 0.129, p < 0.001) were protective factors. Pathogens results showed that 301 strains of 38 species of bacteria were harvested, among which 178 (59.1%) strains were Gram-positive bacteria, and 123 (40.9%) strains were Gram-negative bacteria. Staphylococcus aureus (108, 60.7%) and Enterobacter cloacae (38, 30.9%) accounted for the largest proportion. The susceptibility of Gram-positive bacteria to Vancomycin and Linezolid was almost 100%. The susceptibility of Gram-negative bacteria to Imipenem, Amikacin, and Meropenem exceeded 73%. CONCLUSION Orthopedic surgeons need to develop appropriate surgical plans based on the risk factors and protective factors associated with postoperative SSI to reduce its occurrence. Meanwhile, it is recommended to strengthen blood glucose control in the early stage of admission and for surgeons to be cautious and scientific when choosing antibiotic therapy in clinical practice.
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Affiliation(s)
- Yan-Jun Wang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, Xi'an, 710038, China
| | - Zi-Hou Zhao
- Air Force Medical University, Xi'an, 710032, China
| | - Shuai-Kun Lu
- Orthopedic Oncology Institute of PLA, Xi'an, 710038, China
| | - Guo-Liang Wang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, Xi'an, 710038, China
| | - Shan-Jin Ma
- Department of Urology, Second Affiliated Hospital, Air Force Medical University, Xi'an, 710038, China
| | - Lin-Hu Wang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, Xi'an, 710038, China
| | - Hao Gao
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, Xi'an, 710038, China
| | - Jun Ren
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, Xi'an, 710038, China
| | - Zhong-Wei An
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, Xi'an, 710038, China
| | - Cong-Xiao Fu
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, Xi'an, 710038, China
| | - Yong Zhang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, Xi'an, 710038, China
| | - Wen Luo
- Department of Ultrasound, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China.
| | - Yun-Fei Zhang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, Xi'an, 710038, China.
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Dai Y, Yi X, Huang Y, Qian K, Huang L, Hu J, Liu Y. miR-345-3p Modulates M1/M2 Macrophage Polarization to Inhibit Inflammation in Bone Infection via Targeting MAP3K1 and NF-κB Pathway. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2024; 212:844-854. [PMID: 38231123 DOI: 10.4049/jimmunol.2300561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/20/2023] [Indexed: 01/18/2024]
Abstract
Infection after fracture fixation (IAFF), a complex infectious disease, causes inflammatory destruction of bone tissue and poses a significant clinical challenge. miR-345-3p is a biomarker for tibial infected nonunion; however, the comprehensive mechanistic role of miR-345-3p in IAFF is elusive. In this study, we investigated the role of miR-345-3p in IAFF pathogenesis through in vivo and in vitro experiments. In vivo, in a rat model of IAFF, miR-345-3p expression was downregulated, accompanied by increased M1 macrophage infiltration and secretion of proinflammatory factors. In vitro, LPS induced differentiation of primary rat bone marrow-derived macrophages into M1 macrophages, which was attenuated by miR-345-3p mimics. miR-345-3p promoted M1 to M2 macrophage transition-it reduced the expression of cluster of differentiation (CD) 86, inducible NO synthase, IL-1β, and TNF-α but elevated those of CD163, arginase-1, IL-4, and IL-10. MAPK kinase kinase 1 (MAP3K1), a target mRNA of miR-345-3p, was overexpressed in the bone tissue of IAFF rats compared with that in those of the control rats. The M1 to M2 polarization inhibited MAP3K1 signaling pathways in vitro. Conversely, MAP3K1 overexpression promoted the transition from M2 to M1. miR-345-3p significantly inhibited NF-κB translocation from the cytosol to the nucleus in a MAP3K1-dependent manner. In conclusion, miR-345-3p promotes the polarization of M1 macrophages to the M2 phenotype by inhibiting the MAP3K1 and NF-κB pathways. These findings provide insight into the pathogenesis and immunotherapeutic strategies for IAFF and offer potential new targets for subsequent research.
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Affiliation(s)
- Yan Dai
- Department of Infectious Diseases, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaolan Yi
- Department of Infectious Diseases, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yahui Huang
- Department of Infectious Diseases, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kaoliang Qian
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lili Huang
- Department of Infectious Diseases, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jun Hu
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuan Liu
- Department of Infectious Diseases, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Peel TN, Cherk M, Yap K. Imaging in osteoarticular infection in adults. Clin Microbiol Infect 2024; 30:312-319. [PMID: 37940000 DOI: 10.1016/j.cmi.2023.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/18/2023] [Accepted: 11/02/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Osteoarticular infections are uncommon and required a multimodal approach for diagnosis. Imaging forms an important component of this multimodal approach. OBJECTIVES In this narrative review, we describe the different imaging modalities, features of osteoarticular infections present on these imaging approaches and recommendations for which imaging modality should be considered in different types of osteoarticular infections. SOURCES This narrative review was based on literature review from PubMed and was limited to bacterial infections in adult patients. CONTENT Imaging modalities include modalities that provide information on the anatomy or radionuclide imaging that provides information about the metabolic activity of the area of interest. Anatomical imaging includes plain radiographs (X-ray), computed tomography, and magnetic resonance imaging. Radionuclide approaches include three-phase bone scintigraphy, gallium scans, white blood cell scintigraphy, and 18F-fluorodeoxy-glucose positron emission tomography. The optimal radiological modality for diagnosis is influenced by multiple factors, including infection location, presence of metalware, timing of infection from any preceding surgery or fracture, antibiotic use, and patient comorbidities. Local availability of scanning modality, tracer supply, technical expertise, and patient access also influences choice. IMPLICATIONS A collaborative approach with imaging, pathology and clinical input in a multidisciplinary setting is paramount for the diagnosis of osteoarticular infections. Increasing research and improvements in technology will further improve the utility and accuracy of imaging approaches for imaging in osteoarticular infections.
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Affiliation(s)
- Trisha N Peel
- Department of Infectious Diseases, Monash University and Alfred Health, Melbourne, VIC, Australia.
| | - Martin Cherk
- Department of Nuclear Medicine & PET, Alfred Health, Melbourne, VIC, Australia; Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Kenneth Yap
- Department of Nuclear Medicine & PET, Alfred Health, Melbourne, VIC, Australia; Central Clinical School, Monash University, Melbourne, VIC, Australia
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Guardia-Jimena P, Martínez-Valle Torres MD, Arenas Aguaza R, González Ramírez AR, Becerra-García D, Guirado D. Semi-quantitative analysis with 99mTc-Besilesomab in musculoskeletal system infections. Bone Rep 2023; 19:101708. [PMID: 37664143 PMCID: PMC10474153 DOI: 10.1016/j.bonr.2023.101708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 07/25/2023] [Accepted: 08/16/2023] [Indexed: 09/05/2023] Open
Abstract
Objectives To evaluate the usefulness of 99mTc-Besilesomab to diagnose infectious processes by using monoclonal antibodies BW 250/183 in a semi-quantitative analysis, and to determine the effect on diagnostic capacity of different thresholds for the difference between counts in early versus delayed images. Methods The study included 77 patients with suspected osteomyelitis who underwent scintigraphy with 99mTc-Besilesomab. After confirming the absence of human anti-mouse antibodies in all patients, early and delayed static images were acquired at 4 and 24 h post-injection, respectively. Visual and semi-quantitative analyses were conducted of regions of interest (ROIs) in areas suspected of infection on early and delayed images. Findings were considered positive when the ratio between counts in delayed and early images exceeded a given threshold after correction for decay. The definitive diagnosis was obtained by clinical follow-up, microbiological culture, or response to medical and/or surgical treatment. Results The optimal threshold was 1.02 (i.e., positive result = count increase of >2 % in delayed image), obtaining a sensitivity of 0.864, specificity of 0.858, positive predictive value of 0.708, negative predictive value of 0.940, and accuracy of 0.860. Application of the usual threshold of 1.10 (10 %) reduced the sensitivity to 0.734. Conclusion Semi-quantitative analysis of studies with 99mTc-Besilesomab is a useful technique for the diagnosis of musculoskeletal system infections and contributes to the definitive diagnosis when visual assessments are doubtful or non-conclusive.
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Affiliation(s)
| | | | - Raquel Arenas Aguaza
- Nuclear Medicine Service, San Cecilio Clinical University Hospital, Granada, Spain
| | - Amanda Rocío González Ramírez
- Methodological and Statistical Support Unit of the Fundación Pública Andaluza para la Investigación Biosanitaria Andalucía Oriental (FIBAO), Clinical University Hospital, Granada, Spain
- Instituto de Investigación Biosanitaria (ibs.GRANADA), Radiophysics Unit, San Cecilio Clinical University Hospital, Granada, Spain
| | - Diego Becerra-García
- Nuclear Medicine Service, San Cecilio Clinical University Hospital, Granada, Spain
| | - Damián Guirado
- Instituto de Investigación Biosanitaria (ibs.GRANADA), Radiophysics Unit, San Cecilio Clinical University Hospital, Granada, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Granada, Spain
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Wang X, Gu Q, Wei W, Zi S. Surgical debridement and continuous irrigation for early surgical site infection caused by Staphylococcus aureus with a closed patella fracture surgery: A case report. Int J Surg Case Rep 2023; 113:109068. [PMID: 37988986 PMCID: PMC10667781 DOI: 10.1016/j.ijscr.2023.109068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Management of postoperative surgical site infection (SSI) is a huge challenge to orthopedic surgeons, and significantly impacts patients and their families due to long treatment cycles and associated discomfort experiences. PRESENTATION OF CASE A 68-year-old woman without a medical history of any comorbidities, diabetes, hypertension, allergies, or tuberculosis, was admitted to our hospital complaining of right knee pain following a fall. X-ray and CT scans revealed a closed right patella fracture. The patient underwent open reduction and internal fixation with tension band wiring and circle wire. Preoperative assessment showed normal nutritional status. Prophylactic cefazolin sodium pentahydrate was administered 30 min preoperatively and maintained for 24 h post-operation to prevent infection. The patient was discharged 3 days after the operation. However, the wound exhibited signs of infection: redness, swelling, and the presence of secretions. Outpatient dressings and oral antibiotics were prescribed but failed to control the infection, leading to rehospitalization. Surgical debridement and continuous articular irrigation were implemented to address the infection. Secretion cultures were taken to identify the causative bacteria. Levofloxacin and Rifampicin were used according to drug sensitivity tests. However, the patient experienced severe knee swelling and an iodine irritative reaction subsequently. Anti-allergic treatment and normal saline dressings were applied to alleviate swelling, pain, and skin irritation. MRI results indicated arthroedema and possible infection necessitating further surgical debridement, the patient rejected additional surgery and requested discharge. Levofloxacin and Rifampicin were used for a month to control the infection after discharge, accompanied by regular rehabilitation exercises. Fortunately, the infection was successfully managed, and knee function was satisfactorily restored. DISCUSSION SSI after patella fracture surgery can lead to a worse quality of life, serious economic burden, and psychological distress. Therefore, effective treatment methods for managing postoperative SSIs are very important. CONCLUSION Sufficient surgical debridement is vital to remove infection tissue of early SSI caused by Staphylococcus aureus with a closed patella fracture surgery. Continuous articular irrigation and sensitive antibiotics help control infection, and active rehabilitation training improves knee function recovery.
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Affiliation(s)
- Xiong Wang
- Department of Orthopedics, Shanghai Baoshan Luodian Hospital, Baoshan District, Shanghai 201908, China
| | - Qing Gu
- Department of Orthopedics, Shanghai Baoshan Luodian Hospital, Baoshan District, Shanghai 201908, China
| | - Wenqiang Wei
- Department of Orthopedics, Shanghai Baoshan Luodian Hospital, Baoshan District, Shanghai 201908, China
| | - Shuming Zi
- Department of Orthopedics, Shanghai Baoshan Luodian Hospital, Baoshan District, Shanghai 201908, China.
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Anglitoiu B, Abu-Awwad A, Patrascu JM, Abu-Awwad SA, Dinu AR, Totorean AD, Cojocaru D, Sandesc MA. Staged Treatment of Posttraumatic Tibial Osteomyelitis with Rib Graft and Serratus Anterior Muscle Autografts-Case Report. J Pers Med 2023; 13:1651. [PMID: 38138878 PMCID: PMC10745087 DOI: 10.3390/jpm13121651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 11/23/2023] [Accepted: 11/24/2023] [Indexed: 12/24/2023] Open
Abstract
Osteomyelitis of the tibia is a challenging condition, particularly when it occurs as a result of trauma. This abstract presents a case study detailing the successful staged treatment of posttraumatic tibial osteomyelitis utilizing a unique combination of rib graft and serratus anterior muscle. This medical abstract presents a case study of a 52-year-old male with a history of heavy smoking and obliterating arteriopathy of the lower limbs. The patient sustained a traumatic open fracture classified as Type IIIA Gustilo Anderson involving one-third of the distal right tibia diaphysis, with an associated right fibular malleolus fracture. The treatment approach comprised multiple stages, focusing on wound management, infection control, and limb salvage. The initial stage involved the application of an external fixation device in the emergency setting. Seven days later, an osteosynthesis procedure was performed using a Kuntscher nail and wire cerclage. However, complications emerged, with wound dehiscence and purulent secretion observed at 14 days postsurgery. Subsequently, secondary suturing was carried out at the 20-day mark. The second stage of the treatment involved implant removal, wide excisional debridement, pulse lavage, osteoclasia, and relaxation of the peroneal malleolus. A monoplane external fixation system was applied. As a part of postoperative care, aspiration therapy with a vacuum pump was administered, along with a 10-day course of vancomycin according to the antibiogram. Positive clinical signs of healing were noted, and sterile cultures confirmed the results. The third stage of the intervention focused on grafting the osteo-muscular defect, utilizing autografts from the rib and serratus anterior muscle. The external fixator was maintained in place during this phase. In the fourth and final stage, after an 8-week integration period of the musculocutaneous flap, the external fixator was removed, and internal fixation was accomplished with a blocked Less Invasive Stabilization System (LISS) plate inserted using the Minimally Invasive Plate Osteosynthesis (MIPO) technique. This case underscores the significance of a multistage approach in managing complex limb injuries, emphasizing the importance of timely intervention, infection control, and innovative techniques for limb salvage and restoration of function.
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Affiliation(s)
- Bogdan Anglitoiu
- Department XV—Discipline of Orthopedics—Traumatology, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (B.A.); (J.-M.P.J.); (M.-A.S.)
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (A.R.D.); (A.-D.T.); (D.C.)
- Research Center University Professor Doctor Teodor Șora, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Ahmed Abu-Awwad
- Department XV—Discipline of Orthopedics—Traumatology, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (B.A.); (J.-M.P.J.); (M.-A.S.)
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (A.R.D.); (A.-D.T.); (D.C.)
- Research Center University Professor Doctor Teodor Șora, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Jenel-Marain Patrascu
- Department XV—Discipline of Orthopedics—Traumatology, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (B.A.); (J.-M.P.J.); (M.-A.S.)
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (A.R.D.); (A.-D.T.); (D.C.)
