Search Results (290)

Background: Prosthetic joint infection (PJI) following total shoulder arthroplasty (TSA) is a rare but clinically relevant complication, largely attributable to the distinctive shoulder skin microbiome, predominantly composed of Cutibacterium acnes and coagulase-negative staphylococci (CoNS), which are considered low-virulence pathogens. Standard skin disinfection protocols do not completely prevent bacterial infiltration into the surgical field; therefore, the World Health Organization (WHO) recommends the use of intraoperative irrigation to reduce the risk of shoulder PJIs. Recently, the use of povidone–iodine (PVI) irrigation has been shown to significantly reduce both bacterial load and diversity after TSA; however, its activity against C. acnes remains suboptimal. Therefore, the aim of this study was to evaluate improved in vitro disinfection protocols by combining PVI and hydrogen peroxide for use as intraoperative irrigation in shoulder arthroplasty, which is characterized by a distinctive microbiome. Methods: In vitro broth dilution assays and time-kill experiments were performed to test PVI and H₂O₂, alone or in combination, against CoNS, Staphylococcus aureus, and Escherichia coli as representative aerobic bacteria, and against C. acnes as an anaerobic pathogen. Results: The results revealed that, when used alone, PVI exerted a more pronounced bactericidal effect against staphylococci, whereas H₂O₂ was more effective against C. acnes, even at a high bacterial inoculum, although at cytotoxic concentrations, particularly for PVI. Notably, when the disinfectants were used in combination, bacterial killing was achieved against all the tested pathogens, starting from short exposure times, mainly 3 min, and at low concentrations. Moreover, the antiseptics significantly reduced mature biofilm, although complete eradication was not achieved. Conclusions: A targeted irrigation protocol to prevent shoulder PJI can be achieved by combining PVI and H₂O₂ at non-toxic concentrations and for short exposure times that do not interfere with operating room costs or increase the risk of infection. Full article

Prosthetic joint infections (PJIs) remain a major challenge in orthopedic surgery due to the increasing prevalence of antimicrobial-resistant pathogens and their ability to form biofilms on implant surfaces. Local delivery of non-traditional antimicrobials through implant-associated biomaterials represents a promising strategy for preventing bacterial colonization while minimizing systemic antibiotic exposure. This study evaluated the antimicrobial activity and cytocompatibility of two bacteriophages (Phage K and Phage F1) and two antimicrobial peptide dendrimers (AMPDs; TNS18 and G3KL) against clinical isolates of Staphylococcus aureus and Staphylococcus epidermidis recovered from PJIs. Antimicrobial efficacy was assessed using solid and liquid culture assays, while cytocompatibility was evaluated using human osteoblast progenitor cells. Biofilm formation was also investigated under various in vitro conditions. Phages K and F1 demonstrated strong antibacterial activity against S. aureus isolates, whereas TNS18 showed pronounced inhibitory effects against S. epidermidis. All agents exhibited appropriate osteoblast compatibility, except Phage F1, at the highest multiplicity of infection tested. Biofilm formation was observed under several culture conditions, although substantial variability in biofilm stability limited the quantitative assessment of antimicrobial activity. These findings demonstrate complementary antimicrobial activity profiles between bacteriophages and AMPDs and support their further investigation as candidates for implant-associated antimicrobial delivery systems and orthopedic implant coatings. Full article

