Introduction: Prosthetic infection is a devastating complication of hip arthroplasty. When we are facing multiresistant bacteria, such as Klebsiella pneumoniae carbapenemase (KPC) producing bactéria, treatment effectiveness is low. The mortality rate and loss of quality of life in these cases is high. We exemplify a revision protocol for KPC producing bacteria infected hip arthroplasty in 3 stages. Method: A 67-year-old female patient underwent hip revision surgery for metallosis. Four weeks after the procedure, concomitant with an urosepsis episode, she presented purulent drainage through the surgical wound. Joint debridement and implant retention was performed due to suspected acute infection. A KPC producing bacteria was isolated from intraoperative samples. The treatment plan was revised and the patient was then submitted to a three-stage revision: 1 - explantation of the prosthesis and placement of a cement spacer with amikacin and colistin; 2 - Re-debridement and placement of a new spacer; 3 –Re-implantation of the prosthesis is performed with local antibiotic in a calcium sulfate transporter. She underwent further 12 weeks of antibiotic therapy with ceftazidime + avibactam. Adequate soft tissue healing and normal CRP was achieved. Results: Currently, the patient is walking on a healed hip and undergoing rehabilitation. Conclusion: Poor results with traditional techniques may pave the way for a three-stage revision protocol when dealing with multidrug-resistant bacteria. This protocol allows exclusion of infection before reimplantation and renewal of local antibiotics. There is currently little literature on the treatment of these infections and further studies are essential.

Purpose: The aim of this study was to elucidate the incidence and treatment trends of infectious spondylodiscitis (IS) in South Korea.
Methods: This study used data from the national database of the Korean Health Insurance Review & Assessment Service from 2010 to 2019. Overall, 169,244 patients (average age, 58.0 years) diagnosed with IS for 10 years were enrolled.
Results: The 10-year incidence of IS in South Korea was 33.4 cases per 100,000 population. The incidence rate per 100,000 population increased 1.5 times from 22.90 cases in 2010 to 35.79 in 2019 (P<0.05). The incidence rate of pyogenic spondylodiscitis has increased from 15.35 per 100,000 population in 2010 to 33.75 in 2019 (P<0.05); those of tuberculous spondylodiscitis has decreased from 7.55 per 100,000 population in 2010 to 2.04 in 2019 (P<0.05). Conservative treatment has increased from 82.4% in 2010 to 85.8% in 2019; surgical treatment has decreased from 17.6% to 14.2% (P < 0.05, respectively). Total healthcare costs increased 2.9 times from $29,821,391.65 in 2010 to $86,815,775.81 in 2019. And the share of healthcare costs as a percentage of gross domestic product has increased significantly, thus socio-economic burden of IS has increased rapidly (P < 0.05).
Conclusion: The incidence rate of IS has increased in South Korea. As for the treatment trends of IS, conservative treatment tended to increase, and surgical treatment tended to decrease. The socio-economic burden of IS has increased rapidly.

Introduction: The purpose of this study was to analyze the role of nutritional status as a risk factor for failure after one- stage revision hip or knee arthroplasty for PJI. Methods: Retrospective, single-center, case-control study. Patients with PJI according to the 2018 International Consensus Meeting criteria were evaluated. Minimum follow-up was 4 years. Total lymphocyte count (TLC), albumin values, hemoglobin, C-reactive protein, white blood cell (WBC) count and glucose levels were analyzed. An analysis was also made of the index of malnutrition. Malnutrition was defined as serum albumin < 3.5 g/dL and TLC < 1500/mm3. Septic failure was defined as the presence of local or systemic symptoms of infection and the need of further surgery as a result of persistent PJI. Results: No significant differences were found between increased failure rates after a one-stage revision hip or knee arthroplasty for PJI and TLC, hemoglobin level, WBC count, glucose levels, or malnutrition. Albumin and C-reactive protein values were found to have a positive and significant relationship with failure (p < 0.05). Multivariate logistic regression identified only hypoalbuminemia (serum albumin < 3.5 g/dL) (OR 5.64, 95% CI: 1.26 – 25.18, p = 0.023) as a significant independent risk factor for failure. The ROC curve for the model yielded an AUC of 0.67. Conclusion: TLC, hemoglobin; WBC count; glucose levels; and malnutrition, were not found to be statically significant risk factors for failure after single–stage revision for PJI. However, albumin < 3.5 g/dL, alone was a statically significant risk factor for failure.

