Search Results (24)

Background/Objectives: A missed periprosthetic joint infection (PJI) diagnosis can lead to implant failure. However, to date, no gold standard for PJI diagnosis exists, although several classification scores have been developed in the past years. The primary objective of the study was the evaluation of inter-rater reliability between five PJI classification systems when defining a patient who is infected. Two secondary outcomes were further examined: the inter-rater reliability assessed by comparing the classifications in pairs, and the evaluation of each classification system within the subcategories defined by the World Association against Infection in Orthopaedics and Trauma (WAIOT) definition. Methods: Retrospectively collected data on patients with knee and hip PJIs were used to assess the agreement among five PJI scoring systems: the Musculoskeletal Infection Society (MSIS) 2013 definition, the Infection Consensus Group (ICG) 2018 definition, the European Bones and Joints Infection Society (EBJIS) 2018 definition, the WAIOT definition, and the EBJIS 2021 definition. Results: In total, 203 patients with PJI were included in the study, and the agreement among the examined scores was 0.90 (Krippendorff’s alpha = 0.81; p-value < 0.001), with the MSIS 2013 and ICG 2018 classification systems showing the highest agreement (Cohen’s Kappa = 0.91; p-value < 0.001). Conclusions: There is a strong agreement between the major PJI classification systems. However, a subset of patients (n = 11, 5.42%) still falls into a diagnostic grey zone, especially in cases of low-grade infections. This highlights the need for enhanced diagnostic criteria that incorporate tools that are available even with limited resources, and the potential of artificial intelligence-based techniques in improving early detection and management of PJIs. Full article

With the rising demand for medical implants and the dominance of implant-associated failures including infections, extensive research has been prompted into the development of novel biomaterials that can offer desirable characteristics. This study develops and evaluates new titanium-based alloys containing gallium additions with the aim of offering beneficial antibacterial properties while having a reduced stiffness level to minimise the effect of stress shielding when in contact with bone. The focus is on the microstructure, mechanical properties, antimicrobial activity, and cytocompatibility to inform the suitability of the designed alloys as biometals. Novel Ti-33Nb-xGa alloys (x = 3, 5 wt%) were produced via casting followed by homogenisation treatment, where all results were compared to the currently employed alloy Ti-6Al-4V. Optical microscopy, scanning electron microscopy (SEM), and energy dispersive spectroscopy (EDS) results depicted a single beta (β) phase microstructure in both Ga-containing alloys, where Ti-33Nb-5Ga was also dominated by dendritic alpha (α) phase grains in a β-phase matrix. EDS analysis indicated that the α-phase dendrites in Ti-33Nb-5Ga were enriched with titanium, while the β-phase was richer in niobium and gallium elements. Mechanical properties were measured using nanoindentation and microhardness methods, where the Young’s modulus for Ti-33Nb-3Ga and Ti-33Nb-5Ga was found to be 75.4 ± 2.4 and 67.2 ± 1.6 GPa, respectively, a significant reduction of 37% and 44% with respect to Ti-6Al-4V. This reduction helps address the disproportionate Young’s modulus between titanium implant components and cortical bone. Importantly, both alloys successfully achieved superior antimicrobial properties against Gram-negative P. aeruginosa and Gram-positive S. aureus bacteria. Antibacterial efficacy was noted at up to 90 ± 5% for the 3 wt% alloy and 95 ± 3% for the 5 wt% alloy. These findings signify a substantial enhancement of the antimicrobial performance when compared to Ti-6Al-4V which exhibited very small rates (up to 6.3 ± 1.5%). No cytotoxicity was observed in hGF cell lines over 24 h. Cell morphology and cytoskeleton distribution appeared to depict typical morphology with a prominent nucleus, elongated fibroblastic spindle-shaped morphology, and F-actin filamentous stress fibres in a well-defined structure of parallel bundles along the cellular axis. The developed alloys in this work have shown very promising results and are suggested to be further examined towards the use of orthopaedic implant components. Full article