- Research Center University Professor Doctor Teodor Șora, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Simona-Alina Abu-Awwad
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (A.R.D.); (A.-D.T.); (D.C.)
- Department XII—Discipline of Obstetrics and Gynecology, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Anca Raluca Dinu
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (A.R.D.); (A.-D.T.); (D.C.)
- Department XVI—Balneology, Medical Recovery and Rheumatology, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
- Research Center for Assessment of Human Motion and Functionality and Disability, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Alina-Daniela Totorean
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (A.R.D.); (A.-D.T.); (D.C.)
- Department XVI—Balneology, Medical Recovery and Rheumatology, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
- Research Center for Assessment of Human Motion and Functionality and Disability, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Dan Cojocaru
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (A.R.D.); (A.-D.T.); (D.C.)
- Research Center University Professor Doctor Teodor Șora, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Mihai-Alexandru Sandesc
- Department XV—Discipline of Orthopedics—Traumatology, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (B.A.); (J.-M.P.J.); (M.-A.S.)
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (A.R.D.); (A.-D.T.); (D.C.)
- Research Center University Professor Doctor Teodor Șora, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
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Zhang Y, Li H, Wang W, Shan L, Hao D. Assistive diagnostic indicators for infections related to lumbar posterior interbody fusion internal fixation: platelet count and mean platelet volume. J Orthop Surg Res 2023; 18:883. [PMID: 37986002 PMCID: PMC10658883 DOI: 10.1186/s13018-023-04358-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/08/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND The most severe complication after posterior single-segment lumbar interbody fusion and internal fixation (PIFIF) surgery for degenerative lumbar diseases is deep surgical site infection (DSSI). Preoperatively diagnosing such complications proves to be challenging. Platelets, as acute-phase reactants, undergo changes in response to infections and inflammation. This study aims to assess whether platelet indices can further aid in the diagnosis of DSSI. METHODS A single-center retrospective study was conducted from January 2016 to February 2021 at Xi'an Jiaotong University-Affiliated Honghui Hospital, involving 83 patients who underwent revision surgery after PIFIF due to lumbar degenerative diseases. Among them, 24 patients were diagnosed with DSSI based on combined bacterial culture and imaging data. Preoperative complete serological indicators including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and platelet count and mean platelet volume ratio (P/M ratio) were analyzed using receiver operating characteristic (ROC) curve analysis to determine cutoff values, sensitivity, and specificity. This was done to further assess the ability of these serological indicators to identify the occurrence of DSSI after PIFIF. RESULTS There were no significant differences in baseline demographic characteristics between the two patient groups (P > 0.05). The P/M ratio was 13.54 ± 5.05 in the aseptic revision group, while it was 19.21 ± 6.30 in the DSSI revision patients, showing a significant difference (P < 0.001). ROC curve analysis revealed that the optimal cutoff value for the P/M ratio was 17.50, with a sensitivity of 58.3% and a specificity of 78.6%. The areas under the curve (AUC) for ESR, CRP, and P/M ratio were 0.797, 0.845, and 0.756, respectively. The negative predictive value (NPV) was 87.04%, 89.47%, and 82.45%, respectively; the positive predictive value (PPV) was 58.62%, 69.23%, and 53.84%, respectively, for ESR, CRP, and P/M ratio, respectively. When P/M ratio is used in combination with ESR and CRP, the AUC is 0.887, with a sensitivity of 95.4%, specificity of 67.8%, NPV of 97.56%, PPV of 54.76%. The diagnostic performance of the model for evaluating DSSI is significantly improved compared to using ESR and CRP alone (P < 0.05). CONCLUSION Platelets and their related serum biomarkers are closely associated with DSSI. The P/M ratio can serve as a reliable test for screening DSSI and is worth considering for inclusion in the assessment of patients at risk of developing DSSI after potential PIFIF surgery.
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Affiliation(s)
- Yadong Zhang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
- Graduate School, Xi'an Medical University, Xi'an, 710068, Shaanxi, China
- Shaanxi Key Laboratory of Spine Bionic Treatment, Xi'an, 710054, Shaanxi, China
| | - Houkun Li
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
- Shaanxi Key Laboratory of Spine Bionic Treatment, Xi'an, 710054, Shaanxi, China
| | - Wentao Wang
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Lequn Shan
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Dingjun Hao
- Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China.
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11
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Wang Y, Sun Z, Liang X, Shen C. Inguinal draining-lymph node in 18F-FDG PET/CT images could be a new indicator for the diagnosis of fracture-related infection in the lower extremities. Front Immunol 2023; 14:1206682. [PMID: 37868952 PMCID: PMC10585159 DOI: 10.3389/fimmu.2023.1206682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/28/2023] [Indexed: 10/24/2023] Open
Abstract
Purpose The imaging diagnosis of fracture-related infection is often challenging. The aim of this study was to evaluate the value of 18F-FDG PET/CT for the diagnosis of fracture-related infection (FRI) with internal fixation after orthopedic surgery in lower extremities. Methods A total of 254 consecutive patients who underwent 18F-FDG PET/CT scans with suspected FRI with internal fixation in lower extremities were retrospectively investigated 18F-FDG PET/CT images were semiquantitatively evaluated with multiple metabolic parameters. Additionally, morphological information of the inguinal draining lymph nodes (DLN) with the highest SUV value was also collected and analyzed. Results Patients were divided into two groups according to final diagnosis: the infected (N=197) and the non-infected group (N=57). The differences in the inguinal DLN-related parameters, including the long diameter, short diameter, maximum cross-sectional area, maximum standardized uptake value (SUVmax), metabolic volume (MV) 60%, MV70%, MV80%, total lesional glycolysis (TLG) 60%, TLG70%, TLG80%, and the infection suspected area related parameters, including SUVmax, MV25%, MV30%, MV35%, MV40%, MV50%, and TLG70%, between the two groups were statistically significant. We then compared the highest area under the curves (AUCs) among the morphological parameters of DLN, metabolic parameters of DLN, and metabolic parameters of the suspected infection area. The result demonstrated that SUVmax of the inguinal DLN showed the best diagnostic performance with an AUC of 0.939 (P<0.05). Conclusion Semiquantitative analysis (especially SUVmax) of the inguinal DLN in 18F-FDG PET/CT images could be a promising method for the diagnosis of suspected FRI with internal fixation after orthopedic surgery in lower extremities.
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Affiliation(s)
- Yanbing Wang
- Department of Nuclear Medicine, Rizhao People’s Hospital, Rizhao, Shandong, China
- Department of Nuclear Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhenkui Sun
- Department of Nuclear Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Bone Nonunion and Bone Infection Multidisciplinary Team (MDT), Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao Liang
- Department of Radiology, Rizhao People’s Hospital, Rizhao, Shandong, China
| | - Chentian Shen
- Department of Nuclear Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Bone Nonunion and Bone Infection Multidisciplinary Team (MDT), Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Hu X, Zhong J, Ao H, Wu X, Chen Y, Peng Z. Iodine-Doped 3D Print Ti Alloy for Antibacterial Therapy on Orthopedic Implants. ACS OMEGA 2023; 8:32990-32997. [PMID: 37720783 PMCID: PMC10500661 DOI: 10.1021/acsomega.3c04721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 08/23/2023] [Indexed: 09/19/2023]
Abstract
This study presents a novel approach to mitigating bacterial infections and antibiotic resistance in medical implants through the integration of iodine-doping and 3D printing techniques. Iodine, with its potent antibacterial properties, and titanium alloy (Ti), a popular metal for implants due to its mechanical and biological properties, were combined via electrodeposition on 3D-printed titanium alloy (3D-Ti) implants. Scanning electron microscopy, energy dispersive spectroscopy, and X-ray photoelectron spectroscopy confirmed the successful creation of iodine-doped titanium implants with improved iodine content due to the rough surface of the 3D-printed material. In vitro studies revealed that these implants significantly inhibited bacterial adhesion and biofilm formation and showed favorable release kinetics for iodine ions. Biocompatibility tests demonstrated no cytotoxic effects and good hemocompatibility. The implants demonstrated enhanced antimicrobial efficacy against Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus) bacteria strains. The findings imply that the integration of iodine-doping and 3D printing technologies is a promising strategy for treating postoperative infections associated with medical implants, consequently bettering the prognosis for patients. Future investigations are encouraged to delve into the long-standing impacts and prospective clinical utility of this groundbreaking methodology.
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Affiliation(s)
- Xiaodong Hu
- The
Affiliated Lihuili Hospital, Ningbo University, Ningbo 315040, China
| | - Jiaqi Zhong
- The
Affiliated Lihuili Hospital, Ningbo University, Ningbo 315040, China
| | - Haiyong Ao
- Jiangxi
Key Laboratory of Nanobiomaterials & School of Materials Science
and Engineering, East China Jiaotong University, Nanchang 330000, China
| | - Xinhui Wu
- Xianju
County People’s Hospital, Taizhou 317300, China
| | - Yujiong Chen
- The
Affiliated Lihuili Hospital, Ningbo University, Ningbo 315040, China
| | - Zhaoxiang Peng
- The
Affiliated Lihuili Hospital, Ningbo University, Ningbo 315040, China
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Patel KH, Gill LI, Tissingh EK, Galanis A, Hadjihannas I, Iliadis AD, Heidari N, Cherian B, Rosmarin C, Vris A. Microbiological Profile of Fracture Related Infection at a UK Major Trauma Centre. Antibiotics (Basel) 2023; 12:1358. [PMID: 37760655 PMCID: PMC10525273 DOI: 10.3390/antibiotics12091358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/11/2023] [Accepted: 07/26/2023] [Indexed: 09/29/2023] Open
Abstract
Fracture Related Infection (FRI) represents one of the biggest challenges for Trauma and Orthopaedic surgery. A better understanding of the microbiological profile should assist with decision-making and optimising outcomes. Our primary aim was to report on the microbiological profile of FRI cases treated over a six-year period at one of Europe's busiest trauma centres. Secondarily, we sought to correlate our findings with existing anti-microbiological protocols and report on diagnostic techniques employed in our practice. All adult cases of FRI treated in our institution between 2016 and 2021 were identified, retrospectively. We recorded patient demographics, diagnostic strategies, causative organisms and antibiotic susceptibilities. There were 330 infection episodes in 294 patients. A total of 463 potentially pathogenic organisms (78 different species) were identified from cultures, of which 57.2% were gram-positive and 39.7% gram-negative. Polymicrobial cultures were found in 33.6% of cases and no causative organism was found in 17.5%. The most prevalent organisms were Staphylococcus aureus (24.4%), coagulase-negative Staphylococci (14%), Pseudomonas aeruginosa (8.2%), Enterobacter species (7.8%) and Escherichia coli (6.9%). Resistant gram-positive organisms (methicillin resistant Staphylococcus aureus or vancomycin-resistant Enterococci) were implicated in 3.3% of infection episodes and resistant gram-negatives (extended-spectrum beta-lactamase, ampC or carbapenemase-producing bacteria) in 13.6%. The organisms cultured in 96.3% of infection episodes would have been covered by our empirical systemic antibiotic choice of teicoplanin and meropenem. To our knowledge, this is the largest reported single-centre cohort of FRIs from a major trauma centre. Our results demonstrate patterns in microbiological profiles that should serve to inform the decision-making process regarding antibiotic choices for both prophylaxis and treatment.
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Affiliation(s)
- Kavi H. Patel
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, UK; (E.K.T.); (A.D.I.); (N.H.); (A.V.)
| | - Laura I. Gill
- Department of Infection, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, UK; (L.I.G.); (B.C.); (C.R.)
| | - Elizabeth K. Tissingh
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, UK; (E.K.T.); (A.D.I.); (N.H.); (A.V.)
| | | | - Ioannis Hadjihannas
- Barts and the London School of Medicine, Garrod Building, Turner St., London E1 2AD, UK;
| | - Alexis D. Iliadis
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, UK; (E.K.T.); (A.D.I.); (N.H.); (A.V.)
| | - Nima Heidari
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, UK; (E.K.T.); (A.D.I.); (N.H.); (A.V.)
| | - Benny Cherian
- Department of Infection, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, UK; (L.I.G.); (B.C.); (C.R.)
| | - Caryn Rosmarin
- Department of Infection, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, UK; (L.I.G.); (B.C.); (C.R.)
| | - Alexandros Vris
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London E1 1FR, UK; (E.K.T.); (A.D.I.); (N.H.); (A.V.)
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Xu X, Wang H, Liu Y, Wang D, Diao S, Gao Y, Zhou J. The Role of Combined Inflammatory Biomarkers in the Diagnosis of High- and Low-Virulence FRI Among High-Risk Lower Extremity Fractures. Int J Gen Med 2023; 16:3363-3371. [PMID: 37576914 PMCID: PMC10422992 DOI: 10.2147/ijgm.s426608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023] Open
Abstract
Objective The aim of this study is to evaluate the diagnostic accuracy of infection-related biomarkers in high-risk lower limb injury patients with fracture-related infection (FRI) caused by high-/low-virulence microorganisms. Methods This study was a retrospective analysis of patients with high-risk lower extremity fractures (including tibial plateau, calcaneus, and Pilon fractures) who underwent open reduction internal fixation (ORIF) surgery from January 2017 to February 2022. Peripheral blood samples were collected within 24 hours of admission, and the following information was evaluated: gender, age, BMI, smoking, comorbidities, injury information, surgical details, values for serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), as well as neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR). Results A total of 576 patients receiving lower extremity fracture surgery were included in this study. Fifty-one patients (8.85%) were identified as FRI, and 28 (54.9%) of these 51 cases were further classified as high-virulence group. The median levels of CRP, ESR, NLR, and MLR were significantly higher in the FRI group than in the non-FRI group (p < 0.01). Similarly, the marginally significantly higher levels of CRP and NLR presented in the high-virulence group, compared to the low-virulence group (p < 0.1). The AUC areas of CRP, NLR, and CRP+NLR were 0.826, 0.650, and 0.873, respectively. We calculated the optimal cut-off points for CRP+NLR as diagnostic markers of high-virulent infection was 0.377. Conclusion This study showed the incidence of FRI in high-risk lower extremity fractures was 8.9%, and identified preoperative serum biomarkers, including CRP, ESR, NLR, and PLR, as useful tools for assisting in the diagnosis of infection. Additionally, the combination of CRP with NLR played a discriminating clinical role in postoperative infections caused by different virulence. Level of Evidence Clinical study.
