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Musculoskeletal Infections: Clinical Diagnosis and Treatment
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Musculoskeletal Infections: Clinical Diagnosis and Treatment

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: 20 September 2025 | Viewed by 10120

Special Issue Editors

Dr. Kalliopi Alpantaki

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Guest Editor
Department of Orthopaedics and Traumatology, “Venizeleion” General Hospital of Crete, 71409 Heraklion, Greece
Interests: spinal surgery; trauma; biomaterials
Special Issues, Collections and Topics in MDPI journals
Prof. Dr. Apostolos Karantanas

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Guest Editor
1. Department of Medical Imaging, University Hospital, 71500 Heraklion, Greece
2. Department of Radiology, School of Medicine, University of Crete, 71003 Heraklion, Greece
3. Advanced Hybrid Imaging Systems, Institute of Computer Science, FORTH, 71500 Heraklion, Greece
Interests: imaging of musculoskeletal disorders; applications of newer MR sequences; image-guided treatments

Special Issue Information

Dear Colleagues,

The interest in the diagnosis and treatment of musculoskeletal infections has grown in recent decades, requiring a multidisciplinary approach. On the one hand, unusual pathogens appear to affect the musculoskeletal tissues, and on the other hand, common pathogens have become difficult to eradicate because of antimicrobial resistance development from extensive antibiotic use. Furthermore, a growing number of patients undergoing orthopedic procedures for trauma, degenerative, and other disorders receive orthopedic implants. Surgical site infection following orthopedic surgery with instrumentation is a serious and relatively common complication, which potentially compromises surgical outcomes and increases the overall morbidity and mortality. In addition, musculoskeletal infections have increased due to the fact that many patients undergo image-guided diagnostic and therapeutic procedures and that an increasing number of patients are immunocompromised and thus vulnerable to severe and atypical infections. Iatrogenic infections often result in prolonged hospital stays, readmissions, reoperations, and long-term intravenous antibiotics and significantly increase the cost of care.

The choice of appropriate treatment is often complex and involves the consideration of multiple factors, such as soft-tissue and implant conditions, the duration and severity of the infection, the underlying pathogen, and the patient’s morbidity and functional status.

The early involvement of multidisciplinary teams, analogous to oncological boards, consisting of radiologists, infectious diseases specialists, and orthopedic surgeons, is important to achieve the optimal result for the patient. The evolution of imaging modalities, such as high-field MRI and newer CT scanners with metal artifact reduction techniques, advanced image analysis based on radiomics, and deep learning as well as newer tracers with PET/CT, provide valuable diagnostic capabilities, which have modified the conventional diagnostic algorithm.

This Special Issue invites the participation of specialists from different scientific fields including infectious diseases, orthopedic surgery, rheumatology, and radiology.

Topics such as the diagnosis and treatment of primary bone and joint infection in children and adults and the diagnosis and treatment as well as the preventive measures of prosthetic joint infections are within the scope of this Special Issue. Studies focusing on infections caused by uncommon and difficult-to-treat pathogens such as mycobacterial or fungal infections, spinal infections, and infections related to polytrauma patients are also welcome. Finally, we are interested in imaging studies.

As editors of this Special Issue, we hope to provide a scientific overview of radiological, clinical, surgical, and epidemiological contributions, describing recent advances that can lead to improvements in diagnosis, treatment, and prognosis in the field of musculoskeletal infections.

Dr. Kalliopi Alpantaki
Prof. Dr. Apostolos Karantanas
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • computed tomography
  • magnetic resonance
  • musculoskeletal infections
  • septic arthritis
  • osteomyelitis
  • fungal infections
  • mycobacterium infections
  • prosthetic joint infections
  • postoperative infections
  • surgical treatment
  • VAC
  • hyperbaric oxygen

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Published Papers (6 papers)