Background: Long-acting lipoglycopeptides (LALs), including dalbavancin and oritavancin, may facilitate outpatient-oriented management of Gram-positive infections by reducing the need for prolonged hospitalization and daily intravenous therapy. However, real-world evidence on their use in day hospital pathways, particularly for complex off-label infections, remains limited. This study evaluated the clinical effectiveness, safety, and economic impact of LAL-based day hospital management, comparing in-label acute bacterial skin and skin-structure infections (ABSSSI) with complex off-label indications. Methods: This retrospective, multicenter observational study included 160 adult patients treated with dalbavancin and/or oritavancin in a day hospital setting across nine Italian centers between January 2020 and December 2025. Indications were classified as in-label ABSSSI or off-label infections, including osteomyelitis, prosthetic joint infection, spondylodiscitis, endocarditis, septic arthritis, and prosthetic cardiac infection. The primary endpoint was clinical success at final follow-up. Secondary endpoints included adverse drug events, readmissions, inflammatory marker response, and a budget impact cost-offset analysis based on avoided inpatient bed-days. Results: Overall, 54.4% of patients received LALs for off-label indications, mainly osteomyelitis, prosthetic joint infection, and spondylodiscitis. Clinical outcome was available for 159 patients, with an overall success rate of 86.8% (138/159). Success rates were 90.4% for in-label ABSSSI and 83.7% for off-label indications, with no statistically significant difference between groups (p = 0.247). In exploratory analyses, monotherapy was associated with lower failure odds; this most likely reflects confounding by indication and should not be interpreted as a treatment effect. Inflammatory markers significantly decreased from baseline to end of therapy. Adverse drug events were uncommon (3.3%), mild, and did not lead to treatment discontinuation. In a scenario-based cost-offset model (no matched inpatient comparator), the strategy corresponded to 1107–2214 avoided inpatient bed-days; estimated net savings ranged from approximate cost-neutrality under conservative assumptions (€11,976) to €676,176 under maximum assumptions, and one-way sensitivity analysis showed a possible net loss at low inpatient daily-cost values—underscoring that these are modeled rather than observed savings. Conclusions: In this uncontrolled, retrospective cohort, LAL-based day hospital management was feasible and associated with favorable observed clinical outcomes, an acceptable safety profile, and a potential for cost offset in selected patients with Gram-positive infections, including complex off-label indications. Because no matched inpatient or conventional OPAT comparator was included, these findings should be regarded as hypothesis-generating and cannot establish comparative efficacy, superiority, or actual cost savings. Full article

Background: Cutibacterium avidum is an emerging opportunistic pathogen responsible for device-associated infections, including prosthetic joint and breast implant infections. Unlike its relative C. acnes, for which phage therapy has been explored, C. avidum infections are recalcitrant to antibiotics, and no infecting bacteriophages have been described to date. Here, we report the isolation and characterization of ΦCA1NRNZ, to the best of our knowledge, the first lytic phage described against C. avidum. Methods: ΦCA1NRNZ was obtained from wastewater sampling at the Sorek Treatment Facility in Jerusalem. Wastewater metagenomics, transmission electron microscopy, genome sequencing, host-range testing, efficiency of plating (EOP), aerobic and anaerobic lysis assays, and antibiofilm assays against mature C. avidum biofilms were performed. Results: Metagenomic analysis indicated low and transient detection of C. avidum-classified reads in wastewater. ΦCA1NRNZ was identified as a long-tailed Caudoviricetes with a ~320 nm virion. Its 33,712 bp dsDNA genome (GenBank PV441878.1) encodes 46 predicted proteins, shares 76.5% nucleotide identity with C. acnes phage ΦFD1, and contains divergent tail-fiber and host-recognition genes. No known bacterial virulence, toxin, human pathogenicity-associated, or antibiotic-resistance genes were identified. ΦCA1NRNZ lysed all 11 clinical C. avidum isolates tested under aerobic and anaerobic conditions, with EOP values of 0.11–5.55, mean 1.87, and showed no lytic activity against 25 C. acnes isolates. Against mature biofilms, ΦCA1NRNZ reduced total biomass by 28.4% (p = 0.014), reduced viable cell counts by approximately two logs, and increased extracellular ATP release (p < 0.001). Conclusions: The strict species specificity and significant in vitro antibiofilm activity of ΦCA1NRNZ support its potential for phage therapy of device-associated C. avidum infections. Full article