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Affiliation(s)
- Xiaopei Xu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Hanzhou Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Yang Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Dong Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Shuo Diao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Yuling Gao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Junlin Zhou
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
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Hoyt A, Lawler P, Bostrom M, Carli A, Levack A. Dalbavancin is thermally stable at clinically relevant temperatures against methicillin-sensitive Staphylococcus Aureus. J Bone Jt Infect 2023; 8:175-181. [PMID: 37727824 PMCID: PMC10506503 DOI: 10.5194/jbji-8-175-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/28/2023] [Indexed: 09/21/2023] Open
Abstract
Introduction: While the rate of orthopaedic infections has remained constant over the years, the burden on healthcare systems continues to rise with an aging population. Local antibiotic delivery via polymethyl methacrylate bone cement is a common adjunct in treating bone and joint infections. Dalbavancin is a novel lipoglycopeptide antibiotic in the same class as vancomycin that has shown efficacy against Gram-positive organisms when used systemically but has not been investigated as a local antibiotic. This study aims to identify whether dalbavancin is thermally stable at the temperatures expected during the polymerization of polymethyl methacrylate cement. Methods: Stock solutions of dalbavancin were prepared and heated using a polymerase chain reaction machine based upon previously defined models of curing temperatures in two clinically relevant models: a 10 mm polymethyl methacrylate bead and a polymethyl methacrylate articulating knee spacer model. Aliquots of heated dalbavancin were then transferred to be incubated at core body temperature (37 ∘ C) and analyzed at various time points up to 28 d. The minimum inhibitory concentration at which 90 % of colonies were inhibited (MIC90 ) for each heated sample was determined against methicillin-sensitive Staphylococcus aureus (American Type Culture Collection, ATCC, 0173K) using a standard microbroth dilution assay. Results: The average MIC90 of dalbavancin was 1.63 µ g mL - 1 ± 0.49 against 0173K S. aureus. There were no significant differences in the relative MIC90 values after heating dalbavancin in either model compared to unheated control dalbavancin. Conclusions: Dalbavancin is thermally stable at the curing temperatures of polymethyl methacrylate cement and at human core body temperature over 28 d. Future in vitro and in vivo studies are warranted to further investigate the role of dalbavancin as a local antibiotic prior to its clinical use.
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Affiliation(s)
- Aaron K. Hoyt
- Department of Orthopaedic Surgery
& Rehabilitation, Loyola University Medical Center, Maywood, IL 60153, USA
| | - Patrick Lawler
- Stritch School of Medicine, Loyola University, Maywood, IL 60153, USA
| | - Mathias Bostrom
- Musculoskeletal Integrity Program, Hospital for Special Surgery, New
York, NY 10021, USA
- Adult Reconstruction, Hospital for Special Surgery, New York, NY
10021, USA
| | - Alberto V. Carli
- Musculoskeletal Integrity Program, Hospital for Special Surgery, New
York, NY 10021, USA
- Adult Reconstruction, Hospital for Special Surgery, New York, NY
10021, USA
| | - Ashley E. Levack
- Department of Orthopaedic Surgery
& Rehabilitation, Loyola University Medical Center, Maywood, IL 60153, USA
- Stritch School of Medicine, Loyola University, Maywood, IL 60153, USA
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16
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Wang Z, Mao H, Xu G. Fibrinogen, albumin-to-globulin ratio, and fibrinogen to albumin-to-globulin ratio may be potential diagnostic biomarkers for infected tibial nonunion. Int Immunopharmacol 2023; 121:110542. [PMID: 37356122 DOI: 10.1016/j.intimp.2023.110542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/02/2023] [Accepted: 06/17/2023] [Indexed: 06/27/2023]
Abstract
AIM The accurate preoperative diagnosis of infected tibial nonunion remains challenging. Hence, we evaluated the diagnostic potential of novel biomarkers for infected tibial nonunion. METHODS This single-center retrospective study was conducted in 252 patients divided into two groups: infected tibial nonunion (67 patients) and aseptic tibial nonunion (185 patients). The preoperative clinical biomarkers included D-dimer, fibrinogen, albumin, globulin, total protein, and C-reactive protein (CRP) levels; albumin-to-globulin ratio (AGR); erythrocyte sedimentation rate (ESR); and white blood cell (WBC) count. Receiver operating characteristic (ROC) curves, sensitivity, and specificity were utilized to compare the biomarkers' diagnostic potential. RESULTS The area under the curve (AUC) values for fibrinogen and AGR were 0.829 and 0.821, respectively, suggesting similarly good diagnostic potentials for infected tibial nonunion. Fibrinogen and AGR were better diagnostic biomarkers for infected tibial nonunion than the WBC count; ESR; D-dimer, albumin, globulin, CRP, and total protein levels, whose AUC values were 0.623, 0.684, 0.741, 0.797, 0.765, 0.715, and 0.554, respectively. The sensitivity and specificity of fibrinogen with a cut-off value of 3.35 g/L were 71.64% and 84.86%, respectively. The corresponding values for AGR with a cut-off value of 1.33 were 73.13% and 86.49%. Moreover, the fibrinogen-AGR (FAGR), i.e., the combination of fibrinogen and AGR, had the highest diagnostic accuracy for infected tibial nonunion (AUC = 0.906). The optimal FAGR cut-off was 2.69, with fair sensitivity (74.63%) but the highest specificity (94.59%). CONCLUSION Fibrinogen, AGR, and FAGR are promising biomarkers for the diagnosis of infected tibial nonunion.
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Affiliation(s)
- Zhen Wang
- Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Haijun Mao
- Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Guangyue Xu
- Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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Du B, Su Y, Li D, Ji S, Lu Y, Xu Y, Yang Y, Zhang K, Li Z, Ma T. Analysis of risk factors for serous exudation of biodegradable material calcium sulfate in the treatment of fracture-related infections. Front Bioeng Biotechnol 2023; 11:1189085. [PMID: 37346793 PMCID: PMC10279841 DOI: 10.3389/fbioe.2023.1189085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/24/2023] [Indexed: 06/23/2023] Open
Abstract
Objective: To explore the related risk factors of serous exudation after antibiotic-loaded calcium sulfate treatment of fracture-related infections and to provide a theoretical basis for clinical treatment and prevention of serous exudation complications. Methods: The clinical data of 145 patients with limb fracture-related infection treated with antibiotic-loaded calcium sulfate in Xi'an Honghui Hospital from January 2019 to December 2022 were retrospectively analyzed. All patients were diagnosed with fracture-related infection by preoperative magnetic resonance examination, bacterial culture and gene detection and received antibiotic-loaded calcium sulfate implantation. The postoperative serous exudation was recorded through hospitalization observation, outpatient review or follow-up. The collected clinical data were sorted out, and the patient data were divided into serous exudation groups and non-exudation groups. Firstly, the clinical data of the two groups were compared by single-factor analysis to screen out the risk factors. Then multivariate binary Logistic regression analysis determined the independent risk factors and protective factors. Results: 1) According to the inclusion and exclusion criteria, there were 145 cases with complete clinical data, including 27 cases in the non-infectious exudation group and 118 cases in the non-exudative group; 2) Univariate analysis showed that the history of diabetes, smoking history, calcium sulfate implantation, drainage time, combined flap surgery, geometric shape of implanted calcium sulfate, and thickness of soft tissue covered by the surgical area were all associated with the occurrence of non-infectious exudation after antibiotic-loaded calcium sulfate implantation (p < 0.05); 3) The amount of implanted calcium sulfate was more [OR = 5.310, (1.302-21.657), p = 0.020], combined with flap surgery [OR = 3.565, (1.195-10.641), p = 0.023], and the thickness of soft tissue coverage in the operation area was thinner [OR = 5.305, (1.336-21.057), p = 0.018]. Longer drainage time [OR = 0.210, (0.045-0.967), p = 0.045] was a protective factor for non-infectious exudation after antibiotic-loaded calcium sulfate implantation. Conclusion: 1) The probability of serous exudation in patients with fracture-associated infection after antibiotic-loaded calcium sulfate surgery was 18.62%. This complication may cause a heavier economic and psychological burden on patients; 2) With the increase of bone infection area and the application of more calcium sulfate, the incidence of serous exudation after antibiotic-loaded calcium sulfate surgery in patients with the fracture-related infection will increase, so we should use the amount of calcium sulfate reasonably on the premise of sufficient control of infection in clinical work, and the incidence of serous exudation will also increase due to the recent skin flap surgery and the thinner soft tissue coverage of calcium sulfate implantation area; 3) Under the premise of being able to drain the drainage from the surgical area, the longer drainage time of the drainage tube has a positive effect on preventing the occurrence of serous exudation.
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Affiliation(s)
- Bing Du
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yu Su
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Dongchen Li
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Shuai Ji
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yao Lu
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yibo Xu
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yanling Yang
- Medical College of Yan’an University, Yan’an, Shaanxi, China
| | - Kun Zhang
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Zhong Li
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Teng Ma
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
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18
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Scheuermann-Poley C, Wiessner A, Kikhney J, Gatzer R, Müller M, Stichling M, Moter A, Willy C. Fluorescence In Situ Hybridization as Diagnostic Tool for Implant-associated Infections: A Pilot Study on Added Value. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4994. [PMID: 37360245 PMCID: PMC10287136 DOI: 10.1097/gox.0000000000004994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 03/23/2023] [Indexed: 06/28/2023]
Abstract
Implant-associated infections are a devastating complication in surgery. Especially in infections with biofilm-forming microorganisms, the identification of the causing microorganism remains a challenge. However, the classification as biofilm is not possible with conventional polymerase chain reaction or culture-based diagnostics. The aim of this study was to evaluate the additional value of fluorescence in situ hybridization (FISH) and nucleic acid amplification technique (FISHseq) to discuss a diagnostic benefit of the culture-independent methods and to map spatial organization of pathogens and microbial biofilms in wounds. Methods In total, 118 tissue samples from 60 patients with clinically suspected implant-associated infections (n = 32 joint replacements, n = 24 open reduction and internal fixation, n = 4 projectiles) were analyzed using classic microbiological culture and culture-independent FISH in combination with polymerase chain reaction and sequencing (FISHseq). Results In 56 of 60 wounds, FISHseq achieved an added value. FISHseq confirmed the result of cultural microbiological examinations in 41 of the 60 wounds. In 12 wounds, one or more additional pathogens were detected by FISHseq. FISHseq could show that the bacteria initially detected by culture corresponded to a contamination in three wounds and could exclude that the identified commensal pathogens were a contamination in four other wounds. In five wounds, a nonplanktonic bacterial life form was detected. Conclusions The study revealed that FISHseq gives additional diagnostic information, including therapy-relevant findings that were missed by culture. In addition, nonplanktonic bacterial life forms could also be detected with FISHseq, albeit less frequently than previously indicated.
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Affiliation(s)
- Catharina Scheuermann-Poley
- From the Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Research and Treatment Centre Septic Defect Wounds, Federal Armed Forces of Germany, Bundeswehr (Military) Academic Hospital, Berlin, Germany
| | - Alexandra Wiessner
- Biofilmcenter, Institute for Microbiology, Infectious Diseases, and Immunology, Charité – University Medicine Berlin and MoKi Analytics GmbH, Berlin, Germany
| | - Judith Kikhney
- Biofilmcenter, Institute for Microbiology, Infectious Diseases, and Immunology, Charité – University Medicine Berlin and MoKi Analytics GmbH, Berlin, Germany
| | - Renate Gatzer
- Department of Microbiology, Federal Armed Forces of Germany, Bundeswehr (Military) Academic Hospital, Berlin, Germany
| | - Martin Müller
- Department of Microbiology, Federal Armed Forces of Germany, Bundeswehr (Military) Academic Hospital, Berlin, Germany
| | - Marcus Stichling
- From the Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Research and Treatment Centre Septic Defect Wounds, Federal Armed Forces of Germany, Bundeswehr (Military) Academic Hospital, Berlin, Germany
| | - Annette Moter
- Biofilmcenter, Institute for Microbiology, Infectious Diseases, and Immunology, Charité – University Medicine Berlin and MoKi Analytics GmbH, Berlin, Germany
| | - Christian Willy
- From the Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Research and Treatment Centre Septic Defect Wounds, Federal Armed Forces of Germany, Bundeswehr (Military) Academic Hospital, Berlin, Germany
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19
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Khamkongkaeo A, Jiamprasertboon A, Jinakul N, Srabua P, Tantavisut S, Wongrakpanich A. Antibiotic-loaded hydroxyapatite scaffolds fabricated from Nile tilapia bones for orthopaedics. Int J Pharm X 2023; 5:100169. [PMID: 36861068 PMCID: PMC9969256 DOI: 10.1016/j.ijpx.2023.100169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 02/11/2023] Open
Abstract
This work aimed to develop new antibiotic-coated/ antibiotic-loaded hydroxyapatite (HAp) scaffolds for orthopaedic trauma, specifically to treat the infection after fixation of skeletal fracture. The HAp scaffolds were fabricated from the Nile tilapia (Oreochromis niloticus) bones and fully characterized. The HAp scaffolds were coated with 12 formulations of poly (lactic-co-glycolic acid) (PLGA) or poly (lactic acid) (PLA), blended with vancomycin. The vancomycin release, surface morphology, antibacterial properties, and the cytocompatibility of the scaffolds were conducted. The HAp powder contains elements identical to those found in human bones. This HAp powder is suitable as a starting material to build scaffolds. After the scaffold fabrication, The ratio of HAp to β-TCP changed, and the phase transformation of β-TCP to α-TCP was observed. All antibiotic-coated/ antibiotic-loaded HAp scaffolds can release vancomycin into the phosphate-buffered saline (PBS) solution. PLGA-coated scaffolds obtained faster drug release profiles than PLA-coated scaffolds. The low polymer concentration in the coating solutions (20%w/v) gave a faster drug release profile than the high polymer concentration (40%w/v). All groups showed a trace of surface erosion after being submerged in PBS for 14 days. Most of the extracts can inhibit Staphylococcus aureus (S. aureus) and methicillin-resistant S. aureus (MRSA). The extracts not only caused no cytotoxicity to Saos-2 bone cells but also can increase cell growth. This study demonstrates that it is possible to use these antibiotic-coated/ antibiotic-loaded scaffolds in the clinic as an antibiotic bead replacement.
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Key Words
- Antibiotic
- Antibiotic-coated
- Antibiotic-loaded
- CLSI, The Clinical and Laboratory Standards Institute
- DI, Deionized water
- DMSO, Dimethyl sulfoxide
- F10[PLGA40-Hvanc], Formulation 10, HAp saffolds containing high concentration of vancomycin, coated with PLGA 40%w/v
- F11[PLA20-Hvanc], Formulation 11, HAp saffolds containing high concentration of vancomycin, coated with PLA 20%w/v
- F12[PLA40-Hvanc], Formulation 12, HAp saffolds containing high concentration of vancomycin, coated with PLA 40%w/v
- F1[V-PLGA20-Lvanc], Formulation 1, HAp saffolds containing low concentration of vancomycin, coated with PLGA 20%w/v blended with vancomycin
- F2[V-PLGA40-Lvanc], Formulation 2, HAp saffolds containing low concentration of vancomycin, coated with PLGA 40%w/v blended with vancomycin
- F3[V-PLA20-Lvanc], Formulation 3, HAp saffolds containing low concentration of vancomycin, coated with PLA 20%w/v blended with vancomycin
- F4[V-PLA40-Lvanc], Formulation 4, HAp saffolds containing low concentration of vancomycin, coated with PLA 40%w/v blended with vancomycin
- F5[PLGA20-Lvanc], Formulation 5, HAp saffolds containing low concentration of vancomycin, coated with PLGA 20%w/v
- F6[PLGA40-Lvanc], Formulation 6, HAp saffolds containing low concentration of vancomycin, coated with PLGA 40%w/v
- F7[PLA20-Lvanc], Formulation 7, HAp saffolds containing low concentration of vancomycin, coated with PLA 20%w/v
- F8[PLA40-Lvanc], Formulation 8, HAp saffolds containing low concentration of vancomycin, coated with PLA 40%w/v
- F9[PLGA20-Hvanc], Formulation 9, HAp saffolds containing high concentration of vancomycin, coated with PLGA 20%w/v
- FDA, Food and Drug Administration
- FTIR, Fourier transforms infrared spectroscopy
- HAp, Hydroxyapatite
- Hydroxyapatite
- IFSF, The infection after fixation of skeletal fracture
- Nile tilapia
- P.U., Polyurethane
- PBS, Phosphate-buffered saline
- PLA, Poly(lactic acid)
- PLGA, Poly(lactic-co-glycolic acid)
- PVA, Polyvinyl alcohol
- SEM, Scanning electron microscopy
- Scaffold
- Vancomycin
- XRD, X-ray diffraction
- XRF, X-ray fluorescence spectroscopy
- α-TCP, α-tricalcium phosphate
- β-TCP, β-tricalcium phosphate
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Affiliation(s)
- Atchara Khamkongkaeo
- Department of Metallurgical Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand
| | - Arreerat Jiamprasertboon
- School of Chemistry, Institute of Science, Suranaree University of Technology, Nakhon Ratchasima, Thailand,Institute of Research and Development, Suranaree University of Technology, Nakhon Ratchasima, Thailand
| | - Nanthawan Jinakul
- Department of Microbiology, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Phatraya Srabua
- Scientific and Technological Research Equipment Center (STREC), Chulalongkorn University, Bangkok, Thailand
| | - Saran Tantavisut
- Department of Orthopaedics, Chulalongkorn University, Bangkok, Thailand,Hip Fracture Research Unit, Department of Orthopaedics, Chulalongkorn University, Bangkok, Thailand
| | - Amaraporn Wongrakpanich
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand,Corresponding author.
