Background: Periprosthetic joint infection (PJI) after hip and knee arthroplasty is a leading cause of revision surgery, inferior function, as well as increased morbidity and mortality. Topical, intrawound vancomycin administration is a promising treatment to prevent infection following orthopaedic surgery. However, concerns including increased non-infectious complications and antibiotic resistance remain.
Questions/Purposes: (1) Does topical vancomycin reduce the rate of PJI in hip and knee arthroplasty? (2) Does topical vancomycin lead to increased complications in hip and knee arthroplasty?
Methods: A search of Embase, MEDLINE, and PubMed databases as of June 2020 was performed according to PRISMA guidelines. Studies comparing topical vancomycin to standard care in primary hip and knee arthroplasty were identified. 2408 studies were screened, resulting in nine eligible studies reviewing 3371 patients with topical vancomycin administration and 2884 patients without. Study quality was assessed using the Newcastle Ottawa scale. Rates of PJI and overall complication rates were analyzed.
Results:  Existing evidence is observational and predominantly retrospective. Only one of nine studies found a lower rate of PJI after primary THA or TKA (OR 0.09-1.97). In seven studies which reported complication rates other than PJI, there were no significant differences in overall complication rates with vancomycin administration (OR 0.48-290.94).
Conclusions: There is insufficient evidence to recommend topical vancomycin in primary THA and TKA. Adequately powered prospective studies are required before widespread use.

Introduction: Biodegradable synthetic bone fillers act as antibiotic carriers used in septic orthopaedic and trauma surgery with promising clinical results. This study compared vancomycin elution kinetics of four biodegradable antibiotic carriers within the same in-vitro setting over 42 days. Methods: Of four antibiotic carriers (A: OSmycin V®, allogenic bone chips with vancomycin; B: OSpure, allogenic bone chips without vancomycin; C: STIMULAN®, calcium-sulphate matrix; D: CERAMENT™V, hydroxyapatite/calcium-sulphate composite with vancomycin), four samples of 5 ml each, (16 samples altogether), were analysed in an in-vitro elution assay over 42 days. Carriers A and D already contained vancomycin, whereas carriers B and C had to be mixed with vancomycin. Each sample was mixed with 9 mL PBS and stored at 37°C. At 9 time points, 1.5 mL of elution sample were removed and substituted by the same amount of PBS. Probes were analysed with kinetic microparticle immunoassay. Results: Differences in mean initial and last vancomycin concentrations for carrier A were significantly larger in comparison to B and D. Vancomycin concentrations increased from 48h to 7d and dropped thereafter in carrier C and D, whilst constantly decreasing at any time point for carriers A and B. Conclusion: The most favourable releasing profile was observed for allogenic bone chips with high vancomycin-to-carrier ratio (carrier A). Vancomycin concentrations are still measurable at 42 days for any carrier. The overall merit of all tested devices over non-resorbable bone fillers may be seen in higher drug-to-carrier ratio as well as more constant antibiotic releasing profile.

The optimal means of antibiotic delivery in long bone infection following intramedullary nailing is poorly understood. In this case series, we report the outcomes of the protocol used in our tertiary unit involving nail removal, debridement with the Reamer-Irrigator-Aspirator system, antibiotic loaded calcium sulphate (CS) with or without external fixation and soft tissue reconstruction. We utilise a newly available mode of CS preparation and delivery (Stimulan Bullet mat and introducer). This has been designed to maximise endosteal surface contact which may improve the delivery of antibiotics and reduce surgical time.

We retrospectively evaluated data for all cases managed with the aforementioned protocol in our unit. The primary outcome measure was infection remission, defined as cases which did not require reoperation or further courses of antibiotics for infection, had a healed surgical wound and in whom there were no radiographical or biochemical markers for infection post operatively.

7 cases were treated between 2017 and 2021. 6 cases involved the tibia, 1 case involved the femur. Mean follow up was 21.8 +/- 17.2 months. 5 (71%) patients achieved infection remission. Of these, 4 were formally discharged from routine orthopaedic follow-up at an average of 15.3 months from initial revision. 2 (29%) patients underwent repeat surgery for infection. No patients suffered previously reported adverse effects of CS such as heterotopic ossification, aseptic wound leak or hypercalcaemia.

We conclude that our protocol utilising the newly available Stimulan bullet mat and introducer is safe and effective in treating long bone infection following intramedullary nailing.