Orthopaedic implant-associated infections (OIAIs) represent a notable complication of contemporary surgical procedures, exerting a considerable impact on patient outcomes and escalating healthcare expenditures. Prompt diagnosis holds paramount importance in managing OIAIs, with sonication widely acknowledged as the preferred method for detecting biofilm-associated infections. Recently, dithiothreitol (DTT) has emerged as a potential substitute for sonication, owing to its demonstrated ability to impede biofilm formation. This study aimed to compare the efficacy of DTT with sonication in identifying microorganisms within implants. Conducted as a prospective cohort investigation, the study encompassed two distinct groups: patients with suspected infections undergoing implant removal (Group A) and those slated for hardware explantation (Group B). Hardware segments were assessed for biofilm-related microorganisms using both sonication and DTT, with a comparative analysis of the two methods. A total of 115 patients were enrolled. In Group A, no statistically significant disparity was observed between DTT and sonication. DTT exhibited a sensitivity of 89.47% and specificity of 96.3%. Conversely, in Group B, both DTT and sonication fluid cultures yielded negative results in all patients. Consequently, this investigation suggests that DTT holds comparable efficacy to sonication in detecting OIAIs, offering a novel, cost-effective, and readily accessible diagnostic modality for identifying implant-associated infections. Full article

With the rising demand for implantable orthopaedic medical devices and the dominance of device-associated infections, extensive research into the development of novel materials has been prompted. Among these, new-generation titanium alloys with biocompatible elements and improved stiffness levels have received much attention. Furthermore, the development of titanium-based materials that can impart antibacterial function has demonstrated promising results, where gallium has exhibited superior antimicrobial action. This has been evidenced by the addition of gallium to various biomaterials including titanium alloys. Therefore, this paper aims to review the antibacterial activity of gallium when incorporated into biomedical materials, with a focus on titanium-based alloys. First, discussion into the development of new-generation Ti alloys that possess biocompatible elements and reduced Young’s moduli is presented. This includes a brief review of the influence of alloying elements, processing techniques and the resulting biocompatibilities of the materials found in the literature. The antibacterial effect of gallium added to various materials, including bioglasses, liquid metals, and bioceramics, is then reviewed and discussed. Finally, a key focus is given to the incorporation of gallium into titanium systems for which the inherent mechanical, biocompatible, and antibacterial effects are reviewed and discussed in more detail, leading to suggestions and directions for further research in this area. Full article

Background: Infection of orthopaedic implants after internal fixation of bone fractures remains a major complication with occasionally devastating consequences. Recent studies have reported that the use of absorbable materials, instead of metallic ones, may lead to a lower incidence of postoperative infection. In this experimental pre-clinical animal study, we compared the infection rate between absorbable implants consisting of copolymers composed from trimethylene carbonate, L-polylactic acid, and D, L-polylactic acid monomers, and titanium implants after the inoculation of a pathogenic microorganism. Material and Methods: We used an experimental implant-related infection model in rabbits. Sixty animals were randomly and equally divided into two groups. In all animals, the right femur was exposed via a lateral approach and a 2.5 mm two-hole titanium plate with screws (Group A), or a two-hole absorbable plate and screws (Group B), were applied in the femoral shaft. Afterwards, the implant surface was inoculated with Pseudomonas Aeruginosa at a concentration of 2 × 10⁸ CFU/mL. The primary outcome was the comparison of the incidence of developed infection between the two groups. The wound condition was monitored on a daily basis and radiographies were obtained at 12 weeks postoperatively. Infection-related laboratory markers (white blood cell count, erythrocyte sedimentation rate, and C-reactive protein values) were assessed at 3, 6, and 16 weeks postoperatively. Histologic analysis and cultures of tissue samples were also performed to evaluate the presence of infection. Results: Clinical and laboratory signs of infection were evident in 11 rabbits in Group A (36.7%), and 4 in Group B (13.3%). The difference between the groups was statistically significant (p = 0.04). Five animals in Group B (16.7%) had clinical and histologic signs of a foreign-body reaction with significantly elevated CRP and ESR values but no simultaneous presence of infection was identified (p = 0.04). Bone remodelling with thickening of the periosteum and surrounding sclerosis was demonstrated radiologically in animals developing infection or foreign-body reactions. Conclusions: Absorbable plates and screws show lower susceptibility to infection compared to titanium ones. However, their application is associated with foreign-body reaction and the potential need for a second surgical intervention. Full article