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20
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Corona PS, Carbonell-Rosell C, Vicente M, Serracanta J, Tetsworth K, Glatt V. Three-stage limb salvage in tibial fracture related infection with composite bone and soft-tissue defect. Arch Orthop Trauma Surg 2022; 142:3877-3887. [PMID: 34936017 PMCID: PMC9596551 DOI: 10.1007/s00402-021-04299-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 12/01/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Managing critical-sized tibial defects is one of the most complex challenges orthopedic surgeons face. This is even more problematic in the presence of infection and soft-tissue loss. The purpose of this study is to describe a comprehensive three-stage surgical protocol for the reconstruction of infected tibial injuries with combined bone defects and soft-tissue loss, and report the clinical outcomes. MATERIALS AND METHODS A retrospective study at a specialized limb reconstruction center identified all patients with infected tibial injuries with bone and soft-tissue loss from 2010 through 2018. Thirty-one patients were included. All cases were treated using a three-stage protocol: (1) infected limb damage control; (2) soft-tissue coverage with a vascularized or local flap; (3) definitive bone reconstruction using distraction osteogenesis principles with external fixation. PRIMARY OUTCOMES limb salvage rate and infection eradication. SECONDARY OUTCOMES patient functional outcomes and satisfaction. RESULTS Patients in this series of chronically infected tibias had been operated upon 3.4 times on average before starting our limb salvage protocol. The mean soft-tissue and bone defect sizes were 124 cm2 (6-600) and 5.4 cm (1-23), respectively. A free flap was performed in 67.7% (21/31) of the cases; bone transport was the selected bone-reconstructive option in 51.7% (15/31). Local flap failure rate was 30% (3/10), with 9.5% for free flaps (2/21). Limb salvage rate was 93.5% (29/31), with infection eradicated in all salvaged limbs. ASAMI bone score: 100% good/excellent. Mean VAS score was 1.0, and ASAMI functional score was good/excellent in 86% of cases. Return-to-work rate was 83%; 86% were "very satisfied" with the treatment outcome. CONCLUSION A three-stage surgical approach to treat chronically infected tibial injuries with combined bone and soft-tissue defects yields high rates of infection eradication and successful limb salvage, with favorable functional outcomes and patient satisfaction.
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Affiliation(s)
- Pablo S Corona
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carla Carbonell-Rosell
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Matías Vicente
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Serracanta
- Department of Plastic Surgery and Major Burn, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Orthopaedic Research Centre of Australia, Brisbane, Australia
| | - Vaida Glatt
- Orthopaedic Research Centre of Australia, Brisbane, Australia
- Department of Orthopaedic Surgery, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
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21
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Moriarty TF, Metsemakers WJ, Morgenstern M, Hofstee MI, Vallejo Diaz A, Cassat JE, Wildemann B, Depypere M, Schwarz EM, Richards RG. Fracture-related infection. Nat Rev Dis Primers 2022; 8:67. [PMID: 36266296 DOI: 10.1038/s41572-022-00396-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 11/09/2022]
Abstract
Musculoskeletal trauma leading to broken and damaged bones and soft tissues can be a life-threating event. Modern orthopaedic trauma surgery, combined with innovation in medical devices, allows many severe injuries to be rapidly repaired and to eventually heal. Unfortunately, one of the persisting complications is fracture-related infection (FRI). In these cases, pathogenic bacteria enter the wound and divert the host responses from a bone-healing course to an inflammatory and antibacterial course that can prevent the bone from healing. FRI can lead to permanent disability, or long courses of therapy lasting from months to years. In the past 5 years, international consensus on a definition of these infections has focused greater attention on FRI, and new guidelines are available for prevention, diagnosis and treatment. Further improvements in understanding the role of perioperative antibiotic prophylaxis and the optimal treatment approach would be transformative for the field. Basic science and engineering innovations will be required to reduce infection rates, with interventions such as more efficient delivery of antibiotics, new antimicrobials, and optimizing host defences among the most likely to improve the care of patients with FRI.
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Affiliation(s)
- T Fintan Moriarty
- AO Research Institute Davos, Davos, Switzerland.,Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | | | - Alejandro Vallejo Diaz
- Department of Orthopedics and Traumatology, Hospital Alma Mater de Antioquia, Medellín, Colombia.,Department of Orthopedics and Traumatology, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - James E Cassat
- Department of Paediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Britt Wildemann
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Bacteriology and Mycology, KU Leuven, Leuven, Belgium
| | - Edward M Schwarz
- Center for Musculoskeletal Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - R Geoff Richards
- AO Research Institute Davos, Davos, Switzerland. .,School of Veterinary Science, Aberystwyth University, Aberystwyth, UK.
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22
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Freischmidt H, Armbruster J, Rothhaas C, Titze N, Guehring T, Nurjadi D, Kretzer JP, Schmidmaier G, Grützner PA, Helbig L. Efficacy of an Antibiotic Loaded Ceramic-Based Bone Graft Substitute for the Treatment of Infected Non-Unions. Biomedicines 2022; 10:biomedicines10102513. [PMID: 36289775 PMCID: PMC9599187 DOI: 10.3390/biomedicines10102513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 11/26/2022] Open
Abstract
The treatment of non-unions is often complicated by segmental bone defects and bacterial colonization. Because of the limited availability of autologous bone grafts, tissue engineering focuses on antibiotic-loaded bone graft substitutes. HACaS+G is a resorbable calcium sulphate-hydroxyapatite loaded with gentamicin. The osteoinductive, osteoconductive, and anti-infective effect of HACaS+G has already been demonstrated in clinical studies on patients with chronic osteomyelitis. However, especially for the treatment of infected non-unions with segmental bone defects by HACaS+G, reliable clinical testing is difficult and sufficient experimental data are lacking. We used an already established sequential animal model in infected and non-infected rat femora to investigate the osteoinductive, osteoconductive, and anti-infective efficacy of HACaS+G for the treatment of infected non-unions. In biomechanical testing, bone consolidation could not be observed under infected and non-infected conditions. Only a prophylactic effect against infections, but no eradication, could be verified in the microbiological analysis. Using µ-CT scans and histology, osteoinduction was detected in both the infected and non-infected bone, whereas osteoconduction occurred only in the non-infected setting. Our data showed that HACaS+G is osteoinductive, but does not have added benefits in infected non-unions in terms of osteoconduction and mechanical bone stability, especially in those with segmental bone defects.
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Affiliation(s)
- Holger Freischmidt
- Department of Trauma and Orthopedic Surgery, BG Klinikum Ludwigshafen at Heidelberg University Hospital, 67071 Ludwigshafen am Rhein, Germany
- Correspondence: (H.F.); (L.H.)
| | - Jonas Armbruster
- Department of Trauma and Orthopedic Surgery, BG Klinikum Ludwigshafen at Heidelberg University Hospital, 67071 Ludwigshafen am Rhein, Germany
| | - Catharina Rothhaas
- Department of Trauma and Orthopedic Surgery, BG Klinikum Ludwigshafen at Heidelberg University Hospital, 67071 Ludwigshafen am Rhein, Germany
| | - Nadine Titze
- Department of Trauma and Orthopedic Surgery, BG Klinikum Ludwigshafen at Heidelberg University Hospital, 67071 Ludwigshafen am Rhein, Germany
| | - Thorsten Guehring
- Trauma Centre, Hospital Paulinenhilfe Stuttgart at Tübingen University Hospital, Rosenbergstr. 38, 70176 Stuttgart, Germany
| | - Dennis Nurjadi
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
- Department of Infectious Diseases and Microbiology, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Jan Philippe Kretzer
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Gerhard Schmidmaier
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany
| | - Paul Alfred Grützner
- Department of Trauma and Orthopedic Surgery, BG Klinikum Ludwigshafen at Heidelberg University Hospital, 67071 Ludwigshafen am Rhein, Germany
| | - Lars Helbig
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany
- Correspondence: (H.F.); (L.H.)
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23
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JIANG N, HU YJ, LIN QR, CHEN P, WAN HY, HE SY, STOODLEY P, YU B. Implant surface culture may be a useful adjunct to standard tissue sampling culture for identification of pathogens accounting for fracture-device-related infection: a within-person randomized agreement study of 42 patients. Acta Orthop 2022; 93:703-708. [PMID: 36069480 PMCID: PMC9450250 DOI: 10.2340/17453674.2022.4530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Identification of pathogens causing fracture-device-related infection (FDRI) is always a challenge as the positive rate of standard tissue sampling culture (TSC) remains unsatisfactory. This study evaluates the efficiency of implant surface culture (ISC) as an adjunct to standard TSC for identification of FDRI-associated microorganisms. PATIENTS AND METHODS Between November 2020 and March 2022, patients diagnosed with FDRI defined by the International Fracture-Related Infection (FRI) Consensus Group, and indicated for implant removal, underwent both methods for bacteria detection. The test order of ISC and TSC was randomly selected for each patient included, as a within-person randomized design. For ISC, the recovered implants were gently covered with tryptic soy agar after rinsing with normal saline twice, and then incubated at 37℃ 5% CO2 for up to 14 days. For TSC, 5 specimens were sampled and sent to the Clinical Laboratory of Southern Medical University Nanfang Hospital, Guangzhou, for culture and identification. RESULTS 42 consecutive patients were included, with a mean age of 46 years. The most frequent infection site and implant type were the tibia (21 cases) and plates with screws (30 cases), respectively. Altogether 21 patients were found with positive outcomes by both methods, and the identified pathogens were consistent. ISC found an additional 15 patients showing positive results, which were negative by TSC. Furthermore, the mean culture time of ISC was shorter than that of TSC (1.5 days vs. 3.2 days). INTERPRETATION ISC may be a useful adjunct to TSC for detection of bacteria causing FDRI, with a relatively higher positive rate and a shorter culture time.
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Affiliation(s)
- Nan JIANG
- Division of Orthopaedics & Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou, PR China
| | - Yan-jun HU
- Division of Orthopaedics & Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou, PR China
| | - Qing-rong LIN
- Division of Orthopaedics & Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou, PR China
| | - Peng CHEN
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou, PR China
| | - Hao-yang WAN
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou, PR China
| | - Si-ying HE
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou, PR China
| | - Paul STOODLEY
- Departments of Microbial Infection and Immunity and Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA,National Centre for Advanced Tribology at Southampton (nCATS) and National Biofilm Innovation Centre (NBIC), Department of Mechanical Engineering, University of Southampton, Southampton, UK
| | - Bin YU
- Division of Orthopaedics & Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou, PR China,Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou, PR China
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24
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Yu C, Chen L, Zhou W, Hu L, Xie X, Lin Z, Panayi AC, Zhan X, Tao R, Mi B, Liu G. Injectable Bacteria-Sensitive Hydrogel Promotes Repair of Infected Fractures via Sustained Release of miRNA Antagonist. ACS APPLIED MATERIALS & INTERFACES 2022; 14:34427-34442. [PMID: 35866896 PMCID: PMC9354009 DOI: 10.1021/acsami.2c08491] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/13/2022] [Indexed: 06/15/2023]
Abstract
Fracture nonunion can result in considerable physical harm and limitation of quality of life in patients, exerting an extensive economic burden to the society. Nonunion largely results from unresolved inflammation and impaired osteogenesis. Despite advancements in surgical techniques, the indispensable treatment for nonunion is robust anti-inflammation therapy and the promotion of osteogenic differentiation. Herein, we report that plasma exosomes derived from infected fracture nonunion patients (Non-Exos) delayed fracture repair in mice by inhibiting the osteogenic differentiation of bone marrow stromal cells in vivo and in vitro. Unique molecular identifier microRNA-sequencing (UID miRNA-seq) suggested that microRNA-708-5p (miR-708-5p) was overexpressed in Non-Exos. Mechanistically, miR-708-5p targeted structure-specific recognition protein 1, thereby suppressing the Wnt/β-catenin signaling pathway, which, in turn, impaired osteogenic differentiation. AntagomicroRNA-708-5p (antagomiR-708-5p) could partly reverse the above process. A bacteria-sensitive natural polymer hyaluronic-acid-based hydrogel (HA hydrogel) loaded with antagomiR-708-5p exhibited promising effects in an in vivo study through antibacterial and pro-osteogenic differentiation functions in infected fractures. Overall, the effectiveness and reliability of an injectable bacteria-sensitive hydrogel with sustained release of agents represent a promising approach for infected fractures.