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Research

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13 pages, 935 KiB  
Article
Role of Serum Biomarkers in Differentiating Periprosthetic Joint Infections from Aseptic Failures after Total Hip Arthroplasties
by Flaviu Moldovan
J. Clin. Med. 2024, 13(19), 5716; https://doi.org/10.3390/jcm13195716 - 25 Sep 2024
Cited by 8 | Viewed by 1104
Abstract
Background/Objectives: Periprosthetic joint infection (PJI) is a disastrous complication after joint replacement procedures as the diagnosis remains a significant challenge. The objective of this study is to assess the accuracy and test the interdependency of the proposed compound serum biomarkers for the [...] Read more.
Background/Objectives: Periprosthetic joint infection (PJI) is a disastrous complication after joint replacement procedures as the diagnosis remains a significant challenge. The objective of this study is to assess the accuracy and test the interdependency of the proposed compound serum biomarkers for the diagnosis of PJI after total hip arthroplasties (THA). Methods: From January 2019 to December 2023, 77 consecutive cases that underwent revision total hip arthroplasties (rTHA) were included in a single−retrospective, observational cohort study. A total of 32 arthroplasties were classified as having septic complications using the European Bone and Joint Infection Society (EBJIS) definition from 2021, while the other 45 cases were assigned as aseptic failures (AF). Results: In the univariate analysis between the two groups created, statistically significant differences (p < 0.005) were found for the following variables: time from primary arthroplasty to symptom onset (Time PA−SO), neutrophil count, Lymphocyte count, haematocrit level (HCT) and haemoglobin level (HGB), C−reactive protein (CRP), the neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), monocyte lymphocyte ratio (MLR), systemic inflammation index (SII), systemic inflammation response index (SIRI), and aggregate inflammation systemic index (AISI). The ROC curve analysis showed that the SII (sensitivity 90.6% and specificity 62.2%) and the NLR (sensitivity 84.4% and specificity 64.4%) are the most accurate biomarkers. The multivariate analysis confirmed that NLR > 2.63 (p = 0.006), PLR > 147 (p = 0.021), MLR > 0.31 (p = 0.028), SII > 605.31 (p = 0.002), SIRI > 83.34 (p = 0.024), and AISI > 834.86 (p = 0.011) are all closely related to PJI diagnosis independently. Conclusions: The proposed serum biomarkers can be correlated with PJI diagnosis with the reserve of relatively low specificities. Full article
(This article belongs to the Special Issue Musculoskeletal Infections: Clinical Diagnosis and Treatment)
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Review

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22 pages, 2715 KiB  
Review
Biofilm Formation, Antibiotic Resistance, and Infection (BARI): The Triangle of Death
by Vincenzo Giordano and Peter V. Giannoudis
J. Clin. Med. 2024, 13(19), 5779; https://doi.org/10.3390/jcm13195779 - 27 Sep 2024
Cited by 3 | Viewed by 2265
Abstract
Fracture-related infection (FRI) is a devastating event, directly affecting fracture healing, impairing patient function, prolonging treatment, and increasing healthcare costs. Time plays a decisive role in prognosis, as biofilm maturation leads to the development of antibiotic resistance, potentially contributing to infection chronicity and [...] Read more.
Fracture-related infection (FRI) is a devastating event, directly affecting fracture healing, impairing patient function, prolonging treatment, and increasing healthcare costs. Time plays a decisive role in prognosis, as biofilm maturation leads to the development of antibiotic resistance, potentially contributing to infection chronicity and increasing morbidity and mortality. Research exploring the association between biofilm maturation and antibiotic resistance in orthopaedics primarily addresses aspects related to quality of life and physical function; however, little exists on life-threatening conditions and mortality. Understanding the intrinsic relationship between biofilm maturation, bacterial resistance, and mortality is critical in all fields of medicine. In the herein narrative review, we summarize recent evidence regarding biofilm formation, antibiotic resistance, and infection chronicity (BARI), the three basic components of the “triangle of death” of FRI, and its implications. Preoperative, perioperative, and postoperative prevention strategies to avoid the “triangle of death” of FRI are presented and discussed. Additionally, the importance of the orthopaedic trauma surgeon in understanding new tools to combat infections related to orthopaedic devices is highlighted. Full article
(This article belongs to the Special Issue Musculoskeletal Infections: Clinical Diagnosis and Treatment)
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33 pages, 24273 KiB  
Review
Musculoskeletal Infection: The Great Mimickers on Imaging
by Michail E. Klontzas, Evangelia E. Vassalou, Konstantinos Spanakis, Kalliopi Alpantaki and Apostolos H. Karantanas
J. Clin. Med. 2024, 13(18), 5424; https://doi.org/10.3390/jcm13185424 - 13 Sep 2024
Cited by 1 | Viewed by 1388
Abstract
A series of conditions can mimic musculoskeletal infections on imaging, complicating their diagnosis and affecting the treatment. Depending on the anatomical location, different conditions can manifest with clinical and imaging findings that mimic infections. Herein we present a wide spectrum of the musculoskeletal [...] Read more.
A series of conditions can mimic musculoskeletal infections on imaging, complicating their diagnosis and affecting the treatment. Depending on the anatomical location, different conditions can manifest with clinical and imaging findings that mimic infections. Herein we present a wide spectrum of the musculoskeletal disorders of the axial skeleton, long bones, peripheral joints, and soft tissue that may manifest as infectious processes, and we focus on the potential mimics of osteomyelitis, septic arthritis, and infectious spondylodiscitis that are common in clinical practice. We present the typical imaging characteristics of each musculoskeletal infection, followed by mimicking conditions. Full article
(This article belongs to the Special Issue Musculoskeletal Infections: Clinical Diagnosis and Treatment)
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Other

