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Advances in Understanding the Pathogenesis and Pathophysiology of Orthopaedic-Related Infections
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Advances in Understanding the Pathogenesis and Pathophysiology of Orthopaedic-Related Infections

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

Deadline for manuscript submissions: closed (10 November 2023) | Viewed by 18275

Special Issue Editor

Prof. Dr. Gerald Atkins

E-Mail Website
Guest Editor
Centre for Orthopaedic & Trauma Research, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
Interests: periprosthetic joint infection; osteolysis; osteoarthritis; osteoporosis; osteocyte; bone remodelling
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Osteomyelitis related to orthopaedic interventions and peripheral vascular disease represent a serious health and healthcare burden. Individuals who are obese, diabetic, chronic smokers, immunocompromised, or have undergone dental surgery are at increased risk of developing periprosthetic joint infection (PJI). Patients being treated for bone and joint reconstruction surgery following cancer treatment have a greatly elevated risk of developing a PJI. Individuals who have suffered trauma, in particular, open fractures, are at high risk of developing a fracture-related infection (FRI). These conditions involve infection of surgical implants and of the surrounding soft and hard tissues. Patients with peripheral vascular disease, such as those with diabetes mellitus, are at increased risk of developing a foot ulcer that will develop into a localised osteomyelitis, termed diabetic foot infection (DFI). All of these infection types are contributed to by both host- and pathogen-derived factors, and all are associated with a high incidence of recurrent or chronic disease. In this Special Issue, we seek to explore advances in our understanding of the pathogenesis, pathophysiology, and treatment of these related disease types.

Prof. Dr. Gerald Atkins
Guest Editor

Manuscript Submission Information

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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

  • orthopaedic infection
  • chronic
  • osteomyelitis
  • periprosthetic joint infection
  • fracture-related infection
  • diabetic foot infection
  • pathogenesis
  • pathophysiology

Published Papers (6 papers)