Introduction: The two-stage hip revision remains the “Gold Standard” for treatment of deep periprosthetic infection (PJI). The articulating spacer can improve patient’s quality of life between stages. But it has always the mechanical complications risk which can worsen patient suffering before the second stage. Objectives: to evaluate the functional results of 3D spacers for massive acetabulum bone defects after the first stage of PJI treatment. Materials: From 2018 to 2022 39 patients were divided in two groups: the 1st was operated with 3D (custom-made) spacers (n=18), and the 2d group (n=21) had articulating spacers without 3D technologies during the first-stage revision surgery. The functional outcome and pain were assessed using the Harris Hip Score, WOMAC, and VAS scales. Results: All scalers were equal before surgery. But after surgery in the first group the VAS score was 1.3(±0.9); Harris Hip Score 69.7(± 3.6); according to the WOMAC scale 30.1(±2.4). In the second group after surgery VAS was 3.3( ± 1.3); Harris Hip Score 51.3( ± 9.2); according to the WOMAC scale 42.9( ± 6.1). Mechanical complications in the first group were noted in 2 (11.1%) cases, and in the second in 5 (23.8%). Conclusions: Custom-made with 3D technologies spacers can achieve better functional results and improve the quality of life in patients with IIIA and IIIB defects according to W.G. Paprosky after the first stage PJI treatment.

Introduction: In the last 10 years, we observed a slight increase in numbers of periprosthetic infections (PJI) after primary Total Knee Arthroplasty (TKA) and a previously unknown number of transfemoral amputations.
Aim: We analyzed patients who suffered an uncontrollable PJI after implantation of a TKA. In Germany, the PJI rate 3 years after primary standard TKA is 1.0%. Current statistics from the German Endoprosthetics Register EPRD show that in 2019: 14.5%, in 2021: 15%, PJI is still the 2nd most common reason for primary revision surgery! After a first revision, the probability of a second revision within 2 years is 24.8%, 24.0% and 23.5% – 35.1% respectively (2019, 2020, 2021.

Methods: Based on previous PCT studies at the HELIOS Reha Center, Bad Berleburg, where 787 amputees were rehabilitated from 2007 to 2015: 435 had a transfemoral amputation. 10 patients (2.3%) underwent a tf-amputation due to an uncontrollable PJI after several salvage procedures (7 – 57 surgeries).

Discussion: This PCT showed that transfemoral amputation due to an uncontrollable PJI after implantation of TKA is not uncommon - we found 2.3% in a rehab cohort.
The EPRD registered that in 2019: 14.5%. in 2020: 14.9% and in 2021: 15% a PJI of TKA is the 2nd most common reason for revisions. In 2019, the probability of a second revision according to PJI within 2 years was 24.8%, in 2020 - 24.0%, in 2021 - 23.5% – 35.1%!
These results were compared with other national registries: Nordic countries (NARA), Sweden (SKAR), Norway (NAR), UK (NJR), USA (AJRR), Australia (AOANJRR), Switzerland (SIRIS), the Netherlands (LROI) and found similar numbers for a 1st TKA revision – 2nd revisions were only registered by the UK and Germany!