Background/Objectives: Bacterial contamination of the surgical field during shoulder arthroplasty may contribute to periprosthetic joint infection (PJI), yet data on intraoperative bacterial load and its clinical correlates remain limited. This study aimed to evaluate culture positivity and bacterial load in specimens collected at the end of reverse total shoulder arthroplasty (RTSA) and to explore their association with patient-related factors. Methods: Fifty-five patients undergoing elective RTSA were consecutively enrolled. At the end of surgery, three specimens per patient (two prosthetic swabs and one periprosthetic tissue sample) were collected for qualitative and quantitative microbiological analysis. Associations between bacterial load and clinical variables were assessed using mixed-effects linear regression models, while time to culture positivity was analysed using mixed-effects Cox regression models. Results: Among 165 specimens, Cutibacterium acnes was isolated in 42.4% and coagulase-negative staphylococci in 29.1%. C. acnes showed significantly higher bacterial loads (1.38 × 10³ CFU/mL) compared with aerobic bacteria (6.54 × 10¹ CFU/mL). Higher C. acnes load was associated with male sex, older age, higher body mass index, smoking, and cuff tear arthropathy, whereas massive rotator cuff tear and longer time to positivity were inversely associated. Aerobic bacterial load was primarily associated with longer surgical duration. Time to positivity was shorter for aerobes than for C. acnes. Conclusions: Intraoperative bacterial contamination during RTSA is frequent and characterized by marked differences in bacterial load and growth kinetics. Quantitative assessment of bacterial burden may improve the interpretation of unexpected positive cultures. Full article

Periprosthetic joint infection (PJI) remains a major clinical challenge after total joint arthroplasty because of its association with prolonged antimicrobial therapy, repeated surgery, implant failure, functional disability, and substantial socioeconomic burden. Current strategies, including systemic antibiotics, debridement with implant retention, staged revision, and antibiotic-loaded cement spacers, remain indispensable but are limited by mature biofilm tolerance, protected microbial reservoirs, insufficient local drug penetration, persistent inflammation, and compromised periprosthetic bone repair. Increasing evidence indicates that PJI is not merely bacterial colonization of an implant surface, but a dynamic prosthetic interface disorder involving biofilm persistence, immune dysregulation, inflammatory osteolysis, and failed osseointegration. This review summarizes recent advances in anti-infective prosthetic interface design, emphasizing the transition from passive antibacterial coatings toward multifunctional immuno-antibacterial osseointegrative systems. The pathogenic basis of PJI is first discussed, including conditioning film formation, bacterial adhesion, biofilm maturation, protected reservoirs, immune evasion, and osteolysis. Current clinical management limitations are then evaluated, followed by emerging biomaterial strategies, including anti-adhesive and contact-killing surfaces, active antimicrobial coatings, mature biofilm disruption, biological antibiofilm therapies, smart infection-responsive delivery systems, and osteoimmunomodulatory interfaces. Particular attention is given to balancing early antibacterial activity with cytocompatibility, immune resolution, angiogenesis, mechanical durability, and long-term osseointegration. Finally, key translational barriers are highlighted, including load-bearing and tribological constraints, insufficiently standardized mature biofilm and animal models, limited clinical evidence for advanced smart materials, manufacturing reproducibility, sterilization compatibility, regulatory complexity, and application-specific clinical readiness. Future anti-PJI interfaces should evolve beyond unidirectional bacterial killing toward stage-specific systems integrating biofilm control, immune restoration, vascularized bone regeneration, and durable mechanical performance. Full article

Background/Objectives: Prosthetic joint infection following total knee arthroplasty remains a significant public health challenge. Automated surveillance systems are increasingly used for national monitoring of surgical site infections after arthroplasty. This study assessed the performance of the French ISO-ORTHO automated surveillance indicator after primary total knee arthroplasty by comparing automated surveillance data with exhaustive clinical follow-up. It also reported the incidence of surgical site infections during the initial years of activity of a tertiary care university hospital. Methods: A retrospective cohort analysis of primary total knee arthroplasties performed between January 2016 and December 2018 was conducted using exhaustive clinical chart review and the French ISO-ORTHO automated surveillance system. Prosthetic joint infections were diagnosed according to the 2018 International Consensus Meeting criteria. The local ISO-ORTHO results were compared with the national ISO-ORTHO rates. Results: Clinical chart review identified 1138 primary total knee arthroplasties and five prosthetic joint infections. Prosthetic joint infection incidence was 0.44% with a mean follow-up of 40.5 months. ISO-ORTHO was not yet implemented in 2016. Between 2017 and 2018, ISO-ORTHO identified 519 procedures and one prosthetic joint infection, compared with 807 procedures and three infections identified by clinical review. Conclusions: The French ISO-ORTHO surveillance indicator aided local and national monitoring of surgical site infections after total knee arthroplasty, but discrepancies with clinical chart review highlighted important limitations of automated monitoring and the importance of prolonged clinical follow-up. Future surveillance strategies could integrate these complementary approaches to improve prosthetic joint infection detection. Full article