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Research

12 pages, 1852 KiB  
Article
Positivity Trends of Bacterial Cultures from Cases of Acute and Chronic Periprosthetic Joint Infections
by Rares Mircea Birlutiu, Cristian Ioan Stoica, Octav Russu, Razvan Silviu Cismasiu and Victoria Birlutiu
J. Clin. Med. 2022, 11(8), 2238; https://doi.org/10.3390/jcm11082238 - 16 Apr 2022
Cited by 2 | Viewed by 1717
Abstract
Background: There is no clear distinction in the literature regarding the positivity trends of bacterial cultures in acute and chronic prosthetic joint infections. Methods: We prospectively included in this study all consecutive patients, aged over 18 years, that were hospitalized from September 2016 through [...] Read more.
Background: There is no clear distinction in the literature regarding the positivity trends of bacterial cultures in acute and chronic prosthetic joint infections. Methods: We prospectively included in this study all consecutive patients, aged over 18 years, that were hospitalized from September 2016 through December 2019, that underwent a joint arthroplasty revision surgery. Results: Forty patients were included in our analysis, 11 acute/acute hematogenous and 29 chronic PJIs. We were able to identify all strains of acute/acute hematogenous PJIs within 3 days, whereas this took 8 days for chronic PJIs. Sonication fluid cultures increased the positivity rate and helped in identifying rare pathogens such as Ralstonia pickettii from chronic PJIs, but also increased the number of identified strains from acute PJIs. Culturing synovial fluid in our study did not seem to have a clear benefit compared to sonication fluid and periprosthetic tissue cultures. Conclusion: There was a different positivity trend in bacterial cultures. Empiric broad-spectrum antibiotic therapy can be re-evaluated after 3 days for acute PJIs. A prolonged incubation time, especially in the case of chronic PJIs, is mandatory; however, extending the incubation period beyond 14 days would not further improve the ability to identify microorganisms. Full article
(This article belongs to the Special Issue Advances in Understanding the Pathogenesis and Pathophysiology of Orthopaedic-Related Infections)
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14 pages, 1029 KiB  
Article
Long-Term Outcomes of Staged Revision Surgery for Chronic Periprosthetic Joint Infection of Total Hip Arthroplasty
by Christopher W. Day, Kerry Costi, Susan Pannach, Gerald J. Atkins, Jochen G. Hofstaetter, Stuart A. Callary, Renjy Nelson, Donald W. Howie and Lucian B. Solomon
J. Clin. Med. 2022, 11(1), 122; https://doi.org/10.3390/jcm11010122 - 27 Dec 2021
Cited by 6 | Viewed by 4618
Abstract
Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty. Staged revision surgery is considered effective in eradicating PJI. We aimed to determine the rate of infection resolution after each stage of staged revision surgery (first stage, repeat first stage, second [...] Read more.
Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty. Staged revision surgery is considered effective in eradicating PJI. We aimed to determine the rate of infection resolution after each stage of staged revision surgery (first stage, repeat first stage, second stage, excision arthroplasty, and reimplantation) and to assess functional outcomes and the mortality rate at ten years in a consecutive series of 30 chronic PJI of total hip arthroplasties. Infection resolution was defined as no clinical nor laboratory evidence of infection at 24 months after the last surgery and after a minimum of 12 months following cessation of antimicrobial treatment. Four patients died within 24 months of their final surgery. Nineteen patients, 73% (worst-case analysis (wca) 63%), were infection free after 1 surgery; 22 patients, 85% (wca 73%), were infection free after 2 surgeries; and 26 patients, 100% (wca 87%), were infection free after three and four surgeries. The median Harris Hip Score was 41 prior to first revision surgery and improved to 74 at twelve months and 76 at ten years after the final surgery. Thirteen patients died at a mean of 64 months from first revision, giving a mortality rate of 43% at ten years, which is approximately 25% higher than that of an age-matched general population. The results show that with repeated aggressive surgical treatment, most PJIs of the hip are curable. Ten years after successful treatment of PJI, functional outcomes and pain are improved and maintained compared to before initial surgery, but this must be balanced against the high 10-year mortality. Level of evidence: cohort studies. Full article
(This article belongs to the Special Issue Advances in Understanding the Pathogenesis and Pathophysiology of Orthopaedic-Related Infections)
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13 pages, 258 KiB  
Article
Surgical Site Infection Following Intramedullary Nailing of Subtrochanteric Femoral Fractures
by Michalis Panteli, James S. H. Vun, Robert M. West, Anthony Howard, Ippokratis Pountos and Peter V. Giannoudis