Periprosthetic joint infections (PJI) are among the most difficult complications to treat in orthopaedic surgery. Debridement, antibiotics, and implant retention (DAIR) represent an efficient strategy for acute PJI, especially when resorbable local antibiotic carriers and coatings are used. The aim of this pilot study was to evaluate the difference between using antibiotic-loaded hydrogel (ALH) and calcium sulphate (CS) beads in the DAIR procedure. We analysed 16 patients who had been treated since 2018 for acute PJI, namely eight patients with knee PJI (50%), seven with hip PJI (43.7%), and one with shoulder PJI (6.2%). Nine patients were treated with the Debridement, Antibiotic Coating and Retention of the Implant (DACRI) method, while seven were treated with the Debridement, Antibiotic Pearls, Retention of the Implant (DAPRI) method. We found no significant differences between the two groups in terms of age, sex, the American Society of Anesthesiologists risk score, Charlson Comorbidity Index, localisation, days from onset to diagnosis and pathogenesis. Furthermore, no differences were found between the DACRI and DAPRI groups in terms of infection control (15 patients, 93.75% with p = 0.36) and last C-Reactive Protein values (p = 0.26), with a mean follow-up of 26.1 ± 7.7 months. Treatment for one patient affected by knee Candida albicans PJI in the DACRI group was not successful. In conclusion, DAPRI and DACRI appear to be safe and effective treatments for PJIs. This evidence will encourage the development of new clinical research into local carriers and coatings for use in acute implant-associated infections. Full article

Periprosthetic joint infections (PJIs) in arthroplasty and osteosynthesis-associated infections (OAIs) in reconstructive surgery still represent a challenging complication in orthopaedics and traumatology causing a burden worsening the patient’s quality of life, for caregiver and treating physicians, and for healthcare systems. PJIs and OAIs are the result of bacterial adhesion over an implant surface with subsequent biofilm formation. Therefore, the clinical pathological outcome is a difficult-to-eradicate persistent infection. Strategies to treat PJIs and OAIs involve debridement, the replacement of internal fixators or articular prostheses, and intravenous antibiotics. However, long treatments and surgical revision cause discomfort for patients; hence, the prevention of PJIs and OAIs represents a higher priority than treatment. Local antibiotic treatments through coating-release systems are becoming a smart approach to prevent this complication. Hydrophilic coatings, loaded with antibiotics, simultaneously provide a barrier effect against bacterial adhesion and allow for the local delivery of an antibiotic. The intraoperative use of a hyaluronan (HY)-derivative coating in the form of a gel, loaded with antibiotics to prevent PJI, has recently raised interest in orthopaedics. Current evidence supports the use of this coating in the prophylaxis of PJI and IRIs in terms of clinical outcomes and infection reduction. Thus, the purpose of this narrative review is to assess the use of a commercially available HY derivative in the form of a gel, highlighting the characteristics of this biomaterial, which makes it attractive for the management of PJIs and IRIs in orthopaedics and traumatology. Full article

Background and Objectives: Currently, the worldwide incidence of major amputations in the general population is decreasing whereas the incidence of minor amputations is increasing. The purpose of our study was to analyze whether this trend is reflected among orthopaedic patients treated with lower extremity amputation in our orthopaedic university institution. Materials and Methods: We conducted a single-center retrospective study and included patients referred to our orthopaedic department for lower extremity amputation (LEA) between January 2007 and December 2019. Acquired data were the year of amputation, age, sex, level of amputation and cause of amputation. T test and Chi² test were performed to compare age and amputation rates between males and females; significance was defined as p < 0.05. Linear regression and multivariate logistic regression models were used to test time trends and to calculate probabilities for LEA. Results: A total of 114 amputations of the lower extremity were performed, of which 60.5% were major amputations. The number of major amputations increased over time with a rate of 0.6 amputation/year. Men were significantly more often affected by LEA than women. Age of LEA for men was significantly below the age of LEA for women (men: 54.8 ± 2.8 years, women: 64.9 ± 3.2 years, p = 0.021). Main causes leading to LEA were tumors (28.9%) and implant-associated complications (25.4%). Implant-associated complications and age raised the probability for major amputation, whereas malformation, angiopathies and infections were more likely to cause a minor amputation. Conclusions: Among patients in our orthopaedic institution, etiology of amputations of the lower extremity is multifactorial and differs from other surgical specialties. The number of major amputations has increased continuously over the past years. Age and sex, as well as diagnosis, influence the type and level of amputation. Full article