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Affiliation(s)
- Chenyan Yu
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Lang Chen
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
- Department
of Physics and Center for Hybrid Nanostructure (CHyN), University of Hamburg, Luruper Chaussee 149, Hamburg 22761, Germany
| | - Wu Zhou
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Liangcong Hu
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Xudong Xie
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Ze Lin
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Adriana C. Panayi
- Division
of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02215, United States
| | - Xingjie Zhan
- Tianyou
Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430022, China
| | - Ranyang Tao
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Bobin Mi
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
| | - Guohui Liu
- Department
of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei
Province Key Laboratory of Oral and Maxillofacial Development and
Regeneration, Wuhan 430022, China
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Cichos KH, Spitler CA, Quade JH, Johnson JP, Johnson MD, Ghanem ES. Isothermal Microcalorimetry Improves the Time to Diagnosis of Fracture-related Infection Compared With Conventional Tissue Cultures. Clin Orthop Relat Res 2022; 480:1463-1473. [PMID: 35383603 PMCID: PMC9278947 DOI: 10.1097/corr.0000000000002186] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/04/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND A consensus definition recently was formulated for fracture-related infection, which centered on confirmatory criteria including conventional cultures that take time to finalize and have a 10% to 20% false-negative rate. During this time, patients are often on broad-spectrum antibiotics and may remain hospitalized until cultures are finalized to adjust antibiotic regimens. QUESTIONS/PURPOSES (1) What is the diagnostic accuracy of isothermal microcalorimetry, and how does its accuracy compare with that of conventional cultures? (2) Does isothermal microcalorimetry decrease time to detection (or diagnosis) of fracture-related infection compared with conventional cultures? (3) Does isothermal microcalorimetry have a diagnostic accuracy or time advantage over conventional cultures in patients on chronic suppressive antibiotics? METHODS Between July 2020 and August 2021, we treated 310 patients with concerns for infection after prior fracture repair surgery. Of those, we considered all patients older than 18 years of age with fixation hardware in place at the time of presentation as potentially eligible. All included patients returned to the operating room with cultures obtained and assessed by both isothermal microcalorimetry and conventional cultures, and all were diagnosed using the consensus criteria for fracture-related infection. Based on that, 81% (250 of 310) of patients were eligible; a further 51% (157 of 310) were excluded because of the following reasons: the capacity of the isothermal microcalorimetry instrument limited the throughput on that day (34% [106 of 310]), they had only swab cultures obtained in surgery (15% [46 of 310]), or they had less than 3 months follow-up after surgery for infectious concerns (2% [5 of 310]), leaving 30% (93 of 310) of the originally identified patients for analysis. We obtained two to five cultures from each patient during surgery, which were sent to our clinical microbiology laboratory for standard processing (conventional cultures). This included homogenization of each tissue sample individually and culturing for aerobic, anaerobic, acid-fast bacilli, and fungal culturing. The remaining homogenate from each sample was then taken to our orthopaedic research laboratory, resuspended in growth media, and analyzed by isothermal microcalorimetry for a minimum of 24 hours. Aerobic and anaerobic cultures were maintained for 5 days and 14 days, respectively. Overall, there were 93 patients (59 males), with a mean age of 43 ± 14 years and a mean BMI of 28 ± 8 kg/m 2 , and 305 tissue samples (mean 3 ± 1 samples per patient) were obtained and assessed by conventional culturing and isothermal microcalorimetry. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of isothermal microcalorimetry to diagnose fracture-related infection were compared with conventional cultures using a McNemar test based on the consensus definition of fracture-related infection. This consensus criteria is comprised of two levels of certainty for the diagnostic variables. The first is confirmatory criteria, where infection is considered definitely present and includes the presence of fistula/sinus tract/wound breakdown, purulent drainage or the presence of pus, presence of microorganisms in deep tissue specimens on histopathologic examination, presence of more than five neutrophils/high-powered field by histopathologic examination (only for chronic/late onset cases), and identification of phenotypically indistinguishable pathogens by conventional culture from at least two separate deep tissue/implant specimens. The second is suggestive criteria in which further investigation is required to achieve confirmatory status. Fracture-related infection was diagnosed for this study to minimize subjectivity based on the presence of at least one of the confirmatory criteria as documented by the managing surgeon. When suggestive criteria were present without confirmatory criteria, patients were considered negative for fracture-related infection and followed further in clinic after surgical exploration (n = 25 patients). All 25 patients deemed not to have fracture-related infection were considered infection-free at latest follow-up (range 3 to 12 months). The time to detection or diagnosis was recorded and compared via the Mann-Whitney U test. RESULTS Using the consensus criteria for fracture-related infection, there were no differences with the numbers available between isothermal microcalorimetry and conventional cultures in terms of sensitivity (87% [95% confidence interval 77% to 94%] versus 81% [95% CI 69% to 89%]), specificity (100% [95% CI 87% to 100%] versus 96% [95% CI 79% to 99%]), PPV (100% [95% CI 90% to 100%] versus 98% [95% CI 89% to 99%]), NPV (74% [95% CI 60% to 84%] versus 65% [95% CI 52% to 75%]), or accuracy (90% [95% CI 83% to 96%] versus 85% [95% CI 76% to 91%]; p = 0.13). The concordance by sample between conventional cultures and isothermal microcalorimetry was 85%. Isothermal microcalorimetry had a shorter median (range) time to detection or diagnosis compared with conventional cultures (2 hours [0.5 to 66] versus 51 hours [18 to 147], difference of medians 49 hours; p < 0.001). Additionally, 32 patients used antibiotics for a median (range) duration of 28 days (7 to 1095) before presentation. In these unique patients, there were no differences with the numbers available between isothermal microcalorimetry and conventional cultures in terms of sensitivity (89% [95% CI 71% to 98%] versus 74% [95% CI 53% to 88%]), specificity (100% [95% CI 48% to 100%] versus 83% [95% CI 36% to 99%]), PPV (100% [95% CI 85% to 100%] versus 95% [95% CI 77% to 99%]), NPV (63% [95% CI 37% to 83%] versus 42% [95% CI 26% to 60%]), or accuracy (91% [95% CI 75% to 98%] versus 78% [95% CI 57% to 89%]; p = 0.17). Isothermal microcalorimetry again had a shorter median (range) time to detection or diagnosis compared with conventional cultures (1.5 hours [0.5 to 48] versus 51.5 hours [18 to 125], difference of medians 50 hours; p < 0.001). CONCLUSION Given that isothermal microcalorimetry considerably decreases the time to the diagnosis of a fracture-related infection without compromising the accuracy of the diagnosis, managing teams may eventually use isothermal microcalorimetry-pending developmental improvements and regulatory approval-to rapidly detect infection and begin antibiotic management while awaiting speciation and susceptibility testing to modify the antibiotic regimen. Given the unique thermograms generated, further studies are already underway focusing on speciation based on heat curves alone. Additionally, increased study sizes are necessary for both overall fracture-related infection diagnostic accuracy and test performance on patients using long-term antibiotics given the promising results with regard to time to detection for this groups as well. LEVEL OF EVIDENCE Level II, diagnostic study.
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Affiliation(s)
- Kyle H. Cichos
- Department of Orthopaedic Surgery, University of
Alabama at Birmingham, Birmingham, AL, USA
| | - Clay A. Spitler
- Department of Orthopaedic Surgery, University of
Alabama at Birmingham, Birmingham, AL, USA
| | - Jonathan H. Quade
- Department of Orthopaedic Surgery, University of
Alabama at Birmingham, Birmingham, AL, USA
| | - Joseph P. Johnson
- Department of Orthopaedic Surgery, University of
Alabama at Birmingham, Birmingham, AL, USA
| | - Michael D. Johnson
- Department of Orthopaedic Surgery, University of
Alabama at Birmingham, Birmingham, AL, USA
| | - Elie S. Ghanem
- Department of Orthopaedic Surgery, University of
Alabama at Birmingham, Birmingham, AL, USA
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26
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Zhang Z, Liu P, Wang W, Wang S, Li B, Li J, Yang B, Li M, Li Q, Yang H, Huang Z, Liu L. Epidemiology and Drug Resistance of Fracture-Related Infection of the Long Bones of the Extremities: A Retrospective Study at the Largest Trauma Center in Southwest China. Front Microbiol 2022; 13:923735. [PMID: 35903480 PMCID: PMC9315197 DOI: 10.3389/fmicb.2022.923735] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/06/2022] [Indexed: 11/24/2022] Open
Abstract
Objective To describe the demographic characteristics, risk factors, and bacterial resistance of fracture-related infection (FRI) of the long bones of the extremities. Materials and Methods This single-center study retrospectively evaluated patients with FRI of the long bones of the extremities at West China Hospital between January 2012 and December 2017, and analyzed the demographic characteristics, risk factors, distribution of pathogenic bacteria, and bacterial drug resistance. Results Among 9,900 patients, 535 patients (5.4%) were diagnosed with FRI. The most common site of FRI was tibiofibular (298, 55.7%), with 424 cases (79.2%) of open fractures, and 282 cases (52.7%) due to traffic injuries. The 41–50 years age group had the highest incidence of FRI with 157 (29.3%) cases. Overall, 546 strains of 52 types of bacteria were detected in FRI patients, with 105 strains of multidrug-resistant (MDR) bacteria. Methicillin-resistant Staphylococcus aureus (48, 8.8%) and extended-spectrum-β-lactamase Escherichia coli (32, 5.8%) accounted for the largest proportion. Multivariate logistic regression analysis showed that sex (odds ratio [OR] 1.813; 95% confidence interval [CI], 1.071∼3.070; P = 0.027) and fracture type (OR 3.128; 95% CI, 1.683∼5.815; P < 0.001) were independent risk factors for monomicrobial infection (MI). Female sex (OR 4.190; 95% CI, 1.212∼14.486; P = 0.024) was an independent risk factor for polymicrobial infection (PI). Conclusion This study clarified the infection rates, changes in the bacterial spectrum, and drug resistance characteristics, and risk factors of FRI of the long bones of the extremities in the largest trauma center in southwest China.
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Affiliation(s)
- Zhengdong Zhang
- School of Clinical Medicine, Chengdu Medical College, Chengdu, China
- Department of Orthopedics, The First Affiliated Hospital of Chengdu Medical College, Chengdu Medical College, Chengdu, China
- *Correspondence: Zhengdong Zhang,
| | - Pan Liu
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Wenzhao Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Shanxi Wang
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bohua Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Banyin Yang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Mingxin Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Qin Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Hai Yang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Zeyu Huang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
- Zeyu Huang,
| | - Lei Liu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
- Lei Liu,
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27
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Prior use of antibiotics and immunosuppression are risk factors for fracture-related infection during the COVID-19 pandemic period: a Brazilian prospective cohort study. BMC Musculoskelet Disord 2022; 23:535. [PMID: 35658853 PMCID: PMC9166157 DOI: 10.1186/s12891-022-05493-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/23/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Little is known about the role of COVID-19 pandemic period on the epidemiology of fracture-related infection (FRI). The present study summarizes the changes in the prevalence, microbiology, and risk factors of FRI during this period.
Methods
A prospective single-center cohort study assessed in the setting of COVID-19 pandemic (2020–2021), clinical, microbiological aspects, and independent risk factors (RF) of FRI. RFs were estimated by bivariate and multivariable analyses using prevalence ratio (PR) with significance at P < 0.05. Kaplan–Meier analysis was performed to evaluate treatment outcomes.
Results
Overall, 132 patients were analyzed, with patients with age over 65 years accounting 65.1%. FRI was diagnosed in 21(15.9%) patients. Independent RFs for FRI were recent and preoperative use of systemic antibiotics (PR: 7.0, 95% confidence interval (95% CI): 2.2 – 22.4, p = 0.001) and cancer (PR: 9.8, 95% CI: 2.0 – 48.8, p = 0.005). Cultures yielded Gram-negative bacteria in 77.8%, 33.3% were MDR.
Conclusions
We found higher rates of FRI, predominating in the elderly with closed femoral fractures during the COVID-19 pandemic. Prior use of antibiotics and immunosuppression conditions were independent factor for FRI. Our outcomes provide evidence to avoid the empirical use of antibiotics prior to surgery for fracture stabilization.
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28
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López-Álvarez M, Heuker M, Sjollema KA, van Dam GM, van Dijl JM, IJpma FFA, van Oosten M. Bacteria-targeted fluorescence imaging of extracted osteosynthesis devices for rapid visualization of fracture-related infections. Eur J Nucl Med Mol Imaging 2022; 49:2276-2289. [PMID: 35079847 PMCID: PMC9165280 DOI: 10.1007/s00259-022-05695-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/19/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Fracture-related infection (FRI) is a serious complication in orthopedic trauma surgery worldwide. Especially, the distinction of infection from sterile inflammation and the detection of low-grade infection are highly challenging. The objective of the present study was to obtain proof-of-principle for the use of bacteria-targeted fluorescence imaging to detect FRI on extracted osteosynthesis devices as a step-up towards real-time image-guided trauma surgery. METHODS Extracted osteosynthesis devices from 13 patients, who needed revision surgery after fracture treatment, were incubated with a near-infrared fluorescent tracer composed of the antibiotic vancomycin and the fluorophore IRDye800CW (i.e., vanco-800CW). Subsequently, the devices were imaged, and vanco-800CW fluorescence signals were correlated to the results of microbiological culturing and to bacterial growth upon replica plating of the imaged devices on blood agar. RESULTS Importantly, compared to culturing, the bacteria-targeted fluorescence imaging of extracted osteosynthesis devices with vanco-800CW allows for a prompt diagnosis of FRI, reducing the time-to-result from days to less than 30 min. Moreover, bacteria-targeted imaging can provide surgeons with real-time visual information on the presence and extent of infection. CONCLUSION Here, we present the first clinical application of fluorescence imaging for the detection of FRI. We conclude that imaging with vanco-800CW can provide early, accurate, and real-time visual diagnostic information on FRI in the clinical setting, even in the case of low-grade infections.
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Affiliation(s)
- Marina López-Álvarez
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO BOX 30001, 9700 RB, Groningen, The Netherlands
| | - Marjolein Heuker
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO BOX 30001, 9700 RB, Groningen, The Netherlands
| | - Klaas A Sjollema
- Department of Cell Biology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gooitzen M van Dam
- Departments of Surgery, Nuclear Medicine and Molecular Imaging, Medical Imaging Center Groningen, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- TRACER Europe B.V./AxelaRx, Groningen, The Netherlands
| | - Jan Maarten van Dijl
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO BOX 30001, 9700 RB, Groningen, The Netherlands.
| | - Frank F A IJpma
- Department of Surgery, Division of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marleen van Oosten
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO BOX 30001, 9700 RB, Groningen, The Netherlands
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29
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Zhao X, Tang W, Wan H, Lan Z, Qin H, Lin Q, Hu Y, Yu G, Jiang N, Yu B. Altered Gut Microbiota as an Auxiliary Diagnostic Indicator for Patients With Fracture-Related Infection. Front Microbiol 2022; 13:723791. [PMID: 35495685 PMCID: PMC9048737 DOI: 10.3389/fmicb.2022.723791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 02/16/2022] [Indexed: 12/02/2022] Open
Abstract
Preoperative diagnosis of fracture-related infection (FRI) is difficult for patients without obvious signs of infection. However, specific profiles of gut microbiota may be used as a potential diagnostic tool for FRI as suggested by a previous study. The fecal microbiome was compared between 20 FRI patients (FRI group), 18 fracture healed patients (FH group), and 12 healthy controls (HC group) included after collection of fecal samples and evaluation. The α and β diversity indices were used to characterize the fecal microbiome. Dysbiosis indexes were constructed based on the characteristic high-dimensional biomarkers identified in the fecal microbiota from the three groups by linear discriminant analysis and generalized linear model analysis to quantify the dysbiosis of fecal microbiota. The effectiveness of α and β diversity indices and dysbiosis indexes was assessed in distinguishing the fecal microbiome among the three groups. The influences of serum inflammatory factors on gut microbiota were also addressed. The α diversity indices were significantly different between the three groups, the highest in HC group and the lowest in FRI group (P < 0.05). The β diversity indices showed significant phylogenetic dissimilarity of gut microbiome composition among the three groups (P < 0.001). The dysbiosis indexes were significantly higher in FRI group than in FH and HC groups (P < 0.001). The area under Receiver operating characteristic curve showed the characteristics of gut microbiota and the gut microbiota was found as effective in distinguishing the three groups. The dysbiosis in the FRI patients was associated with systemic inflammatory factors. In addition, significant differences in the gut microbiota were not observed between the FRI patients versus without sinus tract or pus before operation. Since FRI patients, with or without sinus tract or pus, have a characteristic profile of gut microbiota, their gut microbiota may be used as an auxiliary diagnostic tool for suspected FRI.