Introduction; Deep periprosthetic infection is a major cause of implant failure and revision surgery •. While a a low percentage of joint arthroplasties will be infected, Its management is important to get adequate function . The incidence of PJI ranged between 2.0% and 2.4% of THR and TKA and increased over time. • Postoperative site infection, • Revision surgery, • Hematoma , co morbidities, immunosuppressive, smoking, Obesity and operative time are risk factors . • Gram-negative infections are resistant to treatment, (MRSA), group D streptococci, and enterococci are highly virulent. Biofilms are communities of microorganisms embedded in an extracellular matrix that forms on surfaces of implant. (ESR) and CRP) levels are good inflammatory marker, (IL-6) , Procalcitonin is helpful. (CT) and (MRI) will show signs of infection in the affected tissues. Isotope is important techniques in the diagnosis of PJI. Aspiration of Synovial fluid preoperative or intraoperative is good for the diagnosis of PJI. Tissue biopsy is the most accurate tool. In our study files of 129 patients underwent primary hip or knee arthroplasty between January 2015 -2019 infections developed in 3 patients, two infections occurred in the first year. organism were Staphylococcus aureus all hadt wo stage revision .The aim of successful treatment is to clear infection, prevent recurrence, and achieve a functional joint. A multidisciplinary team, including an orthopedic surgeon, microbiologist, and infectious diseases doctor are needed. Antibiotics without surgical intervention, usually fail. The quality of surgical debridement is critical.

Introduction: Infantile Septic arthritis of hip is a devastating condition that may cause permanent disability or sepsis without adequate and timely intervention. Conventionally described surgical approaches for arthrotomy is very extensive for infants. Mini- incision using the lower part of smith petersen approach provides a less extensive surgery. Objective: To analyse the outcomes of infantile septic arthritis of hip treated by mini-inicision arthrotomy. Materials and Methods: All infants diagnosed and admitted for septic arthritis of hip between 2011 to 2020 were included. The infants underwent arthrotomy using mini-incision [1-1.5cm]. Culture specific antibiotics was started, intervenous for 1 week followed by oral antibiotics. Inflammatory markers and ultrasound was done on pod 5, weekly for 4 weeks and then followed up at fixed interval. The data was analysed for rate of persistence or recurrence of infections and incidence of septic sequalae on subsequent follow-up. Results: A total of 621 septic arthritis cases were seen in infants of whom 343 cases had septic arthritis of hip. The mean age was 1.5months and mean follow-up duration was 2years. The most common organism in our study was Staphylococcus aureus (36.36%), followed by klebsiella species and no growth in 48% . 11% required re-arthrotomy during the same admission and 88% recovered with no persistence or re-infection. 4% had recurrence of infection. Conclusion: A mini-incision approach for arthrotomy of hip in infants allows for adequate debridement, decompression and lavage of the joint. It leaves less scarring, hence less iatrogenic damage and it provides adequate clearance of infection.

Abstract:
Background and aims: Spondylodiscitis is an inflammation of intervertebral bodies and intervertebral disc space. For antibiotics to be successful in treatment of spondylodiscitis, it should achieve minimal inhibitory concentration (MIC) to inhibit the growth of the target organism. We present the first systematic review and meta-analysis on this topic.
Aim: The aim of this study is to assess the comparative efficacy of first-line antimicrobials, used prophylactically, to reliably achieve concentrations in vertebral discs above the corresponding minimal inhibitory concentration (MIC) for common spondylodiscitis pathogenic organism (Staphylococcus aureus).
Design and methods: This is a PRISMA compliant systematic review of 5 databases and includes a meta-analysis of Randomized Controlled Trial and prospective comparative studies comparing various antimicrobials penetration into intervertebral discs.
Results: Six studies were included with total number of 941 participants. All antibiotics administered for surgical prophylaxis studies achieved intra-discal concentration above the minimum inhibitory concentration (WMD: 7.04; 95% [CI: 4.72 to 9.37]; P < 0.001) and those administered more than 60 minutes prior to disc tissue sampling had better tissue concentration (> 60 minutes: WMD= 7.94; 95% CI: 5.32 to 10.56; p <001, < 60 minutes: WMD = 3.83; 95% CI: 1.92 to 5.72; p < 0.001).
Conclusion: Various antibiotics studied achieve therapeutic concentration in the intervertebral disc and those administered more than 60 minutes before disc sample collection showed higher therapeutic level.