Background and Objectives: Treating segmental tibial and ankle bone loss after radical surgery for chronic osteomyelitis is one of the most challenging problems encountered by orthopaedic surgeons. Open tibia and ankle fractures occur with an incidence of 3.4 per 100,000 and 1.6 per 100,000, respectively, and there is a high propensity of developing fracture-related infection with associated chronic osteomyelitis in patients. Segmental tibial and ankle bone loss have recently received new and improved treatments. Materials and Methods: Above all, 3D printing allows for the customization of implants based on the anatomy of each patient, using a personalized process through the layer-by-layer deposition of materials. Results: This article presents different cases from the authors’ experience. Specifically, four patients suffered tibia and ankle fractures and after radical surgery for chronic osteomyelitis combined with high-performance antibiotic therapy underwent ankle reconstruction/arthrodesis with custom-made tibial spacers. Conclusions: Thanks to 3D-printed patient-specific devices, it is possible to perform surgical procedures that, for anatomical reasons, would have been impossible otherwise. Moreover, an improvement in overall functionality and an important reduction in pain were shown in the last follow-up in all patients. Full article

Developing antimicrobial surfaces that combat implant-associated infections while promoting host cell response is a key strategy for improving current therapies for orthopaedic injuries. In this paper, we present the application of ultra-short laser irradiation for patterning the surface of a 3D biodegradable synthetic polymer in order to affect the adhesion and proliferation of bone cells and reject bacterial cells. The surfaces of 3D-printed polycaprolactone (PCL) scaffolds were processed with a femtosecond laser (λ = 800 nm; τ = 130 fs) for the production of patterns resembling microchannels or microprotrusions. MG63 osteoblastic cells, as well as S. aureus and E. coli, were cultured on fs-laser-treated samples. Their attachment, proliferation, and metabolic activity were monitored via colorimetric assays and scanning electron microscopy. The microchannels improved the wettability, stimulating the attachment, spreading, and proliferation of osteoblastic cells. The same topography induced cell-pattern orientation and promoted the expression of alkaline phosphatase in cells growing in an osteogenic medium. The microchannels exerted an inhibitory effect on S. aureus as after 48 h cells appeared shrunk and disrupted. In comparison, E. coli formed an abundant biofilm over both the laser-treated and control samples; however, the film was dense and adhesive on the control PCL but unattached over the microchannels. Full article

Background and Objectives: Surgical site infections (SSIs) are the most common healthcare-associated infections (HAIs) in surgical wards. The highest risk of developing SSI is carried by operations involving implants, such as: hip prosthesis (HPRO), knee prosthesis (KPRO), open reduction of fracture (FX), and closed reduction of fracture with internal fixation (CR). Objectives. The objective of the study was to assess the incidence of SSI in patients subjected to HPRO, KPRO, FX, and CR procedures in orthopaedics and trauma wards in 2014–2018 considering risk factors included in the SIR index. Materials and Methods: The study included 6261 patients who were subjected to orthopaedic surgery in 2014–2018. The investigation covered three hospitals with orthopaedics and trauma wards. The research was conducted in the framework of the national HAI surveillance programme according to the methodology of the HAI-Net, ECDC. Results: A total of 6261 surgeries were investigated, of which 111 cases of SSI were detected. The incidence was 1.8%; HPRO (incidence 2.1%, median (Me) surgery duration 90 min, and standardized infection ratio (SIR) above 1 in all units tested); KPRO (incidence 2.0%, Me 103 min, and SIR above 1 for all units tested); FX (incidence 1.9%, Me 70 min, and SIR above 1 for two units tested and below 1 in one unit); CR (incidence 1.0%, Me 55 min, and SIR—not calculated). The etiological agents that were most frequently isolated from patients with SSI were Staphylococcus aureus, coagulase-negative Staphylococcus, and Klebsiella pneumoniae. Conclusions: HPRO, KPRO, and FX operations performed in the studied wards carried a higher risk of developing SSI than that predicted by SIR. SSIs accounted for a significant percentage of the overall infection pool in CR surgeries. Actions should be undertaken to reduce the incidence of SSI in these surgeries. There should be a hospital network which facilitates cooperation in order to better monitor and analyse the incidence of SSI. Full article