J. Clin. Med. 2021, 10(15), 3331; https://doi.org/10.3390/jcm10153331 - 28 Jul 2021
Cited by 4 | Viewed by 2829
Abstract
Aim: To investigate the incidence, risk factors and pathogenic micro-organisms causing superficial and deep infection in subtrochanteric femoral fractures managed with an intramedullary nail. Materials and Methods: Following institutional board approval, all consecutive patients presenting with a subtrochanteric fracture were retrospectively identified, over [...] Read more.
Aim: To investigate the incidence, risk factors and pathogenic micro-organisms causing superficial and deep infection in subtrochanteric femoral fractures managed with an intramedullary nail. Materials and Methods: Following institutional board approval, all consecutive patients presenting with a subtrochanteric fracture were retrospectively identified, over an 8-year period. Basic demographics, fracture characteristics, fracture union, revision operation, mortality and other complications were reported and analysed. Variables deemed statistically significant (p-value < 0.05) were then included into a revised adjusted model of logistic regression analysis, where we reported on the odds ratio (OR). Results: The overall incidence of infection was 6.4% (n = 36/561; superficial: 3.7%; deep: 2.7%). Associations with deep infection included: non-union (OR 9.29 (2.56–3.38)), the presence of an open fracture (OR 4.23 (3.18–5.61)), the need for massive transfusion (OR 1.42 (2.39–8.39)), post-operative transfusion (OR 1.40 (1.10–1.79)) and prolonged length of stay (OR 1.04 (1.02–1.06)). The Commonest causes of superficial infection were Staphylococcus aureus (28.5%), enteric flora (23.8%) and mixed flora (23.8%); whereas coliforms (60%) and Staphylococcus aureus (26.7%) were the commonest micro-organisms isolated in deep infection. Polymicrobial infection was identified in 38.5% and 80% of superficial and deep infections, respectively. Conclusion: Causative micro-organisms identified in both superficial and deep infection were similar to those reported in post-traumatic osteomyelitis. In an attempt to minimise infection, the treating clinician should focus on modifiable risk factors with adequate patient optimisation, prompt surgical treatment, adequate antibiotic coverage and wound care when treating patients with subtrochanteric femur fracture. Full article
(This article belongs to the Special Issue Advances in Understanding the Pathogenesis and Pathophysiology of Orthopaedic-Related Infections)
13 pages, 794 KiB  
Article
Is Negative Pressure Wound Therapy with Instillation Suitable for the Treatment of Acute Periprosthetic Hip Joint Infection?
by Nicholas A. Beckmann, Maximilian G. Hanslmeier, Georg W. Omlor, Manuel Feisst, Michael W. Maier and Burkhard Lehner
J. Clin. Med. 2021, 10(15), 3246; https://doi.org/10.3390/jcm10153246 - 23 Jul 2021
Cited by 2 | Viewed by 2257
Abstract
Background: Periprosthetic joint infection (PJI) can be devastating for the patient and demanding for the surgeon. In acute PJI, attempts are made to retain the prosthesis by debridement of the infected tissue, targeted antibiotic therapy and an exchange of modular components with implant [...] Read more.
Background: Periprosthetic joint infection (PJI) can be devastating for the patient and demanding for the surgeon. In acute PJI, attempts are made to retain the prosthesis by debridement of the infected tissue, targeted antibiotic therapy and an exchange of modular components with implant retention (DAIR). There has been sparse research with adjunctive negative pressure wound treatment with wound irrigation (NPWTI) on the treatment outcome. Questions/purposes: The goal was to assess the efficacy of our protocol of DAIR with adjunctive NPWTI in acute PJI and to reduce the need for later additional DAIR and Irrigation and Debridement (I and D). Patients and Methods: Our cohort of 30 patients (31 hips) with acute PJI was divided into two groups based on symptom presentation up to 6 weeks or >6 weeks from prior (index) surgery (acute early or acute late groups, respectively). All received DAIR with an exchange of modular components and NPWTI with polyhexanide instillation, with the goal of bacterial elimination and biofilm elimination. Postoperatively, the patients were followed up clinically and radiographically for a mean of 4.3 years. Results: Of the 31 PJI hips, 19 were early acute and 12 were late acute. In total, 21 hips had no evidence of residual infection, 10 required further surgical revision: 1 due to dislocation and 9 due to infection. Of these nine, seven had a removal of all the components and two were treated with irrigation and debridement (I and D), with the demise of one patient from pneumonia shortly after the procedure. The Kaplan–Meier 60-month revision free implant survival from infection was 73.2% (CI: 58.9–91.0%) and at the final follow up, the mean Harris Hip Score (HHS) was 81.1 ± 11.8 and the mean WOMAC score was 33.3 ± 20.1. Conclusions: Our results are in line with those reported in prior studies. However, the utility of our protocol is inconclusive and needs further evaluation based on our small cohort and the lack of a control group. Level of Evidence: IV. Full article