Background: Perioperative antibiotic prophylaxis (PAP) is effective for infection prevention in implant-related surgery, with infections being the most feared complications. A total of 15% of all antibiotics in hospitals are used for surgical prophylaxis but less than 50% of them are used according to the guidelines. International guidelines recommend only a single preoperative dose for all surgical procedures. We have developed and implemented new recommendations for PAP duration in primary hip and knee arthroplasty at the University Department for Orthopaedic Surgery. Methods: The development and implementation of new recommendations regarding PAP duration were performed via the following steps: pre-interventional analysis; identification of barriers and facilitators using the Flottorp framework; analyzing the data and preparation of a tailored implementation strategy based on an educational group meeting with the development of new consented to recommendations; and dissemination; followed by postinterventional analysis of PAP duration compliance 6 months later. Results: Before the intervention, 70% of PAP was used inappropriately (longer than 24 h). The major recognized barriers were fear of prosthetic joint infection (PJI) and a lack of concern regarding global antimicrobial resistance problems. Major facilitators were a low local PJI incidence rate (0.28%), etiology of PJI and existing local experience with a single-dose regime. After implementation of new recommendations regarding the duration of PAP, the postinterventional analysis showed that 80% of PAP was used according to the new recommendations, with a significant reduction in prolonged PAP use (from 70% to 12%), leading to an important decline in antimicrobial consumption. Conclusions: Our study showed that a tailored strategy in the development and implementation of new recommendations is complex and time consuming, although necessary for successful clinical practice change. Full article

Background: Peri-prosthetic joint infection (PJI) following total knee arthroplasty complicated by soft tissue compromise presents a major reconstructive challenge. Successful management requires the eradication of infection while restoring durable soft tissue coverage and limb function. This study reports the outcomes of a patient-specific, multidisciplinary orthoplastic approach to complex knee PJI. Methods: We retrospectively reviewed five patients with complex infected knee arthroplasty and associated soft tissue compromise managed at our institution between 2021 and 2025 by a single orthopaedic surgeon and two plastic reconstructive surgeons. All cases required personalized management, including the use of custom spacers, patient-specific orthopaedic reconstruction, and individualized soft tissue reconstruction techniques. Data collected included patient demographics, infection characteristics, reconstructive techniques, and functional outcomes. Results: All patients achieved durable soft tissue coverage and infection eradication at final follow-up. Of the five patients, one underwent primary closure of a persistent sinus, one required a local axial bi-pedicled flap for sinus control and soft tissue closure, two were managed with medial gastrocnemius flaps, and one complex case with an associated bone defect required a custom-designed spacer to achieve stability and dead-space management. Conclusions: In this retrospective case series, we aim to demonstrate that complex knee PJI with associated soft tissue defects may be successfully managed with an individualized, multidisciplinary strategy. We aim to demonstrate the feasibility of such an approach in a tertiary referral centre and to highlight the importance of customisation in achieving infection control and limb preservation. Full article

Background: Late-onset anaerobic prosthetic joint infection (PJI) is uncommon but may indicate underlying, previously asymptomatic colorectal malignancy. While the association between Streptococcus bovis group (SBG) bacteremia and colorectal cancer is well established, links between anaerobic PJIs and colorectal neoplasia are rarely reported. Anaerobic organisms originating from the gastrointestinal tract may translocate via the hematogenous route, and their presence in PJI should prompt clinicians to consider occult colorectal pathology. Methods: All periprosthetic arthroplasty infection cases between 2015 and 2025 were reviewed. Clinical records, diagnostic findings, microbiological data, and treatment outcomes were analyzed. Results: Three female patients (mean age 76.3 years) presented with late-onset PJI occurring at least five years after primary total knee arthroplasty. Causative organisms included Bacteroides fragilis, Morganella morganii, and Klebsiella pneumoniae. All patients underwent two single-stage revision surgeries and one debridement, antibiotics and implant retention (DAIR) procedure. Cross-sectional computed tomography imaging of the abdomen and pelvis (CT-AP) performed to evaluate hematogenous sources of infection consistently revealed previously undiagnosed colorectal malignancy. One patient had additional metastatic disease. Postoperative complications included one case of pulmonary embolism; no other major complications were observed. Conclusions: Anaerobic PJIs are rare, and their association with colorectal malignancy is not well established. These cases highlight the importance of evaluating potential gastrointestinal sources, including occult colorectal cancer, in patients presenting with late-onset anaerobic PJI. Full article