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14 pages, 720 KiB  
Systematic Review
Fungal Shoulder Periprosthetic Infections: A Systematic Review
by Vasileios Giovanoulis, Vasileios Pastamentzas, Enejd Veizi, Charalampos Matzaroglou, Symeon Naoum, George Samonis, Maria Piagkou, Dimitrios V. Papadopoulos, Andreas G. Tsantes and Christos Koutserimpas
J. Clin. Med. 2024, 13(20), 6128; https://doi.org/10.3390/jcm13206128 - 14 Oct 2024
Cited by 2 | Viewed by 976
Abstract
Background: Data regarding fungal PJIs of the shoulder are scarce. The present systematic review aims to identify and evaluate all published shoulder fungal PJIs in an effort to better understand the diagnostic and therapeutic approach to these infections. Methods: A systematic [...] Read more.
Background: Data regarding fungal PJIs of the shoulder are scarce. The present systematic review aims to identify and evaluate all published shoulder fungal PJIs in an effort to better understand the diagnostic and therapeutic approach to these infections. Methods: A systematic review according to the PRISMA guidelines was conducted, locating all shoulder fungal PJIs. The initial search located 1435 articles. Data were collected on demographics, the causative fungus, antifungal treatment (AFT), surgical interventions, and infection outcomes. Results: After screening and implementation of the inclusion criteria, a total of 10 articles, including 10 cases, were eligible. The sample’s mean age was 62.44 years. Diabetes mellitus was the most common comorbidity (30%), while 70% were immunocompromised. Candida spp. was the most common causative fungus (nine cases; 90%), while all cases were confirmed with cultures. In three cases (30%), there was bacterial co-infection. The mean duration of antifungal treatment (AFT) was 8.4 weeks, while the preferred agent was fluconazole (60% of cases), followed by amphotericin B (30%). Most cases (50%) underwent resection arthroplasty as part of the treatment, while two-stage revision arthroplasty was performed in 30%. Infection’s eradication was reported in 90% of the studied cases. Conclusions: The diagnosis and management of fungal periprosthetic shoulder infections are particularly challenging and require a multidisciplinary approach. The combination of antifungal therapy and tailored surgical strategies is crucial, but further research is needed to refine treatment protocols and address the unique considerations in shoulder PJIs. Full article
(This article belongs to the Special Issue Musculoskeletal Infections: Clinical Diagnosis and Treatment)
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29 pages, 755 KiB  
Systematic Review
Graft Infections in Biologic Reconstructions in the Oncologic Setting: A Systematic Review of the Literature
by Andrea Sambri, Renato Zunarelli, Lorenzo Morante, Chiara Paganelli, Stefania Claudia Parisi, Marta Bortoli, Andrea Montanari, Michele Fiore, Cristina Scollo, Alessandro Bruschi and Massimiliano De Paolis
J. Clin. Med. 2024, 13(16), 4656; https://doi.org/10.3390/jcm13164656 - 8 Aug 2024
Viewed by 1127
Abstract
Background: Biologic graft infection (BGI) is one of the main complications in graft reconstructions. However, very little evidence exists regarding the epidemiology of BGI, as most of the data come from sparse reports. Moreover, most of the series did not detail the treatment [...] Read more.
Background: Biologic graft infection (BGI) is one of the main complications in graft reconstructions. However, very little evidence exists regarding the epidemiology of BGI, as most of the data come from sparse reports. Moreover, most of the series did not detail the treatment and outcome of graft infections. The aim of this systematic review of the literature is to provide a comprehensive data collection on BGI after oncologic resections. Methods: Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Results: 139 studies met the inclusion criteria. A total of 9824 grafts were retrieved. Among these, 684 (6.9%) were in the humerus, 