(This article belongs to the Special Issue Advances in Understanding the Pathogenesis and Pathophysiology of Orthopaedic-Related Infections)
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9 pages, 2489 KiB  
Article
Risk Factor Analysis for Infection after Medial Open Wedge High Tibial Osteotomy
by Ta-Wei Liu, Chih-Hao Chiu, Alvin Chao-Yu Chen, Shih-Sheng Chang and Yi-Sheng Chan
J. Clin. Med. 2021, 10(8), 1727; https://doi.org/10.3390/jcm10081727 - 16 Apr 2021
Cited by 9 | Viewed by 2478
Abstract
Background: Medial open wedge high tibial osteotomy (MOWHTO) is a well-established treatment for osteoarthritis of the medial tibiofemoral compartment. Surgical site infection (SSI) after MOWHTO is a devastating complication that may require further surgery. In this study, we aimed to identify the risk [...] Read more.
Background: Medial open wedge high tibial osteotomy (MOWHTO) is a well-established treatment for osteoarthritis of the medial tibiofemoral compartment. Surgical site infection (SSI) after MOWHTO is a devastating complication that may require further surgery. In this study, we aimed to identify the risk factors for infection after MOWHTO over 1 to 4 years of follow-up. Methods: Fifty-nine patients who underwent MOWHTO combined with knee arthroscopic surgery were included in this prospective study. Artificial bone grafts were used in all cases. Possible risk factors, including sex, age, body mass index (BMI), underlying disease, hospitalization length, correction angle, and surgery time, were recorded. Both univariate and multivariate analysis were used. Results: A total of 59 patients who underwent 61 operations were included. Eleven patients (18.0%) were reported to have SSI. Univariate analysis showed that smoking and diabetes mellitus were positively associated with SSI. Multivariate analysis showed that smoking and age were positively associated with SSI. Three patients (4.9%) were reported to suffer from deep SSI, requiring surgical debridement, all of whom were male smokers. Conclusion: Smoking, diabetes mellitus, and old age were identified to be possible risk factors of SSI after MOWHTO. These findings are common risk factors of SSI after orthopedic surgery according to the literature. Patient selection should be performed cautiously, and postoperative prognosis for MOWHTO should be carefully explained to patients who smoke. Full article
(This article belongs to the Special Issue Advances in Understanding the Pathogenesis and Pathophysiology of Orthopaedic-Related Infections)
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9 pages, 1225 KiB  
Article
Long-Term Patient-Related Quality of Life after Knee Periprosthetic Joint Infection
by Nike Walter, Markus Rupp, Katja Hierl, Matthias Koch, Maximilian Kerschbaum, Michael Worlicek and Volker Alt
J. Clin. Med. 2021, 10(5), 907; https://doi.org/10.3390/jcm10050907 - 25 Feb 2021
Cited by 32 | Viewed by 2099
Abstract
Background: We aimed to evaluate the impact of knee periprosthetic joint infection (PJI) by assessing the patients’ long-term quality of life and explicitly their psychological wellbeing after successful treatment. Methods: Thirty-six patients with achieved eradication of infection after knee PJI were included. Quality [...] Read more.
Background: We aimed to evaluate the impact of knee periprosthetic joint infection (PJI) by assessing the patients’ long-term quality of life and explicitly their psychological wellbeing after successful treatment. Methods: Thirty-six patients with achieved eradication of infection after knee PJI were included. Quality of life was evaluated with the EQ-5D and SF-36 outcome instruments as well as with an ICD-10 based symptom rating (ISR) and compared to normative data. Results: At a follow-up of 4.9 ± 3.5 years the mean SF-36 score was 24.82 ± 10.0 regarding the physical health component and 46.16 ± 13.3 regarding the mental health component compared to German normative values of 48.36 ± 9.4 (p < 0.001) and 50.87 ± 8.8 (p = 0.003). The mean EQ-5D index reached 0.55 ± 0.33 with an EQ-5D VAS rating of 52.14 ± 19.9 compared to reference scores of 0.891 (p < 0.001) and 68.6 ± 1.1 (p < 0.001). Mean scores of the ISR revealed the psychological symptom burden on the depression scale. Conclusion: PJI patients still suffer from significantly lower quality of life compared to normative data, even years after surgically successful treatment. Future clinical studies should focus on patient-related outcome measures. Newly emerging treatment strategies, prevention methods, and interdisciplinary approaches should be implemented to improve the quality of life of PJI patients. Full article
(This article belongs to the Special Issue Advances in Understanding the Pathogenesis and Pathophysiology of Orthopaedic-Related Infections)
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