Background/Objectives: Hypoalbuminemia is a marker of poor nutritional status and has been associated with increased postoperative complications following total joint arthroplasty. However, its long-term implications in the revision total hip arthroplasty (THA) population are poorly characterized, and the utility of prealbumin to further risk-stratify these patients remains unclear. We aimed to study the association between preoperative hypoalbuminemia and complications after rTHA. Methods: We identified patients who underwent rTHA with preoperative albumin levels obtained within one month of surgery. Patients were divided into hypoalbuminemia (<3.5 g/dL) and normal albumin (3.5–6.0 g/dL) cohorts. A second analysis was conducted stratifying hypoalbuminemia patients by prealbumin level (<16 mg/dL vs. ≥16 mg/dL), measured within two weeks of surgery. Each cohort was 1:1 propensity score matched with a 1:1 nearest-neighbor greedy matching approach with a 0.10 standard deviation (SD) caliper, following a logistic regression to calculate patient propensity scores. Outcomes were compared at 90-day, 2-year, and 5-year intervals. Results: The matched cohorts included 4137 patients in both the hypoalbuminemia and normal-albumin groups. Hypoalbuminemia was significantly associated with increased short-term rates of any adverse event (38.9% vs. 22.5%; OR 2.195), wound dehiscence (5.4% vs. 3.1%; OR 1.808), surgical site infection (10.7% vs. 5.0%; OR: 2.271), and periprosthetic fracture (13.9% vs. 10.2%; OR: 1.414). Repeat revision THA was significantly more common within 90 days (6.6% vs. 4.5%; OR: 1.490). Periprosthetic fracture and prosthetic loosening were also more common within 2 years and 5 years (q = 0.001). There were no differences in repeat rTHA within 2 years and 5 years. Among hypoalbuminemic patients with prealbumin data, stratification by prealbumin level did not demonstrate any statistically significant differences in 90-day, 2-year, and 5-year complications. Conclusions: Hypoalbuminemia is a strong indicator of increased complication risk after rTHA, with increased risk for complications lasting to at least 5 years postoperatively. However, prealbumin stratification among hypoalbuminemic patients did not differentiate complication risk. These findings support preoperative albumin as a practical biomarker for risk stratification in rTHA patients. Full article

Background: Surgical management of adult patients with post-dysplastic coxarthrosis using total hip arthroplasty is technically demanding and carries an increased risk of complications. In cases of high iliac dislocation classified as Crowe type IV, restoring the acetabular component to the anatomical hip centre often requires femoral shortening osteotomy to enable safe reduction in the prosthetic joint. Nevertheless, long-term evidence on functional outcomes and prosthesis survival with this approach is limited. Methods: A retrospective cohort study included 19 patients with 22 cases of Crowe type IV post-dysplastic hip osteoarthritis treated with uncemented total hip arthroplasty (Pinnacle/S-ROM, DePuy, Warsaw, IN, USA) combined with transverse subtrochanteric femoral shortening osteotomy. Patients underwent serial clinical follow-up, including assessment of range of motion, measurement of limb-length discrepancy, and functional evaluation using the Harris Hip Score and the WOMAC questionnaire. Radiological assessment included evaluation of osteotomy union, implant positioning, and osteolysis on standardized radiographs. Vertical distances of the centre of rotation (CR), the tip of the greater trochanter (GT), and the tip of the lesser trochanter (LT) from both reference lines were measured bilaterally, and inter-side differences were calculated. The reference lines consisted of the line connecting the inferior margins of the ischial bones and the teardrop (TD) line. Results: All osteotomies united at a mean of 5.57 months, with a mean follow-up of 129 months. Mean limb-length discrepancy decreased from 5.27 cm to 1.5 cm, and mean hip flexion improved from 82.9° to 106°. Functional outcomes improved significantly, with mean WOMAC increasing from 55.4 to 80.1 (p < 0.001) and mean Harris Hip Score from 49.8 to 84.66 at up to 3 years of follow-up (p < 0.001). Osteotomy length correlated strongly with lesser trochanter–teardrop distance (p = 0.00000048). Complications included distal femoral fissure (27.3%) and revision (18%), with no infection or permanent neurological deficit. Conclusions: Total hip arthroplasty combined with subtrochanteric femoral shortening osteotomy for Crowe type IV post-dysplastic hip osteoarthritis appears to be a feasible and effective procedure in an experienced centre, providing reliable osteotomy healing and significant early functional improvement that is sustained over time. Limb-length discrepancy was reduced and satisfactory biomechanical restoration was achieved, with an acceptable complication profile and implant survival of 81.3% at long-term follow-up. The LT–TD parameter was identified as a potential predictor of osteotomy length, enabling the proposal of a preoperative planning equation. However, given the limited sample size and lack of validation, these findings should be interpreted cautiously. Further studies are needed to confirm their broader applicability. Full article