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Affiliation(s)
- Xingqi Zhao
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenli Tang
- Department of Bioinformatics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Haoyang Wan
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zixin Lan
- The Second Clinical Medical College, Southern Medical University, Guangzhou, China
| | - Hanjun Qin
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qingrong Lin
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanjun Hu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guangchuang Yu
- Department of Bioinformatics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
- *Correspondence: Guangchuang Yu,
| | - Nan Jiang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Nan Jiang,
| | - Bin Yu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Bin Yu,
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30
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A bibliometric analysis of clinical research on fracture-related infection. BIOMED RESEARCH INTERNATIONAL 2022; 2022:8171831. [PMID: 35463982 PMCID: PMC9023151 DOI: 10.1155/2022/8171831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 12/13/2021] [Accepted: 03/23/2022] [Indexed: 12/19/2022]
Abstract
Background. Infection following orthopaedic trauma surgery is increasingly recognized as one of the major research priorities with as primary goal, improving patient care. This increased interest has been anecdotally recognized through published research, research grants, and, finally, with the development of the fracture-related infection (FRI) consensus group. In 2017, the accepted consensus definition of FRI was published, which has been followed by consensus recommendations from both a surgical and medical perspective. A bibliometric analysis was performed to objectively describe the trends in published clinical research related to FRI. Methods. The terms related to FRI were searched in the Web of Science database between 2000 and 2020. The characteristics of clinical research on FRI regarding the author, country, journal, institution, scientific output, top 100 most cited articles, and trend topics were analyzed using Bibliometrix and WPS Office. Results. A total of 2597 records were eligible for inclusion in this bibliometric approach, with studies originating from 89 countries, including eight languages. The United States of America (USA) published the highest number of articles and citations. International collaborations were present between 72 countries, with the most active country being the USA. The most contributive institution was the University of California. The highest number of papers and citations were from the Injury-International Journal of the Care of the Injured and the Journal of Orthopaedic Trauma. The top 100 most cited articles were published in 27 different journals, with the number of citations ranging between 97 and 1004. The latest trend topics were related to the diagnosis of FRI. Conclusion. The present bibliometric analysis shows the research characteristics and trends of FRI from multiple perspectives. The fact that there is an increasing number of studies being published on FRI shows the agreement among scientists and clinicians that standardization with respect to this topic is very important.
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31
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Shimabukuro M, Hayashi K, Kishida R, Tsuchiya A, Ishikawa K. No-Observed-Effect Level of Silver Phosphate in Carbonate Apatite Artificial Bone on Initial Bone Regeneration. ACS Infect Dis 2022; 8:159-169. [PMID: 34875165 DOI: 10.1021/acsinfecdis.1c00480] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Fracture-related infections require both treatments for bacteria removal and bone reconstruction. The use of combined broad-spectrum antibacterial silver compounds and artificial bone with high osteogenic activity is considered to be an effective strategy for achieving these treatments in one surgery. However, silver compounds are toxic for living tissues even at low concentrations. Herein, we investigated the no-observed-effect level (NOEL) of silver phosphate (Ag3PO4) in a bone substitute composed of carbonate apatite (CO3Ap), a bone mineral, using in vitro and in vivo experiments. In vitro experiments demonstrated that the CO3Ap artificial bone containing ≥0.1 wt % Ag3PO4 exerted antibacterial effects against Staphylococcus epidermidis, while those containing ≤0.3 wt % Ag3PO4 did not affect cellular adhesion, proliferation, differentiation, and calcification of osteoblast-like MC3T3-E1 cells. In vivo experiments demonstrated that the CO3Ap artificial bone containing ≤0.3 wt % Ag3PO4 replaced a new bone to the same levels as those without Ag3PO4 4 weeks after implantation into the bone defect of the rabbit femur condyle. However, the CO3Ap artificial bone containing 0.3 wt % Ag3PO4 caused an inflammatory reaction, whereas those containing ≤0.1 wt % Ag3PO4 did not. Thus, both bone regeneration and infection control without any adverse effects were achieved using the CO3Ap artificial bone containing 0.1 wt % Ag3PO4, indicating that the NOEL of Ag3PO4 was 0.1 wt %. Our results provide an effective strategy for the treatments of fracture-related infections.
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Affiliation(s)
- Masaya Shimabukuro
- Department of Biomaterials, Faculty of Dental Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Koichiro Hayashi
- Department of Biomaterials, Faculty of Dental Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Ryo Kishida
- Department of Biomaterials, Faculty of Dental Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Akira Tsuchiya
- Department of Biomaterials, Faculty of Dental Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Kunio Ishikawa
- Department of Biomaterials, Faculty of Dental Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Müller SLC, Morgenstern M, Kuehl R, Muri T, Kalbermatten DF, Clauss M, Schaefer DJ, Sendi P, Osinga R. Soft-tissue reconstruction in lower-leg fracture-related infections: An orthoplastic outcome and risk factor analysis. Injury 2021; 52:3489-3497. [PMID: 34304885 DOI: 10.1016/j.injury.2021.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/02/2021] [Accepted: 07/13/2021] [Indexed: 02/02/2023]
Abstract
Introduction Fracture-related infection (FRI) is a severe post-traumatic complication which is occasionally accompanied by a deficient or even avital soft-tissue envelope. In these cases, a thoroughly planned orthoplastic approach is imperative as a vital and intact soft-tissue envelope is mandatory to achieve fracture union and infection eradication. The aim of this study was, to analyse if soft-tissue reconstruction (STR) without complications is associated with a better long-term outcome compared to FRI patients with STR complications. In particular, it was investigated if primary flap failure represented a risk factor for compromised fracture union and recurrence of infection. Patients and Methods Patients with a lower leg FRI requiring STR (local, pedicled and free flaps) who were treated from 2010-18 at the University Hospital Basel were included in this retrospective analysis. The main outcome measure was the success rate of STR, further outcome measures were fracture nonunion and recurrence of infection. Results Overall, 145 patients with lower leg FRI were identified, of whom 58 (40%) received STR (muscle flaps: n = 38, fascio-cutaneous flaps: n=19; composite osteo-cutaneous flap: n = 1). In total seven patients required secondary STR due to primary flap failure. All failures and flap-related complications occurred within the first three weeks after surgery. Secondary STR was successful in all cases. A high Charlson Comorbidity Index Score was a significant risk factor for flap failure (p = 0.011). Out of the 43 patients who completed the 9-month follow-up, 11 patients presented with fracture nonunion and 12 patients with a recurrent infection. Polymicrobial infection was a significant risk factor for fracture nonunion (p = 0.002). Primary flap failure was neither a risk factor for compromised fracture consolidation (p = 0.590) nor for recurrence of infection (p = 0.508). Conclusion: A considerable number of patients with lower-leg FRI required STR. This patient subgroup is complex and rich in complications and the long-term composite outcome demonstrated a high rate of compromised fracture consolidation and recurrent infections. It appears that secondary STR should be performed, as primary flap failure was neither a risk factor for compromised fracture consolidation nor for recurrence of infection. We propose to monitor these patients closely for three weeks after STR.
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Affiliation(s)
- Seraina L C Müller
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland.
| | - Richard Kuehl
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland
| | - Thaddaeus Muri
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Martin Clauss
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Dirk J Schaefer
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Parham Sendi
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland; Institute for Infectious Diseases, University of Bern, Switzerland
| | - Rik Osinga
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
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Interleukin-6 versus Common Inflammatory Biomarkers for Diagnosing Fracture-Related Infection: Utility and Potential Influencing Factors. J Immunol Res 2021; 2021:1461638. [PMID: 34595243 PMCID: PMC8478596 DOI: 10.1155/2021/1461638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022] Open
Abstract
Currently, the utility of white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), for diagnosis of fracture-related infection (FRI), is still controversial, and potential efficiency of interleukin-6 (IL-6) as a novel cytokine in assisted diagnosis of FRI remains unclear. This study is aimed at investigating the utility and potential influencing factors of IL-6 and the common biomarkers for diagnosing FRI. Preoperative serological levels of IL-6 and the three biomarkers were compared between 407 FRI patients and 195 fracture-healed (FH) patients. Diagnostic efficiency of the indicators was evaluated using the areas under the receiver operating characteristic (ROC) curves, and their potential influencing factors were also analyzed. Outcomes showed that the median levels of all of the four biomarkers were significantly higher among the FRI patients than those among the FH patients (P < 0.01). The areas below the ROC curves of ESR, CRP, and IL-6 were 76.5%, 76.4%, and 71.8%, respectively, with WBC of only 56.9%. Compared with ESR and CRP, IL-6 displayed a lower sensitivity (ESR vs. CRP vs. IL − 6 = 72.7% vs. 65.6% vs. 57.5%) but a higher specificity (ESR vs. CRP vs. IL − 6 = 70.3% vs. 75.4% vs. 83.6%). Serological IL-6 level was influenced by pathogen culture result and pathogen number; nonetheless, bacteria type appeared to have no influence on the levels of the four biomarkers. In short, this study displayed similar value of IL-6 with that of ESR and CRP in assisted diagnosis of FRI. Whether IL-6 can be regarded as a promising diagnostic indicator requires more studies.
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What is the diagnostic value of the Centers for Disease Control and Prevention criteria for surgical site infection in fracture-related infection? Injury 2021; 52:2879-2885. [PMID: 34412852 DOI: 10.1016/j.injury.2021.08.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/31/2021] [Accepted: 08/04/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fracture-related infection (FRI) remains one of the most challenging complications in orthopaedic trauma surgery. An early diagnosis is of paramount importance to guide treatment. The primary aim of this study was to compare the Centers for Disease Control and Prevention (CDC) criteria for the diagnosis of organ/space surgical site infection (SSI) to the recently developed diagnostic criteria of the FRI consensus definition in operatively treated fracture patients. METHODS This international multicenter retrospective cohort study evaluated 257 patients with 261 infections after operative fracture treatment. All patients included in this study were considered to have an FRI and treated accordingly ('intention to treat'). The minimum follow-up was one year. Infections were scored according to the CDC criteria for organ/space SSI and the diagnostic criteria of the FRI consensus definition. RESULTS Overall, 130 (49.8%) FRIs were captured when applying the CDC criteria for organ/space SSI, whereas 258 (98.9%) FRIs were captured when applying the FRI consensus criteria. Patients could not be classified as having an infection according to the CDC criteria mainly due to a lack of symptoms within 90 days after the surgical procedure (n = 96; 36.8%) and due to the fact that the surgery was performed at an anatomical localization not listed in the National Healthcare Safety Network (NHSN) operative procedure code mapping (n = 37; 14.2%). CONCLUSION This study confirms the importance of standardization with respect to the diagnosis of FRI. The results endorse the recently developed FRI consensus definition. When applying these diagnostic criteria, 98.9% of the infections that occured after operative fracture treatment could be captured. The CDC criteria for organ/space SSI captured less than half of the patients with an FRI requiring treatment, and seemed to have less diagnostic value in this patient population.
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Gemmel F, Van den Broeck B, Vanelstraete S, Van Innis B, Huysse W. Hybrid imaging of complicating osteomyelitis in the peripheral skeleton. Nucl Med Commun 2021; 42:941-950. [PMID: 33852533 DOI: 10.1097/mnm.0000000000001421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Diagnosing complicating osteomyelitis (COM) is clinically challenging. Laboratory tests are of limited utility, and other than isolation of the offending organism, diagnostic imaging tests are of paramount importance. Nuclear Medicine techniques play an important role in noninvasive evaluation of osteomyelitis, using both single-photon emission tomography (SPECT) and positron emission tomography (PET) radiopharmaceuticals. It is well-known that those conventional imaging modalities are not performing well in the distinction between soft-tissue and deep bone infection due to the lack of anatomical information. These difficulties have been overcome, to a great extent, with the introduction of in-line SPECT-CT and PET-CT systems which have revolutionized the field of diagnostic medical imaging. Hybrid imaging is especially useful in sites of suspected COM with underlying structural bone alterations. The first clinical studies with these integrated hybrid machines in the field of COM, including metallic implants imaging, are highly promising. In summary, WBC/AGA SPECT-CT and FDG-PET-CT seem to be the most accurate hybrid imaging modality for COM of the peripheral bone. However, there are still false positives, especially in aseptic tibial nonunions and/or metallic implants, as well as in the immediate postoperative setting. Furthermore, there is a lack of well-designed large multicentre prospective studies. Hopefully, in the future, the complementary use of morphological and functional hybrid imaging modalities may overcome some of the challenges faced in the assessment of COM.
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Affiliation(s)
- Filip Gemmel
- Department of Nuclear Medicine, General Hospital Oudenaarde and University Hospital Ghent
- Department of Nuclear Medicine, University Hospital Ghent
| | | | | | - Benoit Van Innis
- Department of Orthopaedic Surgery and Traumatology, General Hospital Oudenaarde
| | - Wouter Huysse
- Department of Radiology and Molecular Imaging, University Hospital Ghent, Ghent, Belgium
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Teng W, Zhang Z, Wang Y, Ye Y, Yinwang E, Liu A, Zhou X, Xu J, Zhou C, Sun H, Wang F, Zhang L, Cheng C, Lin P, Wu Y, Gou Z, Yu X, Ye Z. Iodine Immobilized Metal-Organic Framework for NIR-Triggered Antibacterial Therapy on Orthopedic Implants. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2021; 17:e2102315. [PMID: 34309186 DOI: 10.1002/smll.202102315] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/01/2021] [Indexed: 05/19/2023]
Abstract
Iodine has been known as an effective disinfectant with broad-spectrum antimicrobial potency yet without drug resistance risk when used in clinic. However, the exploration of iodine for antibacterial therapy in orthopedics remains sparse due to its volatile nature and poor solubility. Herein, leveraging the superior absorption capability of metal-organic frameworks (MOFs) and their inherent photocatalytic properties, iodine-loaded MOF surface is presented to realize responsive iodine release along with intracellular reactive oxygen species(ROS) oxidation under near-infrared (NIR) exposure to achieve synergistic antibacterial effect. Iodine is successfully loaded using vapor deposition process onto zeolitic imidazolate framework-8(ZIF-8), which is immobilized onto micro arc oxidized titanium via a hydrothermal approach. The combination of NIR-triggered iodine release and ZIF-8 mediated ROS oxidative stress substantially augments the antibacterial efficacy of this approach both in vitro and in vivo. Furthermore, this composite coating also supported osteogenic differentiation of bone marrow stromal cells, as well as improved osseointegration of coated implants using an intramedullary rat model, suggesting improvement of antibacterial efficacy does not impair osteogenic potential of the implants. Altogether, immobilization of iodine via MOF on orthopedic implants with synergistic antibacterial effect can be a promising strategy to combat bacterial infections.