Introduction: Septic arthritis(SA) is a dangerous condition that requires emergency treatment. The objectives were to determine the risk factors for SA and risk factors for repeat arthroscopic I&D in SA patients. Methods: All patients ≥ 18 years old presenting to the emergency department, orthopaedic and rheumatology clinics at our major trauma centre over two years with a hot, swollen joint were retrospectively evaluated. Two hundred eleven patients were included(SA: 28;pseudogout:32;gout:50;others:101). Results: Multivariable analysis showed multiple risk factors for SA, namely rheumatoid arthritis(RA) (OR:3.4; 95% CI: 1.2-10.0; p=0.023); skin infection (OR: 3.3; 95% CI: 1.2-9.0; p=0.017), liver disease (OR: 9.9; 95% CI: 2.2-43.9; p=0.003), knee joint involvement(OR: 3.5; 95% CI: 1.3-9.4; p=0.014), and use of immunosuppressive medication(OR: 3.5; 95% CI: 1.2-10.6; p=0.027). Risk factors for multiple washouts included synovial WBC levels > 10.5 × 109 cells/L (OR: 3.0; 95% CI: 2.3-38.8; p=0.009) and RA(OR: 3.5; 95% CI: 1.9-66.3; p=0.017). Conclusions: These findings suggest that prophylactic actions against septic arthritis should be targeted at patients with liver disease, RA, or skin infection. Repeat arthroscopic I&D of septic joints may be needed, especially in patients with synovial WBC levels > 10.5 × 109 cells/L and RA. Key Points • The risk factors for septic arthritis determined in this study are rheumatoid arthritis, skin infection, liver disease, knee joint involvement, and immunosuppressant usage. • Some septic arthritis patients need multiple rounds of arthroscopic irrigation and debridement. The risk factors for this are a synovial WBC count > 10.5 × 109 cells/L and rheumatoid arthritis.

Introduction : Osteoarticular Arthritis is a common manifestation following secondary infection by the blood bourne pathogen in the paediatric age group

Our study evaluated the spectrum of the pathogens(restricted to bacteria) which were encounterd during the course of the illness and the treatment regimen used for the same.The study also evaluated the 1 year follow up of the septic arthritis and the recurrences, pathological fractures and other health issues faced by the child.

The study revealed the changing pattern of the organisms and also the change the antibiotic regimen instituted which led to early recovery and faster return to activity for the child.

Background: Vertebra plana (VP) is a rare radiologic condition characterized by a uniform loss of height of a vertebral body. Aim of this study was to review all possible differential diagnoses that may present with a VP as described in the current literature. Material and Methods. We performed a literature review in compliance with the PRISMA guidelines, analyzing 602 articles (1946-2022). Patient demographics, clinical presentation, imaging characteristics and diagnoses were investigated and data were compared to the experience of a specialized center in musculoskeletal oncology and spine surgery. VP is not a pathognomonic feature of Langerhans cell histiocytosis (LCH), but other conditions should be considered. Results. LCH was the most common etiology (46% of pediatric age). Benign lesions include cases of VP in giant cell tumor (2.7% of all cases), osteoblastoma (2), myofibromatosis (1), hemangioma (1) and aneurysmal bone cyst (1). Malignant tumors include lymphoma (<5 cases), leukemia, myeloma, Ewing's sarcoma (10 cases) and osteolytic metastases. Among the non-oncological causes, Nocardia infections (3), tuberculosis (2.4% of cases), “Chronic Recurrent Multifocal Osteomyelitis” (4), Osteogenesis imperfecta and Kummel's disease were reported. Metabolic diseases and osteoporosis can clinically manifest with VP. Conclusions: The diagnosis and treatment of VP require a multidisciplinary evaluation. We are proposing a univocal definition of VP as a severe (reduction > 70% of anterior vertebra height compared to adjacent cephalic level vertebra) compression-induced vertebral collapse, with somatic flattening and local kyphosis angle > 15°. The list of differential diagnoses can be recalled with the mnemonic HEIGHT OF HOMO.