Implant-related infection remains one of the leading reasons for failure in orthopedics and trauma. Antibacterial coating of implants has been proposed to mitigate the impact of septic complications. Currently, the “Defensive Antibacterial Coating” (DAC®, Novagenit Srl, Mezzolombardo, Italy) is the only hydrogel antibacterial coating cleared for clinical use in orthopedic and trauma in Europe. Aim of the present study was to conduct a systematic review of the literature to assess the safety and efficacy of the DAC coating.
Online database (CINAHL, PubMed, Ovid, Cochrane Reviews e Google Scholar) were searched from year 2010 to April 2021, with the following, variably associated, keywords: “DAC”; “D.A.C.”;“hydrogel”; “coating”; “arthroplasty”; “joint replacement”; “implant”; “infection”. Studies were included if written in English and reporting clinical results on 10 or more patients, at a minimum follow-up of 12 months. For each paper the following data were extracted: type of study, number of patients, type of implant, follow-up, post-surgical infection rate and side effects.
Six studies met the inclusion criteria, reporting on a total of 842 patients, followed for 21.4 ± 7.5 (range 12-30) months after surgery. Overall, the infection rate in the patients treated with the antibacterial coated implants was 0.7% (3/423), compared to 8.6% (36/419) in the controls (P<0.0001). No side effects related to the coating were reported.
This is to our knowledge the first systematic review on the efficacy and safety of the D.A.C. hydrogel in orthopedics and trauma. The results show a significant reduction of post-surgical infection, without side effects.

Introduction: Microbiological diagnosis of periprosthetic joint infection (PJI) still poses a great challenge particularly when clinical signs and laboratory tests are inconsistent, such as in the setting of chronic infections. Biofilms hamper microbial removal from the infected bone and prosthetic hardware rendering conventional culture techniques unreliable. Utilising biofilm debonding techniques has proved to be financially advantageous to hospitals and therefore implementing those methods in the clinical practise is warranted. The aim of this study was to evaluate physical and chemical biofilm detachment methods by analysing the most recent literature in this field.

Methods: Relevant in vitro and clinical publications were critically appraised until 25 March 2021 to address the diagnostic potential of sonication and Dithiothreitol (DTT).

Results: For sensitivity assessment, both sonication and DTT were superior to synovial fluid/tissue cultures (ranges 72%-99% and 65%-97%, respectively). In terms of specificity, no siginificant differences between implant sonicated culture and synovial fluid/tissue culture were detected (range 72%–97%). By contrast, DTT showed better specificity (range from 94% to 100%) compared to synovial fluid/tissue cultures.

Conclusion: Both sonication and DTT were reliable in diagnosing PJI, with DTT presenting higher specificity. Thus, we advocate labs utilise the above modalities to maximise their PJI diagnostic capacity. Of note, further research is needed to optimise the involved techniques with the aim to decrease the number of false positive results (contamination) and increase the bacterial yield from cultures. We also highlight that delineating the economic return of these approaches by means of comparative studies would be of essence.

Though infection is a common and costly complication following fracture, there is a scarcity of literature focused on the additional cost of healthcare when a fracture becomes infected. This literature review compiles existing heterogenous data to evaluate the cost of infected fractures, yielding an estimate of a 1.2-fold to six-fold increase in healthcare costs associated with infection. The increases in cost were largely driven by an increased length of stay. Factors which affect this increase include the infectious agent, the depth of infection and the location of the fracture. In order to reduce healthcare costs, early soft tissue cover and prophylactic antibiotics are effective in that they reduce the infection rates. An alternative approach is to reduce the length of stay, the key driver of cost, for example by reducing the length of inpatient antibiotic therapy. Further cost-utility analyses which focus on the same aspects of the healthcare costs are required for a more accurate estimation of the cost.

Introduction: Joint aspiration with analysis of synovial fluid white blood cell count (WBC) and microbiological culture is a widely established aspect in the diagnosis of shoulder joint infections (SJI) but its value is under debate. The current study aims to answer the following research questions: Joint aspiration has an insufficient predictive value in the diagnosis of SJI in (1) initial workup and (2) before definite arthroplasty with polymethylmethacrylate (PMMA)-Spacer in place. Methods: Of 35 patients that were treated for SJI with a two staged implantation of a TSA, joint aspirations preoperatively (PA) and before re /implantation of the prosthesis (interstage aspiration, IA) were analyzed. Samples were taken for microbiological culture and analysis of WBC. Sensitivity and specificity were calculated with reference to intraoperative microbiological samples. Results: The sensitivity of microbiological cultures from PA was 58.3% and the specificity was 88.9%. The mean WBC was 27 800 leucocytes/mm3 (range 400-96 300). The maximum Youden index (0.857) was a cut-off of 2600 leucocytes/mm³ with a sensitivity of 85.7% and a specificity of 100.0%. The sensitivity and specificity of IA were 0.0% and 88.5%, respectively. Conclusion: PA is likely to miss Cutibacteria spp. Cuand CoNS and cannot rule out infection for sure. However, we recommend PA for its advantages of targeted antibiotic therapy in case of germ identification. Empiric antibiotic therapy should therefore cover these bacteria even if aspiration showed negative microbiological cultures. In contrast, diagnostic value of IA does not qualify for routine use.