365 (3.7%) in the pelvis, 2041 (20.7%) in the femur and 1660 (16.8%) in the tibia. Most grafts were osteoarticular (2481, 26.7%) and intercalary 2112 (22.7%) allografts. In 461 (5.0%), vascularized fibula grafts (VFGs) were used in combination with recycled autografts. Recycled grafts were reported in 1573 (16.9%) of the cases, and allograft-prosthetic composites in 1673 (18.0%). The pelvis and the tibia had the highest incidence of BGI (20.4% and 11.0%, respectively). The most reported first treatment was debridement and implant retention (DAIR) in 187 (42.8%) cases and two-stage revision with graft removal in 152 (34.8%). Very little data are reported on the final outcome specified by site or type of graft. Conclusions: This systematic review of the literature confirms a high incidence of infections in biologic reconstructions after resections of primary bone tumors. Despite DAIR being a viable attempt, in most cases, a two-stage approach with graft removal and reconstruction with endoprosthesis presented the highest chance to overcome infection, guaranteeing a reconstruction. We emphasize the need for future multicentric studies to focus on the management of infections after biological reconstructions in bone sarcomas. Full article
(This article belongs to the Special Issue Musculoskeletal Infections: Clinical Diagnosis and Treatment)
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15 pages, 3738 KiB  
Systematic Review
Evaluating Imaging Techniques for Diagnosing and Drainage Guidance of Psoas Muscle Abscess: A Systematic Review
by Murtadha Qais Al-Khafaji, Mohammad Walid Al-Smadi, Mustafa Qais Al-Khafaji, Siran Aslan, Yousif Qais Al-Khafaji, Panna Bagossy-Blás, Mohammad Hakem Al Nasser, Bálint László Horváth and Árpád Viola
J. Clin. Med. 2024, 13(11), 3199; https://doi.org/10.3390/jcm13113199 - 29 May 2024
Cited by 2 | Viewed by 1882
Abstract
Background: Psoas muscle abscess (PMA) is an uncommon yet severe condition characterized by diagnostic and therapeutic challenges due to its varied etiology and nonspecific symptoms. This study aimed to evaluate the effectiveness and accuracy of various imaging techniques used in the image-guided percutaneous [...] Read more.
Background: Psoas muscle abscess (PMA) is an uncommon yet severe condition characterized by diagnostic and therapeutic challenges due to its varied etiology and nonspecific symptoms. This study aimed to evaluate the effectiveness and accuracy of various imaging techniques used in the image-guided percutaneous drainage (PD) of PMA. Methods: A systematic review was conducted following the PRISMA guidelines. We searched PubMed, Google Scholar, and Science Direct for studies published in English from 1998 onwards that reported on the use of PD in treating PMA, detailing outcomes and complications. Imaging modalities guiding PD were also examined. Results: We identified 1570 articles, selecting 39 for full review. Of these, 23 met the inclusion criteria; 19 were excluded due to unspecified PMA, absence of imaging guidance for PD, or inconclusive results. Eleven studies utilized computed tomography (CT) for PD, with six also using magnetic resonance imaging (MRI). Ten studies implemented ultrasound (US)-guided PD; variations in diagnostic imaging included combinations of US, CT, and MRI. A mixed approach using both CT and US was reported in two articles. Most studies using CT-guided PD showed complete success, while outcomes varied among those using US-guided PD. No studies employed MRI-guided PD. Conclusions: This review supports a multimodal approach for psoas abscess management, using MRI for diagnosis and CT for drainage guidance. We advocate for Cone Beam CT (CBCT)-MRI fusion techniques with navigation systems to enhance treatment precision and outcomes, particularly in complex cases with challenging abscess characteristics. Full article
(This article belongs to the Special Issue Musculoskeletal Infections: Clinical Diagnosis and Treatment)
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