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Affiliation(s)
- Wangsiyuan Teng
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Zengjie Zhang
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Yikai Wang
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Yuxiao Ye
- School of Material Science and Engineering, University of New South Wales, Sydney, 2052, Australia
| | - Eloy Yinwang
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - An Liu
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Xingzhi Zhou
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Jianxiang Xu
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Chengwei Zhou
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Hangxiang Sun
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Fangqian Wang
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Lingling Zhang
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Chongguang Cheng
- Department of Polymer Science and Engineering, Zhejiang University, Hangzhou, 310009, P. R. China
| | - Peng Lin
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Yan Wu
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Zhongru Gou
- Bio-nanomaterials and Regenerative Medicine Research Division, Zhejiang-California International Nanosystem Institute, Zhejiang University, Hangzhou, 310058, P. R. China
| | - Xiaohua Yu
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
| | - Zhaoming Ye
- Orthopedics Research Institute of Zhejiang University, Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, Zhejiang, 310000, P. R. China
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Pérez-Prieto D, Hinarejos P, Alier A, Sorlí L, Martínez S, Puig L, Monllau JC. Adherence to a reliable PJI diagnostic protocol minimizes unsuspected positive cultures rate. BMC Musculoskelet Disord 2021; 22:653. [PMID: 34340666 PMCID: PMC8330036 DOI: 10.1186/s12891-021-04431-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/06/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The aim of the present study was to evaluate the incidence of unsuspected PJI when prosthetic revisions are thoroughly evaluated by PJI dedicated orthopedic surgeon before surgery. The hypothesis is that the incidence of unsuspected PJI is reduced by applying this protocol. METHODS This is a historical cohort study carried out in one university hospital. The prosthetic revision assessment was carried out in January 2019. From that date on, all patients that were programmed for hip or knee revision (either by an orthopedic surgeon specialized or not in septic revisions) were scheduled for a preoperative visit with the same orthopedic surgeon specialized in septic revisions. The diagnostic algorithm applied was based on the Pro-Implant Foundation diagnostic criteria. Prior to the revision assessment, the indication for joint aspiration was done at the surgeons' discretion (non-specialized in septic revisions) and the preoperative identification of PJI was also done by a hip or knee surgeon (not specialized in septic surgery). RESULTS Based on the PIF criteria, there were 15 infections among the revisions in group 1 and 18 PJI in group 2 (p > 0.05). The most interesting finding was that there were 7 patients with unsuspected positive cultures in group 1. That represents 11% of all revisions. No patient in group 2 was found with unsuspected positive cultures (p < 0.001). CONCLUSION A thorough PJI diagnostic algorithm should be implemented before prosthetic revision to avoid unsuspected positive cultures.
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Affiliation(s)
- Daniel Pérez-Prieto
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
- Catalan Institute for Traumatology and Sports Medicine (ICATME), Hospital Universitari Dexeus. - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
| | - Pedro Hinarejos
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Albert Alier
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Lluïsa Sorlí
- Department of Infectious Diseases, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Santos Martínez
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Lluís Puig
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Juan C Monllau
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- Catalan Institute for Traumatology and Sports Medicine (ICATME), Hospital Universitari Dexeus. - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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Zhang Q, Dong J, Shen Y, Yun C, Zhou D, Liu F. Comparative diagnostic accuracy of respective nuclear imaging for suspected fracture-related infection: a systematic review and Bayesian network meta-analysis. Arch Orthop Trauma Surg 2021; 141:1115-1130. [PMID: 32514833 DOI: 10.1007/s00402-020-03506-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 05/31/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim of this study was to compare the accuracy of available nuclear imaging modalities in the diagnosis of suspected fracture-related infection (FRI). METHODS We conducted a comprehensive literature search of PubMed, EMBASE and the Cochrane Library to retrieve diagnostic accuracy studies in which FRI was investigated using different nuclear imaging modalities. The pooled sensitivity, specificity, likelihood ratios and diagnostic odds ratios were constructed using the bivariate meta-analysis framework, while the superior index was pooled using Bayesian network meta-analysis. RESULTS 22 eligible studies (1,565 patients) were included in the quantitative analysis. A broad overlapping confidence interval (CI) of pooled sensitivity was observed among bone scintigraphy (0.94; 95% CI 0.85-0.98), 18F-FDG PET and PET/CT (0.91; 95% CI 0.85-0.94) and leukocyte scintigraphy (0.86; 95% CI 0.53-0.97). Bone scintigraphy (0.34; 95% CI 0.08-0.75) seemed to be less specific than all the other modalities, while leukocyte scintigraphy (0.96, 95% CI 0.92-0.98) was notably more specific than 18F-FDG PET and PET/CT (0.78; 95% CI 0.69-0.85). Based on the superiority index, 18F-FDG PET/CT (3.78; 95% CI 0.14-11.00), 18F-FDG PET (2.98; 95% CI 0.14-9.00) and leukocyte scintigraphy (1.51; 95% CI 0.11-7.00) all achieved high accuracy in detecting FRI. CONCLUSION Bone scintigraphy is a highly sensitive nuclear imaging technique but lacks the specificity needed to unequivocally differentiate among various conditions suspected to be FRI. Leukocyte scintigraphy, 18F-FDG PET/CT and PET all present good satisfactory accuracy for the diagnosis of FRI, but their costs should be further reduced to promote their wide application.
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Affiliation(s)
- Qingyu Zhang
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Jinlei Dong
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Yelong Shen
- Department of Medical Imaging, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Canhua Yun
- Department of Nuclear Medicine, The Second Hospital of Shandong University, No. 247, Road Beiyuan, Jinan, Shandong, China
| | - Dongsheng Zhou
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China
| | - Fanxiao Liu
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Road Jing Wu Wei Qi, Jinan, 250021, Shandong, China.
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Dudareva M, Barrett LK, Morgenstern M, Atkins BL, Brent AJ, McNally MA. Providing an Evidence Base for Tissue Sampling and Culture Interpretation in Suspected Fracture-Related Infection. J Bone Joint Surg Am 2021; 103:977-983. [PMID: 33764925 DOI: 10.2106/jbjs.20.00409] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The recent consensus definition for the diagnosis of fracture-related infection (FRI) includes the identification of indistinguishable microorganisms in at least 2 surgical deep-tissue specimens as a confirmatory criterion. However, this cut-off, and the total number of specimens from a patient with suspected FRI that should be sent for microbiological testing, have not been validated. We endeavored to estimate the accuracy of different numbers of specimens and diagnostic cut-offs for microbiological testing of deep-tissue specimens in patients undergoing surgical treatment for possible FRI. METHODS A total of 513 surgical procedures in 385 patients with suspected FRI were included. A minimum of 2 surgical deep-tissue specimens were submitted for microbiological testing; 5 or more specimens were analyzed in 345 procedures (67%). FRI was defined by the presence of any confirmatory criteria other than microbiology. Resampling was utilized to model the sensitivity and specificity of diagnostic cut-offs for the number of surgical specimens yielding indistinguishable microorganisms and for the total number of specimens. The likelihood of detecting all clinically relevant microorganisms was also assessed. RESULTS A diagnostic cut-off of at least 2 of 5 specimens with indistinguishable microorganisms identified by culture was 68% sensitive (95% confidence interval [CI], 62% to 74%) and 87% specific (95% CI, 81% to 94%) for the diagnosis of FRI. Two out of 3 specimens were 60% sensitive (95% CI, 55% to 66%) and 92% specific (95% CI, 88% to 96%). Submitting only 3 deep-tissue specimens risked missing clinically relevant microorganisms in at least 1 in 10 cases. CONCLUSIONS The present study was the first to validate microbiological criteria for the diagnosis of FRI, supporting the current confirmatory diagnostic criteria for FRI. Analysis of at least 5 deep-tissue specimens in patients with possible FRI is recommended. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- M Dudareva
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| | - L K Barrett
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| | - M Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel , Basel , Switzerland
| | - B L Atkins
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| | - A J Brent
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| | - M A McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
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Li C, Renz N, Trampuz A, Ojeda-Thies C. The value of conventional radiographs for diagnosing internal fixation-associated infection. BMC Musculoskelet Disord 2021; 22:411. [PMID: 33947369 PMCID: PMC8097790 DOI: 10.1186/s12891-021-04170-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/10/2021] [Indexed: 12/15/2022] Open
Abstract
Background The aim of the study is to assess the diagnostic value of preoperative conventional radiographs for diagnosing infection associated with internal fixation devices. Methods We prospectively collected data of patients undergoing removal of internal fixation devices for any reason. Infection was diagnosed in case of purulence, sinus tract, positive histopathology and/or positive peri-implant tissue or sonication fluid culture. In radiographs radiolucent lines, implant breakage or displacement, or periosteal reaction were assessed. White blood cell count (WBC) and serum C-reactive protein (CRP) were determined at admission. Results We included 421 surgeries in 380 patients (median age 53.6 years, range 11–98 years), mainly indicated for infection (24.9%), nonunion (20.0%) and symptomatic implants (13.5%). Radiologic signs of infection included radiolucent lines (11.4%); implant breakage (12.4%) or displacement (10.7%); and periosteal reaction (7.1%). Infection was confirmed in 116 cases (27.6%). Only radiolucent lines (OR = 1.86 [95%CI: 1.00–3.38]) and periosteal reaction (OR = 2.48 [95%CI: 1.17–5.26]) were associated with infection, with a low sensitivity (16.4 and 12.1%, respectively), and high specificity (90.5 and 94.8%, respectively). Preoperative WBC and CRP had a sensitivity of 23.0 and 35.3%, and specificity of 91.7 and 89.5%, respectively. Conclusions Radiological signs suggestive of infection were uncommon. Radiolucency and periosteal reaction were associated with infection, though with low sensitivity. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04170-3.
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Affiliation(s)
- Cheng Li
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Mittelallee 3, 13353, Berlin, Germany
| | - Nora Renz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Mittelallee 3, 13353, Berlin, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Mittelallee 3, 13353, Berlin, Germany.
| | - Cristina Ojeda-Thies
- Department of Traumatology and Orthopedic Surgery, Hospital Universitario 12 de Octubre, Avda Córdoba s/n, 28041, Madrid, Spain
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Ying J, Gao W, Huang D, Ding C, Ling L, Pan T, Yu S. Application of MALDI-TOF MS Profiling Coupled With Functionalized Magnetic Enrichment for Rapid Identification of Pathogens in a Patient With Open Fracture. Front Chem 2021; 9:672744. [PMID: 33996766 PMCID: PMC8120279 DOI: 10.3389/fchem.2021.672744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/19/2021] [Indexed: 01/17/2023] Open
Abstract
Posttraumatic infections can occur in orthopedic trauma patients, especially in open fractures. Rapid and accurate identification of pathogens in orthopedic trauma is important for clinical diagnosis and antimicrobial treatment. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) has been successfully used for first-line identification of pathogens grown on culture plates. However, for direct analysis of liquid clinical specimens, pre-purification of the sample is necessary. Herein, we investigated the feasibility of coupling Fc-MBL@Fe3O4 enrichment with MALDI-TOF MS profiling in the identification of pathogens in liquid-cultured samples. This method is successfully used for the identification of pathogens in a patient with an open-leg fracture obtained at sea. Pathogens were enriched by Fc-MBL@Fe3O4 from briefly pre-cultured liquid media and identified by MALDI-TOF MS. We identified an opportunistic pathogen, Vibrio alginolyticus, which is uncommon in clinical orthopedic trauma infection but exists widely in the sea. Therefore, combining Fc-MBL@Fe3O4 enrichment and MALDI-TOF MS profiling has great potential for direct identification of microbes in clinical samples.
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Affiliation(s)
| | - Wenjing Gao
- Key Laboratory of Advanced Mass Spectrometry and Molecular Analysis of Zhejiang Province, Institute of Mass Spectrometry, School of Material Science and Chemical Engineering, Ningbo University, Ningbo, China
| | | | - Chuanfan Ding
- Key Laboratory of Advanced Mass Spectrometry and Molecular Analysis of Zhejiang Province, Institute of Mass Spectrometry, School of Material Science and Chemical Engineering, Ningbo University, Ningbo, China
| | - Ling Ling
- Key Laboratory of Advanced Mass Spectrometry and Molecular Analysis of Zhejiang Province, Institute of Mass Spectrometry, School of Material Science and Chemical Engineering, Ningbo University, Ningbo, China
| | - Tao Pan
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaoning Yu
- Key Laboratory of Advanced Mass Spectrometry and Molecular Analysis of Zhejiang Province, Institute of Mass Spectrometry, School of Material Science and Chemical Engineering, Ningbo University, Ningbo, China
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mRNA Transcriptome Analysis of Bone in a Mouse Model of Implant-Associated Staphylococcus aureus Osteomyelitis. Infect Immun 2021; 89:IAI.00814-20. [PMID: 33619031 DOI: 10.1128/iai.00814-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/02/2021] [Indexed: 02/06/2023] Open
Abstract
To investigate the molecular pathogenesis of bone with osteomyelitis, we developed implant-associated osteomyelitis (IAOM) models in mice. An orthopedic stainless pin was surgically placed in the right femoral midshaft of mice, followed by an inoculation of Staphylococcus aureus into the medullary cavity. Typical characteristics of IAOM, like periosteal reaction and intraosseous abscess, occurred by day 14 postinfection. By day 28 postinfection, necrotic abscess, sequestrum formation, and deformity of the whole femur were observed. Transcriptional analysis identified 101 and 1,702 differentially expressed genes (DEGs) between groups by days 3 and 14 postinfection, respectively. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses revealed the enrichment of pathways in response to the bacterium, receptor-ligand activity, and chemokine signaling by day 3 postinfection. However, by day 14 postinfection, the enrichment switched to angiogenesis, positive regulation of cell motility and migration, skeletal system development, and cytokine-cytokine receptor interaction. Furthermore, protein-protein interaction network analysis identified 4 cytokines (interleukin 6 [IL-6], Cxcl10, gamma interferon [IFN-γ], and Cxcl9) associated with IAOM at an early stage of infection. Overall, as the pathological changes in this mouse model were consistent with those in human IAOM, our model may be used to investigate the mechanism and treatment of IAOM. Furthermore, the data for transcriptome sequencing and bioinformatic analysis will be an important resource for dissecting the molecular pathogenesis of bone with IAOM.
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Militz M, Ellenrieder M. [Management of suspected early infection after osteosynthesis]. Chirurg 2021; 92:963-972. [PMID: 33770190 DOI: 10.1007/s00104-021-01377-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/29/2022]
Abstract
The infection rate after fracture osteosynthesis depends on many factors. The postoperative infection rate after osteosynthesis (inpatient treatment) was between 1.15% and 2.04% for the years 2017-2019. The total number of postoperative wound infections was estimated at around 225,000 annually in 2018. Essential factors for reducing the infection rate after osteosynthesis are the favorable choice of the timing of the operation and the surgical procedure as well as the treatment of relevant secondary diseases. If a postoperative wound infection is suspected critical assessment of the wounds in the postoperative course is essential in order to be able to identify and treat this complication at an early stage. After osteosynthesis, early diagnosis of a peri-implant infection and differentiated surgical and antibiotic treatment are the prerequisites for the best possible treatment success.