Infections associated with orthopaedic implants represent a major health concern characterized by a remarkable incidence of morbidity and mortality. The wide variety of clinical scenarios encountered in the heterogeneous world of infections associated with orthopaedic implants makes the implementation of an optimal and standardized antimicrobial treatment challenging. Antibiotic bone penetration, anti-biofilm activity, long-term safety, and drug choice/dosage regimens favouring outpatient management (i.e., long-acting or oral agents) play a major role in regards to the chronic evolution of these infections. The aim of this multidisciplinary opinion article is to summarize evidence supporting the use of the different anti-staphylococcal agents in terms of microbiological and pharmacological optimization according to bone penetration, anti-biofilm activity, long-term safety, and feasibility for outpatient regimens, and to provide a useful guide for clinicians in the management of patients affected by staphylococcal infections associated with orthopaedic implants Novel long-acting lipoglycopeptides, and particularly dalbavancin, alone or in combination with rifampicin, could represent the best antibiotic choice according to real-world evidence and pharmacokinetic/pharmacodynamic properties. The implementation of a multidisciplinary taskforce and close cooperation between microbiologists and clinicians is crucial for providing the best care in this scenario. Full article

Introduction Limb salvage surgery for periacetabular malignancies is technically demanding and associated with a considerable likelihood of postoperative complications and surgical revision. Reconstruction using custom-made implants represents the treatment of choice. This study was conducted to analyze treatment outcomes of custom-made implants in a single orthopaedic tumor center. Patients and Methods Twenty patients with a histologically verified periacetabular malignancy and a median follow up time of 5 (1–17) years were included. Results The median number of revision surgeries per patient was 1.5 (0–7). Complications were dislocations in 3 patients, aseptic loosening in 4 patients, deep infections in 9 patients, thromboembolic events in 5 patients and sciatic nerve lesions in 4 patients. Overall survival was 77% after one year, 69% after two years and 46% after five years. Median Harris Hip Score was 81 (37–92) points at last follow up. Conclusion Although internal hemipelvectomy and reconstruction using custom-made implants is linked with a high risk of postoperative complications, good functional outcomes can be regularly achieved. This information may help treating surgeons to find adequate indications, as eligible patients need to be critically selected and integrated into the decision-making process. Full article

Over the years, there has been an increasing number of cardiac and orthopaedic implanted medical devices, which has caused an increased incidence of device-associated infections. The surfaces of these indwelling devices are preferred sites for the development of biofilms that are potentially lethal for patients. Device-related infections form a large proportion of hospital-acquired infections and have a bearing on both morbidity and mortality. Treatment of these infections is limited to the use of systemic antibiotics with invasive revision surgeries, which had implications on healthcare burdens. The purpose of this review is to describe the main causes that lead to the onset of infection, highlighting both the biological and clinical pathophysiology. Both passive and active surface treatments have been used in the field of biomaterials to reduce the impact of these infections. This includes the use of antimicrobial peptides and ionic liquids in the preventive treatment of antibiotic-resistant biofilms. Thus far, multiple in vivo studies have shown efficacious effects against the antibiotic-resistant biofilm. However, this has yet to materialize in clinical medicine. Full article

Our culture-independent nanopore shotgun metagenomic sequencing protocol on biopsies has the potential for same-day diagnostics of orthopaedic implant-associated infections (OIAI). As OIAI are frequently caused by Staphylococcus aureus, we included S. aureus genotyping and virulence gene detection to exploit the protocol to its fullest. The aim was to evaluate S. aureus genotyping, virulence and antimicrobial resistance genes detection using the shotgun metagenomic sequencing protocol. This proof of concept study included six patients with S. aureus-associated OIAI at Akershus University Hospital, Norway. Five tissue biopsies from each patient were divided in two: (1) conventional microbiological diagnostics and genotyping, and whole genome sequencing (WGS) of S. aureus isolates; (2) shotgun metagenomic sequencing of DNA from the biopsies. Consensus sequences were analysed using spaTyper, MLST, VirulenceFinder, and ResFinder from the Center for Genomic Epidemiology (CGE). MLST was also compared using krocus. All spa-types, one CGE and four krocus MLST results matched Sanger sequencing results. Virulence gene detection matched between WGS and shotgun metagenomic sequencing. ResFinder results corresponded to resistance phenotype. S. aureus spa-typing, and identification of virulence and antimicrobial resistance genes are possible using our shotgun metagenomics protocol. MLST requires further optimization. The protocol has potential application to other species and infection types. Full article