INTRODUCTION. Fracture related infection (FRI) is an inherent complication of open tibia fractures (OTF). As a local antibiotic-delivery method, Gentamicin-coated nails (GCN: Protect, De-Puy Synthes, Paoli, Pennsylvania) were designed to prevent early colonization of the hardware with bacteria. The purpose of the study is to determine if GCN is a useful method for prevention of FRI in OTF. METHODS. We compared a prospective group of patients managed with GCN with a retrospective cohort of patients, managed with non-gentamycin-coated nails (NGCN). Inclusion criteria were: patients with OTF managed with GCN or NGCN, and 6 months minimum follow up. Traumatic amputation and loss of follow-up were the exclusion criteria. Severity of injury, according to Gustilo-Anderson, were similar in both groups. Treatment protocol: less than 3 hours for antibiotic prophylaxis after injury, less than 24 hour time delay for irrigation and debridement, and either immediate definitive fixation, or less than 14 days in temporary external fixation. Local or microvascular flap coverage was done within the first 10 days when needed. Confounding variables associated with GCN and FRI were evaluated. RESULTS. 74 OTF underwent GCN and 140 underwent NGCN. We found a lower incidence of FRI in the GCN group (1.35% vs 8.57%, p=0.03). There were no confounding variables between GCN and FRI. CONCLUSION. In this series, the use of GCN has decreased the incidence of FRI in patients with open tibial fractures, when compared with standard nailing.

Non-tuberculous pyogenic spinal infection (PSI) incorporates a variety of different clinical conditions. Surgical interventions may be necessary in some cases. The primary surgical procedure focuses on the anterior approach with aggressive debridement of the infected tissue regions. An alternative treatment method that employs a posterior approach without any formal debridement, is seen as controversial. We aim to evaluate the effectiveness of the posterior approach without formal debridement and the associated clinical outcomes, for PSI cases requiring surgical intervention. Several databases were searched from the date of creation of each database to December 16, 2019. Studies were excluded if they involved the anterior approach, carried out formal debridement, or were tuberculous spinal infection cases. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were used to follow standard systematic review structure. The main clinical outcomes evaluated include pain, neurological recovery (FGS) post-operative complications, and functional outcomes (Kirkaldy-Willis Criteria and Spine Tango Combined Outcome Measure Index, COMI). Post-surgical neurological improvement was demonstrated with a mean FGS improvement of 1.12 in 102 patients over the included four articles. Post-operative neurological function was found to be improved at a statistically significant level when a random-effects model was applied, with the effect size found to be at 0.68 (p < 0.001). Pain level was improved significantly postoperatively. Our results showed that the posterior approach with posterior stabilisation without formal debridement can result in successful infection resolution, improved pain scores and neurological outcomes. However, Larger series with longer follow-up duration is strongly recommended. 

Spinal tuberculosis is a chronic destructive disease with long-term morbidity. Patients are usually young especially from a poor socioeconomic background. Destruction of the intervertebral disk space and the adjacent vertebral bodies is the characteristic lesion. The dorsal spine is the most affected region with multi-level noncontiguous involvement being detected more frequently. Patients usually present with chronic back pain associated with spinal tenderness, paraplegia, spinal deformities, as well as with constitutional symptoms. Magnetic resonance imaging has proved to be more sensitive and specific for its diagnosis, but availability and affordability of this investigation remain a problem in developing countries. Anti-tuberculous drug therapy has revolutionized the treatment of this debilitating disease. Surgery is still required in selected cases especially with evolving neurological deficit, progressive deformity, intractable pain and lack of response to drug therapy. With early diagnosis and effective treatment, prognosis is generally good. We collected the retrospective data of 305 patients with diagnosed spinal tuberculosis, who underwent surgical intervention. There was no significant difference in incidence among males and females. Housewives were the most affected. Lower dorsal spinal was the commonest site involved but our study didn’t confirm the incidence of multi-level disease process. Anterior decompression along with Cage fixation was most performed procedure.

Thoraco-lumber infections are serious infections and remain a challenge to spine surgeons. Surgical treatment is indicated when it is complicated with neurological impairment, epidural abscess, extreme pain, mechanical instability or segmental kyphosis. However, failure of surgical treatment is a major disaster, therefore identifying the outcome of surgery and predictors of failure is mandatory. We did retrospective analysis of 292 patients who had thoracic-lumbar or lumbo sacral spinal infection and were treated by posterior debridement, inter-body graft using titanium mesh cage, and reconstruction of the anterior column, posterior instrumentation and fusion, between 2015-2019. The surgical technique is characterized as less surgical trauma, blood loss, shorter operating time, and less postoperative pain, better bone healing and neurological recovery. There were 159 (54.5%) males and 133 (45.5%) females. The mean age was 41.5 years (range 29-73 years) at the time of surgery. The range of follow up was was 15-54 months with a mean of 36 months. Spinal infection was completely cured in 271(93.2%) with fusion of the grafted bone. However, 21 cases (6.8%) developed recurrent infection; 11 cases were superficial wound infection; 7 developed recurrent vertebral osteomyelitis; and 3 had junctional failure of fixation. Retrospective evaluation of the complicated cases revealed that 15 had uncontrolled diabetes, 11 had severe osteoporosis, 4 had end stage renal disease and 7 patients were non adherent to anti microbial therapy. Our findings showed that one stage posterior surgery was effective in thoraco lumbar lumbo sacral infections.