Rapid and actionable pathogen identification remains a major unmet need in the diagnosis of prosthetic joint infection (PJI). Current diagnostic approaches either provide rapid host response information without pathogen specificity or identify pathogens with delays of days to weeks. Here, we report a chemiresistive nanosensor array combined with machine learning analysis for same-day, pathogen-specific detection based on volatile organic compound (VOC) profiling. A 19-channel nanosensor array was first validated in vitro against a panel of ESKAPEE pathogens, achieving 96% mean classification accuracy using a radial-basis-function support vector machine (SVM) classifier. Data-driven optimization yielded a reduced six-sensor array with high signal-to-noise performance. The optimized platform was evaluated using pooled, uninfected human synovial fluid enriched 1:1 with nutrient media and spiked with Staphylococcus aureus, Staphylococcus epidermidis, or Pseudomonas aeruginosa across a range of 1–10⁶ CFU/mL. All infected samples were detected within 9 h, with distinct VOC signatures enabling accurate pathogen differentiation. Time-to-detection (TTD) demonstrated a strong inverse correlation with initial bacterial concentration, supporting semi-quantitative estimation of bacterial load. Negative controls remained at baseline throughout testing. This chemiresistive VOC-based biosensor platform demonstrates the potential to deliver rapid, integrated detection, identification, and burden estimation of metabolically active PJI pathogens, highlighting its promise for future point-of-care diagnostic applications. Full article

Background/Objectives: Obesity and type 2 diabetes are increasingly common among patients undergoing hip and knee arthroplasty and are associated with higher risks of prosthetic joint infection, impaired wound healing, and prolonged hospitalisation. Dietary carbohydrate restriction has demonstrated benefits in glycemic control and weight reduction, but its feasibility and safety in the perioperative arthroplasty population remain underexplored. This pilot study evaluated the safety, feasibility, and short-term metabolic effects of a low-carbohydrate diet supported by WhatsApp-based meal photo-logging in patients undergoing total hip or knee arthroplasty. Methods: A retrospective cohort analysis was performed on 43 patients enrolled in a carbohydrate-restricted dietary programme between 2021 and 2024. Patients submitted photographs of all meals via WhatsApp with a minimum contact frequency of four times daily, enabling real-time feedback and medication adjustment. Anthropometric and metabolic parameters, including weight, BMI, HbA1c, renal function, and lipid profile, were assessed before and after the intervention. Results: Participants (mean age 69.12 ± 7.51 years) demonstrated significant improvement across several metabolic markers. Mean weight decreased by 5.74 kg (p < 0.001), BMI by 2.26 kg/m² (p < 0.001), and HbA1c by 0.72% (p < 0.001). No episodes of severe hypoglycaemia or perioperative discharge delays related to glycemic instability were observed. Renal function remained stable, with no significant change in eGFR (p = 0.442). Among patients with available lipid data (n = 14), LDL-cholesterol and total cholesterol increased, while triglycerides showed a non-significant downward trend. Conclusions: A low-carbohydrate diet combined with high-frequency digital monitoring appears feasible and safe, achieving meaningful short-term improvements in weight and glycemic control without adverse renal or hypoglycemic events. The lipid changes observed, however, warrant cautious interpretation. These findings are hypothesis-generating, and larger prospective studies are needed to confirm the clinical impact of this approach and its relevance to perioperative optimisation. Full article