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Affiliation(s)
- Matthias Militz
- Abteilung für Septische und Rekonstruktive Chirurgie, BG Unfallklinik Murnau, Prof.-Küntscher-Straße 8, 82418, Murnau, Deutschland.
| | - Martin Ellenrieder
- Orthopädische Klinik und Poliklinik, Doberaner Straße 142, 18057, Rostock, Deutschland
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Wang XJ, Wang Z, Zhang ZT, Qiu XS, Chen M, Chen YX. Plasma Fibrinogen as a Diagnostic Marker of Infection in Patients with Nonunions. Infect Drug Resist 2020; 13:4003-4008. [PMID: 33177850 PMCID: PMC7649214 DOI: 10.2147/idr.s269719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/11/2020] [Indexed: 11/23/2022] Open
Abstract
Background The timely and accurate diagnosis of infected nonunion is challenging, and there is a need for more efficient biomarkers. Previous studies have shown that fibrinogen plays an important role in mediating inflammation in bacterial infections and, therefore, could be a valuable biomarker for infected nonunion. The purpose of this study was to evaluate and compare the performance of plasma fibrinogen and other traditional blood markers for the diagnosis of infected nonunion. Materials and Methods We retrospectively studied 146 patients who underwent surgery for primary nonunion between January 2018 and January 2020. The patients were divided into those with infected nonunion (n = 55) and those with aseptic nonunion (n = 91). The preoperatively analyzed parameters were plasma fibrinogen, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and white blood cell (WBC) count. Receiver operating characteristic (ROC) curve analysis was used to assess the sensitivity and specificity of the biomarkers, and Youden's index was calculated to determine their optimal cut-off values. Results The plasma fibrinogen values were significantly higher (p < 0.001) in the patients with infected nonunion than in those with aseptic nonunion. ROC curve analysis showed that plasma fibrinogen had a high value of area under the curve (0.816), which indicated that it had good diagnostic ability. Further, at the optimal threshold value of 2.75 g/L, plasma fibrinogen had the highest sensitivity (78.2%; 95% CI = 64.6-87.8) and good specificity (82.4%; 95% CI, 72.7-89.3). Conclusion In comparison to the traditional markers of infection, plasma fibrinogen showed good diagnostic ability for the detection of infected nonunion. It may have potential as a practical and cost-efficient biomarker for the diagnosis of infected nonunion.
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Affiliation(s)
- Xiang-Jin Wang
- Department of Orthopedics, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, People's Republic of China.,Department of Orthopedics, XuZhou Central Hospital, Xuzhou, People's Republic of China
| | - Zhen Wang
- Department of Orthopedics, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, People's Republic of China.,Department of Orthopedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People's Republic of China
| | - Zi-Tao Zhang
- Department of Orthopedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People's Republic of China
| | - Xu-Sheng Qiu
- Department of Orthopedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People's Republic of China
| | - Ming Chen
- Department of Orthopedics, XuZhou Central Hospital, Xuzhou, People's Republic of China
| | - Yi-Xin Chen
- Department of Orthopedics, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, People's Republic of China.,Department of Orthopedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People's Republic of China
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Rupp M, Henssler L, Brochhausen C, Zustin J, Geis S, Pfeifer C, Alt V, Kerschbaum M. Can necrotic bone be objectively identified in chronic fracture related infections? - First clinical experience with an intraoperative fluorescence imaging technique. Injury 2020; 51:2541-2545. [PMID: 32771213 DOI: 10.1016/j.injury.2020.07.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Adequate debridement of necrotic bone is of paramount importance for eradication of infection in chronic osteomyelitis. Currently, no tools are available to detect the exact amount of necrotic bone in order to optimize surgical resection. The aim of the present study was to evaluate the feasibility of an intraoperative illumination method (VELscope®) and the correlation between intraoperative and pathohistological findings in surgically treated chronic fracture related infection patients. METHODS Ten consecutive patients with chronic fracture related infections of the lower extremity were included into this prospectively performed case series. All patients had to be treated surgically for fracture related infections requiring bony debridement. An intraoperative illumination method (VELscope®) was used to intraoperatively differentiate between viable and necrotic bone. Tissue samples from the identified viable and necrotic bone areas were histopathologically examined and compared to intraoperative findings. RESULTS In all included patients, the intraoperative illumination was deemed helpful to differentiate between necrotic and viable bone tissues during bony debridement. The histopathological examination of the samples showed good correlation of the intraoperative illumination findings with histopathological signs of necrosis for areas deemed dead and histopathological signs of intact bone for areas deemed vital during illumination. CONCLUSION The fluorescence-assisted, intraoperative detection of necrotic and viable bone using the VELscope® is an easy-to-use procedure that can help surgeons to optimize intraoperative bone resection in chronic fracture related infections by unmasking viable from necrotic bone tissue. This may help to improve resection techniques and eventually treatment outcome in patients in the future.
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Affiliation(s)
- Markus Rupp
- University Medical Centre Regensburg, Department for Trauma Surgery, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Leopold Henssler
- University Medical Centre Regensburg, Department for Trauma Surgery, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Christoph Brochhausen
- Institute of Pathology, University of Regensburg, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Germany
| | - Jozef Zustin
- Institute of Pathology, Dechbettener Str. 5, 93049 Regensburg, Germany
| | - Sebastian Geis
- University Medical Centre Regensburg, Department for Plastic, Hand and Reconstructive Surgery, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Christian Pfeifer
- University Medical Centre Regensburg, Department for Trauma Surgery, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Volker Alt
- University Medical Centre Regensburg, Department for Trauma Surgery, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.
| | - Maximilian Kerschbaum
- University Medical Centre Regensburg, Department for Trauma Surgery, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
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Pérez-Prieto D, Perelli S, Corcoll F, Rojas G, Montiel V, Monllau JC. The vancomycin soaking technique: no differences in autograft re-rupture rate. A comparative study. INTERNATIONAL ORTHOPAEDICS 2020; 45:1407-1411. [PMID: 32944802 DOI: 10.1007/s00264-020-04805-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE The main aim of this study was to evaluate the re-rupture risk after an anterior cruciate ligament reconstruction (ACL-R) using the vancomycin soaking technique and to compare it with the re-rupture risk in patients on whom this technique was not utilized. The secondary purpose was to compare the functional outcomes of those two subsets of patients operated on for ACL-R. The hypotheses are that the vancomycin soaking technique does not affect the re-rupture risk or the functional outcomes. MATERIAL AND METHODS A retrospective historical cohort study was conducted. Two groups were compared in terms of the re-rupture rate (traumatic or atraumatic) and functional outcomes (International Knee Documentation Committee (IKDC), Tegner, and Lysholm). Group 1 consisted of patients that received pre-operative IV antibiotics. In group 2, the patients received pre-operative IV antibiotics along with a graft that had been presoaked in a vancomycin solution. A minimum follow-up of five years was required. RESULTS There were 17 patients that suffered a re-rupture in group 1 (4.7%) and 15 in group 2 (3.9%) (n.s.). IKDC was 82.0 in group 1 and 83.9 in group 2 (p = 0.049); Tegner scored 4 in both groups (n.s.) and Lysholm was 90.3 in group 1 and 92.0 in group 2 (p = 0.015). CONCLUSION The vancomycin soaking technique for ACL autografts is a safe procedure for the daily clinical practice, in terms of re-ruptures. Moreover, it does not impair functional outcomes after an ACL-R.
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Affiliation(s)
- Daniel Pérez-Prieto
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar-Universitat Autònoma de Barcelona (UAB), Passeig Marítim, 25, 08003, Barcelona, Spain. .,Catalan Institute for Traumatology and Sports Medicine (ICATME), Hospital Universitari Dexeus.-Universitat Autònoma de Barcelona (UAB), Sabino Arana 5-19, 08028, Barcelona, Spain.
| | - Simone Perelli
- Catalan Institute for Traumatology and Sports Medicine (ICATME), Hospital Universitari Dexeus.-Universitat Autònoma de Barcelona (UAB), Sabino Arana 5-19, 08028, Barcelona, Spain
| | - Ferran Corcoll
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar-Universitat Autònoma de Barcelona (UAB), Passeig Marítim, 25, 08003, Barcelona, Spain
| | - Gonzalo Rojas
- Hospital Regional Talca, Universidad Católica de Maule, Talca, Chile
| | | | - Juan Carlos Monllau
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar-Universitat Autònoma de Barcelona (UAB), Passeig Marítim, 25, 08003, Barcelona, Spain.,Catalan Institute for Traumatology and Sports Medicine (ICATME), Hospital Universitari Dexeus.-Universitat Autònoma de Barcelona (UAB), Sabino Arana 5-19, 08028, Barcelona, Spain
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Fernando N, Werner S, Elhaddad M, Davies J, Firoozabadi R. Do Antibiotic Beads Need to be Removed? THE ARCHIVES OF BONE AND JOINT SURGERY 2020; 8:502-505. [PMID: 32884970 DOI: 10.22038/abjs.2020.44143.2208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Polymethylmethacrylate antibiotic impregnated beads can be an effective treatment for chronic osteomyelitis or an adjuvant in the treatment of open fractures. It remains unclear however whether the beads cause long-term adverse events if not removed. The purpose of this study was to determine if removal of antibiotic beads was required in order to avoid long term complications. Methods A retrospective chart review was conducted on patients with an extremity or pelvis fracture that had implantation of polymethylmethacrylate (PMMA) antibiotic beads over a five-year period. Results Fifty-one patients met inclusion criteria for this study; thirty-seven patients (73%) did not have complications after surgical debridement and placement of PMMA antibiotic beads necessitating removal. Conclusion Our findings suggest that polymethylmethacrylate antibiotic beads can be utilized as a means of delivering high-dose concentrations of local antibiotics and do not have to be removed in all patients.
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Affiliation(s)
- Navin Fernando
- Hip and Knee Center at Northwest Primary and Specialty Care North Seattle, University of Washington, Seattle, WA, USA
| | - Shawn Werner
- Aurora Medical Center Summit Oconomowoc, WI, USA
| | - Moamen Elhaddad
- Department of Orthopedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Jonah Davies
- Department of Orthopedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Reza Firoozabadi
- Department of Orthopedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
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How to Diagnose Surgical Site Infection After Fracture Surgery: We Have a Problem! Tech Orthop 2020. [DOI: 10.1097/bto.0000000000000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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49
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Helbig L, Guehring T, Titze N, Nurjadi D, Sonntag R, Armbruster J, Wildemann B, Schmidmaier G, Gruetzner AP, Freischmidt H. A new sequential animal model for infection-related non-unions with segmental bone defect. BMC Musculoskelet Disord 2020; 21:329. [PMID: 32460740 PMCID: PMC7254709 DOI: 10.1186/s12891-020-03355-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/19/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The treatment of fracture-related infections (FRI) is still a challenge for orthopedic surgeons. The prevalence of FRI is particularly high in open fractures with extensive soft-tissue damage. This study aimed to develop a new two-step animal model for non-unions with segmental bone defects, which could be used to evaluate new innovative bone substitutes to improve the therapeutic options in humans with FRI and bone defects. METHODS After randomization to infected or non-infected groups, 30 Sprague-Dawley rats underwent a transverse osteotomy of the mid-shaft femur with a 5 mm defect. Additionally, the periosteum at the fracture zone was cauterized at both sides. After intramedullary inoculation with 103 CFU Staphylococcus aureus (infected group) or PBS (non-infected group), a fracture stabilization was done by intramedullary K-wires. After 5 weeks, the bone healing process was evaluated, and revision surgery was performed in order to obtain increased bone healing. The initial K-wires were removed, and debridement of the osteotomy-gap was done followed by a more stable re-osteosynthesis with an angle-stable plate. After further 8 weeks all rats were euthanized and the bone consolidation was tested biomechanically and the callus formation quantitatively by micro-CT analysis. RESULTS We developed and presented a new two-stage non-union animal model through a targeted S. aureus infection. After 5 weeks, all animals showed a non-union irrespective of assignment to the infected and non-infected group. Lane and Sandhu score showed a higher callus formation in the infected group. In all infected animals, the inoculated S. aureus strain was detected in the revision surgery. The second surgery did not improve bone healing, as shown by the Lane Sandhu score and in the μ-CT analysis. Similarly, biomechanical testing showed in both groups a significantly lower maximum torque as compared to the contralateral side (p < 0.0001). CONCLUSIONS We were able to successfully develop a new two-stage non-union animal model, which reflects a genuine clinical situation of an infection-related non-union model with segmental bone defects. This model could be used to evaluate various therapeutic anti-infectious and osteoinductive strategies in FRIs.
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Affiliation(s)
- Lars Helbig
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Thorsten Guehring
- Arcus Sportklinik Pforzheim, Rastatterstr. 17-19, 75179, Pforzheim, Germany
| | - Nadine Titze
- Unfallklinik Ludwigshafen, Klinik für Unfallchirurgie und Orthopädie, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Dennis Nurjadi
- Department of Infectious Diseases Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
| | - Robert Sonntag
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Jonas Armbruster
- Unfallklinik Ludwigshafen, Klinik für Unfallchirurgie und Orthopädie, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Britt Wildemann
- Department of Trauma, Hand and Reconstructive Surgery, Experimental Trauma Surgery, Universitätsklinikum Jena, 07747, Jena, Germany.,Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353, Berlin, Germany
| | - Gerhard Schmidmaier
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Alfred Paul Gruetzner
- Unfallklinik Ludwigshafen, Klinik für Unfallchirurgie und Orthopädie, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Holger Freischmidt
- Unfallklinik Ludwigshafen, Klinik für Unfallchirurgie und Orthopädie, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany.
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Plasma d-Dimer Levels in Non-prosthetic Orthopaedic Implant Infection: Can it Aid Diagnosis? Indian J Orthop 2020; 54:76-80. [PMID: 32952913 PMCID: PMC7474018 DOI: 10.1007/s43465-020-00120-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/13/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE d-Dimer estimation has been proposed as a reliable biomarker in prosthetic joint infections. Its role in non-prosthetic orthopaedic implant infections has, however, not been studied. The objectives of this study were to assess the levels of plasma d-Dimer in non-prosthetic orthopaedic implant infection. The diagnostic efficiency of d-dimer on orthopaedic implant-related infection was evaluated. METHODS The study was designed as a cross-sectional comparative study. Patients who presented with orthopaedic implant-related infection as diagnosed by modified MSIS criteria were allocated to case group (n = 49) and patients who underwent surgical procedures with orthopaedic implants with no evidence of infection at 6 weeks postoperatively were allocated to the control group (n = 48). Serum d-Dimer levels were assessed quantitatively using immunoturbidimetric assays in both groups and compared between both groups. RESULTS The mean (± SD) value of serum d-Dimer in case group was 0.64 (± 0.45) μg/ml and control group was 0.77 (± 0.47) μg/ml. No significant difference was found in serum d-Dimer levels between cases and control groups (p value = 0.183). The diagnostic accuracy of d-dimer in orthopaedic implant-related infection also could not be demonstrated. CONCLUSION The findings of d-dimer as a marker for the diagnosis of prosthetic joint infections cannot be extrapolated to non-prosthetic orthopaedic implant infection.
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